CASE REPORT: Fatal mesenteric artery thrombus following oocyte retrieval

Abstract

Case reportThe patient was a 38 year old woman (ASA I, 157 cm height, 61 kg weight) with a 14-year history of secondary infertility due to endometriosis who had undergone in vitro fertilisation and embryo transfer after ovarian stimulation with gonadotrophins.Between 1989 and 2003, she had two-third trimester and six first and second trimester miscarriages. Her clotting profile studies, including protein-C activation, the resistance of active protein-C and LIA test free protein-S, were all normal. All her autoimmune tests were negative. Her homocysteine level was 10.89 Amol L À1 and normal. Her anti-toxoplasma IgG-IgM, anti-CMV IgM and HSV-IgM were negative but anti-CMV IgG and HSV-1 IgG were positive. Thyroid function tests were normal. Her fasting blood glucose level was 96 mg dL À1 and after 75 g oral glucose tolerance test, type II DM was detected and she was put on a diabetic diet.Diagnostic laparoscopy and hysteroscopy were performed. The right fallopian tube was obstructed. There were no pelvic adhesions. Endometritis and adenomyosis were found in an endometrial biopsy. Semen analysis of the husband was normal. After these tests were performed, she was treated with in vitro fertilisation and embryo transfer.The patient had her first cycle of in vitro fertilisationembryo transfer in October 2003 when 50 IU Â 27 ¼ 1350 units of human menopausal gonadotrophin (HMG) (Pergonal; Serono, Geneva, Switzerland) were administered. After 12 days of stimulation, the patient developed 17 follicles with a diameter of 12-17 mm. Follicle aspiration was carried out 36 hours after administration of 10,000 IU of human chorionic gonadotrophin (hCG) while the oestradiol concentration was 2337 PG mL À1 and seven oocytes were obtained. She had not had any procedures under anaesthesia or embryo transfer prior to this time.After the oocyte pick-up procedure the patient was discharged from hospital, but a few hours later she came to the emergency service with acute abdominal pain and in poor general condition. Her heart rate was 130 minute À1 , blood pressure 110/70 mmHg, fever 36jC and respiration rate 24 minute À1 . On physical examination she had abdominal tenderness and rebound. Bowel sounds were hypoactive, there was costovertebral angle tenderness. On rectal examination, the cervix was rigid, and no blood or melena was detected. Flat and upright abdominal X-rays showed airfluid levels. Ultrasonography showed massive fluid in the left paracolic area and minimal fluid was seen behind the bladder. At culdocentesis no fluid was aspirated.Laboratory findings are shown in Table 1. She was treated conservatively with intravenous infusion of 8 Litre/ day crystalloids. A few hours later she developed restlessness, tachycardia (heart rate ¼ 180 minute À1 ), hypotension (80/60 mmHg), hypercapnia (respiratory rate ¼ 44 minute À1 ), leucocytosis, and her temperature was 38jC. In view of these findings indicative of sepsis, the infectious disease consultant recommended intravenous sulbactamampicillin 4 Â 1.5 g and ciprofloxasin 2 Â 400 mg....

The ‘ART’ of thrombosis: a review of arterial and venous thrombosis in assisted reproductive technology

“…In two women, two distinct sites were involved in the same patient [(choroidal artery and right popliteal artery) [22], (right femoral artery and left popliteal artery [8])]. Two of the women who developed arterial strokes and one woman who had mesenteric infarction died from complications [8, 11,29], representing about 9% mortality among reported arterial cases. For the 61 cases of venous thromboses which were reported, the predominant sites of involvement were the veins in the neck and upper extremities (80%, 49/61) (Table 2).…”

Combined jugular and subclavian vein thrombosis following assisted reproductive technology—new observation

“…The syndrome is the result of a shift of fluids out of the intravascular space to the extravascular compartment. The concurrence of hemoconcentration and hyperestrogenemia in the ovarian hyperstimulation syndrome puts those women at higher risk for arterial and venous thromboses (3)(4)(5)(6). Indeed, jugular and subclavian vein thrombosis is one of the complications of ART, estimated to occur in 0.08% to 0.11% of treatment cycles in women undergoing ART (1).…”