Síndrome de hiperestimulación ovárica: clasificación, fisiopatología y manejo

  • Jaime Saavedra Saavedra

Resumen

El síndrome de hiperestimulación ovárica es una complicación iatrogénica de la inducción de la ovulación con gonadotropinas y puede resultar en una grave amenaza para la vida por sus complicaciones; como son: accidente cerebro-vascular debido a trombosis venosa, disfunción hepática, falla renal aguda, complicaciones respiratorias y torsión anexial. El mayor factor predisponente de la forma severa del SHO es el ovario poliquístico.

El síndrome se caracteriza por una salida del fluido del espacio intravascular, con acumulación de líquido en espacio peritoneal y pleural, produciéndose hipotensión y una disminución del flujo sanguíneo renal y, por consiguiente, una disminución del volumen urinario. El aumento de la permeabilidad capilar es la hipótesis más aceptada para el inicio de la fisiopatología del evento. El factor de crecimiento endotelial y la presencia de otras citoquinas es crucial en la patogénesis del SHO.

La clasificación del síndrome nos permite realizar esquemas de tratamiento lógicos, así tenemos que el SHO leve únicamente amerita reposo e hidratación oral. El SHO moderado se trata conservadoramente con observación ambulatoria, analgésicos, antieméticos, monitorización ecográfica, evaluación de la función renal, hepática, hematocrito y coagulación. El SHO severo, sin cambios anormales del perfil bioquímico, es tratado con aspiración del líquido ascítico, suministro de líquidos endovenosos sobre la base de los cuidados diarios del tratamiento. En caso de SHO con disbalance hidroelectrolítico u otras complicaciones, la paciente debe ser hospitalizada para un manejo apropiado. El manejo quirúrgico se reserva para casos de torsión o ruptura de quiste, o tratamiento de embarazo ectópico.

Biografía del autor/a

Jaime Saavedra Saavedra
 Profesor titular, Departamento de Obstetricia y Ginecología, Universidad del Valle. Jefe del Servicio de Ginecología y Obstetricia del Hospital universitario del Valle. Director General del Centro de Biomedicina Reproductiva, FECUNDAR. Director del Programa de entrenamiento de Cirugía Endoscópica Ginecológica, Clínica Los Andes, Cali, Colombia. Presidente de la Sociedad Colombiana de Cirugía Endoscópica; Secretario para Colombia de la Sociedad Iberoamericana de Endoscopia Ginecológica e Imagenología.

Citas

Rabau E, Serr DM, David A, Mashiach S, Lunenfeld B. Human menopausal gonadotropins for anovulation and sterility. Am J Obstet Gynecol 1967;96:92-98.

World Health Organization: Agents stimulating gonadal function in human. 1973 WHO Technical Report Series no 514.

Lunenfeld B, Isler V, Glezerman M. Diagnosis and treatment of functional infertility. 3rd ed. Berlin: Blackwell; 1993.

Hanning RV Jr, Austin CW, Carlson IH. Plasma estradiol is superior to ultrasound and urinary estriol glucuronide as predictor of ovarian hyperstimulation during induction of ovulation with menotropins. Fertil Steril 1983;40:31-36.

Tulandi T, McInnes RA, Arronet GH. Ovarian hyperstimulation syndrome following ovulation induction with hMG. Int J Fertil 1984;29:113-117.

Rizk B, Tan SL, Morcos S. Heterotopic pregnancies after in vitro fertilization and embryo transfer. Am J Obstet Gynecol 1991;164:161-164.

Reyad RM, Aboulghar MA, Serour GI. Bilateral ectopic pregnancy with an intact intrauterine pregnancy following an ICSI procedure. Middle East Fertil Soc J 1996;3:91-94.

Yan Zh,Weich HA, Bernardt W, Breckwolt M, Neulen J. Vascular endothelial growth factor (VEGF) messenger ribonucleic acid (mRNA) expression in luteinized human granulose cells in vitro. J Clin Endocrinol Metab 1993;77:1723-1725.

McLure N, Healy DL, Royers PA, Sullivan J, Beaton L, Hanning RV, Connoly DT, Roberson DM. Vascular endothelial growth factor as capillary permeability agent in ovarian hyperstimulation syndrome. Lancet 1994;344:235-237.

