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OVARY amp
EMERGENCY
LAKSHMI SUJANICHAlluri Sitaramaraju Academy Of
Medical Sciences
OVARIAN HYPERSTIMULATION
SYNDROME
GRADING OHSSDEGREE GRADE CLINICAL FEATURES
MILD GRADE 1
GRADE 2
Abdominal distention pain
Vomiting diarrhea ovary enlargement less than 5 cms weight gain less than 3kg
MODERATE GRADE 3 Mild OHSS + Ultrasound evidence of asciteselectrolyte disturbances ovarian size upto10cmsweight gain of 10lbs
SEVERE GRADE 4
GRADE 5
GRADE 6
Moderate OHSS + ovary size gt 12cm weight gain gt5kgGrade 4 + tense ascites hydrothorax
Grade 5 + haemoconcenteration coagulation abnormalities renal dysfunction respiratory failure
PREVENTION OF OHSS
Adjunctive use of metformin in
PCOS patientsup1 (GRADE-A evidence)
Cabergoline 05 mg daily x 7
days following retrievalsup2 (GRADE A
evidence)
- dopamine antagoinst
- reduces VEGF production
- Long term use causes
valvular heart defectsup1Tso LO Costello MF Albuquerque LE et alMetformin treatment before and during IVF and ICSI in women with
PCOD Cochraine database Syst Rev 20092CD006105sup2 Garcia-Velasco JA How to avoid ovarian hyperstimulation syndrome a new indication for dopamine agonists
Reprod Biomed Online 200918(Suppl 2) 71-75
PREVENTION OHSS
Cryopreservation of all embryos without transfer will prevent late onset OHSSsup1(GRADE B evidence)
IN VITRO OOCYTE MATURATION completely obviates the need to stimulate ovaries by gonadotrophinssup2
sup1Aboulghar M Symposium update on prediction and management of OHSS Reprod Biomed Online 20091933-42
sup2Siristatidis CS Maheshwari A Bhattacharya S Invitro maturation in subfertile women PCOD undergoing assisted reproduction Cochrane Database Syst Rev 2009192005-2013
PREVENTION OHSS
COASTING is considered when estradiol levels are less than 4500pgml and 15 to 30 mature follicles are present sup1( level B evidence)
- Gonadotropin stimulation is withheld and estradiol levels are checked daily
-patient is triggered when estradiol levels fall below 3500pgmlAlteration of trigger in high risk patientssup1LOW dose FSH use starting from 150IU(grade A evidence)
Reintroduction of gonadodropinantagonists following retrievalsup1
sup1 Garcia-Velasco JA How to avoid ovarian hyperstimulation syndrome a new indication for dopamine agonists Reprod Biomed Online 200918(Suppl 2)
71-75
Reducing the risk of OHSS-what does not work
Intravenous albumin (level A evidence)Follicle aspiration
(level A evidence )
Using recombinant LH instead of HCG (level A evidence)
Using recombinant HCG instead of urinary HCG(level A evidence)
NOTE Usage of letrozoleis banned in india since 2011
PREDICTION OF OHSS
Estradiolconcenteration more than 3500pgml at time if trigger (15 severe OHSS
risk)
More than 20 preovulatory follicles (15 severe OHSS risk)
Doppler changes
RUPTURE OVARIAN PREGNANCY
3 of ectopics amp
most common non tubal ectopicsup1
Increased incidence in IUCD users 1 out of 9 ectopics in IUCD users is ovarian ectopicsup2
Not associated with PID or infertilitysup1
Classical triad of pain bleeding and amenorrhoea absent in ovarian ectopicsup2
sup1 Jonathan S Berek Berek amp Novakrsquos Gynaecology2012sup2John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY
Differential diagnosis hemoperitoniumwith ovarian mass
ruptured ovarian
ectopic
ruptured luteal
hematoma
ruptured ovarian
endometrioma
Rupture ovarian cyst
bull Traumatic rupture common in functional cysts amp dermoid cyst
bull Spontaneous rupture in rapidly growing ovarian neoplasm(muciousepithelial neoplasms)
bull Rupture corpus luteal cyst ddovarian ectopic
- Hcg levels fall in ectopic n not in lueteal cyst
- DampC reveals chorionic villi in corpus leuteal cystsup1
sup1John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY
Ruptured chocolate cyst
Diagnosed by a typical CT picture showingsup1
Bilateral mutilocularovarian cysts with thick wall
Loculated ascites confined to pelvic cavity
Pelvic fat infiltration
HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA
sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian
Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65
Published online Jan 3 2011 doi 103348kjr201112159
Rupture ovarian abscess
Primary ovarian abscess is rare however it can be life threatening(Wetcher and Dunn 1985)
Early surgical intervention recommended to salvage the ovary (Stubblefield1991)
Even after proper periopcare mortality is as high as 71 sup1Prescence of subphrenic pus and
bowel injury are poor prognostic factorssup1
sup1ROBERT G FORMAN
Torsion ovarian cyst
rarr 3 gynaecologicalemergenciessup1
rarr NORMAL VASCULARITY DOESNOT EXCULDE TORSION AS OVARY HAS DUAL SUPPLY FROM UTERINE AND OVARIAN ARTERIESsup1
