卵巢过度刺激综合征一例临床分析
摘要
患者女，31岁，住院号518761。因“体外受精-胚胎移植后腹胀14天”于2003
年8月14日入院。患者因人工流产后8年未孕，双侧输卵管阻塞行体外受精-胚胎
移植(IV-ET)，自7月18日起采用短方案行超促排卵(共用0．1mg达必佳注射液4
支，Gonal-F16支，HMG5支)，至7月26日查血E_2为2187pg/ml，B超见1.0cm
以上卵泡16个(其中1．7cm以上卵泡5个)，于当晚9时肌注HCG10000~U,7月
28日采卵(获卵11个)，7月31日行胚胎移植(移植3个胚胎)，移植当天起应
用黄体酮80mg/d支持黄体功能，同时加用HCG2000~U1次加强黄体功能，8月1
日开始出现腹胀逐渐加重，同时自觉腹部增大，平卧时有胸闷，无明显呼吸困难，
伴食欲不振、尿少，无腹痛、恶心、呕吐、腹泻等不适，至8月14日腹胀加重不
能耐受来院。
既往无结核、肝炎、肾病等慢性病史。
月经规律13岁4-5／30天，量中，无痛经，LMP2003年7月17日，孕_3产_0，
人流2次(93、95年)，94年孕6月死胎引产一次。曾于2002年因子宫输卵管造
影示双侧输卵管阻塞于外院IVF-ETl次失败，具体超促排卵方案不详。
入院体检：生命体征平稳，全身皮肤巩膜无黄染、出血点，无水肿，双下肺
呼吸音明显减弱，胸部叩诊右侧自第9肋间以下为浊音，左侧自第8肋间以下为
浊音，心脏听诊无异常，腹膨隆，腹围88．5cm，腹部皮肤绷紧、发亮，无腹壁静
脉曲张，全腹无压痛、反跳痛及肌紧张，未扪及包块，腹部叩诊仅脐周为鼓音，
余均为浊音，肝、脾肋下未触及，双肾区无叩痛，脊柱、四肢无异常。
入院后急查血T-HCG：935．2mlu／ml，提示生化妊娠未作妇检。当天B超报告：
腹腔积液，左、右髂窝液性暗区分别为2．2cm、1．8cm,双侧卵巢增大呈蜂窝状，右
侧5．5x3．3cm~2，左侧7．1×．5．7cm~2；血常规：Hgb11og/l，HCT 0．319L/L.，余(-)；肝、
肾功能正常。
诊断为卵巢过度刺激综合征(重度)。
诊治经过：入院后鼓励患者多进果汁类饮品与蛋白类食品，严格记录24小时
出入量，每日监测体重、腹围情况；静脉补充低分子右旋糖苷、丹参注射液
500．1000ml／d扩容扩管，补充白蛋白(100-200ml/d)扩容，增加血浆胶体渗透压，
促进腹水回吸收；根据动态监测血电解质情况纠正电解质紊乱，动态监测血浆蛋
白水平调整白蛋白用量，动态监测血常规及凝血功能防止血液浓缩引起凝血、血
栓形成等并发症，在血红细胞比积(HCT)显示血液稀释状态下小剂量应用利尿
剂，同时检测肝肾功能变化；至8月18日(入院第5天)患者诉腹胀难以忍受，
不能平卧，腹围增加至92cm，腹部叩诊正常鼓音界消失，全腹均为浊音，急诊B
超示右卵巢增大为7．7x5．9cm~2，左卵巢11．1 x6．7cm~2，左、右髂窝液性暗区分别为
3.5cm、4.3cm，遂于B超定位下行腹腔穿刺抽出淡黄色清亮腹水1500ml，患者腹
胀症状明显缓解，腹水送检除富含大量蛋白外，其余各项检查均符合漏出液，腹
水细胞学检查未见肿瘤细胞。术后加大白蛋白补充量(150-200ml／d)，自8月24
日(入院第11天)患者病情逐渐好转，24小时出量大于入量，血浆蛋白逐渐上升，
体重、腹围均未继续增加，病程进入恢复期，逐渐减少白蛋白与低右用量至9月2
日停药。8月29日(移植后29天)B超检查示3胎妊娠，经阴道B超引导下减去
1胎，保留2胎。9月20日(入院后37天)复查B超腹水消失，卵巢恢复至正常
大小。此后定期产检无异常，现已足月分娩双胎。
附腹水检查结果：
腹水常规：淡黄色，清亮，比重<1．018，粘蛋白定性试验(-)，有核细胞计数
约为0．27×10~9/L，以淋巴细胞为主。
腹水细胞学检查：未见肿瘤细胞
A 31-year-old female who having been experienced abdominal swelling for 14 days after In Vitro Fertilization and Embryo Transfer was admitted on Aug 14th, 2003. Since July 18th, controlled ovarian induction was performed and 10000U of HCG was injected on July 26th. 11 eggs were retrievaled on July 28th and three embryes were transfered into the uterus on July 31 st.
