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Post laparoscopic massive vulvar edema in woman with ovarian hyperstimulation syndrome
Negjyp Sopa1, Mette Toftager1
1MD, The Fertility Clinic, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark

Article ID: Z01201801CL10140NP
doi: 10.5348/ijcri-201802-CL-10140

Corresponding Author:
Negjyp Sopa, MD,
The Fertility Clinic, section 4071,
Rigshospitalet, Copenhagen University Hospital,
Blegdamsvej 9, DK-2100 Copenhagen,
Denmark

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How to cite this article
Sopa N, Toftager M. Post laparoscopic massive vulvar edema in woman with ovarian hyperstimulation syndrome. Int J Case Rep Images 2018;9(1):66–68.


CASE REPORT

A 39-year-old female gravid 2 para 0 referred for in vitro fertilization (IVF) due to previous ectopic pregnancy followed by salpingectomy, presented with acute abdominal pain after IVF treatment. She was treated with a standardized GnRH antagonist protocol, where she received 150 IU of human menopausal gonadotropin (hMG, Menopur®) daily for ten days. Choriongonadotropin (hCG Ovitrelle®) 6500 IU was given to induce ovulation. Twenty-two oocytes were collected from 25 follicles. At day-5 one blastocyst was transferred and pregnancy was achieved. Luteal support was given using vaginal progesterone tablets (Lutinus®) 100 mg three times daily for two weeks. The patient was admitted to hospital eighteen days after oocyte retrieval with acute lower abdominal pain and symptoms of moderate ovarian hyperstimulation syndrome (OHSS). Adnexal torsion was suspected, thus an emergency laparoscopy was performed. Adnexal torsion was not confirmed and the pain was attributed to OHSS. Two days postoperatively, the patient gradually developed a massive vulva edema (Figure 1).

Blood tests showed that p-albumin had decreased significantly to 18 g/L (normal range 36–48 g/L). The patient was treated with infusion of human albumin “CSL Behring” solution for infusion 20% 100 ml daily for one week until p-albumin was within the normal range. Vulva was completely normalized after one week (Figure 2) and an ultrasound scan showed a normal intrauterine singleton pregnancy in gestational week seven.



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Figure 1: Massive vulva edema associated with ovarian hyperstimulation syndrome.



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Figure 2: Vulva was normalized after a week.



DISCUSSION

Very few publications on ovarian hyperstimulation syndrome involve development of vulva edema. The first case describing OHSS and vulva edema was published in 1995 [1]. The suggested etiology was oncotic and hydrostatic pressure imbalance. Multiple treatments with local use of cortisone, antibiotic ointments and ice packs were initiated in combination with OHSS therapy. Another publication including nine cases of severe OHSS were paracentesis was indicated found presentation of unilateral vulva edema when the paracentesis was performed in the lower abdomen [2]. The location of the edema corresponded to the puncture side and was developed within less than 24 hours. This may be due to a fistula between the peritoneum and subcutaneous tissue caused by the paracentesis together with the increased intraabdominal pressure due to ascites, which forces the passage of fluid to the labia presenting as edema. Patients in whom were paracentesis was performed in the abdominal hypochondriac regions, and no development of vulva edema were seen. The same process is described in another case [3], and also in cirrhotic men and women suffering from scrotal and vulva edema, respectively, after paracentesis [4][5]. Presentation of bilateral vulvar edema after transvaginal paracentesis has been described [6]. Vulva edema after laparoscopic surgery has been described previously, however, without association to IVF treatment and development of OHSS [7][8][9]. The pathogenesis of post laparoscopic vulvar edema is still unclear. In case, the patient developed OHSS laparoscopic surgery after IVF treatment after which. We believe that the rapid decrease of p-albumin to levels significant below normal range has contributed to the development of the vulva edema, with diminished oncotic pressure. One could further speculate that placement of the laparoscopic ports may have create a fistula where ascites fluid is forced into the interstitial space of the vulva area. The patient was successfully treated with infusion of human albumin.


CONCLUSION

We present a rare manifestation of ovarian hyperstimulation syndrome and massive vulvar edema, after laparoscopic surgery. Infusion of human albumin normalized the vulva completely and gives the impression that hypoalbuminemia is important for the development of vulva edema.

Keywords: In vitro fertilization, Massive vulvar edema, Ovarian hyperstimulation syndrome


REFERENCES
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Author Contributions
Negjyp Sopa – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Mette Toftager – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of Submission
The corresponding author is the guarantor of submission.
Source of Support
None
Conflict of Interest
Author declares no conflict of interest.
Copyright
© 2018 Negjyp Sopa et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.