Over Stimulated

Life begins in secret. 

The ovaries develop an "egg" or follicle is released and will travel quietly down the fallopian tube until it is fertilized.  It will implant into the wall of the uterus and eventually, the existence of new life will be discovered. 

It sounds easy enough.

But what happens when the ovaries are over-achievers?  Instead of producing one follicle or "egg," they produce 5, 10, 20 or more?  People actually pay for this service - called hyper-stimulation.  When one egg won't do - maybe a history of infertility or difficulty achieving pregnancy - patients take medicines to stack the deck in their favor.  And sometimes they succeed with one baby...two...or six.   Think Octo-Mom and John & Kate Plus Eight. 

Leave it to humans to take something that is already miraculous and try to super size it, right?

But ovarian hyperstimulation can also occur in the absence of infertility medications, albeit less commonly.  Called Spontaneous Ovarian HyperStimulation, it has been seen in young patients (<21 years), twin pregnancies or abnormal pregnancies (chromosomal abnormalities, molar gestations).  And when I say, "it's been seen" - I mean, most of us have read about it in a medical journal.

CM was an 18 yo G2P0010 at 9 weeks pregnant who came to casualty complaining of abdominal distention, nausea & vomitting and abdominal pain for 4 days.  I was called to evaluate when an ultrasound revealed bilateral ovarian "masses."

I reviewed the patient with "an intent to refer elsewhere."  She was pregnant, but there was a perfect 9 week fetus captured in the ultrasound photos.  Her abdominal distention was tympanic and very tender in the RUQ.  Her labs were off: Na 122/ K 5.4/ Hb 17/ WBC 14.5.  She was tachypneic and a CXR showed a right sided pleural effusion.   I easily ruled out ectopic and was ready to call "not it." 

But then there was this query of ovarian masses.  And I had to admit, she was a classic presention of Ovarian Hyperstimulation.  So I re-took the history.  Any history of any herbal medications?  Any medications?  Anything to help her get pregnant?  History of thyroid problems? PCOS?

No. No. No.  Accidental, unexpected pregnancy. No. No.

Spontaneous Ovarian Hyperstimulation?  I had heard of it.  It occurs so rarely that when trying to find the incidence of occurence - all I could find was: it occurs rarely.  So, unbelieving - I did my own ultrasound.

Her ovaries were so enlarged they were touching her diaphagm. Not even joking.  Sponataneous. Ovarian. Hyperstimulation.

Follicles measuring up to 4.5 to 5 cm.  Done hospital day 4 after abdomen was
less tender.

Viable fetus: 9 wks 6 days

 We admitted the patient to the ICU and started her on IVFs and Lovenox.  She eventually required a thorocentesis for the pleural effusion but otherwise did well.   We are trying to follow her closely during the pregnancy as she may be at risk for complications like fetal growth restriction and preeclampsia.  At her last visit, the fetus was 12 weeks and doing well.  Her ovaries had decreased to roughly 12 cm from 36 cm (!) on the original admission. 

Meanwhile, I am excited to meet the life that has perplexed me, demanding an early discovery of the "rare" type.  Who knows?  Maybe I'll be in the journals.....