On Aug 1st, She began to have a bloated feeling gradually, when she lay down she felt uncomfortable but without obvious dyspnea.The amount of urine decreased and inappetence occurred but the symptoms such as bellyache nausea vomitting and diarrhoea didn't occur.Physical examinations were performed, ascites and pleural fluid was detected. It was sonant below the 9th rib at the right side and the 8th rib at the left side. We did not find any positive signs when examinated the heart and lung. When percuss the abdomen, it was sonant except the part around the bellybutton. Vaginal examinations weren't done because the result of pregnancy test was positive result. Her lab examination results were as follows: on Aug 14th, quantitative assay of blood HCG was 935.2mlu/ml, Blood Routine: Hgb110g/1, HCT0.319. Ultrasonogical reports on the same day were as follows: there were much of ascites, 2.2cm deep on left and 1.8cm deep on right, the sizes of both sides of ovaries increased, the right sized 5.5 X 3.3 cm2 and left sized 7.1 X 5.7 cm2. It was diagnosised as severe ovarian hyperstimulation syndrome.
The patient was encouraged to drink enough syrup and eat the foods rich of protein.24hours'amount of input and output were recorded and weight and abdominal circumference was examinated every day. Albumin and dextran were infused intravenously to compensate the blood volume. The type and volume of intravenous liquids were adjusted according to the conditions of the patient. The low doses of Lasix was used to increase the amount of urine only when the HCT examination showed the blood is diluted. On Aug 18th, the patient complained that she could not bear the bloated feelings, urgent ultrasound B scanning revealed that the ascites deep 3.5cm in left and 4.3cm in right ,right ovary sized 7.7x5.9 cm2 and left one sized 11.1x6.7 cm2. Abdominal paracentesis was performed with the guidance of ultrasound B and 1500ml ascites were drained off and the patient felt much better.
Since then the patient was recovered day after day. The output excess more than input on Aug 24th.Ultrasound scanning revealed tripregnancy in Aug 29th and one embryo was reducted through vaginal. Ascite were absorbed and the size of ovary was normal on Sep 20th. The twin was very well in rountine prenatal care and were delivered.