rarr Inflammatory cysts and malignant cysts rarely undergo torsion due to adhesionssup2
sup1 httpenwikipediaorgwikiOvarian_torsionsup2sup2Jonathan S Berek Berek amp Novakrsquos
Gynaecology2012
Thankyou
OVARIAN HYPERSTIMULATION
SYNDROME
GRADING OHSSDEGREE GRADE CLINICAL FEATURES
MILD GRADE 1
GRADE 2
Abdominal distention pain
Vomiting diarrhea ovary enlargement less than 5 cms weight gain less than 3kg
MODERATE GRADE 3 Mild OHSS + Ultrasound evidence of asciteselectrolyte disturbances ovarian size upto10cmsweight gain of 10lbs
SEVERE GRADE 4
GRADE 5
GRADE 6
Moderate OHSS + ovary size gt 12cm weight gain gt5kgGrade 4 + tense ascites hydrothorax
Grade 5 + haemoconcenteration coagulation abnormalities renal dysfunction respiratory failure
PREVENTION OF OHSS
Adjunctive use of metformin in
PCOS patientsup1 (GRADE-A evidence)
Cabergoline 05 mg daily x 7
days following retrievalsup2 (GRADE A
evidence)
- dopamine antagoinst
- reduces VEGF production
- Long term use causes
valvular heart defectsup1Tso LO Costello MF Albuquerque LE et alMetformin treatment before and during IVF and ICSI in women with
PCOD Cochraine database Syst Rev 20092CD006105sup2 Garcia-Velasco JA How to avoid ovarian hyperstimulation syndrome a new indication for dopamine agonists
Reprod Biomed Online 200918(Suppl 2) 71-75
PREVENTION OHSS
Cryopreservation of all embryos without transfer will prevent late onset OHSSsup1(GRADE B evidence)
IN VITRO OOCYTE MATURATION completely obviates the need to stimulate ovaries by gonadotrophinssup2
sup1Aboulghar M Symposium update on prediction and management of OHSS Reprod Biomed Online 20091933-42
sup2Siristatidis CS Maheshwari A Bhattacharya S Invitro maturation in subfertile women PCOD undergoing assisted reproduction Cochrane Database Syst Rev 2009192005-2013
PREVENTION OHSS
COASTING is considered when estradiol levels are less than 4500pgml and 15 to 30 mature follicles are present sup1( level B evidence)
- Gonadotropin stimulation is withheld and estradiol levels are checked daily
-patient is triggered when estradiol levels fall below 3500pgmlAlteration of trigger in high risk patientssup1LOW dose FSH use starting from 150IU(grade A evidence)
Reintroduction of gonadodropinantagonists following retrievalsup1
sup1 Garcia-Velasco JA How to avoid ovarian hyperstimulation syndrome a new indication for dopamine agonists Reprod Biomed Online 200918(Suppl 2)
71-75
Reducing the risk of OHSS-what does not work
Intravenous albumin (level A evidence)Follicle aspiration
(level A evidence )
Using recombinant LH instead of HCG (level A evidence)
Using recombinant HCG instead of urinary HCG(level A evidence)
NOTE Usage of letrozoleis banned in india since 2011
PREDICTION OF OHSS
Estradiolconcenteration more than 3500pgml at time if trigger (15 severe OHSS
risk)
More than 20 preovulatory follicles (15 severe OHSS risk)
Doppler changes
RUPTURE OVARIAN PREGNANCY
3 of ectopics amp
most common non tubal ectopicsup1
Increased incidence in IUCD users 1 out of 9 ectopics in IUCD users is ovarian ectopicsup2
Not associated with PID or infertilitysup1
Classical triad of pain bleeding and amenorrhoea absent in ovarian ectopicsup2
sup1 Jonathan S Berek Berek amp Novakrsquos Gynaecology2012sup2John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY
Differential diagnosis hemoperitoniumwith ovarian mass
ruptured ovarian
ectopic
ruptured luteal
hematoma
ruptured ovarian
endometrioma
Rupture ovarian cyst
bull Traumatic rupture common in functional cysts amp dermoid cyst
bull Spontaneous rupture in rapidly growing ovarian neoplasm(muciousepithelial neoplasms)
bull Rupture corpus luteal cyst ddovarian ectopic
- Hcg levels fall in ectopic n not in lueteal cyst
- DampC reveals chorionic villi in corpus leuteal cystsup1
sup1John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY
Ruptured chocolate cyst
Diagnosed by a typical CT picture showingsup1
Bilateral mutilocularovarian cysts with thick wall
Loculated ascites confined to pelvic cavity
Pelvic fat infiltration
HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA
sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian
Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65
Published online Jan 3 2011 doi 103348kjr201112159
Rupture ovarian abscess
Primary ovarian abscess is rare however it can be life threatening(Wetcher and Dunn 1985)
Early surgical intervention recommended to salvage the ovary (Stubblefield1991)
Even after proper periopcare mortality is as high as 71 sup1Prescence of subphrenic pus and
bowel injury are poor prognostic factorssup1
sup1ROBERT G FORMAN
Torsion ovarian cyst
rarr 3 gynaecologicalemergenciessup1
rarr NORMAL VASCULARITY DOESNOT EXCULDE TORSION AS OVARY HAS DUAL SUPPLY FROM UTERINE AND OVARIAN ARTERIESsup1
