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Ovarian Hyperstimulation Syndrome: Protocols for Nursing Care
]OGM IN REVIEW
S A N D R A J. H A H N , R N C , B S N C O R I N N E R. B U T K O W S K I , R N , B S N L I N D A L. C A P P E R , R N , B S N
Ovarian Hyperstimuhtion Syndrome: Protocok for Nursing Care
0
varian hyperstimulation is a potentially lifethreatening complication of treatment with ovulation induction medications. Because its dynamics are poorly understood, treatment is supportive, aimed at limiting and alleviating symptoms. The outpatient nurse who is in daily contact with the patient is the team member most likely to teach the patient about signs and symptoms to report and to receive communication regarding early signs and symptoms. That nurse has an important role in surveillance of the patient being cared for at home. When hyperstimulation becomes severe, admittance to the hospital is required, and the inpatient nurse is challenged by the needs of a dramatically ill patient. The nursing role is collaborative between the outpatient and inpatient units and with a multidisciplinary team. Ovarian byperstimulation is an iatrogenic condition resulting from treatment with ovulation induction agents.
Literature Review
One of the few lqe-threatening conditions encountered by the nurse caring for reproductive endocrinology and infertility patients is ovarian hyperstimulation syndrome (OHS). Having protocols for the nursing care of the patient with OHS enhances patient safety and quality of care. Model OHS protocols for outpatient and inpatient settings are presented. Tbe collaborative nursing role i n patient care also is discussed. Accepted: April 1993
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Ovulation Induction Ovulation induction agents are used in the treatment of infertility in two ways: (1) to correct ovulatory dysfunction and (2) to achieve simultaneous development of multiple ovarian follicles to increase the likelihood of pregnancy associated with intra-uterine insemination or in vitro fertilization (IVF) procedures. Both uses can result in ovarian hyperstimulation syndrome (OHS). The ovulation cycle is driven by the hypothalamic-pituitary-ovarian axis (see Figure 1). It is initiated at the level of the hypothalamus, where, in response to neurotransmitters, gonadotropin-releasing hormone (GnRH) is emitted in a pulsatile manner approximately every 90 minutes (Flynn, 1991). Via portal circulation, GnRH reaches the next level of the axis, the anterior pituitary, where it regulates release of the gonadotropins FSH (follicle-stimulating hormone) and LH (luteinizing hormone) into systemic circulation. Arriving at the third level, the ovary, FSH stimulates follicle growth, and LH brings about estradiol and progesterone synthesis (Flynn, 1991). I n turn, a pituitary LH surge is triggered by rising serum estradiol levels. That LH surge brings about final maturation of oocytes and their release from the ovary, which initiates corpus luteum function. Some ovulation induction agents act indirectly to enhance function at one or more levels of the hypotha-
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-0 GnRH
FSH
LH
Figure 1. The ovulation ycle Is driven by the hypothalamic-pituitaty-ovarianaris.
lamic-pituitary-ovarian axis. The oral medication clomiphene citrate is one such agent. At the hypothalamus and pituitary, clomiphene citrate binds to estrogen receptors, blocking negative feedback and allowing increased FHS and LH secretion (Flynn, 1991). At the level of the hypothalamus, absent or deficient secretion of GnRH can be corrected directly with exogenous GnRH, administered subcutaneously or intravenously in a pulsatile fashion. The pituitary is thus stimulated to secrete gonadotropins, and the ovulation cycle is restored. As the ovary responds to gonadotropins, the health-care provider can monitor progress via sonograms of ovarian follicles and serum estradiol levels. After ovulation, administration of hCG (human chorionic gonadotropin) or progesterone can provide luteal phase support. The health-care provider can administer gonadotropins (purified FSH or Metrodin [Serono Laboratories, Inc., Randolph, MA] and human menopausal gonadotropins hMG or Pergonal [Serono]) to correct or add to pituitary secretion of LH and FSH. These medications are administered intramuscularly in a wide variety of protocols and often in combination with other agents. Dosages may be fixed or adjusted in a stepwise fashion, according to patient response in terms of serial estradiol levels and follicle size as determined by pelvic ultrasound. With these agents, it usually is necessary to artificially supply the ovulatory stimulus of an LH surge. This is done by intramuscular (IM) injection of hCG, which is chemically similar to LH. Timing of hCG administration is based on serum estradiol levels and ultrasound measurement of ovarian
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follicles. An example of criteria for hCG administration is estradiol levels of more than 500 pg/mL and two follicles larger than 18 mm. It is common for hCG or progesterone to be administered for luteal phase support after gonadotropins are used. A recent addition to this group of agents is GnRH agonists, such as subcutaneous leuprolide acetate or nasal spray nafarelin acetate. These medications inhibit pituitary release of gonadotropins and allow more control in ovarian stimulation, because gonadotropins are exclusively supplied exogenously. GnRH agonists also prevent problematic premature LH surges.
Etiology and Incidence of OHS Current ultrasound technology, with its ability to assess ovarian size and detect ascites, suggests that some degree of OHS exists in most successful ovulation inductions. Incidence of severe hyperstimulation after use of ovulation induction agents is reported to range from 0.008% to 10% (Forman, Freydman, Egan, & Ross, 1990). That incidence varies with the clinical condition for which ovulation induction agents are used. Clinical conditions associated with increased risk include age younger than 35 years; anovulation caused by hypothalamic or pituitary defects; and polycystic ovarian disease, in which ovaries are enlarged and characterized by numerous small follicles. Estradiol levels of more than 4,000 pg/mL at the time of administration of hCG as the ovulatory stimulus and multiple (more than 30) follicles, particularly many follicles of less than 15 mm in diameter, are other risk factors for OHS (Cowan, 1991). Occurrence of severe OHS also varies with medication type and protocols. Although clomiphene citrate rarely is associated with severe OHS, the literature suggests an increased incidence associated with GnRH agonists used in conjunction with gonadotropins (Dale, Tanbo, Henriksen, Magnus, & Abyholm, 1989; Forman et al., 1990). Repeated luteal phase hCG administration also may increase the likelihood of OHS (Herman et al., 1990). OHS occurs more often in conceptional cycles (Amso, Ahuja, Morris, & Shaw, 1990; Golan et al., 1989), and the clinical course is more severe and prolonged. The 1990 In Vitro Fertilization Registry reports a 0.3% incidence of OHS in pregnant cycles and a 0.2% incidence in nonpregnant cycles (Medical R e search International, 1992). Pathophysiology and Clinical Features Although specific factors responsible for development of OHS are unknown, two prerequisites exist. The first is enhanced ovarian follicle development in
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response to gonadotropins, either injected (Pergonal and Metrodin) or endogenous, secreted in response to clomiphene citrate, GnRH, or GnRH agonists.Asecond prerequisite is hCG, which appears to be necessary to trigger the manifestations of OHS. HCG can be exogenous, in the case of its administration as an owlatory stimulus or for luteal phase support, or endogenous, in the case of pregnancy (Cowan, 1991). The central defect in ons is altered capillary permeability, resulting in capillary leakage and third space fluid accumulation.
The central defect in OHS is altered capillary permeability, which results in increased capillary leakage of protein-rich fluid into the peritoneal space (third space fluid accumulation). The primary site of increased capillary permeability is the enlarged and cystic ovaries, but the peritoneum, omentum, and pleura are other sites (Golan et al., 1989). Because the exact cause of increased permeability is unknown, n o treatment exists to reverse it. Treatment is focused on minimizing a cascade of manifestations (see Figure 2) as OHS runs its self-limited course. A universal feature of OHS is marked ovarian enlargement, which engenders risk for ruptured ovarian cysts and ovarian torsion. If OHS progresses, ascites and pleural effusion interfere with respiratory function, and adult respiratory distress syndrome can develop. Other worrisome features are attributable to depletion of intravascular volume. Associated with the resulting hemoconcentration are coagulopathies and potential for deep venous thrombosis and stroke. As electrolyte disturbance progresses, hyperkalemia can produce cardiac arrhythmias. A consequence of hypovolemia is compromised renal perfusion, with ensuing oliguria, anuria, and acute renal failure. OHS symptoms commonly begin 3-10 days after administration of hCG. In the absence of pregnancy, symptoms subside in 1-2 weeks. When pregnancy exists, OHS persists until endogenous hCG titers decline, around 60-70 days of gestation (Cowan, 1991). Classification of OHS as “mild,” “moderate,” or “severe” is the basis for decision-making regarding management and hospital admittance. Signs and symptoms defining these classes are listed in Table 1. The appearance of significant clinical symptoms differentiates more severe OHS from mild, with gastrointestinal symptoms a frequent landmark of progression. According to Cowan (1991), 30-40% of patients with moderate hyperstimulation experience vomiting
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Ovaries stimulated by gonadotropins
1 Multiple ovarian follicles
I High estrogen levels hCG (+ unknown factors)
-I
.(
Ovarian enlargement
1 Increased capillary permeability
1 Third space fluid accumulates Ascites Pleural effusion
Decreased intravascular volume Hypotension Hemoconcentration Oliguria Electrolyte imbalance
Figure 2. Treafmentisfocused on minimizing a cascade ofman@stafionsas OHS runs its se~~Iim~fed course.