年8月14日入院。患者因人工流产后8年未孕，双侧输卵管阻塞行体外受精-胚胎
移植(IV-ET)，自7月18日起采用短方案行超促排卵(共用0．1mg达必佳注射液4
支，Gonal-F16支，HMG5支)，至7月26日查血E_2为2187pg/ml，B超见1.0cm
以上卵泡16个(其中1．7cm以上卵泡5个)，于当晚9时肌注HCG10000~U,7月
28日采卵(获卵11个)，7月31日行胚胎移植(移植3个胚胎)，移植当天起应
用黄体酮80mg/d支持黄体功能，同时加用HCG2000~U1次加强黄体功能，8月1
日开始出现腹胀逐渐加重，同时自觉腹部增大，平卧时有胸闷，无明显呼吸困难，
伴食欲不振、尿少，无腹痛、恶心、呕吐、腹泻等不适，至8月14日腹胀加重不
能耐受来院。
既往无结核、肝炎、肾病等慢性病史。
月经规律13岁4-5／30天，量中，无痛经，LMP2003年7月17日，孕_3产_0，
人流2次(93、95年)，94年孕6月死胎引产一次。曾于2002年因子宫输卵管造
影示双侧输卵管阻塞于外院IVF-ETl次失败，具体超促排卵方案不详。
入院体检：生命体征平稳，全身皮肤巩膜无黄染、出血点，无水肿，双下肺
呼吸音明显减弱，胸部叩诊右侧自第9肋间以下为浊音，左侧自第8肋间以下为
浊音，心脏听诊无异常，腹膨隆，腹围88．5cm，腹部皮肤绷紧、发亮，无腹壁静
脉曲张，全腹无压痛、反跳痛及肌紧张，未扪及包块，腹部叩诊仅脐周为鼓音，
余均为浊音，肝、脾肋下未触及，双肾区无叩痛，脊柱、四肢无异常。
入院后急查血T-HCG：935．2mlu／ml，提示生化妊娠未作妇检。当天B超报告：
腹腔积液，左、右髂窝液性暗区分别为2．2cm、1．8cm,双侧卵巢增大呈蜂窝状，右
侧5．5x3．3cm~2，左侧7．1×．5．7cm~2；血常规：Hgb11og/l，HCT 0．319L/L.，余(-)；肝、
肾功能正常。
诊断为卵巢过度刺激综合征(重度)。
诊治经过：入院后鼓励患者多进果汁类饮品与蛋白类食品，严格记录24小时
出入量，每日监测体重、腹围情况；静脉补充低分子右旋糖苷、丹参注射液
500．1000ml／d扩容扩管，补充白蛋白(100-200ml/d)扩容，增加血浆胶体渗透压，
促进腹水回吸收；根据动态监测血电解质情况纠正电解质紊乱，动态监测血浆蛋
白水平调整白蛋白用量，动态监测血常规及凝血功能防止血液浓缩引起凝血、血
栓形成等并发症，在血红细胞比积(HCT)显示血液稀释状态下小剂量应用利尿
剂，同时检测肝肾功能变化；至8月18日(入院第5天)患者诉腹胀难以忍受，
不能平卧，腹围增加至92cm，腹部叩诊正常鼓音界消失，全腹均为浊音，急诊B
超示右卵巢增大为7．7x5．9cm~2，左卵巢11．1 x6．7cm~2，左、右髂窝液性暗区分别为
3.5cm、4.3cm，遂于B超定位下行腹腔穿刺抽出淡黄色清亮腹水1500ml，患者腹
胀症状明显缓解，腹水送检除富含大量蛋白外，其余各项检查均符合漏出液，腹
水细胞学检查未见肿瘤细胞。术后加大白蛋白补充量(150-200ml／d)，自8月24
日(入院第11天)患者病情逐渐好转，24小时出量大于入量，血浆蛋白逐渐上升，
体重、腹围均未继续增加，病程进入恢复期，逐渐减少白蛋白与低右用量至9月2
日停药。8月29日(移植后29天)B超检查示3胎妊娠，经阴道B超引导下减去
1胎，保留2胎。9月20日(入院后37天)复查B超腹水消失，卵巢恢复至正常
大小。此后定期产检无异常，现已足月分娩双胎。
附腹水检查结果：
腹水常规：淡黄色，清亮，比重<1．018，粘蛋白定性试验(-)，有核细胞计数
约为0．27×10~9/L，以淋巴细胞为主。
腹水细胞学检查：未见肿瘤细胞
A 31-year-old female who having been experienced abdominal swelling for 14 days after In Vitro Fertilization and Embryo Transfer was admitted on Aug 14th, 2003. Since July 18th, controlled ovarian induction was performed and 10000U of HCG was injected on July 26th. 11 eggs were retrievaled on July 28th and three embryes were transfered into the uterus on July 31 st.
