ODP430 Unusual Complication after a controlled ovarian stimulation presenting as ascites
Authors: Ortiz Yineli , Aviles Astrid , Maldonado Hiram , Irizarry Maria , Magraner Miguel 
Published: November 2022

Abstract
Assisted Reproductive Technologies have become an integral element of care for women suffering from infertility. These comprise all interventions that include in vitro handling of both human oocytes and sperm, or of embryos for the purposes of reproduction. Ovarian hyperstimulation syndrome (OHSS) is the most serious complication of controlled ovarian hyperstimulation (COH) for assisted reproduction technologies (ART). Hereby we are describing the case of a patient who developed severe OHSS presenting prominent ascites who benefitted from early onset cabergoline therapy and paracentesis. Case of 28 y/o female with past medical history of hypothyroidism and hyperprolactinemia admitted after presenting worsening abdominal pain and distention, nausea, vomiting and decreased urine output 3 days after receiving treatment before a planned follicular extraction. She initially was started on intramuscular follistim and Menopur, exogenous gonadotropins, preceded by intramuscular progesterone in preparation for said extraction. On physical examination, there was a pronounced abdominal ascites with positive fluid wave accompanied by abdominal discomfort at palpation, tachycardia of 103bpm, oliguria (less than 0.5cc/kg/hr) but no palpable masses or visceromegaly. Evaluation showed leukocytosis of 23. 0K/uL, hematocrit level of 43.5 g/dl (N: 36-48% in females), hypotonic hyponatremia with sodium level: 134 (136-145mmol/L), serum osmolality of 268 mOsm/L (N: 269-295mOsm/L), estradiol level of 3,057 pg/ml and progesterone level of 253.3 ng/ml; hormones both well above normal range compatible with response to ovarian stimulation therapy received. Afterwards, the patient underwent an abdominal ultrasound reporting small to moderate amount of ascites and findings highly suggestive of OHHS. Endovaginal Ultrasound was done which showed a prominent endometrium measuring 6.5×5. 0x 3.2 cm with bilateral large ovaries containing numerous complex cysts. Patient was started with intravenous hydration with normal saline to maintain adequate intravascular volume and cabergoline 0.25mg intravaginally daily, a dopamine agonist associated with a significant reduction in the incidence of symptoms and signs of moderate to severe OHSS. Her symptoms improved initially, but three days later she complained of worsening abdominal distention, to which abdominal ultrasound was repeated to localize a pocket for abdominal paracentesis. Paracentesis was performed: 1.8 liters of yellow fluid were aspirated and ascites resolved. Although the most severe form of OHSS is rare as in our patient, the incidence observed over time is less than 1% reported in literature. This case is an example of women with low risk factors who develop severe OHSS who had a good response to dopamine agonist therapy. As strategies to reduce the incidence of OHSS and its severity, clinical trials are needed to study the efficacy as well as safety of different doses and durations of cabergoline administration for both prophylactic and therapeutic purposes.
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