and diarrhea, which may induce hypovolemia, dehydration, and minor electrolyte imbalance. Rising hCG levels in pregnancy may compound nausea and vomiting. Moderate and severe forms of OHS are potentially dangerous. Although few deaths have been reported, mortality has been associated with thromboembolic phenomena and hemorrhage secondary to ruptured ovarian cysts (Cowan, 1991).
Prevention Overall, identification of patients likely to have OHS develop and efforts to prevent OHS have met with limited success. Preventive measures for non-IVF ovulation induction patients have included withholding hCG when the estradiol level is greater than 2,000 pg/ mL or when many follicles have developed. Alternately, such patients can be offered ultrasound-guided needle aspiration of most of their follicles to minimize their risk of OHS. Using decreased doses of ovulation induction agents in subsequent treatment cycles is another preventive measure.
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Table I . OHS ClassiJication, and Signs and Symptoms
Mild
Moderate
Severe
Ovaries 5-8 cm Fluid retention N o significant clinical symptoms <5 Ib weight gain
Ovaries 8-12 cm Abdominal distention Nausea, vomiting, diarrhea Abdominal pain > 5 lb weight gain
Ovaries > 12cm Ascites and/or hydrothorax Hypovolemia, hematocrit >50% Hypotension Dyspnea Blood urea nitrogen > 20 Abnormal electrolytes Abdominal pain 10-20 Ib weight gain
For IVF patients, OHS can be avoided by cryopreserving all embryos and delaying their transfer to the uterus or fallopian tubes until a subsequent cycle, when ovaries and estrogen levels have returned to normal. Although this delay avoids the enhancing effect of pregnancy on OHS should OHS develop, embryo cryopreservation may decrease the likelihood of achieving pregnancy. Asch, Ivery, Stone, and Balmaceda (1992) describe treating high-risk IVF patients (more than 30 oocytes retrieved and estradiol levels greater than 6,000 pg/ mL) with intravenous albumin in an effort to increase serum oncotic pressure and reverse the leakage of fluids from the intravascular space.
N u ming lmplica tio ns Outpatient Care
arranges for and assists with a pelvic ultrasonographic evaluation, which is the best examination for assessing ovarian size (Cowan, 1991). Caregivers must be cautioned to avoid performing manual pelvic examinations on these patients because ovarian rupture could result. The nurse coordinates appropriate diagnostic studies and participates in interpreting results to patients. Nursing management. Women with mi Id-t 0 -moderate OHS require reassurance and observation for worsening symptoms (Cowan, 1991). Safe outpatient care includes daily nurse-patient telephone conversations to assess the severity of the patient’s symptoms. The nurse obtains a detailed patient history, completes a nursing assessment, provides necessary patient teaching, and documents the findings. In developing the nursing care plan, the nurse considers physical and emotional concerns.
Collaborative management. Care of the outpatient with OHS is dependent on early identification, accurate diagnosis, and classification of severity (see Table 1). The diagnosis is made and the severity of the OHS .is determined by a combination of the history, physical examination, and laboratory data (Brzyski, Jones, & Boyers, 1988). The nurse collaborates with the physician in patient assessment and care. A protocol for the nursing care of the patient with OHS helps ensure comprehensive and safe care. The protocol for outpatient nursing management ‘of OHS at University of Iowa Hospitals and Clinics details nursing responsibilities (see Table 2). The frequency of outpatient visits depends on the progression of OHS and, therefore, is patient specific (Cedars, 1992). Interventions are based on the degree of ovarian enlargement and the presence or absence of ancillary problems (Brzyski et al., 1988). The nurse
patient’s anxiety can be minimized by awareness of what she can expect to experience. Similarly, patients need clear and simple explanations of how to prevent additional complications. Topics to cover with the patient are listed in Table 2 . The nurse should encourage the patient to verbalize her feelings and listen to the patient’s concerns. The patient who feels comfortable
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Dairy nurse-patient telephone contact to assess the patient’s condition permits safe outpatient management of mild-to-moderate OHS.
A common nursing diagnosis for the patient with OHS is anxiety related to progression of OHS. The
Ovarian Hyperstimulation
Table 2. Ovarian Hyperstimulation Syndrome
Outpatient Procotol Purpose: To outline the nursing management of patients with symptoms of ovarian hyperstimulation syndrome. Leuel: Interdependent (requires physician order for dependent functions). Content
Assessment: 1. Assess patient for the following: dyspnea postural hypotension (orthostatic blood pressure, pulse) weight gain > 5 Ib ( 2 kg) decreased urine output abdominal girth level of discomfort (subjective and objective) B appetite, nausea, vomiting emotional status, coping mechanisms 2 . Diagnostic studies per physician order: complete blood count (CBC) coagulation studies blood urea nitrogen (BUN) 'I
electrolytes creatinine serum proteins quantitative serum pregnancy test electrocardiogram (EKG) ultrasonography to assess ovarian size and ascites Intervention: 1. Patient education: daily weight measure urine output restrict fluid intake low sodium diet
bed rest pelvic rest and vaginal inactivity symptoms to report: fainting lightheadedness shortness of breath nausea and vomiting severe abdominal pain 2 . Use resources as needed: counselor dietitian Admission Planning: 1 . Criteria for hospitalization: weight gain of 10-20 Ib (5-10 kg over preoperative weight) hematocrit greater than 50% oliguria dyspnea postural hypotension excessive discomfort severe and/or prolonged nausea and vomiting 2 . If hospitalization occurs, collaborate with the inpatient nurse and/or team in the initial development of a care plan for the patient. Documentation: assessments diagnostic studies and results interventions and patient responses written and verbal patient education referrals
Note: Copyright 1993 by the University of Iowa Hospitals and Clinics, Nursing Division of Obstetrics and Gynecology. Reprinted by permission.
and at ease to speak freely will be more of a collaborator in her plan of care (Gath, 1992). Both the patient and her family may have a knowledge deficit related to dietary restrictions. The nurse may recommend consultation with a dietitian. Providing written examples of a low sodium diet and discussing the use of herbs and spices as alternatives to
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salt are helpful interventions (McCloskey & Bulechek, 1992). Education regarding the risks of OHS must precede initiation of fertility drugs to promote informed consent and decision-making. Caregivers need to allow time to provide information on OHS, including discussion of the risks, alternatives, and answers to
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Inpatient Care Education regarding OHS must precede initiation of ovulation induction to promote informed consent and decision-making.
questions raised. This information should be reiterated before hCG is administered to trigger ovulation, because hCG is a critical element in development of OHS, and because at that point estradiol levels and number of developing follicles are known. Patients need to know if they are considered at high risk for development of OHS. Patients, in accepting the risk of OHS, must acknowledge the potential for costly hospital stays and prolonged absence from work and family. Anxiety can be lessened if the patient is aware of the physiologic basis, potential complications, and expected outcomes of OHS. Although in its severe form OHS can be serious, the nurse can reassure the patient that it is self-limited. If the patient is not pregnant, the symptoms will resolve quickly. If the patient is pregnant, the symptoms will worsen before improving. When the patient with OHS is pregnant, and the pregnancy is aggravating the syndrome, some ambivalence toward the pregnancy may be expected in the patient and her significant other. Conversely, a positive pregnancy test can be the light at the end of the tunnel for the patient to focus on as she progresses through OHS. Regardless of her reaction, pregnancy monitoring throughout treatment of OHS is indicated. Patients may harbor anxiety that OHS will adversely affect the pregnancy. Reports of low incidence of spontaneous abortion associated with OHS can reassure patients. Serial quantitative pregnancy tests and transvaginal ultrasonographic evaluations may be used to document appropriate growth of the pregnancy. OHS can progress quickly to the severe form, which necessitates hospital admittance (Cowan, 1991). The decision to admit the patient to the hospital is based on the criteria outlined in Table 2. The patient needs explanation during the process of admission to help alleviate the anxiety of hospital admittance. To help smooth the transition and transfer of patient care, the outpatient nurse who has provided primary care to the patient can collaborate in planning with the inpatient nurse, patient, and family. The outpatient nurse can share information regarding history; emotional status; support system; and social concerns such as employment, child care, and financial resources. The multidisciplinary approach to management of the patient with OHS provides a comprehensive plan of care, but detailed communication is important to maintain continuity of care.
