1
|
Al-Sadawi M, Chowdhury R, Asun S, Ray J, Soni L, Bahtiyar G, Ponse D, McFarlane SI. Ovarian Hyperstimulation Syndrome and Myocardial Infarction: A Systematic Review. INTERNATIONAL JOURNAL OF CLINICAL ENDOCRINOLOGY AND METABOLISM 2019; 5:009-12. [PMID: 31428746 PMCID: PMC6699777 DOI: 10.17352/ijcem.000035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Ovarian hyperstimulation syndrome (OHSS) is a rare but serious complication of ovarian stimulation occurring during assisted reproduction technologies (ART). It is characterized by increased vascular permeability and hypercoagulable states resulting in strokes and peripheral ischemia. Acute myocardial infarction and cardiac thrombosis, however, have been rarely reported complications of OHSS. METHODS A literature search was performed for reports on myocardial infarction and cardiac thrombosis associated with ovarian stimulation with a summary of their clinical characteristics. RESULTS A total of twelve published cases were reviewed with 5 out of 12 (41.67%) of the reported cases were 35 years of age or older. Myocardial infarction was reported in 10 out of the 12 cases (83.3%). Two of the cases were pregnant at presentation (16.67%). The mean duration between starting ovarian stimulation medications and clinical presentation was 23 days. Chest pain was the most common presenting symptom (66.67%), 2 cases presented with stroke (16.67%) and 2 cases presented with abdominal distention (16.67%). A total of 8 patients underwent coronary angiography with 2 of these cases were treated with percutaneous coronary intervention. No mortality reported in any of the twelve cases. CONCLUSION Women of a relatively younger age undergoing ovarian stimulation may be at risk for developing myocardial infarction and cardiac thrombosis. Once thrombosis is suspected, initiating appropriate therapy in a timely manner is crucial.
Collapse
Affiliation(s)
- Mohammed Al-Sadawi
- Department of Internal Medicine, Division of Endocrinology, State University of New York, Downstate Medical Center, Brooklyn, New York, USA
| | - Richi Chowdhury
- Department of Internal Medicine, Division of Endocrinology, State University of New York, Downstate Medical Center, Brooklyn, New York, USA
| | - Seline Asun
- Department of Internal Medicine, Division of Endocrinology, State University of New York, Downstate Medical Center, Brooklyn, New York, USA
| | - Justina Ray
- Department of Internal Medicine, Division of Endocrinology, State University of New York, Downstate Medical Center, Brooklyn, New York, USA
| | - Lina Soni
- Department of Internal Medicine, Division of Endocrinology, State University of New York, Downstate Medical Center, Brooklyn, New York, USA
| | - Gul Bahtiyar
- Department of Medicine, Division of Endocrinology, New York University, NY, USA
| | - Debora Ponse
- Department of Internal Medicine, Division of Endocrinology, State University of New York, Downstate Medical Center, Brooklyn, New York, USA
| | - Samy I McFarlane
- Department of Internal Medicine, Division of Endocrinology, State University of New York, Downstate Medical Center, Brooklyn, New York, USA,Corresponding author: Samy I McFarlane, MD, MPH, MBA, FACP, Distinguished Teaching Professor and Associate Dean College of Medicine, Department of Medicine, Division of Endocrinology Internal Medicine Residency Program Director, State University of New York, Downstate Medical Center, 450 Clarklson Ave, Box 50, Brooklyn, NY 11203-2098, USA, Tel: 718-270-6707; Fax: 718-270-4488;
| |
Collapse
|
2
|
