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Obstructive uropathy secondary to ovarian hyperstimulation syndrome (OHSS)

The patient is a 33-year-old woman with polycystic ovaries and a complex surgical history secondary to Crohn’s disease, including previous restorative proctocolectomy and J pouch defunctioning ileostomy. She presented with infertility issues and underwent two unsuccessful cycles of in vitro fertilisation (IVF). Following her third cycle of IVF and subsequent embryo implantation, the patient was admitted unwell with abdominal pain. Ultrasound scan (USS) demonstrated two viable pregnancies, enlarged ovaries secondary to ovarian hyperstimulation syndrome (OHSS) and a grade I hydronephrotic1 left kidney with normal right kidney. Initial blood tests showed a creatinine of 62, normal C-reactive protein (CRP) and negative urine cultures. The next day, the patient’s white cell count had risen to 24 and a repeat urine culture had grown a Group B streptococcus. The patient was commenced on intravenous antibiotics. Three days later, her bloods demonstrated acute kidney injury (AKI) and her creatinine had risen from 62 to 120. It was presumed that her AKI was secondary to urosepsis; however, her creatinine continued to rise to a maximum of 234. Clinically the patient was responding to antibiotics and her inflammatory markers were improving. Despite catheterisation and a good urine output, the patient’s renal function failed to improve and a repeat USS of her urinary tract was requested (three days following her initial scan). Her USS demonstrated enlarged multicystic ovaries in keeping with OHSS – right ovary 10 × 8 × 14 cm, left ovary 16 × 15 × 14 cm (Figure 1). The scan also demonstrated bilateral grade II hydronephrosis1 (Figures 2 and 3). This combined with her refractory AKI resulted in the decision to insert bilateral percutaneous nephrostomies (PCN) to treat her obstructive uropathy, which was undertaken under local anaesthetic using ultrasound guidance without fluoroscopy. Immediately following PCN insertion there was a brisk post-obstructive diuresis with a rapid fall in the creatinine from 239 to 87. The patient was discharged home without further complication. Her case was discussed at the MDT and the decision was made to continue her care with bilateral PCN throughout the pregnancy or until there was good evidence of the resolution of the obstruction.