A 33-year-old woman, gravida 0, presents to the emergency department (ED) for sudden onset of shortness of breath 1 week after in vitro fertilization (IVF). Her shortness of breath began acutely earlier in the day, but for the last few days she states she has had generalized abdominal pain associated with distension, nausea, and occasional nonbloody, nonbilious vomiting. Her pain became worse overnight, and she states that it now hurts in her abdomen when she takes a deep breath. She also cannot lie flat because it exacerbates both the pain and the difficulty breathing.

She has a known history of polycystic ovary syndrome (PCOS) and has failed to conceive for several years. Three weeks prior to presentation, controlled ovarian stimulation was performed with gonadotropins. A total of 25 embryos were retrieved. The peak estradiol during ovarian stimulation was 4638 pg/mL (17026 pmol/L). She then underwent transvaginal ultrasound-guided oocyte retrieval, followed by embryo transfer 1 week prior to presentation.

Her past medical history is otherwise unremarkable. Other than the recent hormonal therapy, her only medication has been a daily multivitamin, and she has no known drug allergies. She denies smoking or the use of drugs or alcohol.

On physical exam, the patient is awake, alert, and oriented. She appears to be in moderate distress. Her pulse is 108 bpm and her blood pressure is 110/60 mm Hg. She has rapid, shallow breathing, with a respiratory rate of 26 breaths/min. The pulse oximetry reading is 95% while she is breathing room air, but it rises to 98% on 2 L/min oxygen supplementation. She weighs 200 lb (90.7 kg). Her head and neck examinations are unremarkable and without jugular venous distension. Her pulmonary examination demonstrates egophony, bilaterally decreased breath sounds, and a loss of tactile fremitus. The heart is regular, tachycardic, and without murmurs. The abdomen is distended, but normal bowel sounds are noted. There is no palpable mass or organomegaly, but there is moderate tenderness to palpation throughout the abdomen, with a positive fluid wave. A pelvic speculum examination reveals no vaginal bleeding or discharge. The bimanual examination is deferred.

Serum blood testing performed in the ED reveals a white blood cell (WBC) count of 12.2 × 103/µL (12.2 × 109/L), hemoglobin of 16.2 g/dL (162 g/L), hematocrit of 48.7% (0.487), sodium of 130 mEq/L (130 mmol/L), potassium of 5.2 mEq/L (5.2 mmol/L), blood urea nitrogen (BUN) of 10 mg/dL (3.57 mmol/L), and a creatinine of 1 mg/dL (88.4 µmol/L). The liver function tests and the remaining chemistry profile are normal.

An abdomen-shielded chest radiograph is obtained that reveals bilateral pleural effusions (not shown).

A transvaginal ultrasound is also obtained (see Figures 1 and 2).A 33-year-old woman, gravida 0, presents to the emergency department (ED) for sudden onset of shortness of breath 1 week after in vitro fertilization (IVF). Her shortness of breath began acutely earlier in the day, but for the last few days she states she has had generalized abdominal pain associated with distension, nausea, and occasional nonbloody, nonbilious vomiting. Her pain became worse overnight, and she states that it now hurts in her abdomen when she takes a deep breath. She also cannot lie flat because it exacerbates both the pain and the difficulty breathing.

She has a known history of polycystic ovary syndrome (PCOS) and has failed to conceive for several years. Three weeks prior to presentation, controlled ovarian stimulation was performed with gonadotropins. A total of 25 embryos were retrieved. The peak estradiol during ovarian stimulation was 4638 pg/mL (17026 pmol/L). She then underwent transvaginal ultrasound-guided oocyte retrieval, followed by embryo transfer 1 week prior to presentation.

Her past medical history is otherwise unremarkable. Other than the recent hormonal therapy, her only medication has been a daily multivitamin, and she has no known drug allergies. She denies smoking or the use of drugs or alcohol.

On physical exam, the patient is awake, alert, and oriented. She appears to be in moderate distress. Her pulse is 108 bpm and her blood pressure is 110/60 mm Hg. She has rapid, shallow breathing, with a respiratory rate of 26 breaths/min. The pulse oximetry reading is 95% while she is breathing room air, but it rises to 98% on 2 L/min oxygen supplementation. She weighs 200 lb (90.7 kg). Her head and neck examinations are unremarkable and without jugular venous distension. Her pulmonary examination demonstrates egophony, bilaterally decreased breath sounds, and a loss of tactile fremitus. The heart is regular, tachycardic, and without murmurs. The abdomen is distended, but normal bowel sounds are noted. There is no palpable mass or organomegaly, but there is moderate tenderness to palpation throughout the abdomen, with a positive fluid wave. A pelvic speculum examination reveals no vaginal bleeding or discharge. The bimanual examination is deferred.

Serum blood testing performed in the ED reveals a white blood cell (WBC) count of 12.2 × 103/µL (12.2 × 109/L), hemoglobin of 16.2 g/dL (162 g/L), hematocrit of 48.7% (0.487), sodium of 130 mEq/L (130 mmol/L), potassium of 5.2 mEq/L (5.2 mmol/L), blood urea nitrogen (BUN) of 10 mg/dL (3.57 mmol/L), and a creatinine of 1 mg/dL (88.4 µmol/L). The liver function tests and the remaining chemistry profile are normal.

An abdomen-shielded chest radiograph is obtained that reveals bilateral pleural effusions (not shown).

A transvaginal ultrasound is also obtained (see Figures 1 and 2).