Jiang X, Deng CY, Sun ZY, Chen WL, Wang HB, Zhou YZ, Jin L. Pregnancy Outcomes of In Vitro Fertilization with or without Ovarian Hyperstimulation Syndrome: A Retrospective Cohort Study in Chinese Patients. Chin Med J (Engl) 2016; 128:3167-72. [PMID: 26612291 PMCID: PMC4794889 DOI: 10.4103/0366-6999.170280] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Background: The effect of ovarian hyperstimulation syndrome (OHSS) on pregnancy outcomes of in vitro fertilization (IVF) patients is still ambiguous. This study aimed to analyze pregnancy outcomes of IVF with or without OHSS in Chinese patients. Methods: A retrospective cohort study was undertaken to compare pregnancy outcomes between 190 women with OHSS and 197 women without OHSS. We examined the rates of clinical pregnancy, multiple pregnancies, miscarriage, live birth, preterm delivery, preterm birth before 34 weeks’ gestation, cesarean delivery, low birth weight (LBW), and small-for-gestational age (SGA) between the two groups. Odds ratios (ORs) and 95% confidence intervals (CIs) of measure of clinical pregnancy were also analyzed. Results: The clinical pregnancy rate of OHSS patients was significantly higher than that of non-OHSS patients (91.8% vs. 43.5%, P < 0.001). After controlling for drug protocol and causes of infertility, the adjusted ORs of moderate OHSS and severe/critical OHSS for clinical pregnancy were 4.65 (95% CI, 1.86–11.61) and 5.83 (95% CI, 3.45–9.86), respectively. There were no significant differences in rates of multiple pregnancy (4.0% vs. 3.7%) and miscarriage (16.1% vs. 17.5%) between the two groups. With regard to ongoing clinical pregnancy, we also found no significant differences in the rates of live birth (82.1% vs. 78.8%), preterm delivery (20.9% vs. 17.5%), preterm birth before 34 weeks’ gestation (8.6% vs. 7.9%), cesarean delivery (84.9% vs. 66.3%), LBW (30.2% vs. 23.5%), and SGA (21.9% vs. 17.6%) between the two groups. Conclusion: OHSS, which occurs in the luteal phase or early pregnancy in IVF patients and represents abnormal transient hemodynamics, does not exert any obviously adverse effect on the subsequent pregnancy.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Li Jin
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| |
Collapse
|
3
|
Abstract
Assisted reproductive technologies (ART) encompass fertility treatments, which involve manipulations of both oocyte and sperm in vitro. This chapter provides a brief overview of ART, including indications for treatment, ovarian reserve testing, selection of controlled ovarian hyperstimulation (COH) protocols, laboratory techniques of ART including in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI), embryo transfer techniques, and luteal phase support. This chapter also discusses potential complications of ART, namely ovarian hyperstimulation syndrome (OHSS) and multiple gestations, and the perinatal outcomes of ART.
Collapse
|
4
|
Right ventricular thrombus: a rare complication of ovarian hyperstimulation syndrome. Int Cardiovasc Res J 2012; 6:131-2. [PMID: 24757608 PMCID: PMC3987413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 11/20/2012] [Accepted: 12/03/2012] [Indexed: 11/27/2022] Open
Abstract
A 22 years old lady was admitted because of progressive dyspnea, severe abdominal protrusion and lower extremity edema. She had undergone ovarian hyperstimulation for primary infertility by Clomiphen and Human chorionic gonadotropin for 3 months. Abdominopelvic ultrasonography revealed bilateral enlarged multi cystic ovaries and massive ascites. Transesophageal echocardiography revealed a large thrombus in right ventrice apex. Spiral chest CT scan showed normal pulmonary vasculature with no evidence of pulmonary thromboembolism. Heparin was started and repeat echocardiographic study showed gradual disappearance of right ventricular thrombus. Human chorionic gonadotropin is the most important substance which leads to capillary leakage and fluid accumulation in third space. Fluid shift and hypovolemia may cause hypotension, hemoconcentration and formation of vascular thrombus.