rarr Inflammatory cysts and malignant cysts rarely undergo torsion due to adhesionssup2
sup1 httpenwikipediaorgwikiOvarian_torsionsup2sup2Jonathan S Berek Berek amp Novakrsquos
Gynaecology2012
Thankyou
GRADING OHSSDEGREE GRADE CLINICAL FEATURES
MILD GRADE 1
GRADE 2
Abdominal distention pain
Vomiting diarrhea ovary enlargement less than 5 cms weight gain less than 3kg
MODERATE GRADE 3 Mild OHSS + Ultrasound evidence of asciteselectrolyte disturbances ovarian size upto10cmsweight gain of 10lbs
SEVERE GRADE 4
GRADE 5
GRADE 6
Moderate OHSS + ovary size gt 12cm weight gain gt5kgGrade 4 + tense ascites hydrothorax
Grade 5 + haemoconcenteration coagulation abnormalities renal dysfunction respiratory failure
PREVENTION OF OHSS
Adjunctive use of metformin in
PCOS patientsup1 (GRADE-A evidence)
Cabergoline 05 mg daily x 7
days following retrievalsup2 (GRADE A
evidence)
- dopamine antagoinst
- reduces VEGF production
- Long term use causes
valvular heart defectsup1Tso LO Costello MF Albuquerque LE et alMetformin treatment before and during IVF and ICSI in women with
PCOD Cochraine database Syst Rev 20092CD006105sup2 Garcia-Velasco JA How to avoid ovarian hyperstimulation syndrome a new indication for dopamine agonists
Reprod Biomed Online 200918(Suppl 2) 71-75
PREVENTION OHSS
Cryopreservation of all embryos without transfer will prevent late onset OHSSsup1(GRADE B evidence)
IN VITRO OOCYTE MATURATION completely obviates the need to stimulate ovaries by gonadotrophinssup2
sup1Aboulghar M Symposium update on prediction and management of OHSS Reprod Biomed Online 20091933-42
sup2Siristatidis CS Maheshwari A Bhattacharya S Invitro maturation in subfertile women PCOD undergoing assisted reproduction Cochrane Database Syst Rev 2009192005-2013
PREVENTION OHSS
COASTING is considered when estradiol levels are less than 4500pgml and 15 to 30 mature follicles are present sup1( level B evidence)
- Gonadotropin stimulation is withheld and estradiol levels are checked daily
-patient is triggered when estradiol levels fall below 3500pgmlAlteration of trigger in high risk patientssup1LOW dose FSH use starting from 150IU(grade A evidence)
Reintroduction of gonadodropinantagonists following retrievalsup1
sup1 Garcia-Velasco JA How to avoid ovarian hyperstimulation syndrome a new indication for dopamine agonists Reprod Biomed Online 200918(Suppl 2)
71-75
Reducing the risk of OHSS-what does not work
Intravenous albumin (level A evidence)Follicle aspiration
(level A evidence )
Using recombinant LH instead of HCG (level A evidence)
Using recombinant HCG instead of urinary HCG(level A evidence)
NOTE Usage of letrozoleis banned in india since 2011
PREDICTION OF OHSS
Estradiolconcenteration more than 3500pgml at time if trigger (15 severe OHSS
risk)
More than 20 preovulatory follicles (15 severe OHSS risk)
Doppler changes
RUPTURE OVARIAN PREGNANCY
3 of ectopics amp
most common non tubal ectopicsup1
Increased incidence in IUCD users 1 out of 9 ectopics in IUCD users is ovarian ectopicsup2
Not associated with PID or infertilitysup1
Classical triad of pain bleeding and amenorrhoea absent in ovarian ectopicsup2
sup1 Jonathan S Berek Berek amp Novakrsquos Gynaecology2012sup2John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY
Differential diagnosis hemoperitoniumwith ovarian mass
ruptured ovarian
ectopic
ruptured luteal
hematoma
ruptured ovarian
endometrioma
Rupture ovarian cyst
bull Traumatic rupture common in functional cysts amp dermoid cyst
bull Spontaneous rupture in rapidly growing ovarian neoplasm(muciousepithelial neoplasms)
bull Rupture corpus luteal cyst ddovarian ectopic
- Hcg levels fall in ectopic n not in lueteal cyst
- DampC reveals chorionic villi in corpus leuteal cystsup1
sup1John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY
Ruptured chocolate cyst
Diagnosed by a typical CT picture showingsup1
Bilateral mutilocularovarian cysts with thick wall
Loculated ascites confined to pelvic cavity
Pelvic fat infiltration
HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA
sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian
Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65
Published online Jan 3 2011 doi 103348kjr201112159
Rupture ovarian abscess
Primary ovarian abscess is rare however it can be life threatening(Wetcher and Dunn 1985)
Early surgical intervention recommended to salvage the ovary (Stubblefield1991)
Even after proper periopcare mortality is as high as 71 sup1Prescence of subphrenic pus and
bowel injury are poor prognostic factorssup1
sup1ROBERT G FORMAN
Torsion ovarian cyst
rarr 3 gynaecologicalemergenciessup1
rarr NORMAL VASCULARITY DOESNOT EXCULDE TORSION AS OVARY HAS DUAL SUPPLY FROM UTERINE AND OVARIAN ARTERIESsup1
