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However, intravenous fluids have a role where the patient is unable to drink, or for initial rehydration when the patient presents with severe haemoconcentration. Initial fluid replacement is usually with crystalloids. Initial crystalloid rehydration not followed by improvement in haemoconcentration (haematocrit >45%) or persistent oliguria (urine output Ergoloid poor despite adequate fluid replacement (as judged by invasive hemodynamic monitoring such as central venous pressure measurements) and paracentesis. Paracentesis should be considered in patients with respiratory embarrassment due to abdominal distension and in those who remain oliguric despite adequate rehydration, which occurs due to a reduction of renal preload. This should be done under ultrasound guidance to avoid injury to the enlarged ovaries. There is some evidence that paracentesis shortens the course of the disease and there may be a role for this in patients with a prolonged course of OHSS.[19] Rarely, pleural effusions causing respiratory compromise unresolved by ascitic tap may need to be drained separately. Thrombosis is a serious complication of OHSS with a AMPK inhibitor reported incidence of 0.7�C10%. A recent review suggested that arterial thrombosis usually occurs with the clinical manifestation of OHSS while venous thrombosis may occur weeks after apparent resolution of symptoms.[20] Thromboembolism may be a life threatening complication of severe OHSS and prophylactic measures are warranted despite the lack of clinical studies on the value of thromboprophylaxis. Venous support stockings and prophylactic low molecular weight heparin should be used in all women with severe OHSS and those who are admitted AC220 research buy to hospital or have reduced mobility. Current RCOG guidance[21] suggests consideration for continuing prophylactic heparin until the end of the first trimester of pregnancy. However, patients should be individualised and counselled depending on their risk factors and in some cases it may be reasonable to continue thromboprophylaxis for the duration of pregnancy if complicated by other thrombophilic conditions. In women who do not conceive, thromboprophylaxis is usually discontinued at the time of the withdrawal bleed. Signs and symptoms of thromboembolism demand prompt additional diagnostic measures (arterial blood gas measurements, ventilation/perfusion scan) and therapeutic anticoagulation when the diagnosis is confirmed or strongly suspected. Atypical presentations of thrombosis should be kept in mind in women with OHSS, with frequent involvement of the arterial system and upper body vessels.