Article

Concurrent ovarian hyperstimulation syndrome with perforated appendicitis following induction ovulation with HMG and HCG

Case Report

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American Journal of Emergency Medicine

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Concurrent ovarian hyperstimulation syndrome with perforated appendicitis following induction ovulation with HMG and HCG

Abstract

Ovarian hyperstimulation syndrome of the ovary is a medi- cal complication of the ovulation induction, and it has been shown that OHSS may both mask the typical manifestations of appendicitis and compromise the concurrent intraperitoneal infection.

A 23-year-old nulligravid woman presented with complications of nausea, vomiting, and generalized abdominal pain after ovarian stimu- lation with HMG and HCG. OHSS was diagnosed on the basis of the clin- ical presentation and ultrasonographic evidence.

An emergency laparotomy showed the definitive diagnosis of perito- nitis due to perforated appendicitis. Appendectomy and vigorous irriga- tion with drainage were performed.

Severe OHSS is life threatening and the diagnosis of appendicitis was difficult and complicated in this case. When the patient with OHSS un- dergoes supportive medical care, and despite their treatment, he or she does not stabilize and abdominal pain and distention continue, we consider other problems of acute abdominal pain, such as appendicitis. Ovarian hyperstimulation syndrome of the ovary is a medical compli- cation of the ovulation induction, which can be life threatening. The signs of this syndrome are caused by extravasation of a protein-rich fluid, which leads to Fluid shifts from intravascular to third-space compartment or interstitial. Clinical manifestations of Severe forms of this syndrome in- clude ovarian enlargement, hem concentration, hypercoagulability, hypervolemia, oliguria, hypotension, pleural effusion, liver functional ab- normalities, electrolyte imbalance, and ascites. The abdominal pain in this syndrome can imitate the signs of acute abdomen, conservative manage- ment with medication is enough in most of the patients, and the surgery treatment often makes the lack of electrolytic balance and morbidity in- crease. In this case, we describe a woman with severe OHSS, which had caught the perforated appendicitis at the same time and led to peritonitis. A 23-year-old nulligravid woman was hospitalized at Ayatollah Rohani Hospital of Babol, Iran. The patient with a diagnosis of severs OHSS underwent supportive care treatment. Vital signs every 6 hours, abdominal girth, and weight (daily) were checked. The complete blood count, plasma proteins, electrolytes, hematocrit, and the creati- nine clearance rate were also recorded daily. The patient began treat- ment with bed rest and intravenous Fluid replacement with crystalloid solution, heparin (5000 IU 3 times a day), and 20% albumin (150 mL/ d). Despite supportive treatment, on the fifth day of hospitalization, her generalized abdominal pain continued with tenderness and abdom- inal size and ascites increased. She appeared ill and suffered shortness of breath; therefore, paracentesis was performed to reduce abdominal dis- tension from severe ascites. A yellow, foul-smelling fluid exited. Simul- taneously, the patient had a temperature of 38.2?C and her blood pressure was normal. During this time, she had normal urinary output.

With a diagnosis of infectious peritonitis, after a Midline incision, an emergency laparotomy was performed. At laparotomy, the abundant thick fibrin secretions were observed and sucked. The appendix had been perforated from the base from which the appendectomy had been performed. The ovaries were inflamed and swollen. They contained multiple cysts with hemorrhagic view. One of the cysts was perforated intraoperatively, which was stopped by the bleeding cautery. Following vigorous irrigation the surgery was ended by the open- abdomen procedure. The patient was transferred to the intensive care unit. The diagnosis of appendicitis was histologically confirmed.

In this study woman presented complications of nausea, vomiting,

and generalized abdominal pain. The date of her last menstrual period was 15 days before she was admitted. In her medical history, she had been under primary infertility treatment 1.5 years ago, and recently she underwent ovarian stimulation with a total dose of 75 IU HMG on the 8th and 10th days of her last menstrual period. Next, the HCG of 1000 IU was injected on the 12th day.

The patient had brief abdominal distension and tenderness without guarding, and rebound tenderness in the lower abdomen by abdominal and pelvic examination, at the time of being admitted. Her vital sign were also stable: A pulse rate of 78, temperature of 36.7?C, and blood pressure of 120/70 mmHg. A transvaginal ultrasonographic revealed bi- lateral multi loculated cystic ovaries and ascites. OHSS was diagnosed on the basis of the clinical presentation and ultrasonographic evidence. The laboratory evaluations were performed and the results are as fol- lows: ?-HCG, negative; hemoglobin, 11.5 g/dL; platelet count, 25,000/ uL; leukocyte count, 8000/mm; serum albumin, 3.4 g/dL; creatinine,

0.5 mg/dL; sodium, 125 mmol/L; and potassium, 3.8 mmol/L.