Shweiki D, Itin A, Neufeld G, Gitay- Goren H, Keshet E. Patterns of expression of vascular endothelial growth factor (VEGF) and VEGF receptors in mice suggest a role in hormonally regulated angiogenesis. J Clin Invest 1993;91: 2235-2243.

Dahl CA, Wheeler CA, Frishman GN, Seifer DB, Hanning RV Jr. Early and late presentation of the ovarian hyperstimulation syndrome: Two distinct entities weigh different risk factors. Hum Reprod 1994;9:792-799.

Polishuk WZ, Schenker JG. Ovarian over stimulation syndrome. Fertil Steril 1969;20:443-448.

Schenker JG, Schumert Z, Shifrin A, Spitz I. Steroid pattern in experimental hyperstimulation syndrome and the response to indomethacin. Presented at the Second International Congress of Human Reproduction; October 1977; Tel Aviv.

Schenker JG, Polishuk WZ. The role of prostanglandins in ovarian hyper stimulation syndrome. Eur J Obstet Gynecol Reprod 1976;6:47-52.

Pride SM, Yuen BH, Young SM, Leung PCS. Relationship of gonadotropin releasing hormone, danazol and prostaglandin blockade to ovarian enlargement and ascitis formation or the ovarian hyperstimulation syndrome in rabbit. Am J Obstet Gynecol 1986;154:1155-1160.

Davis JS. Hormonal control of plasma and erythrocyte volume of rat uterus. Am J Phsysiol 1960;154:1155-1160.

Cecil HC, Hannun JA Jr, Bitman J. Quantitative characterization of uterine vascular permeability changes with estrogen. Am J Physiol 1966;211:1099-1104.

Schenker JG, Polishuk WZ. An experimental model of ovarian hyperstimulation syndrome. In: Tischer M, Pilch J, editors. Proceedings of the International Congress on Animal Reproduction; 1976; vol 4 Drukarnia Naukowa, Cracow. P.635-645.

Engel J, Jewelewicz R, Dyrenfurth I, Speroff L, Vande Wiele RL. Ovarian hyperstimulation syndrome. Report of case notes on pathogenesis and treatment. Am J Obstet Gynecol 1972;112:1052-1058.

Sims EA. Renal function in normal pregnancy. Clin Obstet Gynecol 1967;11:961-966.

Mudge GH, Welt LG. Agents affecting volume and composition of body fluids. In: Goodman LS, Gilman A, editors. The pharmacological basis of therapeutics, 5th edn. New York: Macmillan; 1975; p.733-781.

Navot D, Margalioth EJ, Laufer N, Birkenfeld A, Relou A, Rosler A, Schenkedr JG. Direct correlation between plasma rennin activity and severity of the ovarian hyperstimulation syndrome 1987;48:57-61.

Landau RL, Lugibihl K. Inhibition of the sodium-retaining influence of aldosterone by progesterone. J Clin Endocrinol Metab 1958;18:1237-1242.

Ferrara N, Houck K, Jakeman L, et al. Molecular and biological properties of the vascular endothelial growth factor family of proteins. Endocr Rev 1992;13:18-32.

Keck PJ, Hauser SD, Krivi G, et al. Vascular permeability factor, an endothelial cell mitogen related to PDGF. Science 1989;246:1309-1312.

Millauer B, Wizigmann-Voos S, Schnurch H, et al. High affinity VEGF binding and developmental expression suggest FLK-1 as a major regulator of vasculogenesis and angiogenesis. Cell 1993;72:835-846.

Charnock Jones DS, Sharley AM, Rajput-Williams J, et al. Identification and localization of alternately spliced mRNAs for vascular endothelial growth factor in human uterus and estrogen regulation in endometrial carcinoma cell line. Biol Reprod 1993;48:1120-1160.

Ravindranath N, Little-Ihrig LL, Phllions HS, et al. Vascular endothelial growth factor messenger ribonucleic acid expression in primate ovary. Endocrinol 1992;131:254-260.

Kim KJ, Li B, Winer J, et al. Inhibition of vascular endothelial growth factor induced angiogenesis suppresses tumor growth in vivo. Nature 1993;362:841-844.

