J Infertil Reprod Biol, 2020, Volume 8, Issue 3, Pages: 53-56. https://doi.org/10.47277/JIRB/8(3)/53  
Meticulous Management of a Case of Severe  
Ovarian Hyperstimulation Syndrome Using  
Dopamine Agonist and GnRH Antagonist: a  
Case Report  
*
Reena Yadav, Kanika Chopra , Pratibha Roy, Barkha Vats  
Department of Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi, India  
Received: 18/06/2020  
Accepted: 09/08/2020  
Published: 20/09/2020  
Abstract  
Ovarian hyperstimulation syndrome (OHSS) is characterised by increased capillary permeability and thus fluid shift from  
intravascular to extravascular compartment. Presence of abdominal distension causing discomfort to the patient, diameter of  
ovary more than 12 cm and ascites are the criteria to diagnose a case of severe OHSS. A, 28-year-old patient, P4L5 presented  
to our hospital, after ovulation induction and pick-up for oocyte donation, with abdominal distension and pain. She has history  
of severe OHSS, 4 months back as well. She was managed symptomatically, with close watch on her vitals, input-output,  
hematological and ultrasonological parameters. She was administered dopamine agonist in a dose of 1 mg/day and GnRH  
antagonist, injection cetrorelix 0.25 mg subcutaneously for 7 days. Paracentesis was also done twice for the patient under  
ultrasound guidance. Patient improved significantly over the course and was discharged in a stable condition.  
Keywords: Dopamine agonists, Cabergoline, GnRH, Cetrorelix  
Introduction  
OHSS is  
a
serious complication of artificial  
135 mmol/l), hyperkalemia (potassium > 5 mmol/l),  
hypoproteinemia (serum albumin <35g/l) and diameter of  
ovarian size more than 12 cm (1). Early diagnosis and  
scrupulous management are the key to successful  
recovery. Antithrombotic measures, dopamine agonist and  
GnRH antagonists are considered to be useful in the  
treatment of established early OHSS as reported in various  
studies (2, 3).  
reproductive technology and its incidence is increasing.  
The syndrome is characterized by massive ovarian  
enlargement, ascites, pleural or pericardial effusion,  
oliguria, electrolyte imbalance, hemoconcentration,  
hypotension, thromboembolism, acute respiratory distress  
syndrome and death in severe conditions. OHSS can be of  
four types depending on the presence of symptoms into  
mild, moderate, severe and critical. Severe OHSS is  
defined by the presence of clinical ascites, oliguria (<  
Case  
3
1
00ml/day), haematocrit > 0.45, hyponatremia (sodium <  
35 mmol/l), hyperkalemia (potassium > 5 mmol/l),  
A, 28-year-old, P4L5, patient presented to the  
emergency department of obstetrics and gynaecology of  
our hospital with complaints of abdominal distension and  
pain for 3 days. She also complaint of 8-10 episodes of  
vomiting and unable to tolerate orally. On enquiring,  
patient told that she was undergoing ovulation induction  
for oocyte donation. Patient was stimulated with GnRH  
agonist i.e. recombinant FSH 400 IU from day 2 of cycle  
hypoproteinemia (serum albumin <35g/l) and diameter of  
ovarian size more than 12 cm (1). Early diagnosis and  
scrupulous management are the key to successful  
recovery. Antithrombotic measures, dopamine agonist and  
GnRH antagonists are considered to be useful in the  
treatment of established early OHSS as reported in various  
studies (2, 3).  
th  
th  
for 5 days, injection HMG from 6 to 10 day in dose of  
3
OHSS is  
a
serious complication of artificial  
th  
75 IU and 300 IU on 11-12 day and GnRH antagonist,  
reproductive technology and its incidence is increasing.  
The syndrome is characterized by massive ovarian  
enlargement, ascites, pleural or pericardial effusion,  
oliguria, electrolyte imbalance, hemoconcentration,  
hypotension, thromboembolism, acute respiratory distress  
syndrome and death in severe conditions. OHSS can be of  
four types depending on the presence of symptoms into  
mild, moderate, severe and critical. Severe OHSS is  
defined by the presence of clinical ascites, oliguria (<  
cetrorelix acetate 0.25 mg from day 5 to day 12. Injection  
Hcg, 10,000 IU was given and around 30 oocyte pick-ups  
were done 3 days back. As she developed, pain abdomen  
and distension, she was referred to our hospital for further  
management accompanied by an agent.  
Her menstrual cycles were regular with average flow.  