The patient was transferred into the operating room for the second time a week later. First the abdomen’s internal space was washed, then the skin, fascia, and the restoration were performed. On the 25th day of her hospitalization, the patient got diarrhea and had abdominal pain. Laboratory tests and CT scans were performed and showed, in order, increased serum amylase and lipase and swelling of the pancreas. Thus, with a diagnosis of pancreatitis, the patient was under TPN and supportive treatments. Ultimately, on the 33rd day of her hospitaliza- tion, she was discharged in good general health.

The synchronization of perforated appendicitis and OHSS syndrome, based on our knowledge, was reported for the first time by Van Hoorde et al in 1992. This report described a case of perforated appendicitis fol- lowing transvaginal oocyte retrieval [1].Next, in 2002, Fujimoto and co- workers reported a patient with OHSS, which was complicated by peri- tonitis due to perforated appendicitis. The patient had fever, tachycar- dia, and severe abdominal distension. In this case there was, simultaneously, a right tubal pregnancy [2]. Here, we report another case of perforated appendicitis with OHSS, which led to peritonitis.

0735-6757/(C) 2016

Unlike the case reported by Hoorde et al, in patients in our studies with OHSS and perforated appendicitis, and according to Fujimoto reports, transvaginal procedures were not performed. Thus, the appen- dix damage probability is canceled. But in the present case, the patient had no fever until we performed paracentesis for the relief of ab- dominal distension.

Patients with OHSS may complain of clinical symptoms and signs such as abdominal discomfort, a bloated feeling, abdominal distension and pain, nausea, and vomiting [3], which we can see in appendicitis [4]. Abdominal pain [5] and acute appendicitis are the most common complaint in the emergency department [6].

The clinical presentation is often atypical and the diagnosis is partic- ularly difficult because symptoms often overlap with other conditions [7]. The pain associated with migration of appendicitis to the right lower quadrant [4] was not manifested in this case. Both fever and an el- evated white blood count [8], as observed in appendicitis, were not found with any relevance.

The question here is whether perforated appendicitis should be in- cluded as a complication of OHSS or not. As was stated previously, there is a question of which of these two pathologies belongs to each other or which condition of each one affects the clinical aspect of the other [2].

The immunodeficiency role of OHSS has been reported. The infection is high in severe OHSS for lack of plasma globulins, which leads to some degree of immunodeficiency [9]. Hypoglobulinemia in the patients with severe OHSS leads to immunodeficiency. Thus, the rate of infectious dis- ease rises. The probability of the effect of OHSS on the course of appen- dicitis increases [9], and there is a probability on which the appendicitis with OHSS can play a more aggressive role than that without OHSS. Through the existing albumin in the ascites fluid, it is a proper culture medium for the bacteria to grow rapidly [10].

Moreover, the immunoprotective status is impaired by severe stresses associated with symptoms of OHSS, a hospital stay, multiple monitoring, and therapies [11,12]. Severe stress can be a determining factor in the co-existence of OHSS with a perforated Duodenal ulcer [11]. Severe OHSS is life threatening and the diagnosis of appendicitis was difficult and complicated in this case. Because the patient with OHSS may complain of some clinical symptoms and signs, which can be ob- served in other acute abdominal ailments, such as appendicitis, we rec- ommend the following: When the patient with OHSS undergoes supportive medical care and despite their treatment, he or she does not stabilize and abdominal pain and distention continue, we consider

other problems of acute abdominal pain, such as appendicitis.

Severe OHSS is life threatening and the diagnosis of appendicitis was difficult and complicated in this case. When the patient with OHSS un- dergoes supportive medical care and despite their treatment, he or she does not stabilize and abdominal pain and distention continue, we consider other problems of acute abdominal pain, such as appendicitis.

Acknowledgements

We thank the Clinical Research Development Unit of Rouhani Hospital.

Zinatossadat Bouzari, MD Cellular & Molecular Biology Research Center Associate of Department of Obstetrics & Gynecology Babol University of Medical Sciences, Babol, Iran

Fateme Zahra Fertility & Infertility Research Health Center Associate of Obstetrics & Gynecology Department Babol of University of Medical Science, Babol, Iran

Shahla Yazdani, MD Cellular & Molecular Biology Research Center Associate of Department of Obstetrics & Gynecology Babol University of Medical Sciences, Babol, Iran

Fateme Zahra Fertility & Infertility Research Health Center Associate of Obstetrics & Gynecology Department Babol of University of Medical Science, Babol, Iran Clinical Research Development Unit of Rouhani Hospital Associate of Obstetrics & Gynecology Department Babol of University of Medical Science, Babol, Iran

Corresponding author. Fateme Zahra Fertility & Infertility Research Health Center, Clinical Research Development Unit of Rouhani Hospital

Associate of Obstetrics & Gynecology Department Babol of University of Medical Science, Ganjafroz street

Babol, Iran, 47745-47176 Tel.: +98 9112142116; fax: +98 1112229591

E-mail address: [email protected]

Toktam Sadeghi, MD

Student Committee Research, Babol University of Medical Sciences

Babol, Iran

http://dx.doi.org/10.1016/j.ajem.2016.03.015

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