1991, The British Journal of Radiology, 64, 1073-1074
Case of the month A leaking laparoscopy wound By F. Regan, MRCP and M. E. Crofton, MRCP, FRCR Department of Radiology, The Samaritan Hospital for Women, Marylebone Road, London NW1 (Received May 1990 )
A 34-year-old Bahrainian woman presented to the Accident and Emergency Department complaining of fluid leaking from a recent laparoscopy scar. She spoke very little English so no further history was available. Examination of the abdomen was unremarkable. She was referred for an ultrasound examination of the
abdomen to exclude an intra-abdominal collection or urinoma. A midline sagittal scan of the pelvis and a parasagittal scan to the left are shown (Figs 1 & 2). What is the diagnosis? What were the likely indications for the laparoscopy?
Figure 1. Parasagittal scan of the pelvis showing a thickened endometrium.
Figure 2. Parasagittal scan to the left showing an enlarged ovary with multiple cysts.
Vol. 64, No. 767
1073
Case of the month
The ultrasound examination revealed a moderate amount of ascites, later confirmed to be the source of the leaking fluid. The uterus was normal in size but had a very thickened endometrial echo (16-18 mm anteroposterior diameter). Both ovaries were enlarged (8 x 4 cm approximately) and contained multiple 1.5-2.0 cm cysts. These appearances are those of Ovarian Hyperstimulation Syndrome (OHSS). It was subsequently learnt that she had undergone ovulation induction therapy prior to in vitro fertilization. Laparoscopic egg collection had been performed in Belgium 2 days before presentation, but unfortunately none of the retrieved oocytes had fertilized so no embryos had been returned to her uterus. The patient insisted on returning to Bahrain following her diagnosis and as far as we are aware made an uneventful recovery. Discussion
The OHSS has frequently been described in the literature since Gemzell first described successful induction of ovulation and pregnancy in humans in 1958. The syndrome is usually of minimal consequence but can be a potentially life threatening condition, characterized by enlarged ovaries containing multiple cysts and extravascular fluid collections, ascites and pleural effusions. Exceptionally, pleural effusions may occur without an increase in ovarian size. There is haemoconcentration and in severe cases circulatory collapse and various coagulation disorders including disseminated intravascular coagulation can occur. Abnormally high levels of oestrogen are found in the patients serum, urine and follicular fluid and there are raised plasma levels of progesterone, 17-hydroxyprogesterone and testosterone. It is usually seen in association with various ovulation induction regimes (to treat ovarian dysfunction in infertility or to induce superovulation prior to in vitro fertil-
ization), but has been reported in association with hydatidiform moles and multiple pregnancies occurring without the aid of ovulation inducing agents. The severe form of the disease is rare with a reported incidence of 0.4-4% of patients on ovulation induction therapy. The milder form is much commoner (reported rates vary from 3-80%) and many cases undoubtedly go unrecognized. The pathogenesis and aetiology of the syndrome are unclear. There is thought to be a sudden increase in the permeability of the ovarian vessels and the fact that the extravascular fluid collections are transudates supports this. Crooke et al (1963) found that high follicle stimulating hormone (FSH)/Luteinizing hormone (LH) ratios resulted in a lower incidence of OHSS, but subsequently this could not be confirmed. Schenker and Weinstein (1978) showed the dose of gonadotrophins was significant but that the critical dose varied enormously between individuals. Histamine release blocking agents and prostaglandin inhibitors have been tried with variable success, but treatment of the condition is mainly supportive with correction of any fluid and electrolyte imbalance. It usually resolves spontaneously in 7-10 days. Primarily effort should be directed at preventing development of the syndrome by careful monitoring of all ovulation induction regimes and removal of the stimulating agent should the condition arise. References CROOKE, A. C ,
BUTT, W. R.,
PALMER, R. F. & MORRIS,
R.,
1963. Clinical trial of human gonadotrophins. Journal of Obstetrics and Gynaecology (Br. Commonwealth) 70, 604. SCHENKER,
J. G.
&
WEINSTEIN,
G.,
1978.
Ovarian
Hyperstimulation syndrome—a current survey. Fertility and Sterility, 30, 255-268.