She was para 4, live 5 with all vaginal deliveries with age  
of last child 5 years which was twin delivery and that was  
a spontaneous conception. There was no significant past  
300ml/day), haematocrit > 0.45, hyponatremia (sodium <  
*
Corresponding authors: Kanika Chopra, Department of Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi,  
India, Email: kank2kanu@yahoo.co.in  
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J Infertil Reprod Biol, 2020, Volume 8, Issue 3, Pages: 53-56. https://doi.org/10.47277/JIRB/8(3)/53  
suggestive of any chronic illness. There was significant  
history of ovarian hyperstimulation syndrome four months  
back which even required paracentesis.  
cabergoline 0.5mg on first day and was increased to 1 mg  
and was continued. Thromboprophylaxis with low  
molecular weight heparin was started with injection  
enoxaparin 40 mg subcutaneously. Intravenous fluids  
were administered and oral intake was encouraged as per  
thirst of the patient, once her vomiting settled with  
antiemetics. Pain relief was done with opioids.  
On examination, general condition of the patient was  
average, her vitals were pulse rate 104 per minute, blood  
pressure 100/60 mmHg, respiratory rate 37/minute,  
saturation 98% on room air and temperature 37.5 degree  
Celsius. On cardiovascular examination, S1S2 were  
normal with no added sounds and on chest examination,  
air entry was decreased on right basal lung. On abdominal  
examination, abdomen was distended, with shifting  
dullness and tenderness in lower abdomen. Her abdominal  
girth was 35 inches. Her body weight was 53 kg.  
All her investigations were done, including  
hemogram, haematocrit, coagulation profile, ABG, liver,  
kidney function tests and serum estradiol levels as  
depicted in Table 1. Chest Xray was done and was  
suggestive of right sided pleural effusion, figure 1.  
Ultrasound pelvis was done and showed anteverted  
normal size uterus with endometrial thickness of 10.1mm.  
Bilateral adnexa showed complex cystic lesions. Right  
side measured 4.5x3.5x 4.2cm (33 cc) and left side  
measured 5.4x5.3x 5.3cm (75.8cc) with peripheral as well  
as septal vascularity, ovaries were not seen separately.  
Moderate ascites was seen with no internal echoes.  
On day 4 of presentation, patient’s condition  
deteriorated, patient developed multiple episodes of  
vomiting, output decreased to less than 20-25 ml/hour,  
abdomen became tense, abdominal girth increased, body  
weight increased, hematocrit increased and serum sodium  
decreased. Ultrasound pelvis was done and size of right  
adnexal region was 7.0x9.9x7.9 cm (285 cc) and left  
adnexal region was 11.5x8.7x9.1 (470 cc) with ascites,  
figure 2. Decision to do ultrasound guided paracentesis  
was done and under all aseptic precautions, 800 cc of  
ascitic fluid was drained. 200 ml of 20 % albumin was  
transfused and injection cetrorelix 0.25 mg  
subcutaneously was administered. Ultrasound guided  
paracentesis was repeated on day 6 of presentation and 1.5  
litres of ascitic fluid was drained. Size of ovaries gradually  
decreased to 103cc of right side and 92 cc of left side on  
day 11 of presentation i.e. after 13 days of oocyte pick-up  
and patient started menstruating.  
Patient was catheterised and strict input and output  
monitoring was done. Vital monitoring, daily weight  
measurement, abdominal girth charting, and daily blood  
investigations (Table 1) were continued. Patient was given  
Patient improved symptomatically and clinically over  
the time. She received total seven doses of cetrorelix  
acetate. Patient was discharged explaining her not to  
undergo ovulation induction in future.  
Table 1: Biochemical and clinical parameters over the course of admission stay  
Parameters  
DAY 1  
DAY 3  
DAY 4  
DAY 6  
DAY 7  
DAY 11  
(
admission)  
(discharge)  
Hemoglobin (gm%)  
TLC  
13.7  
14.8  
20500  
3.59  
16  
14.1  
14600  
3.33  
12.4  
8540  
3.42  
12.3  
5550  
3.73  
17400  
22500  
3.41  
PLATELET COUNT  
2
4
1
.15  
0.5  
.00  
HEMATOCRIT  
INR  
41.1  
1.00  
49.7  
0.95  
42.7  
0.93  
37.1  
0.93  
37  
0.97  
BU/S CREAT  
Na/ K  
1
7/0.8  
15/0.7  
31/0.9  
19/0.7  
15/0.6  
10/0.5  
1
37/4.0  
138/5.9  
1.5/66/41/185  
131/4.6  
1.3/62/67/103  
134/4.2  
0.7/80/63/92  
134/4.2  
141/4.5  
0.3/65/94/110  
TBIL/ALT/AST/ALP  
0.6/43/34/83  
> 3000 pg/ml  
0.3/173/131/104  
SERUM ESTRADIOL  
Weight  
5
3
54  
55  
55  
54  
35  
50  
32  
Abdominal girth  
37.5  
37.5  
38.5  
38.5  
Figure 1: Chest X-RAY showing right sided pleural effusion, marked by red arrow  
54