Koch AE, Harlow LA, Haines GK, et al: Vascular endothelial growth factor: a cytokine modulating endothelial function in rheumatoid arthritis. J Immunol 1994;152:4149-4156.

McLaren J, Prentice A, Charnock-Jones DS, et al. Vascular endothelial growth factor (VEGF) concentrations are elevated in peritoneal fluid with endometriosis. Hum Reprod 1996;11: 220-223.

Abdalla HI, Rizk B. Pathogenesis of endometriosis. In: Abdalla HI, Rizk B, editors. Endometriosis. Abingdon, Oxford: Health Press, 1998; p.42-44.

Gordon JD, Mesiano S, Zaloudek CJ, et al. Vascular endothelial growth factor localization in human ovary and fallopian tubes: possible role in reproductive function and ovarian cyst formation. J Clin Endocrinol Metab 1996;81:353-359.

Yang Z, Weich HA, Bernart W, et al. Vascular endothelial growth factor (VEGF) messenger ribonucleic acid (mRNA) expression in luteinized human granulose cells in vitro. J Clin Endocrinol Metab 1993:1723-1725.

Neulen J, Yan Z, Raczeck S, et al. Ovarian hyperstimulation syndrome: vascular endothelial growth factor/vascular permeability factor from luteinized granulosa cells is the pathophysiological principal. In: Abstracts of the 11th Annual Meeting of the ESHRE. Hamburg, 1995.

McClure N, Healy DL, Rogers PA, et al. Vascular endothelial growth factor as capillary permeability agent in ovarian hyperstimulation syndrome. Lancet 1994;344:235-236.

Krasnow JJ, Berga SL, Guzick DS, et al. Vascular permeability factor and vascular endothelial growth factor in ovarian hyperstimulation syndrome. Fertil Steril 1996;65:552-555.

Moses M, Bogowsky H, Anteby E, Lunenfeld B, et al. Thromboembolic phenomena after ovarian stimulation with human menopausal gonadotrophins. Lancet 1965;2:1213-1215.

Phillips LL, Glanstone W, VandeWiele R. Studies of the coagulation and fibrinolytic systems in hyperstimulation syndrome after administration of human gonadotrophins. J Reprod Med 1975;14:138-143.

Schenker JG, Weinstein D. Ovarian hyperstimulation syndrome: a current survey. Fertil Steril 1978;30:255-268.

Navoth D, Relou A, Birkenfeld A et al. Risk factors and prognostic variables in the ovarian hyperstimulation syndrome. Am J Obstet Gynecol 1988;159:210-215.

Salat-Baroux J, Tibi L, Álvarez S, Gómez A, et al. Ultrasonographic prediction of ovarian hyperstimulation after IVF. In: Mashiach S, Ben-Rafael Z, Laufer N, Schenker JG, editors. Advances in assisted reproductive technologies. New York: Plenum Publishing; 1990; p. 559-565.

Blankstein J, Shalev J, Saadon T, Kukia EE, et al. Ovarian hyperstimulation syndrome: prediction by number and size of preovulatory ovarian follicles. Fertil Steril 1987;47:597-602.

Haning RV Jr, Boehnlein LM, Carlson IH, Kuzma DL, Zweibel DJ. Diagnosis-specific serum 17 B-estradiol (E2) upper limits for the treatment with menotropins using a 125-I direct E2 assay. Fertil Steril 1987;42:882-889.

Tal J, Paz B, Samberg Y, Lazrov N, et al. Ultrasonographic and clinical correlates of menotropins versus sequential clomiphene citrate: menotropin therapy for induction of ovulation. Fertil Steril 1985;44:342-349.

Bryce RL, Ricker RH, Saunders DM: Ultrasound in gonadotropin therapy: a better predictor of ovarian hyper stimulation? Aust N Z J Obstet Gynecol 1981;21:237-241.

Hanning RV Jr, Austin CW, Carlson IH, et al. Plasma estradiol is superior to ultrasound and urinary estriolglucoronide as a predictor of ovarian hyperstimulation during induction of ovulation with menotropins. Fertil Steril 1983;40:31-36.

Schenker JG. Prevention and treatment of ovarian hyperstimulation. Hum Reprod 1993;8:653-659.