Collaborative management. The patient admitted to the hospital with OHS often is gravely ill and experiencing acute pain. With ovaries enlarged to more than 12 cm in diameter, the patient’s abdomen appears distended and tense. Because admission of women with OHS is relatively uncommon, a protocol for inpatient OHS nursing care, such as that outlined in Table 3 , provides helpful guidance. Upon admission, the inpatient nurse assesses the patient and identifies and sets priorities for clinical management. Pain, nausea, and vomiting are common symptoms. Relief can be achieved with analgesics and antiemetics as ordered by the physician, with consideration given to the safety of medications in light of potential pregnancy. Respiratory distress requires early attention. Oxygen may be administered per nasal cannula. The head of the bed should be maintained at a 45-degree angle or at the level the patient desires for respiratory comfort. Excess fluid from the peritoneal or pleural spaces may be removed to decrease the patient’s level of discomfort and dyspnea. It is the nurse’s role to educate the patient about paracentesis or thoracentesis and to assist with the procedure. Transabdominal or transvaginal ultrasound determination of ovarian size and location performed before or in conjunction with paracentesis improves the safety of the procedure by helping the physician avoid rupturing the ovary. N o more than 2,000 mL of fluid should be withdrawn at a time to avoid compensatory intravascular volume reduction (Cowan, 1991). A dramatic diuresis is common after fluid has been removed (Cowan, 1991). The use of intravenous albumin may be needed to replace plasma proteins (Borenstein, Elhalah, Lunenfeld, & Schwartz, 1989). Ascitic fluid reaccumulates rapidly, sometimes necessitating daily paracentesis during the time OHS is most severe. Hypovolemia and accompanying hemoconcentration and electrolyte imbalance warrant aggressive attention. Laboratory values are monitored closely to assess these variables. The nurse collaborates with the physician in facilitating serial laboratory assessments (see Table 3 ) and instituting supportive corrective therapy. Hematocrit values greater than 45% imply risk for thromboembolic phenomena (Cowan, 1991). Intravenous colloid solutions, such as albumin, may be administered to expand the vascular compartment and reduce hemoconcentration and ascites by moving fluid from the extravascular space to the intravascular space through diffusion (Cowan, 1991). An anticoagulant, such as heparin, may be given subcutaneously if
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Ovarian Hyperstimulation
Table 3. Severe Ovarian Hyperstimulation Syndrome Inpatient Protocol Puqose: To outline nursing management of patients with severe ovarian hyperstimulation syndrome Leuel: interdependent (requires physician order for dependent functions). COll tell t:
Assessment: 1. Assess patient for the following: 8 dyspnea 8 respiratory character, rate, and rhythm 8 vital signs (orthostatic pulse and blood pressure), syncope 8 level of discomfort (subjective and objective) 8 appetite, nausea, vomiting 8 dehydration 8 fluid intake and output # abdominal girth 8 daily weight 8 emotional status, coping mechanisms 2 . Diagnostic studies per physician order: 8 complete blood count (CBC) 8 coagulation studies 8 blood urea nitrogen (BUN) 8 electrolytes 8 creatinine 8 serum proteins 8 urine sodium and potassium 8 quantitative serum pregnancy test 8 electrocardiogram (EKG) 8 ultrasonography Intervention: 1. Administer oxygen as ordered by physician 2. Establish intravenous line and administer solution as ordered by physician
3. Restrict oral fluid intake-as
4 . Low sodium diet-as
ordered
5. Provide comfort measures-analgesics, antiemetics as ordered 6. Water or foam mattress 7. Restrict activity-as ordered 8. Avoid abdominal palpation and pelvic examination 9. Assist physician with ultrasound guided thoracentesis and/or paracentesis 10. Use resources as needed: 8 relaxation therapist 8 music therapist 8 activities therapist 8 chaplain 8 social worker 8 infertility counselor dietitian 1 1 . Patient education: 8 diagnostic studies and results 8 plan of care and interventions 8 available resources Discharge Planning: 1. Communicate with IVF ambulatory care team for ascites follow-up and inform patient of potential for outpatient paracentesis 8 follow-up ultrasounds to assess ovarian size and fluid accumulation 8 early pregnancy monitoring Documentation: assessments 8 diagnostic studies and results 8 interventions and patient responses 8 written and verbal patient education 8 referrals
ordered
Note: Copyright 1993 by the University of Iowa Hospitals and Clinics, Nursing Division of Obstetrics and Gynecology. Reprinted by oerrnission.
there is evidence of hypercoagulability. Electrolyte imbalances, particularly hyperkalemia, can be improved by oral or rectal administration of cation exchange resins, such as sodium polystyrene sulfonate (Cowan, 1991),although sodium polystyrene sulfonate will aggravate the gastrointestinal symptoms and fluid loss
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through diarrhea. If a patient has a very high serum potassium level (K+), insulin and glucose can be used to force the K+ intracellular. Another problem associated with hypovolemia is decreased renal perfusion. A consultation with renal specialists may be sought to assist in reversal of de-
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clining renal function. The nurse monitors urinary output and coordinates renal function studies.
The stress accompanying OHS is superimposed on the crisis of infertility.
Nursing management. The patient with OHS who is admitted to the hospital frequently has the diagnosis “high risk for injury related to hypotension.” Strict bed rest usually is imposed initially, with bathroom privileges allowed as hypotension resolves. The patient needs to be instructed to have assistance when ambulating to the bathroom. The nurse can help the patient appreciate the benefits to be gained from bed rest-hydrostatic pressure is decreased and venous return is increased. Encouraging the patient to lie in the lateral recumbent position also may increase renal perfusion (Cedars, 1992). I t is important to recognize that the immobility of bed rest may aggravate the existing risk for thromboembolism. Use of a water mattress and range of motion exercises are important preventive measures. A challenge to the nurse caring for the OHS patient is to respond to the patient’s knowledge deficit related to OHS and its treatment. Salient topics to be addressed in offering patient education are listed in Table 3 . Especially important to the patient will be information about other women’s experience -with procedures such as thoracentesis, which often provides such relief that patients request to have it repeated when the fluid reaccumulates. Anxiety and discomfort accompanying severe OHS may impair learning, and artful timing of teaching coupled with repetition are in order. “Anxiety related to change in health status or threat of death” may be descriptive of the woman admitted to the hospital with OHS. Providing the patient with accurate information diminishes anxiety stemming from the unknown and any misconceptions. An effective nursing intervention is to encourage the patient’s significant other to actively participate in her care and support. Allowing the patient and her family to talk about their concerns helps to dispel anxiety. Assigning the same nurse to care for the patient when possible is desirable because consistency in caregivers may reduce anxiety. When the diagnosis “ineffective individual or family coping related to situational crisis” applies, it may be appropriate to offer consultation with a counselor or a visit from clergy. The nurse’s assessment may uncover coping mechanisms that have helped the patient previously and that can be fostered when appropriate. Other effective interventions include relaxation and music therapy. Many infertile women suffer from “self-concept disturbance related to infertility.” The stress accompanying OHS often is superimposed on the prolonged
After Discharge After discharge from the hospital, the patient needs monitoring on an outpatient basis. The clinic nurse may continue telephone assessments to evaluate abdominal distention and level of discomfort until resolution is complete. Outpatient ultrasound may be indicated to assess reaccumulation of ascitic fluid. Paracentesis in the outpatient setting may be indicated for lingering ascites and abdominal distention. The nurse coordinates assessments and interventions during these follow-up visits. Pregnancy often is an additional focus of care. Nursing care of the pregnant OHS patient entails nursing interventions that will facilitate adjustment and adaptation to early pregnancy (Rescildo & Carleo, 1992). Serial quantitative serum pregnancy tests serve as an
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life crisis of infertility, which may profoundly affect self-concept, marital relations, career orientation, and sense of well-being (Bernstein, Brill, Levin, & Seibel, 1992). Olshansky (1992) addresses the process of taking on an identity of self as infertile, in which infertility becomes a central focus in one’s life, while other more positive identities, such as spouse, friend, or career person, are pushed aside. Previously infertile pregnant women sometimes have difficulty becoming part of the fertile world. One of the consequences of the low success rates in assisted reproductive technologies, according to Olshansky, is that infertile people often view themselves as failures. OHS may be viewed as one more instance in which “my body didn’t work right.” Nurses can help infertile couples to redefine their concepts of success and failure, separating treatment success and failure from personal success and failure. Nurses can assist infertile couples in focusing on areas of their lives in which they view themselves as successful. Nurses can help by avoiding language such as “failed cycle,” which the patient may internalize to mean personal failure. Patients are in the hospital for 2-4 weeks and are discharged when their symptoms improve and their laboratory values and fluid and electrolyte status return to normal. Discharge planning is collaborative among inpatient and outpatient health-care teams, the patient, and her family. Discharge teaching encompasses the possibility of outpatient paracentesis and symptoms that need to be reported to the outpatient infertility team.