On Aug 1st, She began to have a bloated feeling gradually, when she lay down she felt uncomfortable but without obvious dyspnea.The amount of urine decreased and inappetence occurred but the symptoms such as bellyache nausea vomitting and diarrhoea didn't occur.Physical examinations were performed, ascites and pleural fluid was detected. It was sonant below the 9th rib at the right side and the 8th rib at the left side. We did not find any positive signs when examinated the heart and lung. When percuss the abdomen, it was sonant except the part around the bellybutton. Vaginal examinations weren't done because the result of pregnancy test was positive result. Her lab examination results were as follows: on Aug 14th, quantitative assay of blood HCG was 935.2mlu/ml, Blood Routine: Hgb110g/1, HCT0.319. Ultrasonogical reports on the same day were as follows: there were much of ascites, 2.2cm deep on left and 1.8cm deep on right, the sizes of both sides of ovaries increased, the right sized 5.5 X 3.3 cm2 and left sized 7.1 X 5.7 cm2. It was diagnosised as severe ovarian hyperstimulation syndrome.
The patient was encouraged to drink enough syrup and eat the foods rich of protein.24hours'amount of input and output were recorded and weight and abdominal circumference was examinated every day. Albumin and dextran were infused intravenously to compensate the blood volume. The type and volume of intravenous liquids were adjusted according to the conditions of the patient. The low doses of Lasix was used to increase the amount of urine only when the HCT examination showed the blood is diluted. On Aug 18th, the patient complained that she could not bear the bloated feelings, urgent ultrasound B scanning revealed that the ascites deep 3.5cm in left and 4.3cm in right ,right ovary sized 7.7x5.9 cm2 and left one sized 11.1x6.7 cm2. Abdominal paracentesis was performed with the guidance of ultrasound B and 1500ml ascites were drained off and the patient felt much better.
Since then the patient was recovered day after day. The output excess more than input on Aug 24th.Ultrasound scanning revealed tripregnancy in Aug 29th and one embryo was reducted through vaginal. Ascite were absorbed and the size of ovary was normal on Sep 20th. The twin was very well in rountine prenatal care and were delivered.
引文
1．陆湘云，全国第二界妇产科内分泌学术会议纪要，中华妇产科杂志 1993，27(7)．
2．张松英，石一复．自然妊娠并发重度OHSS两例分析，中华妇产科杂志 2002，37(7)：422-423．
3. TaherBM, GhariabenRA, JarrahNS, et al. Spontaneous ovarian hyperstimulation syndrome caused by hypothyroidism in an adult. Eur J Obstet Gynecol Reprod Biol, 2004, 15, 112(1): 107-109.
4．翁世湘，邱华娟，李锐等．中、重度OHSS缓解后的黄体支持治疗．生殖医学杂志 2000，9(6)351-355．
5. Hoh Y, LeeRK, LinMH, et al. Estradiol level on day 9 as a predictor of risk for ovarian hyperresponse during controlled ovarian hyperstimulation. J Assist Reprod Genet. 2003, 20(6): 222-226.
6. DayaS.Updated meta-analysis of recombinant follicle-stimulating hormone (FSH) versus urinary FSH for ovarian stimulation in assisted reproduction. Fertil Steril 2002, 77(4): 711-714.
7. YongPY, BrettS, BairdDT, et al. A prospective randomized clinical trial comparing 150 IU and 225 IU of recombinant follicle-stimulation hormone (Gonal-F) in a fixed-dose regimen for controlled ovarian stimulation in in vitro fertilization treatment. Fertil Steril2003, 79(2): 308-315.