Navot D, Bergh PA, Laufer N. Ovarian hyperstimulation syndrome in novel reproductive technologies: prevention and treatment. Fertil Steril 1992;58:249-261.

Tulandi T, Meinnes RA, Arronet GH. Ovarian hyperstimulation syndrome following ovulation induction with hMG. Int J Fertil 1984;29:113-117.

Kemmann E, Tavakoli F, Shelden RM, Jones JR. Induction of ovulation with menotropins women with polycystic ovary syndrome. Am J Obstet Gynecol 1981;141:58-64.

Caspi E, Levin S, Bukovsky Y, Weintraub Z. Induction of pregnancy with human gonadotropins after clomiphene failure in menstruating ovulatory infertility patients. Isr J Med Sci 1974;10:249-255.

Forman RG, Frydman R, Egan D, Ross C, Barlow DH. Severe ovarian hyperstimulation syndrome using agonists of gonadotropin-realising hormone for in vitro fertilization: a European series and a proposal for prevention. Fertil Steril 1990;53:502-509.

Golan A, Ron-El, Herman A, Caspi E. Ovarian hyperstimulation syndrome following D-Trp-6-luteinizing hormone-realizing hormone microcapsules and menotropin for in vitro fertilization. Fertil Steril 1988;50:912-916.

Crooke AC, Butt WR, Palmer RF, Morris R, Edward RL, Andson CJ. Clinical trial of human gonadotrophins. J Obstet Gynecol Br Commonw 1963;70:604-631.

Raj SJ, Berger MJ, Grimes EM, Taymor ML. The use of gonadotropins for the induction of ovulation in women with polycistic ovarian disease. Fertil Steril 1977;28:1280-1284.

Rizk B. Prevention of ovarian hyperstimulation syndrome: the Ten Commandments. Presented at the 1993 European Society of Human Reproduction and Embryology Symposium. Tel Aviv, Israel; 1993. p. 1-2.

Rizk B, Aboulghar M. Modern management of ovarian hyperstimulation syndrome. Hum Reprod 1991;56:1077-1083.

Rabinovici J, Kushnir O, Shalev J, et al. Rescue of menotropin cycles prone to develop ovarian hyperstimulation. Br J Obstet Gynecol 1987;94:1098-1210.

Urman B, Pride SM, Ho Yuen B. Management of overstimulated gonadotrophin cycles with a controlled drift period. Human Reprod 1992;7:213-217.

Sher G, Salem R, Fernman M, et al. Eliminating the risks of life endangering complications following overstimulation with menotropin fertility agents: a report on women undergoing in vitro fertilization and embryo transfer. Obstet Gynecol 1993;81: 1009-1020.

Benadiva CA, Davis O, Kilgman I, et al. Withholding gonadotrophin administration is an effective alternative for the prevention of ovarian hyperstimulation syndrome. Fertil Steril 1997;67:724-727.

Gonen Y, Balakier H, Powell, et al. Use of gonadotrophin releasing hormone agonist to trigger follicular maturation for in vitro fertilization. J Clin Endocrinol Metab 1990;918-922.

Itskovitz J, Boldes R, Levron J, et al. Induction of preovulatory luteinizing hormone surge and prevention of hyperstimulation syndrome by gonadotrophin releasing hormone against. Fertil Steril 1991;56:213-220.

Emperaire JC, Ruffie A. Triggering ovulation with endogenous luteinizing hormone may prevent ovarian hyperstimulation syndrome. Fertil Steril 1991;56:506-510.

Imoedemhe DAG, Chan RCW, Signe AB et, al. A new approach to the management of patients at risk of ovarian hyperstimulation in an in vitro fertilization program. Hum Reprod 1991;6:1088-1091.

Aboulghar MA, Mansour RT, Serour GI et al. Follicular aspiration does not protect against the development of ovarian hyperstimulation syndrome. J Assist Reprod Genet 1992;9:238-243.

Amso NN, Ahuga KK, Morris N, et al. The management of predicted OHS involving gonadotrophin-realizing analogue with elective cryopreservation of all pre-embryos. Fertil Steril 1990;53:1087-1090.

Rizk B, Manners CV, Davies MC, et al. Immunohistochemical expression of endometrial proteins and pregnancy outcomes in frozen embryo replacement cycles. Hum Reprod 1992;7:413-417.