index of whether the pregnancy is growing normally. The nurse participates in interpreting results t o the patient and individualizes patient-care needs. Serial ultrasounds document location of the pregnancy (intrauterine versus ectopic), number of gestational sacs, and viability of the fetus(es). It is the nurse’s role to
provide
to the patient
assist-
ing with these suspenseful obstetric ultrasound procedures. It also is the nurse’s role to help educate the patient on the precautions related to spontaneous miscarriage and ectopic pregnancies. In the case of pregnancy loss, the nurse is challenged to provide bereave-
ment support. If the pregnancy is viable, the nurse reaches the patient about early pregnancy, giving special attention to nutrition in this patient with abdominal distention and poor appetite. In addition, the nurse encourages positive health practices, while bridging the gap between infertility treatment and established prenatal care. In the case of a multiple pregnancy, the nurse is called upon to help educate the patient regarding risks, special needs, and alternatives, such as multifetal reduction. Throughout early pregnancy, these patients need continued reassurance that usually no harm is posed to the pregnancy by OHS.
Summary Along with ectopic pregnancy, severe OHS is one of the few acute conditions encountered in an infertility practice. The nurse must be knowledgeable regarding OHS to identify its onset and safely monitor its progression. The outpatient nurse provides nursing care of the patient with mild-to-moderate OHS. When OHS is severe and hospital admittance becomes necessary, collaboration between the inpatient and outpatient nurses can greatly improve continuity and quality of care. It is useful for the outpatient nurse to visit the patient in the hospital to offer information and emotional support and to communicate with hospital caregivers about plans after discharge. Outpatient care during the resolution of OHS continues to be a challenge, particularly in the presence of pregnancy. Using definitive nursing protocols for OHS helps ensure safe, comprehensive care.
References Amso, N., Ahuja, E., Morris, N., & Shaw, R. (1990). The management of predicted ovarian hyperstimulation involving gonadotropin-releasing hormone analog with elective cryopreservation of all pre-embryos. Fertility GSterility, 53, 1087-1090.
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Asch, R., Ivery, G., Stone, S., & Balmaceda, H . (1992). Intravenous albumin prevents the development of severe ovarian hyperstimulation syndrome in an ART program. Abstracts of Oral and Poster Presentations. 40th Annual Meeting of the Pacijic Coast Fertility Society Program Supplement (pp. Ab-A7). La Mirada, CA: Pacific Coast Fertility Society. Bernstein, J , , Brill, M., Levin, S,, 8 Seibel, M , (1992). Coping with infertility: A new nursing perspective. NAACOG’s Clinical Issues in Perinatal and Women’sHealth Nursing, 3, 335-342. Borenstein, R., Elhalah, U., Lunenfeld, B., & Schwartz, 2. (1989). Severe ovarian hyperstimulation syndrome: A reevaluated therapeutic approach. Fertility & Sterility, 51, 791-795. Brzyski, R., Jones, E., & Boyers, S. (1988). Hyperstimulation syndrome. In A. H. DeCherney, M. L. Polan, R. D. Lee, 8 S. P. Boyers (Eds.), Decision making in infertility (pp. 40-43). Philadelphia: B. C. Decker Inc. Cedars, M. (1992, October). Hyperstimulation syndrome. In M. Cedars (Chair), Course IX New Trends in Reproductive Biolog), and Genetics for Nurses in ART Programs. Symposium conducted at the meeting of the American Fertility Society, New Orleans, LA. Cowan, B. (1991). Ovarian hyperstimulation syndrome. The Female Patient, 16, 37-44. Dale, P., Tanbo, R., Henriksen, R., Magnus, O., &Abyholm, T. (1989). Gonadotropin therapy of female infertility. Acta Endocrinologica (Copenhagen), 120, 395-399. Flynn, M. T. (1991). Ovulation disorders. In C . Garner (Ed.), Princzples of infertility nursing (pp. 31-55). Boca Raton, FL: CRC Press, Inc. Forman, R. G., Freydman, R., Egan, D., 8 Ross, C. (1990). Severe ovarian hyperstimulation syndrome using agonists of gonadotropin-releasing hormone for in vitro fertilization: A European series and a proposal for prevention. Fertility G Sterility, 53, 502-509. Gath, C. E. (1992, May). Ovarian byperstimulation syndrome. Symposium conducted at the meeting of the Fifth National Conference for IVF Nurse Coordinators and Support Personnel, Newport Beach, CA. Golan, A., Ron-El, R., Herman,A., Soffer,Y., Weinraub, Z . , & Caspi, E. (1989). Ovarian hyperstimulation syndrome: An update review. Obstetrical and Gynecological Survey, 44, 430-440. Herman, A., Ron-El, R., Golan, A., Raziel, A , , Soffer, U., & Caspi, E. (1990). Pregnancy rate and ovarian hyperstimulation after luteal human chorionic gonadotropin in in vitro fertilization stimulated with gonadotropin-releasing hormone analog and menotropins. Fertility & Sterility, 53, 92-96. McCloskey, J., & Bulechek, G. M. (Eds.). (1992). Nursing interventions classiJfcation(NIC). St. Louis: Mosby Year Book. Medical Research International, Society for Assisted Reproductive Technology, The American Fertility Society. (1992). In vitro fertilization-embryo transfer (IVF-ET) in the United States: 1990 results from the IVF registry. Fertility &Sterility, 57, 15-24.
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Olshansky, E. (1992). Redefining the concepts of success and failure in infertility treatment. NAACOGS Clinical Issues in Perinatal and Women's Health Nursing, 3, 343-346. Rescildo, M.M.,&Z Carleo, J. L. (1992, December). Pregnancy after infertility management protocol. In C. A. James (Ed.), Nurses in Reproductive Medicine Special Interest Group (NSIG) Newsletter (pp. 6-8).
Address for correspondence: Sandra J . Hahn, RNC, BSN, Department of Obstetrics and Gynecology, 200 Hawkins
Dr., University of Iowa Hospitals and Clinics, Iowa City, IA 52242-1080. Sandra J. Hahn b an in vitro fertilization nurse coordtnator at the Untversity of Iowa Hospitals and Clinics in Iowa City. Corinne R. Butkowski is an in vitro fertilization clinic nurse at the University of Iowa Hospitals and Cltnics in Iowa City. Linda L. Capper is an obstetrics and gynecology nurse clinician at Midwest Obstetrics and Gynecology in Lake St. Louis, Missouri.
