Spontaneous ovarian hyperstimulation in a naturally conceived pregnancy with uncontrolled hypothyroidism

Spontaneous ovarian hyperstimulation syndrome is a rare occurrence in pregnancy. This is a case of pregnancy with spontaneous ovarian hyperstimulation syndrome, uncontrolled hypothyroidism, elevated human chorionic gonadotropin (hCG), deep vein thrombosis, and Rh isoimmunization.

An African-American woman in her mid-30s, gravida 3 para 0, with hypothyroidism presented with abdominal pain, hCG 291,206 milli-International Units/mL, thyroid stimulating hormone 41.7 milliunits/L, hematocrit 12.8%, and Anti-D titer 1:256. Pelvic ultrasonography revealed a pregnancy at 10 weeks of gestation with enlarged adnexal masses. Doppler images demonstrated a right, lower extremity, deep vein thrombosis. Conservative maternal treatment involved levothyroxine and heparin with regression of the ovaries by 22 weeks of gestation after adequate thyroid repletion. Fetal surveillance was with serial ultrasound examinations of the estimated fetal weight, amniotic fluid index, and the fetal middle cerebral artery Doppler images. Cesarean delivery of a nonhydropic 1,400-gram newborn occurred at 35 weeks of gestation. Although born prematurely, the newborn required only 2 liters of oxygen through nasal cannula initially, received only 2 blood transfusions, advanced to oral feeds quickly, had good urine output throughout the hospitalization, and had a normal hearing examination upon discharge. The bilirubin levels remained stable with some phototherapy, so exchange transfusion was not necessary.

Spontaneous ovarian hyperstimulation syndrome can occur in pregnant women with severe hypothyroidism or extremely elevated hCG and present with enlarged adnexal masses and acute abdominal pain. Accurate diagnosis and continuation of pregnancy with conservative management is a viable option, once ovarian malignancy is ruled out.