rarr Inflammatory cysts and malignant cysts rarely undergo torsion due to adhesionssup2
sup1 httpenwikipediaorgwikiOvarian_torsionsup2sup2Jonathan S Berek Berek amp Novakrsquos
Gynaecology2012
Thankyou
PREVENTION OF OHSS
Adjunctive use of metformin in
PCOS patientsup1 (GRADE-A evidence)
Cabergoline 05 mg daily x 7
days following retrievalsup2 (GRADE A
evidence)
- dopamine antagoinst
- reduces VEGF production
- Long term use causes
valvular heart defectsup1Tso LO Costello MF Albuquerque LE et alMetformin treatment before and during IVF and ICSI in women with
PCOD Cochraine database Syst Rev 20092CD006105sup2 Garcia-Velasco JA How to avoid ovarian hyperstimulation syndrome a new indication for dopamine agonists
Reprod Biomed Online 200918(Suppl 2) 71-75
PREVENTION OHSS
Cryopreservation of all embryos without transfer will prevent late onset OHSSsup1(GRADE B evidence)
IN VITRO OOCYTE MATURATION completely obviates the need to stimulate ovaries by gonadotrophinssup2
sup1Aboulghar M Symposium update on prediction and management of OHSS Reprod Biomed Online 20091933-42
sup2Siristatidis CS Maheshwari A Bhattacharya S Invitro maturation in subfertile women PCOD undergoing assisted reproduction Cochrane Database Syst Rev 2009192005-2013
PREVENTION OHSS
COASTING is considered when estradiol levels are less than 4500pgml and 15 to 30 mature follicles are present sup1( level B evidence)
- Gonadotropin stimulation is withheld and estradiol levels are checked daily
-patient is triggered when estradiol levels fall below 3500pgmlAlteration of trigger in high risk patientssup1LOW dose FSH use starting from 150IU(grade A evidence)
Reintroduction of gonadodropinantagonists following retrievalsup1
sup1 Garcia-Velasco JA How to avoid ovarian hyperstimulation syndrome a new indication for dopamine agonists Reprod Biomed Online 200918(Suppl 2)
71-75
Reducing the risk of OHSS-what does not work
Intravenous albumin (level A evidence)Follicle aspiration
(level A evidence )
Using recombinant LH instead of HCG (level A evidence)
Using recombinant HCG instead of urinary HCG(level A evidence)
NOTE Usage of letrozoleis banned in india since 2011
PREDICTION OF OHSS
Estradiolconcenteration more than 3500pgml at time if trigger (15 severe OHSS
risk)
More than 20 preovulatory follicles (15 severe OHSS risk)
Doppler changes
RUPTURE OVARIAN PREGNANCY
3 of ectopics amp
most common non tubal ectopicsup1
Increased incidence in IUCD users 1 out of 9 ectopics in IUCD users is ovarian ectopicsup2
Not associated with PID or infertilitysup1
Classical triad of pain bleeding and amenorrhoea absent in ovarian ectopicsup2
sup1 Jonathan S Berek Berek amp Novakrsquos Gynaecology2012sup2John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY
Differential diagnosis hemoperitoniumwith ovarian mass
ruptured ovarian
ectopic
ruptured luteal
hematoma
ruptured ovarian
endometrioma
Rupture ovarian cyst
bull Traumatic rupture common in functional cysts amp dermoid cyst
bull Spontaneous rupture in rapidly growing ovarian neoplasm(muciousepithelial neoplasms)
bull Rupture corpus luteal cyst ddovarian ectopic
- Hcg levels fall in ectopic n not in lueteal cyst
- DampC reveals chorionic villi in corpus leuteal cystsup1
sup1John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY
Ruptured chocolate cyst
Diagnosed by a typical CT picture showingsup1
Bilateral mutilocularovarian cysts with thick wall
Loculated ascites confined to pelvic cavity
Pelvic fat infiltration
HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA
sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian
Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65
Published online Jan 3 2011 doi 103348kjr201112159
Rupture ovarian abscess
Primary ovarian abscess is rare however it can be life threatening(Wetcher and Dunn 1985)
Early surgical intervention recommended to salvage the ovary (Stubblefield1991)
Even after proper periopcare mortality is as high as 71 sup1Prescence of subphrenic pus and
bowel injury are poor prognostic factorssup1
sup1ROBERT G FORMAN
Torsion ovarian cyst
rarr 3 gynaecologicalemergenciessup1
rarr NORMAL VASCULARITY DOESNOT EXCULDE TORSION AS OVARY HAS DUAL SUPPLY FROM UTERINE AND OVARIAN ARTERIESsup1
rarr Inflammatory cysts and malignant cysts rarely undergo torsion due to adhesionssup2
sup1 httpenwikipediaorgwikiOvarian_torsionsup2sup2Jonathan S Berek Berek amp Novakrsquos
Gynaecology2012
Thankyou
PREVENTION OHSS
Cryopreservation of all embryos without transfer will prevent late onset OHSSsup1(GRADE B evidence)
IN VITRO OOCYTE MATURATION completely obviates the need to stimulate ovaries by gonadotrophinssup2
sup1Aboulghar M Symposium update on prediction and management of OHSS Reprod Biomed Online 20091933-42
