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Towards a clinically useful classification of OHSS
RBMOnline - Vol 19. No 3. 2009 434 Reproductive BioMedicine Online; www.rbmonline.com/Article/4619 on web 11 August 2009
Letter Towards a clinically useful classification of OHSS To the Editor We were delighted to read Professor Abraham Golan’s overview of the historical development of classification systems for OHSS (Golan and Weissman, 2009) and agree with his conclusion that there is an unmet clinical need for a consensus on the classification of OHSS. Professor Golan highlights the variability and weaknesses in some of the classification systems.
than early OHSS (Mathur et al., 2000). Distinguishing between the two forms may, therefore, help to focus clinical attention on patients who are likely to experience further deterioration or a prolonged course of OHSS. Late OHSS is very poorly predicted from markers of ovarian response and continues to be a major cause of serious morbidity among healthy women undergoing fertility treatment.
One of the functions of the classification system, Professor Golan rightly states, is to identify clinical situations in which further rapid deterioration may occur to guide clinical management. The Royal College of Obstetricians and Gynaecologists undertook a formal clinical guideline process with international review to provide evidence-based guidance on the management of OHSS (RCOG, 2006), using the classification system of Mathur et al. (2005). In this classification, patients with significant abdominal pain, nausea or vomiting are classified as having moderate OHSS. These patients may represent a group who are more likely to go on to develop problems with their fluid and electrolyte balance. The presence of significant pain, nausea and/or vomiting may identify a subgroup of patients who need closer monitoring than suggested by a label of ‘mild’ OHSS that would apply from some classification systems. In fact, this is the rationale for classifying patients with only ultrasound evidence of free fluid and no clinical ascites as moderate OHSS. Accordingly, we recommend that patients with these features should be classified as moderate OHSS.
We look forward to a consensus emerging in this important area of clinical practice and hope that our comments will add to this debate.
In addition, the differing severity profile of ‘early’ and ‘late’ OHSS means that a modern classification system should distinguish between these two forms of OHSS. Late OHSS, which is crucially dependent on HCG from an early implantation, is much more likely to develop into a severe clinical picture
Mathur R1, Jenkins J2 Consultant in Reproductive Medicine and Surgery, Addenbrookes Hospital, Cambridge CB2 0QQ, UK; 2Director Medical Sciences, OB/GYN, Ferring International Centre SA, Av. de Vergognausaz 50, CH 1162 St. Prex, Switzerland
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References Golan A, Weissman A 2009 A modern classification of OHSS. Reproductive BioMedicine Online 19, 28–32. Mathur R, Evboumwan I, Jenkins J 2005 Prevention and management of ovarian hyperstimulation syndrome. Clinical Obstetrics and Gynaecology 15, 132–138. Mathur RS, Akande AV, Keay SD et al. 2000 Distinction between early and late OHSS. Fertility and Sterility 73, 901–907. Royal College of Obstetricians and Gynaecologists (RCOG) 2006 The Management of Ovarian Hyperstimulation Syndrome. London (UK): RCOG; Green-top guideline; no. 5. Received 30 July 2009; accepted 6 August 2009.
434 © 2009 Published by Reproductive Healthcare Ltd, Duck End Farm, Dry Drayton, Cambridge CB23 8DB, UK
Letter Towards a clinically useful classification of OHSS To the Editor We were delighted to read Professor Abraham Golan’s overview of the historical development of classification systems for OHSS (Golan and Weissman, 2009) and agree with his conclusion that there is an unmet clinical need for a consensus on the classification of OHSS. Professor Golan highlights the variability and weaknesses in some of the classification systems.
than early OHSS (Mathur et al., 2000). Distinguishing between the two forms may, therefore, help to focus clinical attention on patients who are likely to experience further deterioration or a prolonged course of OHSS. Late OHSS is very poorly predicted from markers of ovarian response and continues to be a major cause of serious morbidity among healthy women undergoing fertility treatment.
One of the functions of the classification system, Professor Golan rightly states, is to identify clinical situations in which further rapid deterioration may occur to guide clinical management. The Royal College of Obstetricians and Gynaecologists undertook a formal clinical guideline process with international review to provide evidence-based guidance on the management of OHSS (RCOG, 2006), using the classification system of Mathur et al. (2005). In this classification, patients with significant abdominal pain, nausea or vomiting are classified as having moderate OHSS. These patients may represent a group who are more likely to go on to develop problems with their fluid and electrolyte balance. The presence of significant pain, nausea and/or vomiting may identify a subgroup of patients who need closer monitoring than suggested by a label of ‘mild’ OHSS that would apply from some classification systems. In fact, this is the rationale for classifying patients with only ultrasound evidence of free fluid and no clinical ascites as moderate OHSS. Accordingly, we recommend that patients with these features should be classified as moderate OHSS.
We look forward to a consensus emerging in this important area of clinical practice and hope that our comments will add to this debate.
In addition, the differing severity profile of ‘early’ and ‘late’ OHSS means that a modern classification system should distinguish between these two forms of OHSS. Late OHSS, which is crucially dependent on HCG from an early implantation, is much more likely to develop into a severe clinical picture
Mathur R1, Jenkins J2 Consultant in Reproductive Medicine and Surgery, Addenbrookes Hospital, Cambridge CB2 0QQ, UK; 2Director Medical Sciences, OB/GYN, Ferring International Centre SA, Av. de Vergognausaz 50, CH 1162 St. Prex, Switzerland
1
References Golan A, Weissman A 2009 A modern classification of OHSS. Reproductive BioMedicine Online 19, 28–32. Mathur R, Evboumwan I, Jenkins J 2005 Prevention and management of ovarian hyperstimulation syndrome. Clinical Obstetrics and Gynaecology 15, 132–138. Mathur RS, Akande AV, Keay SD et al. 2000 Distinction between early and late OHSS. Fertility and Sterility 73, 901–907. Royal College of Obstetricians and Gynaecologists (RCOG) 2006 The Management of Ovarian Hyperstimulation Syndrome. London (UK): RCOG; Green-top guideline; no. 5. Received 30 July 2009; accepted 6 August 2009.
434 © 2009 Published by Reproductive Healthcare Ltd, Duck End Farm, Dry Drayton, Cambridge CB23 8DB, UK