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S A N D R A J. H A H N , R N C , B S N C O R I N N E R. B U T K O W S K I , R N , B S N L I N D A L. C A P P E R , R N , B S N
Ovarian Hyperstimuhtion Syndrome: Protocok for Nursing Care
0
varian hyperstimulation is a potentially lifethreatening complication of treatment with ovulation induction medications. Because its dynamics are poorly understood, treatment is supportive, aimed at limiting and alleviating symptoms. The outpatient nurse who is in daily contact with the patient is the team member most likely to teach the patient about signs and symptoms to report and to receive communication regarding early signs and symptoms. That nurse has an important role in surveillance of the patient being cared for at home. When hyperstimulation becomes severe, admittance to the hospital is required, and the inpatient nurse is challenged by the needs of a dramatically ill patient. The nursing role is collaborative between the outpatient and inpatient units and with a multidisciplinary team. Ovarian byperstimulation is an iatrogenic condition resulting from treatment with ovulation induction agents.
Literature Review
One of the few lqe-threatening conditions encountered by the nurse caring for reproductive endocrinology and infertility patients is ovarian hyperstimulation syndrome (OHS). Having protocols for the nursing care of the patient with OHS enhances patient safety and quality of care. Model OHS protocols for outpatient and inpatient settings are presented. Tbe collaborative nursing role i n patient care also is discussed. Accepted: April 1993
Murch/April 1994
Ovulation Induction Ovulation induction agents are used in the treatment of infertility in two ways: (1) to correct ovulatory dysfunction and (2) to achieve simultaneous development of multiple ovarian follicles to increase the likelihood of pregnancy associated with intra-uterine insemination or in vitro fertilization (IVF) procedures. Both uses can result in ovarian hyperstimulation syndrome (OHS). The ovulation cycle is driven by the hypothalamic-pituitary-ovarian axis (see Figure 1). It is initiated at the level of the hypothalamus, where, in response to neurotransmitters, gonadotropin-releasing hormone (GnRH) is emitted in a pulsatile manner approximately every 90 minutes (Flynn, 1991). Via portal circulation, GnRH reaches the next level of the axis, the anterior pituitary, where it regulates release of the gonadotropins FSH (follicle-stimulating hormone) and LH (luteinizing hormone) into systemic circulation. Arriving at the third level, the ovary, FSH stimulates follicle growth, and LH brings about estradiol and progesterone synthesis (Flynn, 1991). I n turn, a pituitary LH surge is triggered by rising serum estradiol levels. That LH surge brings about final maturation of oocytes and their release from the ovary, which initiates corpus luteum function. Some ovulation induction agents act indirectly to enhance function at one or more levels of the hypotha-
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-0 GnRH
FSH
LH
Figure 1. The ovulation ycle Is driven by the hypothalamic-pituitaty-ovarianaris.
lamic-pituitary-ovarian axis. The oral medication clomiphene citrate is one such agent. At the hypothalamus and pituitary, clomiphene citrate binds to estrogen receptors, blocking negative feedback and allowing increased FHS and LH secretion (Flynn, 1991). At the level of the hypothalamus, absent or deficient secretion of GnRH can be corrected directly with exogenous GnRH, administered subcutaneously or intravenously in a pulsatile fashion. The pituitary is thus stimulated to secrete gonadotropins, and the ovulation cycle is restored. As the ovary responds to gonadotropins, the health-care provider can monitor progress via sonograms of ovarian follicles and serum estradiol levels. After ovulation, administration of hCG (human chorionic gonadotropin) or progesterone can provide luteal phase support. The health-care provider can administer gonadotropins (purified FSH or Metrodin [Serono Laboratories, Inc., Randolph, MA] and human menopausal gonadotropins hMG or Pergonal [Serono]) to correct or add to pituitary secretion of LH and FSH. These medications are administered intramuscularly in a wide variety of protocols and often in combination with other agents. Dosages may be fixed or adjusted in a stepwise fashion, according to patient response in terms of serial estradiol levels and follicle size as determined by pelvic ultrasound. With these agents, it usually is necessary to artificially supply the ovulatory stimulus of an LH surge. This is done by intramuscular (IM) injection of hCG, which is chemically similar to LH. Timing of hCG administration is based on serum estradiol levels and ultrasound measurement of ovarian
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follicles. An example of criteria for hCG administration is estradiol levels of more than 500 pg/mL and two follicles larger than 18 mm. It is common for hCG or progesterone to be administered for luteal phase support after gonadotropins are used. A recent addition to this group of agents is GnRH agonists, such as subcutaneous leuprolide acetate or nasal spray nafarelin acetate. These medications inhibit pituitary release of gonadotropins and allow more control in ovarian stimulation, because gonadotropins are exclusively supplied exogenously. GnRH agonists also prevent problematic premature LH surges.
Etiology and Incidence of OHS Current ultrasound technology, with its ability to assess ovarian size and detect ascites, suggests that some degree of OHS exists in most successful ovulation inductions. Incidence of severe hyperstimulation after use of ovulation induction agents is reported to range from 0.008% to 10% (Forman, Freydman, Egan, & Ross, 1990). That incidence varies with the clinical condition for which ovulation induction agents are used. Clinical conditions associated with increased risk include age younger than 35 years; anovulation caused by hypothalamic or pituitary defects; and polycystic ovarian disease, in which ovaries are enlarged and characterized by numerous small follicles. Estradiol levels of more than 4,000 pg/mL at the time of administration of hCG as the ovulatory stimulus and multiple (more than 30) follicles, particularly many follicles of less than 15 mm in diameter, are other risk factors for OHS (Cowan, 1991). Occurrence of severe OHS also varies with medication type and protocols. Although clomiphene citrate rarely is associated with severe OHS, the literature suggests an increased incidence associated with GnRH agonists used in conjunction with gonadotropins (Dale, Tanbo, Henriksen, Magnus, & Abyholm, 1989; Forman et al., 1990). Repeated luteal phase hCG administration also may increase the likelihood of OHS (Herman et al., 1990). OHS occurs more often in conceptional cycles (Amso, Ahuja, Morris, & Shaw, 1990; Golan et al., 1989), and the clinical course is more severe and prolonged. The 1990 In Vitro Fertilization Registry reports a 0.3% incidence of OHS in pregnant cycles and a 0.2% incidence in nonpregnant cycles (Medical R e search International, 1992). Pathophysiology and Clinical Features Although specific factors responsible for development of OHS are unknown, two prerequisites exist. The first is enhanced ovarian follicle development in
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Ovarian Hyperstimulation
response to gonadotropins, either injected (Pergonal and Metrodin) or endogenous, secreted in response to clomiphene citrate, GnRH, or GnRH agonists.Asecond prerequisite is hCG, which appears to be necessary to trigger the manifestations of OHS. HCG can be exogenous, in the case of its administration as an owlatory stimulus or for luteal phase support, or endogenous, in the case of pregnancy (Cowan, 1991). The central defect in ons is altered capillary permeability, resulting in capillary leakage and third space fluid accumulation.
The central defect in OHS is altered capillary permeability, which results in increased capillary leakage of protein-rich fluid into the peritoneal space (third space fluid accumulation). The primary site of increased capillary permeability is the enlarged and cystic ovaries, but the peritoneum, omentum, and pleura are other sites (Golan et al., 1989). Because the exact cause of increased permeability is unknown, n o treatment exists to reverse it. Treatment is focused on minimizing a cascade of manifestations (see Figure 2) as OHS runs its self-limited course. A universal feature of OHS is marked ovarian enlargement, which engenders risk for ruptured ovarian cysts and ovarian torsion. If OHS progresses, ascites and pleural effusion interfere with respiratory function, and adult respiratory distress syndrome can develop. Other worrisome features are attributable to depletion of intravascular volume. Associated with the resulting hemoconcentration are coagulopathies and potential for deep venous thrombosis and stroke. As electrolyte disturbance progresses, hyperkalemia can produce cardiac arrhythmias. A consequence of hypovolemia is compromised renal perfusion, with ensuing oliguria, anuria, and acute renal failure. OHS symptoms commonly begin 3-10 days after administration of hCG. In the absence of pregnancy, symptoms subside in 1-2 weeks. When pregnancy exists, OHS persists until endogenous hCG titers decline, around 60-70 days of gestation (Cowan, 1991). Classification of OHS as “mild,” “moderate,” or “severe” is the basis for decision-making regarding management and hospital admittance. Signs and symptoms defining these classes are listed in Table 1. The appearance of significant clinical symptoms differentiates more severe OHS from mild, with gastrointestinal symptoms a frequent landmark of progression. According to Cowan (1991), 30-40% of patients with moderate hyperstimulation experience vomiting
March/April 1994
Ovaries stimulated by gonadotropins
1 Multiple ovarian follicles
I High estrogen levels hCG (+ unknown factors)
-I
.(
Ovarian enlargement
1 Increased capillary permeability
1 Third space fluid accumulates Ascites Pleural effusion
Decreased intravascular volume Hypotension Hemoconcentration Oliguria Electrolyte imbalance
Figure 2. Treafmentisfocused on minimizing a cascade ofman@stafionsas OHS runs its se~~Iim~fed course.
and diarrhea, which may induce hypovolemia, dehydration, and minor electrolyte imbalance. Rising hCG levels in pregnancy may compound nausea and vomiting. Moderate and severe forms of OHS are potentially dangerous. Although few deaths have been reported, mortality has been associated with thromboembolic phenomena and hemorrhage secondary to ruptured ovarian cysts (Cowan, 1991).