Collapse
|
5
|
|
6
|
Ravel P, Marcaggi X, Ferrier N, Vignancour S, Clerfond G, Boch C, Amat G. [Myocardial infarction and ovarian stimulation: case report]. Ann Cardiol Angeiol (Paris) 2009; 58:313-317. [PMID: 19819419 DOI: 10.1016/j.ancard.2009.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Female infertility treated by ovarian stimulation can lead to arterial thrombosis particularly when ovarian hyperstimulation syndrome emerges. Myocardial infarction have been reported thrice, in one case even before artificial ovulation induction. A 25-year-old female with primary infertility underwent ovarian stimulation and eight days after ovulation induction and intra-uterine insemination suffered from a troponin positive non-ST-elevation myocardial infarction of the inferior wall. Coronary angiogram was normal and contrast-enhanced cardiovascular magnetic resonance imaging confirmed the subendocardial inferior infarct. This protocol included sole triptorelin administration followed by 23 recombinant follicle stimulating hormone injections and concluded by recombinant choriogonadotrophin. There was no ovarian hyperstimulation syndrome. Large biological screening did not retrieve any predisposition for arterial thrombosis. Clinical outcome was excellent. Despite weak causal link, we emphasize that chest pain during ovarian stimulation protocol should rise clinical concern for acute coronary syndrome.
Collapse
Affiliation(s)
- P Ravel
- Service de Réanimation, Centre Hospitalier de Vichy, Vichy, France
| | | | | | | | | | | | | |
Collapse
|
7
|
Salomon O, Schiby G, Heiman Z, Avivi K, Sigal C, Levran D, Dor J, Itzchak Y. Combined jugular and subclavian vein thrombosis following assisted reproductive technology—new observation. Fertil Steril 2009; 92:620-5. [DOI: 10.1016/j.fertnstert.2008.07.1708] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Revised: 06/12/2008] [Accepted: 07/09/2008] [Indexed: 11/24/2022]
|
8
|
Chan WS. The ‘ART’ of thrombosis: a review of arterial and venous thrombosis in assisted reproductive technology. Curr Opin Obstet Gynecol 2009; 21:207-18. [DOI: 10.1097/gco.0b013e328329c2b8] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
9
|
Ovarian hyperstimulation syndrome: a potentially fatal complication of early pregnancy. J Emerg Med 2008; 35:283-6. [PMID: 18403169 DOI: 10.1016/j.jemermed.2007.11.074] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2006] [Revised: 04/21/2007] [Accepted: 11/15/2007] [Indexed: 11/23/2022]
Abstract
We present the case of a patient who presented to the Emergency Department (ED) 48 h after successful in vitro fertilization with abdominal pain, hypotension, and free fluid on an ED-focused abdominal sonogram for trauma study. This presentation is typical of Ovarian Hyperstimulation Syndrome (OHSS), a diagnosis that may be unfamiliar to many Emergency Physicians. With the increasing frequency of in vitro fertilization procedures, this disease process is becoming more common. Numerous complications can occur with OHSS, including third-space fluid accumulation, hemoconcentration, renal failure, and thromboembolic phenomena. Vigilance is required as these patients are at increased risk of ovarian torsion, ovarian rupture with internal hemorrhage, ectopic pregnancy, and infection. This case report provides an overview of clinical features and emergent management of OHSS.
Collapse
|
10
|
Chan WS, Dixon ME. The “ART” of thromboembolism: A review of assisted reproductive technology and thromboembolic complications. Thromb Res 2008; 121:713-26. [PMID: 17659766 DOI: 10.1016/j.thromres.2007.05.023] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Revised: 01/30/2007] [Accepted: 05/29/2007] [Indexed: 11/24/2022]
Abstract
Since its development over 25 years ago, the use of assisted reproductive technology (ART) is on the increase. Along with its use, are also reports of thromboembolic complications (TEC); these events could resulted in significant maternal morbidity and even mortality. In this article, we reviewed the general principles of ART. We also performed a search of all published cases of TEC associated with ART, and summarized the results of studies investigating underlying hemostatic changes with ART. The goal of this article is to provide non-fertility specialists an understanding of ART, so as to better manage TEC when they occur in predisposed patients. The most common ART procedure performed today, is in-vitro fertilization-embryo transfer (IVF-ET). The process of IVF involves the use of exogeneous hormones to achieve cycle control, stimulate the ovaries, and support implantation. During this process, supraphysiological estradiol levels can result. One major complication of this intervention, ovarian hyperstimulation syndrome (OHSS), can be associated with both arterial and venous thrombotic complications. These events (especially venous thrombosis) have also been reported to occur weeks after OHSS has resolved; and they can present in unusual sites (upper extremities) resulting in treatment challenges. From current available studies, it is clear that with ovarian stimulation, both the coagulation and fibrinolytic systems are activated. This activation appears to be exaggerated and prolonged with the development of OHSS. Whether these changes are sufficient by themselves to explain the occurrence of TEC is yet unknown. Future studies should be focused on defining the frequency and risk factors of these complications; provide a closer examination of the resultant changes in the coagulation cascade during ART, OHSS and early pregnancy; and investigating the appropriate treatment and thromboprophylaxis for patients undergoing a procedure considered "elective".
