Communications m brief
Volume 121 Number 8
Acute hydrothorax as the only • L. • I . symptom of ovaiian "yperstimu.ation syndrome R. JEWELEWICZ R. L. VANDE WIELE
Department of Obstetrics-Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
THE
~'ovARIAN
hyperstimulation syndrome" is one
of the major complications of gonadotropin therapy. Based on the severity of the symptoms and signs, three degrees of hyperstimulation are distinguished 1 : ( 1) Mild hyperstimulation-there is a feeling of slight bloating and lower abdominal discomfort. The ovaries are slightly enlarged but no more than 5 by 5 em. There is no
marked weight gain. ( 2)
~vfoderate
hyperstimulation-a
feeling of bloating and lower abdominal discomfort. The ovaries are enlarged up to 10 by 10 em. There is some ascites, and weight gain is up to 10 pounds. ( 3) Severe hyperstimulation-the ovaries are extremely enlarged and easily palpated abdominally. Ascites, pleural effusion, oliguria, hemoconcentration, hypotension, azotemia, and electrolyte ifnbalance occur. Increased blood coagulability and weight gain of more than 10 pounds are found. Recently we examined a patient who developed acute hydrothorax as the only symptom of ovarian hyperstimulation, and this case is reported. E. T., age 24 years, had telarche and pubarche at age 11 and menarche at age 12 Y2 • After one year of regular menses she developed amenorrhea. During the following 6 years, she had no complaints except amenorrhea. She was examined several times, but nothing was found and no specific treatment was given except for several cycles of "cyclic therapy" to induce vaginal bleeding. At the age of 19, she developed frontal headaches, and, in addition to the amenorrhea, galactorrhea was discovered. A skull x-ray revealed an enlarged sella turcica, and examination of the visual fields revealed bitemporal hemianopsia with decreased visual acuity in the left eye. Based on this finding, a diagnosis of a pituitary tumor was made, and ~he was treated by radiation therapy. She receh·ed a midplain depth dose of 4,550 r over 60 days. After treatment, the visual fields improved significantly; however, she developed hypothyroidism and hypoadrenalism and has been given replacement therapy since then. Plasma luteinizing hormone (LH) was 9 ng. per milliliter (normal 32 to 260 ng. per milliliter), and follicle-stimulating hormone (FSH) 235 ng. per mi!!i!iter (normal 50 to 380 ng. per milliliter). Physical examination was within normal limits, except for galactorrhea. A gonadotropin-releasing hormone stimulation test revealed that there was no release of LH but an almost normal release of FSH.
Reprint requests: Dr. R. Jewelewicz, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 630 W. 168th St., New York, New York 10032.
1121
Since she was interested in conception, treatment with human menopausal gonadotropins (HMG) and human chorionic gonadotropins ( HCG) was given. She received a total dose of 44 vials of Pergonal* ( 3,300 I.U. of LH and 3,300 I.U. of FSH) over a 12 day period and 10,000 I.U. of HCG and conceived during the first treatment cycle. The preovulatory estrogen level was 180 p.g per 24 hours, which was somewhat above the optimal level of 100 to 150 J.tg per 24 hours2 but nevertheless within the treatment range. After ovulation, she felt very well, and there was no evidence of any symptoms of hyperstimulation. Ten days after ovulation she complained of a "chest cold," but there was no abdominal discomfort. Two davs later. she developed acute respiratory distress, dyspnea: and tightness in the chest. She had dullness to percussion on the right chest and decreased respiratory sounds. Right hydrothorax was diagnosed, and the patient was hospitalized. A chest x-ray revealed minimal pleural fluid on the left base but a large amount of pleural fluid on the right. The abdomen was soft and nontender, and both ovaries were easily palpable and only slightly enlarged. There was no evidence of ascites. This was confirmed by two independent, experienced observers. Blood urea nitrogen and electrolytes were within the normal limits, but the hematocrit was 46 per cent which suggested hemoconcentration and the possibility of ovarian hyperstimulation. A purified protein derivative test was negative. An electrocardiogram ( ECG) revealed borderline low voltage and flat T waves. No treatment was given. Over the next 5 days, her condition generally improved. She was not dyspneic, the hematocrit returned to normal, diuresis increa:sed spontaneously, and she lost 9 pounds. The hydrothorax decreased. She was discharged from the hospital after 5 days, and repeat chest x-ray and ECG 3 weeks later were within the normal limits. The pregnancy is progressing uneventfully. The symptomatology, pathogenesis, and management of the ovarian hyperstimu!ation syndrome have been previously described. 1 Hydrothorax was always a component of the severe cases, but we have never before seen it as the only symptom of hyperstimulation. Meigs described hydrothorax in association with ascites in some cases of fibroma of the ovary, and over the years "Meigs' syndrome" was described in combination with other solid tumors of the ovary. In gonadotropin-treated patients, where multiple ovulations are common, the ovaries are always enlarged to a certain extent, and it is conceivable that this was the cause of hydrothorax in our patient. Ovarian hyperstimulation is not uncommon when gonadotropins are used for induction of ovulation, however, the gynecologist should be alert not only to the common side effects and complications but to the extraordinary as well and thus avoid unnecessary and maybe harmful treatment. *Cutter Laboratories, Inc., 4th & Parker Sts., Berkeley, California 94710. REFERENCES
1. Engel, T., Jewelewicz, R., Dyrenfurth, I., Speroff, L., and Vande Wiele, R. L.: AM. J. OnsTET. GYNEC. 112: 1052, 1972. 2. Jewelewicz, R., Dyrenfurth, I., Warren, M. P., and Vande Wiele, R. L.: In Rosenberg, E., editor: Gonadotropin in Female Infertility, Amsterdam, 1973, Excerpta Medica Foundation, p. 235.