Prevention Overall, identification of patients likely to have OHS develop and efforts to prevent OHS have met with limited success. Preventive measures for non-IVF ovulation induction patients have included withholding hCG when the estradiol level is greater than 2,000 pg/ mL or when many follicles have developed. Alternately, such patients can be offered ultrasound-guided needle aspiration of most of their follicles to minimize their risk of OHS. Using decreased doses of ovulation induction agents in subsequent treatment cycles is another preventive measure.
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Table I . OHS ClassiJication, and Signs and Symptoms
Mild
Moderate
Severe
Ovaries 5-8 cm Fluid retention N o significant clinical symptoms <5 Ib weight gain
Ovaries 8-12 cm Abdominal distention Nausea, vomiting, diarrhea Abdominal pain > 5 lb weight gain
Ovaries > 12cm Ascites and/or hydrothorax Hypovolemia, hematocrit >50% Hypotension Dyspnea Blood urea nitrogen > 20 Abnormal electrolytes Abdominal pain 10-20 Ib weight gain
For IVF patients, OHS can be avoided by cryopreserving all embryos and delaying their transfer to the uterus or fallopian tubes until a subsequent cycle, when ovaries and estrogen levels have returned to normal. Although this delay avoids the enhancing effect of pregnancy on OHS should OHS develop, embryo cryopreservation may decrease the likelihood of achieving pregnancy. Asch, Ivery, Stone, and Balmaceda (1992) describe treating high-risk IVF patients (more than 30 oocytes retrieved and estradiol levels greater than 6,000 pg/ mL) with intravenous albumin in an effort to increase serum oncotic pressure and reverse the leakage of fluids from the intravascular space.
N u ming lmplica tio ns Outpatient Care
arranges for and assists with a pelvic ultrasonographic evaluation, which is the best examination for assessing ovarian size (Cowan, 1991). Caregivers must be cautioned to avoid performing manual pelvic examinations on these patients because ovarian rupture could result. The nurse coordinates appropriate diagnostic studies and participates in interpreting results to patients. Nursing management. Women with mi Id-t 0 -moderate OHS require reassurance and observation for worsening symptoms (Cowan, 1991). Safe outpatient care includes daily nurse-patient telephone conversations to assess the severity of the patient’s symptoms. The nurse obtains a detailed patient history, completes a nursing assessment, provides necessary patient teaching, and documents the findings. In developing the nursing care plan, the nurse considers physical and emotional concerns.
Collaborative management. Care of the outpatient with OHS is dependent on early identification, accurate diagnosis, and classification of severity (see Table 1). The diagnosis is made and the severity of the OHS .is determined by a combination of the history, physical examination, and laboratory data (Brzyski, Jones, & Boyers, 1988). The nurse collaborates with the physician in patient assessment and care. A protocol for the nursing care of the patient with OHS helps ensure comprehensive and safe care. The protocol for outpatient nursing management ‘of OHS at University of Iowa Hospitals and Clinics details nursing responsibilities (see Table 2). The frequency of outpatient visits depends on the progression of OHS and, therefore, is patient specific (Cedars, 1992). Interventions are based on the degree of ovarian enlargement and the presence or absence of ancillary problems (Brzyski et al., 1988). The nurse
patient’s anxiety can be minimized by awareness of what she can expect to experience. Similarly, patients need clear and simple explanations of how to prevent additional complications. Topics to cover with the patient are listed in Table 2 . The nurse should encourage the patient to verbalize her feelings and listen to the patient’s concerns. The patient who feels comfortable
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Dairy nurse-patient telephone contact to assess the patient’s condition permits safe outpatient management of mild-to-moderate OHS.
A common nursing diagnosis for the patient with OHS is anxiety related to progression of OHS. The
Ovarian Hyperstimulation
Table 2. Ovarian Hyperstimulation Syndrome
Outpatient Procotol Purpose: To outline the nursing management of patients with symptoms of ovarian hyperstimulation syndrome. Leuel: Interdependent (requires physician order for dependent functions). Content
Assessment: 1. Assess patient for the following: dyspnea postural hypotension (orthostatic blood pressure, pulse) weight gain > 5 Ib ( 2 kg) decreased urine output abdominal girth level of discomfort (subjective and objective) B appetite, nausea, vomiting emotional status, coping mechanisms 2 . Diagnostic studies per physician order: complete blood count (CBC) coagulation studies blood urea nitrogen (BUN) 'I
electrolytes creatinine serum proteins quantitative serum pregnancy test electrocardiogram (EKG) ultrasonography to assess ovarian size and ascites Intervention: 1. Patient education: daily weight measure urine output restrict fluid intake low sodium diet
bed rest pelvic rest and vaginal inactivity symptoms to report: fainting lightheadedness shortness of breath nausea and vomiting severe abdominal pain 2 . Use resources as needed: counselor dietitian Admission Planning: 1 . Criteria for hospitalization: weight gain of 10-20 Ib (5-10 kg over preoperative weight) hematocrit greater than 50% oliguria dyspnea postural hypotension excessive discomfort severe and/or prolonged nausea and vomiting 2 . If hospitalization occurs, collaborate with the inpatient nurse and/or team in the initial development of a care plan for the patient. Documentation: assessments diagnostic studies and results interventions and patient responses written and verbal patient education referrals
Note: Copyright 1993 by the University of Iowa Hospitals and Clinics, Nursing Division of Obstetrics and Gynecology. Reprinted by permission.
and at ease to speak freely will be more of a collaborator in her plan of care (Gath, 1992). Both the patient and her family may have a knowledge deficit related to dietary restrictions. The nurse may recommend consultation with a dietitian. Providing written examples of a low sodium diet and discussing the use of herbs and spices as alternatives to
Murch/;lpril 1994
salt are helpful interventions (McCloskey & Bulechek, 1992). Education regarding the risks of OHS must precede initiation of fertility drugs to promote informed consent and decision-making. Caregivers need to allow time to provide information on OHS, including discussion of the risks, alternatives, and answers to
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Inpatient Care Education regarding OHS must precede initiation of ovulation induction to promote informed consent and decision-making.
questions raised. This information should be reiterated before hCG is administered to trigger ovulation, because hCG is a critical element in development of OHS, and because at that point estradiol levels and number of developing follicles are known. Patients need to know if they are considered at high risk for development of OHS. Patients, in accepting the risk of OHS, must acknowledge the potential for costly hospital stays and prolonged absence from work and family. Anxiety can be lessened if the patient is aware of the physiologic basis, potential complications, and expected outcomes of OHS. Although in its severe form OHS can be serious, the nurse can reassure the patient that it is self-limited. If the patient is not pregnant, the symptoms will resolve quickly. If the patient is pregnant, the symptoms will worsen before improving. When the patient with OHS is pregnant, and the pregnancy is aggravating the syndrome, some ambivalence toward the pregnancy may be expected in the patient and her significant other. Conversely, a positive pregnancy test can be the light at the end of the tunnel for the patient to focus on as she progresses through OHS. Regardless of her reaction, pregnancy monitoring throughout treatment of OHS is indicated. Patients may harbor anxiety that OHS will adversely affect the pregnancy. Reports of low incidence of spontaneous abortion associated with OHS can reassure patients. Serial quantitative pregnancy tests and transvaginal ultrasonographic evaluations may be used to document appropriate growth of the pregnancy. OHS can progress quickly to the severe form, which necessitates hospital admittance (Cowan, 1991). The decision to admit the patient to the hospital is based on the criteria outlined in Table 2. The patient needs explanation during the process of admission to help alleviate the anxiety of hospital admittance. To help smooth the transition and transfer of patient care, the outpatient nurse who has provided primary care to the patient can collaborate in planning with the inpatient nurse, patient, and family. The outpatient nurse can share information regarding history; emotional status; support system; and social concerns such as employment, child care, and financial resources. The multidisciplinary approach to management of the patient with OHS provides a comprehensive plan of care, but detailed communication is important to maintain continuity of care.
