A 35-year-old female (G0P0) presented to the emergency department with two days of worsening, severe abdominal pain. Three days prior, she underwent transvaginal oocyte retrieval (TVOR) for cryopreservation. She received half of the normal hCG dose two days prior to the TVOR.

Figure 1: Coronal CT scan of the abdomen and pelvis demonstrating bilateral cystic ovaries up to 16 cm and ascites. (Click to enlarge.)

She reported nausea, vomiting, decreased bowel movements, and scant vaginal bleeding, but no fevers. Initially, she was tachycardic, with otherwise unremarkable vital signs. She appeared pale and diaphoretic. Abdominal examination was notable for distension with diffuse tenderness to percussion and palpation. Labs were notable for mild leukocytosis but no anemia. A point-of-care ultrasound (POCUS) revealed dilated bowel loops with free fluid in the right upper quadrant, left upper quadrant, and suprapubic region. A computed tomography (CT) scan of the abdomen and pelvis with IV contrast was obtained after the case was discussed with OBGYN and surgery in order to investigate for causes of peritonitis. (Figure 1)

The second patient was also a G0P0 35-year-old female who had undergone TVOR for cryopreservation that morning and presented to the emergency department with severe abdominal pain, nausea, and vomiting. Her last leuprolide dose was 3 days prior, and no hCG trigger shot had been administered due to her elevated estradiol levels putting her at higher risk of ovarian hyperstimulation syndrome. She was hypotensive but otherwise had unremarkable vital signs. She appeared pale and diaphoretic. Abdominal examination was notable for a soft, but distended abdomen, and suprapubic tenderness to palpation without pain with percussion and no rebound tenderness. Labs were notable for leukocytosis with mild anemia. POCUS revealed free fluid in all three views of the abdomen with enlarged ovarian follicles (Figure 2.) A CT scan of the abdomen/pelvis with IV contrast was obtained after discussion with OBGYN to rule out other etiology of peritonitis including bowel perforation or active bleed due to the recent egg retrieval.

Figure 2: Transabdominal ultrasound of the first patient demonstrating enlarged ovarian follicles. (Click to enlarge.)

Both patients received fentanyl, acetaminophen, ondansetron, and a crystalloid fluid bolus in the emergency department with normalization of vital signs and improvement in symptoms. 

Diagnosis and Management

CT scans and ultrasounds of both patients revealed ascites and bilateral enlarged ovaries containing numerous follicles (Figure 1 and 2).  The first patient also had small bilateral pleural effusions.