Wada I, Matson PL, Trooup SA, et al. Does elective cryopreservation of all embryos from women at risk of ovarian hyperstimulation syndrome reduce the incidence of the condition? Br J Obstet Gynecol 1993;10:265-269.

Rizk B, Smitz J. Ovarian hyperstimulation syndrome after superovulation for IVF and related procedures. Hum Reprod 1992;7:320-327.

Belaish-Allart J, Hazout A. Selective oocyte retrieval: a new approach to ovarian hyperstimulation. Fertil Steril 1988;50:654-656.

Tan SL, Balen A, Hussein E, et al. The administration of glucocorticosteroids for the prevention of the ovarian hyperstimulation syndrome in in-vitro fertilization: a prospective randomized study. Fertil Steril 1992;58:378-383.

Hombourg R, Armar NA, Eshel J, et al. Influence of serum luteinizing hormone concentrations on ovulation, conception and early pregnancy loss in polycystic ovary syndrome. Br Med J 1988;297:1024-1026.

Aboulghar MA, Mansour RT, Serour GI. Recombinant follicle stimulating hormone in the treatment of patients with history of severe ovarian hyperstimulation syndrome. Fertil Steril 1996;66:757-760.

Asch RH, Ivery G, Goldman M, Frederik JL, et al. The role of intravenous albumin in patients at high risk for severe ovarian hyperstimulation syndrome. Hum Reprod 1993;8:1015-1020.

Fischer R, Baukohl V, Naether O, Nuckel M. Human serum albumin and 10% hydroxeyethyl starch infusion as a preventive treatment of sever ovarian hyperstimulation syndrome. Hum Reprod 1994;9:123-124.

Borenstein R, Elhalah U, Lunenfeld B, Schwartz ZS. Severe ovarian hyperstimulation syndrome: a revaluated therapeutic approach. Fertil Steril 1989:791-795.

Forman RG, Frydman R, Egan D, Ross C, Barlow DH. Severe ovarian hyperstimulation syndrome using agonists of gonadatropin releasing hormone for in vitro fertilization: a European series and a proposal for prevention. Fertil Steril 1990;53:502-509.

Meldrum DR, Wisot A, Hamilton F, Gutkay AL, et al. Routine pituitary suppression with leuprolide before ovarian stimulation for oocyte retrieval. Fertil Steril 1989;51:455-459.

Padilla SL, Zamaria S, Baramki TA, García JE. Abdominal paracentesis for the ovarian hyperstimulation syndrome with severe pulmonary compromise. Fertil Steril 1990;53:365-367.

Zosmer A, Katz Z, Lancet M, Konichezky S, et al. Adult respiratory distress syndrome complicating ovarian hyperstimulation syndrome. Fertil Steril 1987;47:524-526.

Rosen GF, Lew MW. Severe ovarian hyperstimulation in a spontaneous singleton pregnancy. Am J Obstet Gynecol 1991;39:464-467.

Fakih H, Bello S Ovarian cyst aspiration: a therapeutic approach to ovarian hyperstimulation syndrome after GnRH agonist/hMG super ovulation for in vitro fertilization. Hum Reprod 1990;5:993-997.

Ferraretti AP, Gianaroli L, Diotallevi L. Dopamine treatment for severe hyperstimulation syndrome. Hum Reprod 1992;7:180-183.

Moses M, Bogowsky H, Anteby E. Thromboembolic phenomena after ovarian stimulation with human menopausal gonadotropin. Lancet 1965;2:1213-1215.

Rizk B, Aboulghar MA, Smitz J, Ron-El R. The role of vascular endothelial growth factor and interleukins in the pathogenesis of sever ovarian hyperstimulation syndrome. Hum Reprod Update 1997;3:255-266.

Ong ACM, Eisen V, Rennie DP. The pathogenesis of the ovarian hyperstimulation syndrome (OHS): a possible role of ovarian renin. Clin Endocrinol 1991;34:43-49.

Mashiach S, Bider D, Moran O, Goldenber M. Adnexal torsion of hyper stimulated ovaries in pregnancies after gonadotropin therapy. Fertil Steril 1990;53:76-80.

Publicado
2002-09-30
Sección
Revisión de Tema