A Young Woman with Liver Disease?

As advances are made in medicine, new syndromes are introduced by man's tinkering with nature. As women undergo fertility treatments with increasing frequency, new complications arise. One of the complications of these treatments is the ovarian hyperstimulation syndrome (OHSS). The ascites associated with this syndrome is well described in the fertility literature. However, there is a paucity of literature describing the liver test abnormalities in this syndrome. We recently encountered a young woman who underwent in vitro fertilization and presented with ascites and a moderate elevation of her transaminases. She was diagnosed with and treated for severe OHSS. Her ascites and liver test abnormalities resolved within weeks of onset. A 34 year-old woman presented with increasing abdominal girth, a 5-pound weight gain and shortness of breath over a one-week period. She had a history of asthma, endometriosis and infertility. Eight days prior to admission, she had undergone in vitro fertilization. She took only a prenatal vitamin and progesterone. She did not drink alcohol, nor use illicit drugs. She denied a family history of liver disease, abdominal malignancies and other complaints. The only positive findings on her examination were: decreased breath sounds and dullness to percussion in the bases of the lungs and a moderately distended abdomen with a protruding umbilicus. Her CBC showed a WBC of 12.8, Hb of 16.4 and Hct of 47. The platelet count, MCV, basic metabolic panel and coagulation studies were all within normal limits. Liver function tests showed a low albumin of 2.9, but were otherwise normal. The patient was diagnosed with severe OHSS and admitted to the gynecology service of our institution. She had an ultrasound of the chest, abdomen and pelvis, which confirmed pleural effusions, ascites and enlarged ovaries. On the fourth hospital day, her transaminases started to rise (maximum elevation of 7–8x normal). An acute viral hepatitis panel and other markers of liver disease were negative. Her symptoms resolved with paracentesis and sodium restriction. She was discharged home on the seventh hospital day. Her transaminases normalized 28 days after admission. OHSS is a rare cause of ascites and abnormal liver tests. Liver function test abnormalities accompany this syndrome in 30% of cases. The mechanism for liver abnormalities is not yet known. Gastroenterologists should be aware of OHSS as a cause of ascites and abnormal liver tests with potentially lethal consequences in its most severe form.