Volume 121 Number 8
Acute hydrothorax as the only • L. • I . symptom of ovaiian "yperstimu.ation syndrome R. JEWELEWICZ R. L. VANDE WIELE
Department of Obstetrics-Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
THE
~'ovARIAN
hyperstimulation syndrome" is one
of the major complications of gonadotropin therapy. Based on the severity of the symptoms and signs, three degrees of hyperstimulation are distinguished 1 : ( 1) Mild hyperstimulation-there is a feeling of slight bloating and lower abdominal discomfort. The ovaries are slightly enlarged but no more than 5 by 5 em. There is no
marked weight gain. ( 2)
~vfoderate
hyperstimulation-a
feeling of bloating and lower abdominal discomfort. The ovaries are enlarged up to 10 by 10 em. There is some ascites, and weight gain is up to 10 pounds. ( 3) Severe hyperstimulation-the ovaries are extremely enlarged and easily palpated abdominally. Ascites, pleural effusion, oliguria, hemoconcentration, hypotension, azotemia, and electrolyte ifnbalance occur. Increased blood coagulability and weight gain of more than 10 pounds are found. Recently we examined a patient who developed acute hydrothorax as the only symptom of ovarian hyperstimulation, and this case is reported. E. T., age 24 years, had telarche and pubarche at age 11 and menarche at age 12 Y2 • After one year of regular menses she developed amenorrhea. During the following 6 years, she had no complaints except amenorrhea. She was examined several times, but nothing was found and no specific treatment was given except for several cycles of "cyclic therapy" to induce vaginal bleeding. At the age of 19, she developed frontal headaches, and, in addition to the amenorrhea, galactorrhea was discovered. A skull x-ray revealed an enlarged sella turcica, and examination of the visual fields revealed bitemporal hemianopsia with decreased visual acuity in the left eye. Based on this finding, a diagnosis of a pituitary tumor was made, and ~he was treated by radiation therapy. She receh·ed a midplain depth dose of 4,550 r over 60 days. After treatment, the visual fields improved significantly; however, she developed hypothyroidism and hypoadrenalism and has been given replacement therapy since then. Plasma luteinizing hormone (LH) was 9 ng. per milliliter (normal 32 to 260 ng. per milliliter), and follicle-stimulating hormone (FSH) 235 ng. per mi!!i!iter (normal 50 to 380 ng. per milliliter). Physical examination was within normal limits, except for galactorrhea. A gonadotropin-releasing hormone stimulation test revealed that there was no release of LH but an almost normal release of FSH.
Reprint requests: Dr. R. Jewelewicz, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 630 W. 168th St., New York, New York 10032.
1121
Since she was interested in conception, treatment with human menopausal gonadotropins (HMG) and human chorionic gonadotropins ( HCG) was given. She received a total dose of 44 vials of Pergonal* ( 3,300 I.U. of LH and 3,300 I.U. of FSH) over a 12 day period and 10,000 I.U. of HCG and conceived during the first treatment cycle. The preovulatory estrogen level was 180 p.g per 24 hours, which was somewhat above the optimal level of 100 to 150 J.tg per 24 hours2 but nevertheless within the treatment range. After ovulation, she felt very well, and there was no evidence of any symptoms of hyperstimulation. Ten days after ovulation she complained of a "chest cold," but there was no abdominal discomfort. Two davs later. she developed acute respiratory distress, dyspnea: and tightness in the chest. She had dullness to percussion on the right chest and decreased respiratory sounds. Right hydrothorax was diagnosed, and the patient was hospitalized. A chest x-ray revealed minimal pleural fluid on the left base but a large amount of pleural fluid on the right. The abdomen was soft and nontender, and both ovaries were easily palpable and only slightly enlarged. There was no evidence of ascites. This was confirmed by two independent, experienced observers. Blood urea nitrogen and electrolytes were within the normal limits, but the hematocrit was 46 per cent which suggested hemoconcentration and the possibility of ovarian hyperstimulation. A purified protein derivative test was negative. An electrocardiogram ( ECG) revealed borderline low voltage and flat T waves. No treatment was given. Over the next 5 days, her condition generally improved. She was not dyspneic, the hematocrit returned to normal, diuresis increa:sed spontaneously, and she lost 9 pounds. The hydrothorax decreased. She was discharged from the hospital after 5 days, and repeat chest x-ray and ECG 3 weeks later were within the normal limits. The pregnancy is progressing uneventfully. The symptomatology, pathogenesis, and management of the ovarian hyperstimu!ation syndrome have been previously described. 1 Hydrothorax was always a component of the severe cases, but we have never before seen it as the only symptom of hyperstimulation. Meigs described hydrothorax in association with ascites in some cases of fibroma of the ovary, and over the years "Meigs' syndrome" was described in combination with other solid tumors of the ovary. In gonadotropin-treated patients, where multiple ovulations are common, the ovaries are always enlarged to a certain extent, and it is conceivable that this was the cause of hydrothorax in our patient. Ovarian hyperstimulation is not uncommon when gonadotropins are used for induction of ovulation, however, the gynecologist should be alert not only to the common side effects and complications but to the extraordinary as well and thus avoid unnecessary and maybe harmful treatment. *Cutter Laboratories, Inc., 4th & Parker Sts., Berkeley, California 94710. REFERENCES
1. Engel, T., Jewelewicz, R., Dyrenfurth, I., Speroff, L., and Vande Wiele, R. L.: AM. J. OnsTET. GYNEC. 112: 1052, 1972. 2. Jewelewicz, R., Dyrenfurth, I., Warren, M. P., and Vande Wiele, R. L.: In Rosenberg, E., editor: Gonadotropin in Female Infertility, Amsterdam, 1973, Excerpta Medica Foundation, p. 235.
