Correspondence

Cardiac Tamponade after Ovarian Stimulation

N Engl J Med 2007; 356:425-426January 25, 2007

Article

To the Editor:

The ovarian hyperstimulation syndrome is a potentially lethal complication of the administration of gonadotropin for the induction of ovulation. The condition occurs in up to 5% of patients undergoing in vitro fertilization.1 Typical manifestations include marked ovarian enlargement associated with shifts in extravascular fluid, leading to ascites and pleural and pericardial effusion.

We report a case of cardiac tamponade in a 27-year-old woman after ovarian stimulation (administration of follicle-stimulating hormone at a daily dose of 75 IU for 15 days, gonadotropin-releasing hormone antagonist at a single dose of 3 mg, and human chorionic gonadotropin at a dose of 5000 IU) and the transfer of two embryos. Fourteen days after the embryo transfer, worsening dyspnea developed, and she was admitted to the intensive care unit with acute respiratory failure. The heart rate was 130 beats per minute, the blood pressure was 105/85 mm Hg with pulsus paradoxus, and the respiratory rate was 40 breaths per minute. The oxygen saturation on oximetry was 88% while the patient was receiving nasal oxygen (at a rate of 10 liters per minute). Chest auscultation showed decreased breath sounds. The presence of tense ascites was noted. Chest radiography revealed bilateral pleural effusions. Transthoracic two-dimensional echocardiography disclosed a large anterior pericardial effusion (Figure 1Figure 1Transthoracic Two-Dimensional Echocardiogram.) with respiratory variation in transvalvular flow on Doppler imaging and impaired right atrial and ventricular filling. Emergency percutaneous drainage of the chest and surgical drainage of the subxiphoid pericardial cavity and abdominal cavity recovered 1800 ml, 450 ml, and 600 ml of clear fluid, respectively. The patient's condition improved dramatically, and she was weaned from the ventilator 1 hour later. Pelvic ultrasonography disclosed bilateral ovarian enlargement. The plasma level of human chorionic gonadotropin beta subunit was 127 IU per liter. The patient was discharged from the intensive care unit on day 11 but had a spontaneous abortion on day 30.

We are not aware of previous reports of the ovarian hyperstimulation syndrome with cardiac tamponade and bilateral pleural effusions. Rare cases of isolated right-sided pleural effusion have been described.2 In a Belgian multicenter study of 128 patients with the ovarian hyperstimulation syndrome, only 4 patients (3%) had pericardial effusions, without tamponade.3 In our patient, the echocardiographic findings suggest that right pleural effusion may have contributed to the cardiac compression, as previously described.4

Because individual responses to the induction of ovulation are unpredictable, prevention of the ovarian hyperstimulation syndrome is difficult. The main risk factors are an age of less than 35 years, a history of the polycystic ovary syndrome, pregnancy, and an exaggerated ovarian response, with serum estradiol levels of more than 200 pg per milliliter and the presence of more than 10 follicles at the end of the stimulation period.3

In 2003, a total of 122,872 assisted-reproduction procedures were reported in the United States.5 The widespread use of such procedures underscores the need for recognition of the complications. Physicians should be aware that cardiac tamponade is a rare but life-threatening potential complication of the ovarian hyperstimulation syndrome.

Frédéric Le Saché, M.D.
Alain Dibie, M.D.
Christian Lamer, M.D.
Institut Mutualiste Montsouris, 75014 Paris, France
christian.lamer@imm.fr

5 References

1. 1

   Budev MM, Arroliga AC, Falcone T. Ovarian hyperstimulation syndrome. Crit Care Med 2005;33:Suppl:S301-S306
   CrossRef | Medline

2. 2

   Thomas F, Kalfon P, Niculescu M. Acute respiratory failure, lactic acidosis, and shock associated with a compressive isolated right pleural effusion following ovarian hyperstimulation syndrome. Am J Med 2003;114:165-166
   CrossRef | Web of Science | Medline

3. 3

   Delvigne A, Dubois M, Battheu B, et al. The ovarian hyperstimulation syndrome in in-vitro fertilization: a Belgian multicentric study. II. Multiple discriminant analysis for risk prediction. Hum Reprod 1993;8:1361-1366
   Web of Science | Medline

4. 4

   Kaplan LM, Epstein SK, Schwartz SL, Cao QL, Pandian NG. Clinical, echocardiographic, and hemodynamic evidence of cardiac tamponade caused by large pleural effusions. Am J Respir Crit Care Med 1995;151:904-908
   Web of Science | Medline

5. 5

   Wright VC, Chang J, Jeng G, Macaluso M. Assisted reproductive technology surveillance — United States, 2003. MMWR Surveill Summ 2006;55(SS-4):1-22. (Also available at http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5504a1.htm.)