sup2Siristatidis CS Maheshwari A Bhattacharya S Invitro maturation in subfertile women PCOD undergoing assisted reproduction Cochrane Database Syst Rev 2009192005-2013
PREVENTION OHSS
COASTING is considered when estradiol levels are less than 4500pgml and 15 to 30 mature follicles are present sup1( level B evidence)
- Gonadotropin stimulation is withheld and estradiol levels are checked daily
-patient is triggered when estradiol levels fall below 3500pgmlAlteration of trigger in high risk patientssup1LOW dose FSH use starting from 150IU(grade A evidence)
Reintroduction of gonadodropinantagonists following retrievalsup1
sup1 Garcia-Velasco JA How to avoid ovarian hyperstimulation syndrome a new indication for dopamine agonists Reprod Biomed Online 200918(Suppl 2)
71-75
Reducing the risk of OHSS-what does not work
Intravenous albumin (level A evidence)Follicle aspiration
(level A evidence )
Using recombinant LH instead of HCG (level A evidence)
Using recombinant HCG instead of urinary HCG(level A evidence)
NOTE Usage of letrozoleis banned in india since 2011
PREDICTION OF OHSS
Estradiolconcenteration more than 3500pgml at time if trigger (15 severe OHSS
risk)
More than 20 preovulatory follicles (15 severe OHSS risk)
Doppler changes
RUPTURE OVARIAN PREGNANCY
3 of ectopics amp
most common non tubal ectopicsup1
Increased incidence in IUCD users 1 out of 9 ectopics in IUCD users is ovarian ectopicsup2
Not associated with PID or infertilitysup1
Classical triad of pain bleeding and amenorrhoea absent in ovarian ectopicsup2
sup1 Jonathan S Berek Berek amp Novakrsquos Gynaecology2012sup2John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY
Differential diagnosis hemoperitoniumwith ovarian mass
ruptured ovarian
ectopic
ruptured luteal
hematoma
ruptured ovarian
endometrioma
Rupture ovarian cyst
bull Traumatic rupture common in functional cysts amp dermoid cyst
bull Spontaneous rupture in rapidly growing ovarian neoplasm(muciousepithelial neoplasms)
bull Rupture corpus luteal cyst ddovarian ectopic
- Hcg levels fall in ectopic n not in lueteal cyst
- DampC reveals chorionic villi in corpus leuteal cystsup1
sup1John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY
Ruptured chocolate cyst
Diagnosed by a typical CT picture showingsup1
Bilateral mutilocularovarian cysts with thick wall
Loculated ascites confined to pelvic cavity
Pelvic fat infiltration
HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA
sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian
Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65
Published online Jan 3 2011 doi 103348kjr201112159
Rupture ovarian abscess
Primary ovarian abscess is rare however it can be life threatening(Wetcher and Dunn 1985)
Early surgical intervention recommended to salvage the ovary (Stubblefield1991)
Even after proper periopcare mortality is as high as 71 sup1Prescence of subphrenic pus and
bowel injury are poor prognostic factorssup1
sup1ROBERT G FORMAN
Torsion ovarian cyst
rarr 3 gynaecologicalemergenciessup1
rarr NORMAL VASCULARITY DOESNOT EXCULDE TORSION AS OVARY HAS DUAL SUPPLY FROM UTERINE AND OVARIAN ARTERIESsup1
rarr Inflammatory cysts and malignant cysts rarely undergo torsion due to adhesionssup2
sup1 httpenwikipediaorgwikiOvarian_torsionsup2sup2Jonathan S Berek Berek amp Novakrsquos
Gynaecology2012
Thankyou
PREVENTION OHSS
COASTING is considered when estradiol levels are less than 4500pgml and 15 to 30 mature follicles are present sup1( level B evidence)
- Gonadotropin stimulation is withheld and estradiol levels are checked daily
-patient is triggered when estradiol levels fall below 3500pgmlAlteration of trigger in high risk patientssup1LOW dose FSH use starting from 150IU(grade A evidence)
Reintroduction of gonadodropinantagonists following retrievalsup1
sup1 Garcia-Velasco JA How to avoid ovarian hyperstimulation syndrome a new indication for dopamine agonists Reprod Biomed Online 200918(Suppl 2)
71-75
Reducing the risk of OHSS-what does not work
Intravenous albumin (level A evidence)Follicle aspiration
(level A evidence )
Using recombinant LH instead of HCG (level A evidence)
Using recombinant HCG instead of urinary HCG(level A evidence)
NOTE Usage of letrozoleis banned in india since 2011
PREDICTION OF OHSS
Estradiolconcenteration more than 3500pgml at time if trigger (15 severe OHSS
risk)
More than 20 preovulatory follicles (15 severe OHSS risk)
Doppler changes
RUPTURE OVARIAN PREGNANCY
3 of ectopics amp
most common non tubal ectopicsup1
Increased incidence in IUCD users 1 out of 9 ectopics in IUCD users is ovarian ectopicsup2
Not associated with PID or infertilitysup1
Classical triad of pain bleeding and amenorrhoea absent in ovarian ectopicsup2