Collapse
Affiliation(s)
- W S Chan
- Department of Medicine and Obstetrics & Gynecology, Women's College Hospital and Sunnybrook Health Sciences Centre, 76, Grenville Street, Toronto, Ontario, Canada M5S 1B2.
| | | |
Collapse
|
11
|
Girolami A, Scandellari R, Tezza F, Paternoster D, Girolami B. Arterial thrombosis in young women after ovarian stimulation: case report and review of the literature. J Thromb Thrombolysis 2007; 24:169-74. [PMID: 17265135 DOI: 10.1007/s11239-007-0009-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2006] [Accepted: 01/04/2007] [Indexed: 10/23/2022]
Abstract
Both venous and arterial thrombosis have been described in women after ovarian stimulation and/or hyperstimulation for infertility management. The ratio between venous and arterial thrombosis in this condition is about 2 or 3 to 1, contrary to what seen during pregnancy or oral contraception where it is 5 or 10 to 1. An accurate perusal of the literature and of personal files has yielded 34 cases of arterial thrombosis after assisted reproductive technologies (ART) which entailed ovarian stimulation. There were 15 cases of ischemic strokes; 7 cases of carotid and/or vertebral artery occlusion; 6 of aorta and peripheral vessel thrombosis, 2 of mesenteric artery occlusion, 3 with myocardial infarction and 2 with intracardiac thrombosis. Associated risk factors were as follow: smoking in 4 women; antiphospholipid antibodies in 2; decrease in protein S in 1. Furthermore, polycystic ovaries were present in two women. Ovarian hyperstimulation was obtained with several protocols which included human chorionic gonadotropin (HCG) in all but a few instances. Age of women varied between 22 and 41 with an average of 32. Nineteen women were pregnant at the time of thrombosis. Only seven of these 19 pregnancies were brought to term with fetal survival. Abortion was spontaneous in 5 cases and therapeutic in the additional 7. There were two maternal fatalities.
Collapse
Affiliation(s)
- Antonio Girolami
- Department of Medical and Surgical Sciences, University of Padua Medical School, via Ospedale 105, 35128 Padua, Italy.
| | | | | | | | | |
Collapse
|
12
|
Coli S, Magnoni M, Melisurgo G, Persico P, Doldi N, De Cobelli F, Del Maschio A, Cianflone D, Maseri A. Myocardial infarction complicating the initial phase of an ovarian stimulation protocol. Int J Cardiol 2006; 115:e56-7. [PMID: 17067704 DOI: 10.1016/j.ijcard.2006.07.166] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2006] [Accepted: 07/22/2006] [Indexed: 11/15/2022]
Abstract
Two previous reports have reported myocardial infarction during ovarian hyperstimulation syndrome, a complication of controlled ovarian stimulation characterized by ascites, pleural effusion, hemoconcentration and an increased thromboembolic risk, but no association with the initial phase (before treatment with human chorionic gonadotropin) of a normal ovarian stimulation protocol for infertility has ever been described. We report the first case, to our knowledge, of acute myocardial infarction occurring during the initial phase of an otherwise uncomplicated ovarian stimulation protocol. A young woman with infertility associated to polycystic ovary syndrome was treated with leuprolide acetate and recombinant follicle stimulating hormone to induce ovarian stimulation for in vitro fertilization and embryo transfer. After 12 days the patient presented a non-ST elevation myocardial infarction, which was treated with aspirin, clopidogrel, enoxaparin, intravenous nitrates and beta blockers. Cardiac catheterization showed angiographically normal coronary arteries. Echocardiography showed a circumscribed akinesis of the inferior apical segment of the left ventricle and right ventricular apex, which was confirmed by cardiac magnetic resonance. A screening for thrombophilic diathesis was negative. The patient was discharged and remained asymptomatic at 1 and 3 months follow up. Further ovarian stimulations were excluded and a trial of oocyte retrieval on spontaneous cycle was planned. Myocardial infarction can complicate ovarian stimulation protocols for infertility even in their early phase without any sign of ovarian hyperstimulation syndrome.