Collaborative management. The patient admitted to the hospital with OHS often is gravely ill and experiencing acute pain. With ovaries enlarged to more than 12 cm in diameter, the patient’s abdomen appears distended and tense. Because admission of women with OHS is relatively uncommon, a protocol for inpatient OHS nursing care, such as that outlined in Table 3 , provides helpful guidance. Upon admission, the inpatient nurse assesses the patient and identifies and sets priorities for clinical management. Pain, nausea, and vomiting are common symptoms. Relief can be achieved with analgesics and antiemetics as ordered by the physician, with consideration given to the safety of medications in light of potential pregnancy. Respiratory distress requires early attention. Oxygen may be administered per nasal cannula. The head of the bed should be maintained at a 45-degree angle or at the level the patient desires for respiratory comfort. Excess fluid from the peritoneal or pleural spaces may be removed to decrease the patient’s level of discomfort and dyspnea. It is the nurse’s role to educate the patient about paracentesis or thoracentesis and to assist with the procedure. Transabdominal or transvaginal ultrasound determination of ovarian size and location performed before or in conjunction with paracentesis improves the safety of the procedure by helping the physician avoid rupturing the ovary. N o more than 2,000 mL of fluid should be withdrawn at a time to avoid compensatory intravascular volume reduction (Cowan, 1991). A dramatic diuresis is common after fluid has been removed (Cowan, 1991). The use of intravenous albumin may be needed to replace plasma proteins (Borenstein, Elhalah, Lunenfeld, & Schwartz, 1989). Ascitic fluid reaccumulates rapidly, sometimes necessitating daily paracentesis during the time OHS is most severe. Hypovolemia and accompanying hemoconcentration and electrolyte imbalance warrant aggressive attention. Laboratory values are monitored closely to assess these variables. The nurse collaborates with the physician in facilitating serial laboratory assessments (see Table 3 ) and instituting supportive corrective therapy. Hematocrit values greater than 45% imply risk for thromboembolic phenomena (Cowan, 1991). Intravenous colloid solutions, such as albumin, may be administered to expand the vascular compartment and reduce hemoconcentration and ascites by moving fluid from the extravascular space to the intravascular space through diffusion (Cowan, 1991). An anticoagulant, such as heparin, may be given subcutaneously if
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Ovarian Hyperstimulation
Table 3. Severe Ovarian Hyperstimulation Syndrome Inpatient Protocol Puqose: To outline nursing management of patients with severe ovarian hyperstimulation syndrome Leuel: interdependent (requires physician order for dependent functions). COll tell t:
Assessment: 1. Assess patient for the following: 8 dyspnea 8 respiratory character, rate, and rhythm 8 vital signs (orthostatic pulse and blood pressure), syncope 8 level of discomfort (subjective and objective) 8 appetite, nausea, vomiting 8 dehydration 8 fluid intake and output # abdominal girth 8 daily weight 8 emotional status, coping mechanisms 2 . Diagnostic studies per physician order: 8 complete blood count (CBC) 8 coagulation studies 8 blood urea nitrogen (BUN) 8 electrolytes 8 creatinine 8 serum proteins 8 urine sodium and potassium 8 quantitative serum pregnancy test 8 electrocardiogram (EKG) 8 ultrasonography Intervention: 1. Administer oxygen as ordered by physician 2. Establish intravenous line and administer solution as ordered by physician
3. Restrict oral fluid intake-as
4 . Low sodium diet-as
ordered
5. Provide comfort measures-analgesics, antiemetics as ordered 6. Water or foam mattress 7. Restrict activity-as ordered 8. Avoid abdominal palpation and pelvic examination 9. Assist physician with ultrasound guided thoracentesis and/or paracentesis 10. Use resources as needed: 8 relaxation therapist 8 music therapist 8 activities therapist 8 chaplain 8 social worker 8 infertility counselor dietitian 1 1 . Patient education: 8 diagnostic studies and results 8 plan of care and interventions 8 available resources Discharge Planning: 1. Communicate with IVF ambulatory care team for ascites follow-up and inform patient of potential for outpatient paracentesis 8 follow-up ultrasounds to assess ovarian size and fluid accumulation 8 early pregnancy monitoring Documentation: assessments 8 diagnostic studies and results 8 interventions and patient responses 8 written and verbal patient education 8 referrals
ordered
Note: Copyright 1993 by the University of Iowa Hospitals and Clinics, Nursing Division of Obstetrics and Gynecology. Reprinted by oerrnission.
there is evidence of hypercoagulability. Electrolyte imbalances, particularly hyperkalemia, can be improved by oral or rectal administration of cation exchange resins, such as sodium polystyrene sulfonate (Cowan, 1991),although sodium polystyrene sulfonate will aggravate the gastrointestinal symptoms and fluid loss
March/April 1994
through diarrhea. If a patient has a very high serum potassium level (K+), insulin and glucose can be used to force the K+ intracellular. Another problem associated with hypovolemia is decreased renal perfusion. A consultation with renal specialists may be sought to assist in reversal of de-
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clining renal function. The nurse monitors urinary output and coordinates renal function studies.
The stress accompanying OHS is superimposed on the crisis of infertility.
Nursing management. The patient with OHS who is admitted to the hospital frequently has the diagnosis “high risk for injury related to hypotension.” Strict bed rest usually is imposed initially, with bathroom privileges allowed as hypotension resolves. The patient needs to be instructed to have assistance when ambulating to the bathroom. The nurse can help the patient appreciate the benefits to be gained from bed rest-hydrostatic pressure is decreased and venous return is increased. Encouraging the patient to lie in the lateral recumbent position also may increase renal perfusion (Cedars, 1992). I t is important to recognize that the immobility of bed rest may aggravate the existing risk for thromboembolism. Use of a water mattress and range of motion exercises are important preventive measures. A challenge to the nurse caring for the OHS patient is to respond to the patient’s knowledge deficit related to OHS and its treatment. Salient topics to be addressed in offering patient education are listed in Table 3 . Especially important to the patient will be information about other women’s experience -with procedures such as thoracentesis, which often provides such relief that patients request to have it repeated when the fluid reaccumulates. Anxiety and discomfort accompanying severe OHS may impair learning, and artful timing of teaching coupled with repetition are in order. “Anxiety related to change in health status or threat of death” may be descriptive of the woman admitted to the hospital with OHS. Providing the patient with accurate information diminishes anxiety stemming from the unknown and any misconceptions. An effective nursing intervention is to encourage the patient’s significant other to actively participate in her care and support. Allowing the patient and her family to talk about their concerns helps to dispel anxiety. Assigning the same nurse to care for the patient when possible is desirable because consistency in caregivers may reduce anxiety. When the diagnosis “ineffective individual or family coping related to situational crisis” applies, it may be appropriate to offer consultation with a counselor or a visit from clergy. The nurse’s assessment may uncover coping mechanisms that have helped the patient previously and that can be fostered when appropriate. Other effective interventions include relaxation and music therapy. Many infertile women suffer from “self-concept disturbance related to infertility.” The stress accompanying OHS often is superimposed on the prolonged
After Discharge After discharge from the hospital, the patient needs monitoring on an outpatient basis. The clinic nurse may continue telephone assessments to evaluate abdominal distention and level of discomfort until resolution is complete. Outpatient ultrasound may be indicated to assess reaccumulation of ascitic fluid. Paracentesis in the outpatient setting may be indicated for lingering ascites and abdominal distention. The nurse coordinates assessments and interventions during these follow-up visits. Pregnancy often is an additional focus of care. Nursing care of the pregnant OHS patient entails nursing interventions that will facilitate adjustment and adaptation to early pregnancy (Rescildo & Carleo, 1992). Serial quantitative serum pregnancy tests serve as an
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life crisis of infertility, which may profoundly affect self-concept, marital relations, career orientation, and sense of well-being (Bernstein, Brill, Levin, & Seibel, 1992). Olshansky (1992) addresses the process of taking on an identity of self as infertile, in which infertility becomes a central focus in one’s life, while other more positive identities, such as spouse, friend, or career person, are pushed aside. Previously infertile pregnant women sometimes have difficulty becoming part of the fertile world. One of the consequences of the low success rates in assisted reproductive technologies, according to Olshansky, is that infertile people often view themselves as failures. OHS may be viewed as one more instance in which “my body didn’t work right.” Nurses can help infertile couples to redefine their concepts of success and failure, separating treatment success and failure from personal success and failure. Nurses can assist infertile couples in focusing on areas of their lives in which they view themselves as successful. Nurses can help by avoiding language such as “failed cycle,” which the patient may internalize to mean personal failure. Patients are in the hospital for 2-4 weeks and are discharged when their symptoms improve and their laboratory values and fluid and electrolyte status return to normal. Discharge planning is collaborative among inpatient and outpatient health-care teams, the patient, and her family. Discharge teaching encompasses the possibility of outpatient paracentesis and symptoms that need to be reported to the outpatient infertility team.