sup1 Jonathan S Berek Berek amp Novakrsquos Gynaecology2012sup2John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY
Differential diagnosis hemoperitoniumwith ovarian mass
ruptured ovarian
ectopic
ruptured luteal
hematoma
ruptured ovarian
endometrioma
Rupture ovarian cyst
bull Traumatic rupture common in functional cysts amp dermoid cyst
bull Spontaneous rupture in rapidly growing ovarian neoplasm(muciousepithelial neoplasms)
bull Rupture corpus luteal cyst ddovarian ectopic
- Hcg levels fall in ectopic n not in lueteal cyst
- DampC reveals chorionic villi in corpus leuteal cystsup1
sup1John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY
Ruptured chocolate cyst
Diagnosed by a typical CT picture showingsup1
Bilateral mutilocularovarian cysts with thick wall
Loculated ascites confined to pelvic cavity
Pelvic fat infiltration
HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA
sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian
Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65
Published online Jan 3 2011 doi 103348kjr201112159
Rupture ovarian abscess
Primary ovarian abscess is rare however it can be life threatening(Wetcher and Dunn 1985)
Early surgical intervention recommended to salvage the ovary (Stubblefield1991)
Even after proper periopcare mortality is as high as 71 sup1Prescence of subphrenic pus and
bowel injury are poor prognostic factorssup1
sup1ROBERT G FORMAN
Torsion ovarian cyst
rarr 3 gynaecologicalemergenciessup1
rarr NORMAL VASCULARITY DOESNOT EXCULDE TORSION AS OVARY HAS DUAL SUPPLY FROM UTERINE AND OVARIAN ARTERIESsup1
rarr Inflammatory cysts and malignant cysts rarely undergo torsion due to adhesionssup2
sup1 httpenwikipediaorgwikiOvarian_torsionsup2sup2Jonathan S Berek Berek amp Novakrsquos
Gynaecology2012
Thankyou
Reducing the risk of OHSS-what does not work
Intravenous albumin (level A evidence)Follicle aspiration
(level A evidence )
Using recombinant LH instead of HCG (level A evidence)
Using recombinant HCG instead of urinary HCG(level A evidence)
NOTE Usage of letrozoleis banned in india since 2011
PREDICTION OF OHSS
Estradiolconcenteration more than 3500pgml at time if trigger (15 severe OHSS
risk)
More than 20 preovulatory follicles (15 severe OHSS risk)
Doppler changes
RUPTURE OVARIAN PREGNANCY
3 of ectopics amp
most common non tubal ectopicsup1
Increased incidence in IUCD users 1 out of 9 ectopics in IUCD users is ovarian ectopicsup2
Not associated with PID or infertilitysup1
Classical triad of pain bleeding and amenorrhoea absent in ovarian ectopicsup2
sup1 Jonathan S Berek Berek amp Novakrsquos Gynaecology2012sup2John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY
Differential diagnosis hemoperitoniumwith ovarian mass
ruptured ovarian
ectopic
ruptured luteal
hematoma
ruptured ovarian
endometrioma
Rupture ovarian cyst
bull Traumatic rupture common in functional cysts amp dermoid cyst
bull Spontaneous rupture in rapidly growing ovarian neoplasm(muciousepithelial neoplasms)
bull Rupture corpus luteal cyst ddovarian ectopic
- Hcg levels fall in ectopic n not in lueteal cyst
- DampC reveals chorionic villi in corpus leuteal cystsup1
sup1John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY
Ruptured chocolate cyst
Diagnosed by a typical CT picture showingsup1
Bilateral mutilocularovarian cysts with thick wall
Loculated ascites confined to pelvic cavity
Pelvic fat infiltration
HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA
sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian
Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65
Published online Jan 3 2011 doi 103348kjr201112159
Rupture ovarian abscess
Primary ovarian abscess is rare however it can be life threatening(Wetcher and Dunn 1985)
Early surgical intervention recommended to salvage the ovary (Stubblefield1991)
Even after proper periopcare mortality is as high as 71 sup1Prescence of subphrenic pus and
bowel injury are poor prognostic factorssup1
sup1ROBERT G FORMAN
Torsion ovarian cyst
rarr 3 gynaecologicalemergenciessup1
rarr NORMAL VASCULARITY DOESNOT EXCULDE TORSION AS OVARY HAS DUAL SUPPLY FROM UTERINE AND OVARIAN ARTERIESsup1
rarr Inflammatory cysts and malignant cysts rarely undergo torsion due to adhesionssup2
sup1 httpenwikipediaorgwikiOvarian_torsionsup2sup2Jonathan S Berek Berek amp Novakrsquos
Gynaecology2012
Thankyou
PREDICTION OF OHSS
Estradiolconcenteration more than 3500pgml at time if trigger (15 severe OHSS
risk)
More than 20 preovulatory follicles (15 severe OHSS risk)
Doppler changes
RUPTURE OVARIAN PREGNANCY
3 of ectopics amp
most common non tubal ectopicsup1
Increased incidence in IUCD users 1 out of 9 ectopics in IUCD users is ovarian ectopicsup2
Not associated with PID or infertilitysup1