Keywords: Ovarian hyperstimulation syndrome, Ovarian enlargement
1074
The British Journal of Radiology, November 1991
Case of the month A leaking laparoscopy wound By F. Regan, MRCP and M. E. Crofton, MRCP, FRCR Department of Radiology, The Samaritan Hospital for Women, Marylebone Road, London NW1 (Received May 1990 )
A 34-year-old Bahrainian woman presented to the Accident and Emergency Department complaining of fluid leaking from a recent laparoscopy scar. She spoke very little English so no further history was available. Examination of the abdomen was unremarkable. She was referred for an ultrasound examination of the
abdomen to exclude an intra-abdominal collection or urinoma. A midline sagittal scan of the pelvis and a parasagittal scan to the left are shown (Figs 1 & 2). What is the diagnosis? What were the likely indications for the laparoscopy?
Figure 1. Parasagittal scan of the pelvis showing a thickened endometrium.
Figure 2. Parasagittal scan to the left showing an enlarged ovary with multiple cysts.
Vol. 64, No. 767
1073
Case of the month
The ultrasound examination revealed a moderate amount of ascites, later confirmed to be the source of the leaking fluid. The uterus was normal in size but had a very thickened endometrial echo (16-18 mm anteroposterior diameter). Both ovaries were enlarged (8 x 4 cm approximately) and contained multiple 1.5-2.0 cm cysts. These appearances are those of Ovarian Hyperstimulation Syndrome (OHSS). It was subsequently learnt that she had undergone ovulation induction therapy prior to in vitro fertilization. Laparoscopic egg collection had been performed in Belgium 2 days before presentation, but unfortunately none of the retrieved oocytes had fertilized so no embryos had been returned to her uterus. The patient insisted on returning to Bahrain following her diagnosis and as far as we are aware made an uneventful recovery. Discussion
The OHSS has frequently been described in the literature since Gemzell first described successful induction of ovulation and pregnancy in humans in 1958. The syndrome is usually of minimal consequence but can be a potentially life threatening condition, characterized by enlarged ovaries containing multiple cysts and extravascular fluid collections, ascites and pleural effusions. Exceptionally, pleural effusions may occur without an increase in ovarian size. There is haemoconcentration and in severe cases circulatory collapse and various coagulation disorders including disseminated intravascular coagulation can occur. Abnormally high levels of oestrogen are found in the patients serum, urine and follicular fluid and there are raised plasma levels of progesterone, 17-hydroxyprogesterone and testosterone. It is usually seen in association with various ovulation induction regimes (to treat ovarian dysfunction in infertility or to induce superovulation prior to in vitro fertil-
ization), but has been reported in association with hydatidiform moles and multiple pregnancies occurring without the aid of ovulation inducing agents. The severe form of the disease is rare with a reported incidence of 0.4-4% of patients on ovulation induction therapy. The milder form is much commoner (reported rates vary from 3-80%) and many cases undoubtedly go unrecognized. The pathogenesis and aetiology of the syndrome are unclear. There is thought to be a sudden increase in the permeability of the ovarian vessels and the fact that the extravascular fluid collections are transudates supports this. Crooke et al (1963) found that high follicle stimulating hormone (FSH)/Luteinizing hormone (LH) ratios resulted in a lower incidence of OHSS, but subsequently this could not be confirmed. Schenker and Weinstein (1978) showed the dose of gonadotrophins was significant but that the critical dose varied enormously between individuals. Histamine release blocking agents and prostaglandin inhibitors have been tried with variable success, but treatment of the condition is mainly supportive with correction of any fluid and electrolyte imbalance. It usually resolves spontaneously in 7-10 days. Primarily effort should be directed at preventing development of the syndrome by careful monitoring of all ovulation induction regimes and removal of the stimulating agent should the condition arise. References CROOKE, A. C ,
BUTT, W. R.,
PALMER, R. F. & MORRIS,
R.,
1963. Clinical trial of human gonadotrophins. Journal of Obstetrics and Gynaecology (Br. Commonwealth) 70, 604. SCHENKER,
J. G.
&
WEINSTEIN,
G.,
1978.
Ovarian
Hyperstimulation syndrome—a current survey. Fertility and Sterility, 30, 255-268.
Keywords: Ovarian hyperstimulation syndrome, Ovarian enlargement
1074
The British Journal of Radiology, November 1991