Collapse
|
13
|
Rao AK, Chitkara U, Milki AA. Subclavian vein thrombosis following IVF and ovarian hyperstimulation: a case report. Hum Reprod 2005; 20:3307-12. [PMID: 16085662 DOI: 10.1093/humrep/dei235] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Thromboembolic phenomena are a serious consequence of assisted reproductive technology. We present a case of upper extremity deep vein thrombosis (DVT) at 7 weeks gestation following ovarian hyperstimulation syndrome (OHSS) and IVF. Three weeks after recovering from OHSS, the patient presented with left neck pain and swelling. Ultrasound revealed a thrombus in the left jugular vein and left subclavian vein. Low molecular weight heparin (LMWH) was initiated with symptom resolution within 1 week. The patient remained on LWMH throughout her pregnancy and delivered at term. A literature review showed 97 published cases of thromboembolism following ovulation induction. A majority of these cases was associated with OHSS and pregnancy and the site of involvement was predominantly in the upper extremity and neck. Infertility physicians and obstetricians should be aware of this complication and keep in mind that it may occur weeks after resolution of OHSS symptoms.
Collapse
Affiliation(s)
- Anjali K Rao
- Department of Obstetrics and Gynecology, Divisions of Reproductive Endocrinology/Infertility and Maternal Fetal Medicine, Stanford University Medical Center, Stanford, CA 94305, USA
| | | | | |
Collapse
|
14
|
Bennett TA, Adams MM. Safe motherhood in the United States: challenges for surveillance. Matern Child Health J 2002; 6:221-6. [PMID: 12512763 DOI: 10.1023/a:1021153915360] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVES Maternal mortality ratios in the United States are higher than those of many other industrialized nations. Moreover, these ratios have not changed in the past 20 years, and large racial disparities persist in measures of both maternal mortality and morbidity. In an affluent developed country, maternal deaths should serve as rare sentinel events, highlighting opportunities for prevention and reduction of morbidities. However, existing surveillance efforts are poorly developed, and pregnancy-related deaths and illnesses tend to be underreported. To formulate recommendations for improved surveillance, the authors reviewed existing data on maternal health. METHODS This review examines the scope and quality of existing information and the strengths and limitations of definitions of maternal mortality and morbidity used in data collection and reporting. RESULTS This review suggests numerous gaps in surveillance of U.S. maternal health. Psychological as well as physical morbidity, and the presence and adequacy of appropriate treatment, should be ascertained. Quality of pregnancy-related care at the clinical and community levels, and the impact on mortality and morbidity, must be assessed. Collection of morbidity data outside of health care delivery sites is also essential. Trade-offs between nationally representative and other less comprehensive data sources, such as sentinel clinics, large healthcare organizations, and public healthcare financing systems, should be considered. CONCLUSION Maternal health remains an important frontier for U.S. public health surveillance efforts. Improved surveillance offers opportunities for reducing pregnancy-related mortality and gaining a better understanding of the relationship between maternal morbidity and mortality.
Collapse
Affiliation(s)
- Trude A Bennett
- Department of Maternal and Child Health, School of Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7445, USA.
| | | |
Collapse
|