Classical triad of pain bleeding and amenorrhoea absent in ovarian ectopicsup2
sup1 Jonathan S Berek Berek amp Novakrsquos Gynaecology2012sup2John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY
Differential diagnosis hemoperitoniumwith ovarian mass
ruptured ovarian
ectopic
ruptured luteal
hematoma
ruptured ovarian
endometrioma
Rupture ovarian cyst
bull Traumatic rupture common in functional cysts amp dermoid cyst
bull Spontaneous rupture in rapidly growing ovarian neoplasm(muciousepithelial neoplasms)
bull Rupture corpus luteal cyst ddovarian ectopic
- Hcg levels fall in ectopic n not in lueteal cyst
- DampC reveals chorionic villi in corpus leuteal cystsup1
sup1John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY
Ruptured chocolate cyst
Diagnosed by a typical CT picture showingsup1
Bilateral mutilocularovarian cysts with thick wall
Loculated ascites confined to pelvic cavity
Pelvic fat infiltration
HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA
sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian
Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65
Published online Jan 3 2011 doi 103348kjr201112159
Rupture ovarian abscess
Primary ovarian abscess is rare however it can be life threatening(Wetcher and Dunn 1985)
Early surgical intervention recommended to salvage the ovary (Stubblefield1991)
Even after proper periopcare mortality is as high as 71 sup1Prescence of subphrenic pus and
bowel injury are poor prognostic factorssup1
sup1ROBERT G FORMAN
Torsion ovarian cyst
rarr 3 gynaecologicalemergenciessup1
rarr NORMAL VASCULARITY DOESNOT EXCULDE TORSION AS OVARY HAS DUAL SUPPLY FROM UTERINE AND OVARIAN ARTERIESsup1
rarr Inflammatory cysts and malignant cysts rarely undergo torsion due to adhesionssup2
sup1 httpenwikipediaorgwikiOvarian_torsionsup2sup2Jonathan S Berek Berek amp Novakrsquos
Gynaecology2012
Thankyou
RUPTURE OVARIAN PREGNANCY
3 of ectopics amp
most common non tubal ectopicsup1
Increased incidence in IUCD users 1 out of 9 ectopics in IUCD users is ovarian ectopicsup2
Not associated with PID or infertilitysup1
Classical triad of pain bleeding and amenorrhoea absent in ovarian ectopicsup2
sup1 Jonathan S Berek Berek amp Novakrsquos Gynaecology2012sup2John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY
Differential diagnosis hemoperitoniumwith ovarian mass
ruptured ovarian
ectopic
ruptured luteal
hematoma
ruptured ovarian
endometrioma
Rupture ovarian cyst
bull Traumatic rupture common in functional cysts amp dermoid cyst
bull Spontaneous rupture in rapidly growing ovarian neoplasm(muciousepithelial neoplasms)
bull Rupture corpus luteal cyst ddovarian ectopic
- Hcg levels fall in ectopic n not in lueteal cyst
- DampC reveals chorionic villi in corpus leuteal cystsup1
sup1John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY
Ruptured chocolate cyst
Diagnosed by a typical CT picture showingsup1
Bilateral mutilocularovarian cysts with thick wall
Loculated ascites confined to pelvic cavity
Pelvic fat infiltration
HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA
sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian
Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65
Published online Jan 3 2011 doi 103348kjr201112159
Rupture ovarian abscess
Primary ovarian abscess is rare however it can be life threatening(Wetcher and Dunn 1985)
Early surgical intervention recommended to salvage the ovary (Stubblefield1991)
Even after proper periopcare mortality is as high as 71 sup1Prescence of subphrenic pus and
bowel injury are poor prognostic factorssup1
sup1ROBERT G FORMAN
Torsion ovarian cyst
rarr 3 gynaecologicalemergenciessup1
rarr NORMAL VASCULARITY DOESNOT EXCULDE TORSION AS OVARY HAS DUAL SUPPLY FROM UTERINE AND OVARIAN ARTERIESsup1
rarr Inflammatory cysts and malignant cysts rarely undergo torsion due to adhesionssup2
sup1 httpenwikipediaorgwikiOvarian_torsionsup2sup2Jonathan S Berek Berek amp Novakrsquos
Gynaecology2012
Thankyou
Differential diagnosis hemoperitoniumwith ovarian mass
ruptured ovarian
ectopic
ruptured luteal
hematoma
ruptured ovarian
endometrioma
Rupture ovarian cyst
bull Traumatic rupture common in functional cysts amp dermoid cyst
bull Spontaneous rupture in rapidly growing ovarian neoplasm(muciousepithelial neoplasms)
bull Rupture corpus luteal cyst ddovarian ectopic
- Hcg levels fall in ectopic n not in lueteal cyst
- DampC reveals chorionic villi in corpus leuteal cystsup1
sup1John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY
Ruptured chocolate cyst
Diagnosed by a typical CT picture showingsup1
Bilateral mutilocularovarian cysts with thick wall
Loculated ascites confined to pelvic cavity
Pelvic fat infiltration
HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA
sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian
Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65
Published online Jan 3 2011 doi 103348kjr201112159
Rupture ovarian abscess
Primary ovarian abscess is rare however it can be life threatening(Wetcher and Dunn 1985)
Early surgical intervention recommended to salvage the ovary (Stubblefield1991)
Even after proper periopcare mortality is as high as 71 sup1Prescence of subphrenic pus and
bowel injury are poor prognostic factorssup1
sup1ROBERT G FORMAN
Torsion ovarian cyst
rarr 3 gynaecologicalemergenciessup1
rarr NORMAL VASCULARITY DOESNOT EXCULDE TORSION AS OVARY HAS DUAL SUPPLY FROM UTERINE AND OVARIAN ARTERIESsup1
rarr Inflammatory cysts and malignant cysts rarely undergo torsion due to adhesionssup2
sup1 httpenwikipediaorgwikiOvarian_torsionsup2sup2Jonathan S Berek Berek amp Novakrsquos
Gynaecology2012
Thankyou
Rupture ovarian cyst
bull Traumatic rupture common in functional cysts amp dermoid cyst
bull Spontaneous rupture in rapidly growing ovarian neoplasm(muciousepithelial neoplasms)
bull Rupture corpus luteal cyst ddovarian ectopic
- Hcg levels fall in ectopic n not in lueteal cyst
- DampC reveals chorionic villi in corpus leuteal cystsup1
sup1John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY
Ruptured chocolate cyst
Diagnosed by a typical CT picture showingsup1
Bilateral mutilocularovarian cysts with thick wall
Loculated ascites confined to pelvic cavity
Pelvic fat infiltration
HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA
sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian
Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65
Published online Jan 3 2011 doi 103348kjr201112159
Rupture ovarian abscess
Primary ovarian abscess is rare however it can be life threatening(Wetcher and Dunn 1985)
Early surgical intervention recommended to salvage the ovary (Stubblefield1991)
Even after proper periopcare mortality is as high as 71 sup1Prescence of subphrenic pus and
bowel injury are poor prognostic factorssup1
sup1ROBERT G FORMAN
Torsion ovarian cyst
rarr 3 gynaecologicalemergenciessup1
rarr NORMAL VASCULARITY DOESNOT EXCULDE TORSION AS OVARY HAS DUAL SUPPLY FROM UTERINE AND OVARIAN ARTERIESsup1
rarr Inflammatory cysts and malignant cysts rarely undergo torsion due to adhesionssup2
sup1 httpenwikipediaorgwikiOvarian_torsionsup2sup2Jonathan S Berek Berek amp Novakrsquos
Gynaecology2012
Thankyou
Ruptured chocolate cyst
Diagnosed by a typical CT picture showingsup1
Bilateral mutilocularovarian cysts with thick wall
Loculated ascites confined to pelvic cavity
Pelvic fat infiltration
HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA
sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian
Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65
Published online Jan 3 2011 doi 103348kjr201112159
Rupture ovarian abscess
Primary ovarian abscess is rare however it can be life threatening(Wetcher and Dunn 1985)
Early surgical intervention recommended to salvage the ovary (Stubblefield1991)
Even after proper periopcare mortality is as high as 71 sup1Prescence of subphrenic pus and
bowel injury are poor prognostic factorssup1
sup1ROBERT G FORMAN
Torsion ovarian cyst
rarr 3 gynaecologicalemergenciessup1
rarr NORMAL VASCULARITY DOESNOT EXCULDE TORSION AS OVARY HAS DUAL SUPPLY FROM UTERINE AND OVARIAN ARTERIESsup1
rarr Inflammatory cysts and malignant cysts rarely undergo torsion due to adhesionssup2
sup1 httpenwikipediaorgwikiOvarian_torsionsup2sup2Jonathan S Berek Berek amp Novakrsquos
Gynaecology2012
Thankyou
Rupture ovarian abscess
Primary ovarian abscess is rare however it can be life threatening(Wetcher and Dunn 1985)
Early surgical intervention recommended to salvage the ovary (Stubblefield1991)
Even after proper periopcare mortality is as high as 71 sup1Prescence of subphrenic pus and
bowel injury are poor prognostic factorssup1
sup1ROBERT G FORMAN
Torsion ovarian cyst
rarr 3 gynaecologicalemergenciessup1
rarr NORMAL VASCULARITY DOESNOT EXCULDE TORSION AS OVARY HAS DUAL SUPPLY FROM UTERINE AND OVARIAN ARTERIESsup1
rarr Inflammatory cysts and malignant cysts rarely undergo torsion due to adhesionssup2
sup1 httpenwikipediaorgwikiOvarian_torsionsup2sup2Jonathan S Berek Berek amp Novakrsquos
Gynaecology2012
Thankyou
Torsion ovarian cyst
rarr 3 gynaecologicalemergenciessup1
rarr NORMAL VASCULARITY DOESNOT EXCULDE TORSION AS OVARY HAS DUAL SUPPLY FROM UTERINE AND OVARIAN ARTERIESsup1
rarr Inflammatory cysts and malignant cysts rarely undergo torsion due to adhesionssup2
sup1 httpenwikipediaorgwikiOvarian_torsionsup2sup2Jonathan S Berek Berek amp Novakrsquos
Gynaecology2012
Thankyou
Thankyou
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