Severe OHSS after IVF — structured SAQ (15 marks)

(a) Grade the severity of her OHSS — Golan with REI modification (3 marks)

One mark for the grade, one for the criteria, one for the classification system. ^[1]

• Severe OHSS — Golan classification with the reproductive endocrinology modification. ^[1]
• Criteria met — clinical (tense) ascites, oliguria under 500 mL per 24 hours (15 mL per hour for 8 hours is well under), haematocrit over 0.45 (her 0.51 qualifies), weight gain over 4.5 kg, palpable ovaries to the umbilicus. The hypotension and tachycardia are early signs of impending critical disease. ^[1][2]
• Critical OHSS is defined by life-threatening complications — anuria, ARDS, thromboembolism, haematocrit over 0.55, or severe leucocytosis. She does not yet meet these criteria, but the trajectory is worrying.^[2]

(b) Immediate resuscitation and supportive management bundle in the first hour (5 marks)

One mark per element with the named intervention. ^[1][2]

• Admit to a monitored bed with senior cover; discuss with ICU given the deteriorating trend.
• Two large-bore IV cannulae; send FBC, U&E, LFTs, coagulation, beta-hCG, group and save.
• Strict fluid balance with a urinary catheter; hourly urine output is the dynamic marker.
• Initial crystalloid — Hartmann's or normal saline 1 L over 1 hour, then maintenance.
• Switch to colloid if haemodynamics remain unstable — 4 to 6 per cent albumin or 6 per cent hydroxyethyl starch.
• Thromboprophylaxis with LMWH — mandatory in severe OHSS.
• Paracentesis if the tense ascites is producing respiratory compromise or oliguria unresponsive to fluids — the most effective single intervention in established severe disease.
• Avoid NSAIDs for analgesia (renal risk) and avoid diuretics first (intravascular depletion).
• Analgesia with paracetamol; antiemetics.
• Send beta-hCG — late OHSS in pregnancy will change prognosis.

(c) Prophylaxis you would have used — the cycle before trigger (4 marks)

Two marks for the most effective intervention with trial evidence, two for the alternative. ^[1][3][6]

• The most effective single intervention is the combination of a GnRH antagonist protocol plus a GnRH agonist trigger (leuprolide 0.5 to 1 mg subcutaneously or triptorelin 0.2 mg subcutaneously) plus freeze-all with deferred frozen embryo transfer. Humaidan 2013 (Fertil Steril) showed severe OHSS near zero with this combination.^[4][6]
• If fresh transfer is required (cultural, religious, financial reasons), use hCG trigger (reduced dose 5000 IU) plus prophylactic cabergoline 0.5 mg orally daily for 5 to 8 days from the day of trigger — dopamine agonist reduces VEGFR-2 phosphorylation and halves moderate-to-severe OHSS. The Carizza 2008 prospective RCT (Fertil Steril) and the Tang 2012 Cochrane review support this.^[3][5]
• Additional measures — identify the at-risk patient pre-cycle (PCOS, AMH over 35 pmol/L, antral follicle count over 24); consider in-vitro maturation as a no-stimulation alternative.^[6]

(d) Prognosis and counselling for future fertility (3 marks)

One mark for the prognostic statement, one for the disease course, one for the future-cycle plan. ^[1][2]

• Long-term ovarian function is preserved — OHSS does not accelerate follicular depletion; her future natural or stimulated fertility is unaffected.
• The disease itself will resolve over 7 to 14 days if she is not pregnant (early OHSS) or 2 to 3 weeks if she is pregnant (late OHSS). She is at risk of progression to critical OHSS if not optimally managed.
• For her next cycle — pre-cycle counselling, GnRH antagonist protocol with agonist trigger and freeze-all, prophylactic cabergoline, and an explicit note in the record about her prior severe OHSS. Recurrence risk is high in subsequent cycles without prophylaxis modification.
• Critical reassurance — most women who conceive after an OHSS episode have a healthy pregnancy and a healthy baby; OHSS is a treatable condition.