Anesthetic management of a parturient with fetal sacrococcygeal teratoma and mirror syndrome complicated by elevated hCG and subsequent hyperthyroidism

HUMAN CHORIONIC GONADOTROPIN (hCG) is part of the family of glycoprotein hormones, which have a common alpha-subunit and a unique beta-subunit. This family includes thyroid stimulating hormone (TSH). As a result, hCG has weak thyroid-stimulating activity [1]. In normal pregnancy, serum hCG concentrations rise soon after implantation and peak at 10 to 12 weeks of gestation, after which they decline. During the period of highest serum hCG concentrations, serum free triiodothyronine (fT3) and free thyroxine (fT4) concentrations increase, usually within the normal range, and serum TSH concentrations are correspondingly reduced. Transient subclinical hyperthyroidism occurs in 10% to 20% of normal pregnant women during the period of highest serum hCG concentrations; these women do not require treatment [2].Change of maternal thyroid function in twin-twin transfusion syndrome Masachi Hanaoka 1), 2) , Naoko Arata 2) and Haruhiko Sago Abstract. Human chorionic gonadotropin (hCG) has weak thyroid-stimulating activity because of its homology with thyroid stimulating hormone (TSH). In twin-twin transfusion syndrome (TTTS), which is a severe complication of monochorionic twin pregnancies, a close association between maternal serum hCG concentration and TTTS has been reported. And, TTTS can be treated by fetoscopic laser coagulation of the communicating vessels. To clarify the relationship between maternal serum hCG and maternal thyroid function in TTTS, the present study investigated the change in thyroid hormone and hCG levels after laser therapy. The protocol included collection of serial maternal blood samples in TTTS before laser therapy, and at two and four weeks after laser therapy. For 131 cases of TTTS, the following parameters were determined at each point: hCG, TSH, free triiodothyronine (fT3), and free thyroxine (fT4). The multiple of the median (MoM) of pre-operative hCG concentration in TTTS was 5.39 MoM (interquartile range, 2.83 -8.64). There was a moderate positive correlation between hCG and fT3 in TTTS pre-operatively (R = 0.22, P = 0.030). fT4 was also positively correlated with hCG (R = 0.33, P < 0.001). Some cases showed very high concentration in fT3. When laser therapy for TTTS was effective, the hCG concentration significantly decreased, and fT3 and fT4 decreased progressively in concert with the decrease in hCG. The relationship between hCG and thyroid function in TTTS supports the finding of TTTS as a novel etiology of hCG-mediated hyperthyroidism during pregnancy.Key words: Pregnancy, Human chorionic gonadotropin (hCG), Twin-twin transfusion syndrome (TTTS), Hyperthyroidism, Laser thearpyTwin-twin transfusion syndrome (TTTS) accounts for approximately 10% of monochorionic twin pregnancies. If left untreated, TTTS is associated with a high fetal morbidity and mortality rate [3]. A net transfusion of blood flow from one fetus (donor twin) to the other (recipient twin) via placental vascular anastomoses has been proposed as the major etiology of TTTS [4,5]. The donor twin becomes hypovolemic and oli...

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“…And two case reports have shown similar hCGmediated hyperthyroidism due to fetal abnormalities secondary to mirror syndrome [19,20].…”

Section: Methodsmentioning

confidence: 92%

Change of maternal thyroid function in twin-twin transfusion syndrome

2015

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“…L'identification de ce syndrome est essentielle puisque la prise en charge de la grossesse en cours ainsi que des grossesses ultérieures en dépend ; le syndrome miroir semble sous-diagnostiqué et le diagnostic de prééclamp-sie est souvent retenu. Le diagnostic différentiel repose sur la présence d'une hémodilution contrastant avec l'hémoconcentration retrouvée dans les prééclampsies, les plaquettes sont stables et l'anémie est non hémolytique [5] permettant de distinguer le syndrome de Ballantyne d'un HELLP syndrome en particulier lorsqu'il existe une cytolyse hépatique [3]. Contrairement à la prééclampsie où la symptomatologie persiste tant que l'unité foetoplacentaire est en place, le syndrome miroir va régresser s'il existe une résolution de l'hydrops [1,4].…”

Section: Discussionunclassified

“…Cependant, si l'anasarque foetoplacentaire régresse suite au traitement de l'anémie, la symptomatologie maternelle peut disparaître et permettre la poursuite de la grossesse comme le prouve notre second cas. La prise en charge est fonction de la gravité des symptômes [9] cardiopathie congénitale [8] hydrothorax [2] ascite urinaire [3] tératome péricardique [2] tachycardie supraventriculaire foetale [4] …”

Section: Discussionunclassified

“…Complications OAP, pleurésie [5] Défaillance cardiaque avec cardiomégalie [3] Crises convulsives [6] Cardiomyopathie du péripartum [7] Insuffisance rénale aiguë [ Le traitement optimal, lorsque l'état maternel l'autorise, est la transfusion in utero. Il s'agit d'un geste invasif dont l'indication doit être pesée en fonction du degré estimé d'anémie foetale.…”

Section: Complicationsunclassified

“…Ont été décrits dans ce contexte : photocoagulation laser pour les syndromes transfuseur-transfusé ou foeticide sélectif dans les situations inaccessibles à la photocoagulation, drainage pleuro-ou péritonéo-amniotique dans les épan-chements compressifs, traitement antiarythmique des troubles du rythme cardiaque foetal [4] et même dilatation valvulaire lors d'une sténose de la valve aortique [2,3].…”

Section: Complicationsunclassified

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Fetal laser therapy: applications in the management of fetal pathologies

2015

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Fetoscopic coagulation of placental anastomoses is the treatment of choice for severe twin-to-twin transfusion syndrome. In the present day, fetal laser therapy is also used to treat amniotic bands, chorioangiomas, sacrococcygeal teratomas, lower urinary tract obstructions and chest masses, all of which will be reviewed in this article. Amniotic band syndrome can cause limb amputation by impairing downstream blood flow. Large chorioangiomas (>4 cm), sacrococcygeal teratomas or fetal hyperechoic lung lesions can lead to fetal compromise and hydrops by vascular steal phenomenon or compression. Renal damage, bladder dysfunction and lastly death because of pulmonary hypolasia may be the result of megacystis caused by a posterior urethral valve. The prognosis of these pathologies can be dismal, and therapy options are limited, which has brought fetal laser therapy to the forefront. Management options discussed here are laser release of amniotic bands, laser coagulation of the placental or fetal tumor feeding vessels and laser therapy by fetal cystoscopy. This review, largely based on case reports, does not intend to provide a level of evidence supporting laser therapy over other treatment options. Centralized evaluation by specialists using strict selection criteria and long-term follow-up of these rare cases are now needed to prove the value of endoscopic or ultrasound-guided laser therapy.

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Anesthetic management of a parturient with fetal sacrococcygeal teratoma and mirror syndrome complicated by elevated hCG and subsequent hyperthyroidism

Cited by 10 publications

References 12 publications

Change of maternal thyroid function in twin-twin transfusion syndrome

Change of maternal thyroid function in twin-twin transfusion syndrome

Syndrome de Ballantyne secondaire à une infection maternofœtale à Parvovirus B19 : à propos de deux cas

Fetal laser therapy: applications in the management of fetal pathologies

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