8. LudwigM, KatalinicA, FelbergbattmRE, et al. Safety aspects of gonadotrophinreleasing hormone antagonists in ovarian stimulaton procedure: ovarian hyperstimulation syndrome and health of children born. Reprod Biomed Online 2002, 5(3): 61-67.
9. Geneva, Switzerland. Human recombinant luteinizing hormone is as effective as, but safer than, urinary human chorionic gonadotropin in inducing final follicular maturation and ovulation in in vitro fertilization procedures: results of a multocenter double-blind study. J Clin Endocrinol Metab, 2001, 86(6): 2607-2618.
10. FatemiHM, PlatteauP, AlbanoC, et al. Resue IVF and coasting with the use of a GnRH antagonist after ovulation induction. Reprod Biomed Online. 2003, 5(3): 273-75.
11. OhataY, HaradaT, ItoM, et al. Coasting may reduce the severity of the ovarian hyperstimulation syndrome in patients with polycystic ovary syndrome. Gynecol Obstet Invest 2000, 50(3): 186-188.
12. UlugU, BahceciM, ErdenHF, et al. The significance of coasting duration ovarian stimulation for conception in assisted fertilization cycles. Hum Reprod. 2002, 17(2): 310-313.
13. EgbasePE, Al SharhanM, BerlingieriP, et al. Serum oestradiol and progesterone concentrations during prolonged coasting in 15 women at risk of ovarian hperstimulation syndrome following ovarian stimulation for assisted reproduction treatment. Hum Reprod. 2000, 15(10): 2082-2086.
14. Al SharhanT, ZosmerA, TozerA, et al. Value of measuring serum FSH in addition to serum estradiol in a coasting programme to prevent severe OHSS. Hum Reprod 2002, 17(5): 1217-1221.
15. AlboulgharM, EversJH, Al-InanyH.Intravenous albumin for preventing severe ovarian hyperstimulation syndrome: a cochrane review. Hum Reprod 2002, 17(12): 3027-3032.
16. Ben-ChetritA, Eldar-GevaT, GalM, et al. The questionable use of albumin for the prevention of ovarian hyperstimulation syndrome in an IVF programme: a randomized placebo-controlled trial. Hum Reprod 2001, 16(9): 1880-1884.
17. GokmenO, UgerM, EkinM, et al. Intravenous albumin versus hydroxyethyl starch for the prevention of ovarian hyperstimulation in an in-vitro fertilization programme: a prospective randomized placobo controlled study. Euro J Obstet Gynecol Reprod Biology 2001, 96: 187-192.
18. KingetK, NijsM, CoxAM, et al. Anovel approach for patients at risk for ovarian hyperstimulation syndrome: elective transfer of a single zona-free blastoeyst on day5. Reprod Biomed Online 2002, 4(1): 51-55.
19. TomazevieT, Meden-VrtovecH. Early unilateral follicular aspiration prevents severe ovarian hyperstimulation syndrome. J Assist Reprod Genet1996, 13: 282-6.
20. SchroderA, SchopperB, Al-HasaniS, et al. Unilateral follicular aspiration and in-vitro maturation before contralateral oocyte retrieval: a method to prevent ovarian hyperstimulation syndrome. Euro J Obstet Gyneeol Reprod Biology 2003, 110: 186-189.
21. SmithSD, MikkelsenAL, LindenbergS. Development of human oocytes matured in vitro for 28 or 36 hours. Fertil Steril 2000, 73: 541-544.
22. SonWY, YoonSH, LeeSW, et al. Blastocyst development and pregnancies after IVFof mature oocytes retreived from unstimulated patients with PCOS after in-vivo HCG priming. Hum Reprod 2002, 17(1): 134-136.
23. DngeloA, AmsoNN. Embryo freezing for preventing ovarian hyperstimulation syndrome: a Cochrane review. Hum Reprod 2002, 17(11): 2787.
24. LainasT, PetsasG, StavropoulouG, et al. Administation of methypredisolone to prevent severe ovarian hyperstimulation syndrome in patients undergoing in vitrofertilization. Fertil Steril 2002, 78(3): 529-533.