index of whether the pregnancy is growing normally. The nurse participates in interpreting results t o the patient and individualizes patient-care needs. Serial ultrasounds document location of the pregnancy (intrauterine versus ectopic), number of gestational sacs, and viability of the fetus(es). It is the nurse’s role to
provide
to the patient
assist-
ing with these suspenseful obstetric ultrasound procedures. It also is the nurse’s role to help educate the patient on the precautions related to spontaneous miscarriage and ectopic pregnancies. In the case of pregnancy loss, the nurse is challenged to provide bereave-
ment support. If the pregnancy is viable, the nurse reaches the patient about early pregnancy, giving special attention to nutrition in this patient with abdominal distention and poor appetite. In addition, the nurse encourages positive health practices, while bridging the gap between infertility treatment and established prenatal care. In the case of a multiple pregnancy, the nurse is called upon to help educate the patient regarding risks, special needs, and alternatives, such as multifetal reduction. Throughout early pregnancy, these patients need continued reassurance that usually no harm is posed to the pregnancy by OHS.
Summary Along with ectopic pregnancy, severe OHS is one of the few acute conditions encountered in an infertility practice. The nurse must be knowledgeable regarding OHS to identify its onset and safely monitor its progression. The outpatient nurse provides nursing care of the patient with mild-to-moderate OHS. When OHS is severe and hospital admittance becomes necessary, collaboration between the inpatient and outpatient nurses can greatly improve continuity and quality of care. It is useful for the outpatient nurse to visit the patient in the hospital to offer information and emotional support and to communicate with hospital caregivers about plans after discharge. Outpatient care during the resolution of OHS continues to be a challenge, particularly in the presence of pregnancy. Using definitive nursing protocols for OHS helps ensure safe, comprehensive care.
References Amso, N., Ahuja, E., Morris, N., & Shaw, R. (1990). The management of predicted ovarian hyperstimulation involving gonadotropin-releasing hormone analog with elective cryopreservation of all pre-embryos. Fertility GSterility, 53, 1087-1090.
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Asch, R., Ivery, G., Stone, S., & Balmaceda, H . (1992). Intravenous albumin prevents the development of severe ovarian hyperstimulation syndrome in an ART program. Abstracts of Oral and Poster Presentations. 40th Annual Meeting of the Pacijic Coast Fertility Society Program Supplement (pp. Ab-A7). La Mirada, CA: Pacific Coast Fertility Society. Bernstein, J , , Brill, M., Levin, S,, 8 Seibel, M , (1992). Coping with infertility: A new nursing perspective. NAACOG’s Clinical Issues in Perinatal and Women’sHealth Nursing, 3, 335-342. Borenstein, R., Elhalah, U., Lunenfeld, B., & Schwartz, 2. (1989). Severe ovarian hyperstimulation syndrome: A reevaluated therapeutic approach. Fertility & Sterility, 51, 791-795. Brzyski, R., Jones, E., & Boyers, S. (1988). Hyperstimulation syndrome. In A. H. DeCherney, M. L. Polan, R. D. Lee, 8 S. P. Boyers (Eds.), Decision making in infertility (pp. 40-43). Philadelphia: B. C. Decker Inc. Cedars, M. (1992, October). Hyperstimulation syndrome. In M. Cedars (Chair), Course IX New Trends in Reproductive Biolog), and Genetics for Nurses in ART Programs. Symposium conducted at the meeting of the American Fertility Society, New Orleans, LA. Cowan, B. (1991). Ovarian hyperstimulation syndrome. The Female Patient, 16, 37-44. Dale, P., Tanbo, R., Henriksen, R., Magnus, O., &Abyholm, T. (1989). Gonadotropin therapy of female infertility. Acta Endocrinologica (Copenhagen), 120, 395-399. Flynn, M. T. (1991). Ovulation disorders. In C . Garner (Ed.), Princzples of infertility nursing (pp. 31-55). Boca Raton, FL: CRC Press, Inc. Forman, R. G., Freydman, R., Egan, D., 8 Ross, C. (1990). Severe ovarian hyperstimulation syndrome using agonists of gonadotropin-releasing hormone for in vitro fertilization: A European series and a proposal for prevention. Fertility G Sterility, 53, 502-509. Gath, C. E. (1992, May). Ovarian byperstimulation syndrome. Symposium conducted at the meeting of the Fifth National Conference for IVF Nurse Coordinators and Support Personnel, Newport Beach, CA. Golan, A., Ron-El, R., Herman,A., Soffer,Y., Weinraub, Z . , & Caspi, E. (1989). Ovarian hyperstimulation syndrome: An update review. Obstetrical and Gynecological Survey, 44, 430-440. Herman, A., Ron-El, R., Golan, A., Raziel, A , , Soffer, U., & Caspi, E. (1990). Pregnancy rate and ovarian hyperstimulation after luteal human chorionic gonadotropin in in vitro fertilization stimulated with gonadotropin-releasing hormone analog and menotropins. Fertility & Sterility, 53, 92-96. McCloskey, J., & Bulechek, G. M. (Eds.). (1992). Nursing interventions classiJfcation(NIC). St. Louis: Mosby Year Book. Medical Research International, Society for Assisted Reproductive Technology, The American Fertility Society. (1992). In vitro fertilization-embryo transfer (IVF-ET) in the United States: 1990 results from the IVF registry. Fertility &Sterility, 57, 15-24.
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Olshansky, E. (1992). Redefining the concepts of success and failure in infertility treatment. NAACOGS Clinical Issues in Perinatal and Women's Health Nursing, 3, 343-346. Rescildo, M.M.,&Z Carleo, J. L. (1992, December). Pregnancy after infertility management protocol. In C. A. James (Ed.), Nurses in Reproductive Medicine Special Interest Group (NSIG) Newsletter (pp. 6-8).
Address for correspondence: Sandra J . Hahn, RNC, BSN, Department of Obstetrics and Gynecology, 200 Hawkins
Dr., University of Iowa Hospitals and Clinics, Iowa City, IA 52242-1080. Sandra J. Hahn b an in vitro fertilization nurse coordtnator at the Untversity of Iowa Hospitals and Clinics in Iowa City. Corinne R. Butkowski is an in vitro fertilization clinic nurse at the University of Iowa Hospitals and Cltnics in Iowa City. Linda L. Capper is an obstetrics and gynecology nurse clinician at Midwest Obstetrics and Gynecology in Lake St. Louis, Missouri.
25th Silver Anniversary Pin Order Form H This AWHONN Silver Anniversary Pin demonstrates your commitment to quality care for women, infants, and their families, while commemorating AWH0N"s 25th Silver Anniversary. Only $14 (DC residents add 6% sales tax). Return this order form along with payment in U.S.dollars to:
AWHONN Pin Department 3001 Washington, DC 20042-3001 I of pin(@x $14 = 1-1 check or money order encloacd 1-1 charge my MasterCardNlSA
NAME @ieaac print neatly)
ADDRESS (No P.O. Boxes; We ship UPS)
_____---------_charge card number
CITY
SIGNATURE
STATUPROVINCE
ZIP/WSTAL CODE
DAY PHONE
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MEMBER NO.
N O T E Figure is lager than actual size. This AWHONN pin should not be worn while administering clinical services.
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