Neda Nozari - Gastroenterology & Hepatology department, Masoud Clinic, Tehran, Iran

Background and Aim : Ovarian hyperstimulation syndrome (OHSS) is a serious iatrogenic complicationof in vitro fertilization (IVF). One of the characteristic features of OHSS is a high level of vascularpermeability which leads to fluid shifts from intravascular to interstitial or third-space compartments. Oneof the clinical manifestations of this complication is ascites. Studies reported that a low level of plasmaimmunoglobulin in severe OHSS predisposes patients to serious infections such as a complicated ascites.We reported a case of OHSS without the prior liver disease who developed spontaneous bacterial peritonitis(SBP) on severe ascites. In addition, reviewed articles investigating the associations between OHSS andSBP in this case report.Methods : We reviewed the recent literature in websites of Google scholar and Pub Med with keywords:spontaneous bacterial peritonitis, ovarian hyperstimulation syndrome, and ascites.Results : A 31-year-old female with polycystic ovarian syndrome and primary infertility was treated withIVF. She received intravenous gonadotropin-releasing hormone along with follicle-stimulating hormone ina private clinic. She presented to our emergency department with fever, severe abdominal distention,nausea, dyspnea, weight gain and decreasing urine output. A large volume ascites revealed in transabdominal ultrasonography. Laboratory findings were as follows: hemoglobin: 13 g/dL, leukocyte count:16,000/mm3, platelet count: 310,000/mL, creatinine: 1.6 mg/dL, albumin: 3g/dL, AST:25 IU/L, ALT:20IU/L, and total bilirubin: 1.5 mg/dl.The diagnosis of severe OHSS was made based on her symptoms anddrug history. A diagnostic and therapeutic transvaginal paracentesis was done. The ascites analysis revealed620 cells/mm3 with 430 polymorphonuclear cells/mm3 and a total protein concentration of 4 g/dL. Ascitesanalysis revealed a complicated ascites and culture confirmed SBP. Escherichia coli was reported as themain pathogen of SBP. Ceftriaxone was started based on a culture antibiogram. Albumin was administeredat 1.5 g/kg on the first day and at 1.0 g/kg on the third day of SBP diagnosis. The patient’s general condition,fever and ascites improved in the next days. No other source of infection was discovered in furtherevaluations during hospitalization. Ascites analysis confirmed the improvement of SBP after 5 days oftreatment. Ceftriaxone was discontinued after 7 days of treatment.Conclusion : SBP is rare in OHSS but should be considered in OHSS with unexplained sepsis and ascites.Ascitic fluid culture is negative in one third of patients. The gram-negative enteric bacteria includingEscherichia coli or Klebsiella pneumonia usually grows in a positive culture. Early antibiotic treatment isthe main management of SBP.

Spontaneous bacterial peritonitis, ovarian hyperstimulation syndrome, ascites