25. GalM, Edlar-GevaT, MargaliothEJ, et al. Attenuation of ovarian respose by lw-dose ketocanazole during superovulation in patients with polycystic ovary syndrome. Fertil Steril 1999, 27: 26-31.
26. ParsanezhadME, AlborziS, PakniatM, et al. Adouble-blind, randomized, placebo-controlled study to assess the efficacy of ketoconazole for reducing the risk of ovarian hyperstimulation syndrome. Fertil Steril 2003, 80(5): 1151-1155.
27. IsikAZ, VicdanK. combined approach as an effective method in the prevention of severe ovarian hyperstimulation syndrome. Euro J Obstet Gynecol Reprod Biology 2001, 97: 208-212.
28. KoibeT, ArabiS, MibabamiH, et al. Clinical efficacy of peritoneovenous shunting for the treatment of severe ovarian hyperstimulation syndrome. Hum Reprod, 2000, 15(1): 113.
29．吕杰强，陈文宾，涂权梅等，腹水自体回输治疗重度OHSS的探讨，山西医科大学学报，2001，33(3)：260-63．
30. Amarinzo. Bilateral partial oophrectomy in the management of severe ovarian hyperstimulation syndrome: An aggressive, but perhaps life-saving procedure. Hum Reprod 2003, 18(4): 659-664.
2．张松英，石一复．自然妊娠并发重度OHSS两例分析，中华妇产科杂志 2002，37(7)：422-423．
3. TaherBM, GhariabenRA, JarrahNS, et al. Spontaneous ovarian hyperstimulation syndrome caused by hypothyroidism in an adult. Eur J Obstet Gynecol Reprod Biol, 2004, 15, 112(1): 107-109.
4．翁世湘，邱华娟，李锐等．中、重度OHSS缓解后的黄体支持治疗．生殖医学杂志 2000，9(6)351-355．
5. Hoh Y, LeeRK, LinMH, et al. Estradiol level on day 9 as a predictor of risk for ovarian hyperresponse during controlled ovarian hyperstimulation. J Assist Reprod Genet. 2003, 20(6): 222-226.
6. DayaS.Updated meta-analysis of recombinant follicle-stimulating hormone (FSH) versus urinary FSH for ovarian stimulation in assisted reproduction. Fertil Steril 2002, 77(4): 711-714.
7. YongPY, BrettS, BairdDT, et al. A prospective randomized clinical trial comparing 150 IU and 225 IU of recombinant follicle-stimulation hormone (Gonal-F) in a fixed-dose regimen for controlled ovarian stimulation in in vitro fertilization treatment. Fertil Steril2003, 79(2): 308-315.
8. LudwigM, KatalinicA, FelbergbattmRE, et al. Safety aspects of gonadotrophinreleasing hormone antagonists in ovarian stimulaton procedure: ovarian hyperstimulation syndrome and health of children born. Reprod Biomed Online 2002, 5(3): 61-67.
9. Geneva, Switzerland. Human recombinant luteinizing hormone is as effective as, but safer than, urinary human chorionic gonadotropin in inducing final follicular maturation and ovulation in in vitro fertilization procedures: results of a multocenter double-blind study. J Clin Endocrinol Metab, 2001, 86(6): 2607-2618.
10. FatemiHM, PlatteauP, AlbanoC, et al. Resue IVF and coasting with the use of a GnRH antagonist after ovulation induction. Reprod Biomed Online. 2003, 5(3): 273-75.
11. OhataY, HaradaT, ItoM, et al. Coasting may reduce the severity of the ovarian hyperstimulation syndrome in patients with polycystic ovary syndrome. Gynecol Obstet Invest 2000, 50(3): 186-188.
12. UlugU, BahceciM, ErdenHF, et al. The significance of coasting duration ovarian stimulation for conception in assisted fertilization cycles. Hum Reprod. 2002, 17(2): 310-313.
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