Transient Thyrotoxicosis in Molar Pregnancy

Abstract

A 20-year-old nulliparous woman, married since one year, presented to the outpatient department with complaints of three months of amenorrhea followed by increased bleeding per vagina, hyperemesis and abdominal pain of one week duration. She also complained of tremors and palpitation. There was no history of abdominal distension or diarrhoea. There was no history of menstrual irregularity prior to the current episode.On examination, her pulse rate was 110 beats per minute and regular in rhythm, blood pressure was 120/78 mmHg, respiratory rate was 16 breaths per minute and oxygen saturation was 99% at room air. She was found to have conjunctival pallor and diffuse non tender enlargement of the thyroid gland. On abdominal examination, there was no palpable mass present. On per vaginal examination, the uterus was found to be bulky (about 10 weeks of gestational size), anteverted, with mild cervical motion tenderness present. Bilateral fornices were free and non tender. Urine pregnancy test was found to be positive. Transvaginal ultrasound of pelvis revealed uterus which measured 10.6x7 cm, with intrauterine gestational sac measuring 4.3 cm and presence of anechoic areas likely to be cystic, suggestive of molar pregnancy. Bilateral ovaries on ultrasound showed theca lutein cysts with the largest measuring 18 mm. Laboratory data showed β-hCG levels of 8,04,578 mIU/ ml, haemoglobin of 8.4 g/dl, peripheral smear showed microcytic hypochromic picture, TSH levels of 0.015 mIU/ml, T3 of 3.07 ng/ ml and T4 of 24.86 μg/dl. Thyroid profile was done after seeking consultation with physician for tremors and palpitation. Ultrasound of the thyroid gland showed diffuse enlargement of the gland without nodularity and Technetium-99m scan of thyroid was done which was found to be normal. Electrocardiogram showed sinus tachycardia and 2D-ECHO was normal.She was subsequently admitted and transfused 2 units of packed red blood cells and was started on propranolol (60 mg/day). An ultrasound guided suction evacuation of products of conception was done under general anaesthesia three days following admission. Histopathology report of specimen confirmed diagnosis of hydatidiform mole [Table/ Fig-1]. A repeat ultrasound scan done following evacuation showed retained products of conception and laboratory data showed β-hCG of 89,677 mIU/ml, TSH of 0. AbSTRACTMolar pregnancy is one of the components of a broader spectrum of diseases known as Gestational Trophoblastic Disease (GTD), presenting with amenorrhoea and irregular bleeding which may be rarely associated with passage of vesicles per vagina. However, it can rarely be associated with hyperthyroidism, which may be associated with clinical features of hyperthyroidism. The following is a report of a 20-year-old woman who presented with amenorrhea followed by irregular bleeding per vagina, thyromegaly and abnormal levels of thyroid hormones. Transvaginal ultrasound revealed features consistent with molar pregnancy. A suction evacuation was done following which serum levels of β-hCG reduced ...

Biochemical Derangement in Twin Pregnancy: Complete Hydatidiform Mole and Viable Foetus

“…Hyperthyroidism occurred in the patient as extremely high level hCG had thyrotrophic activity because of structural similarity to thyroid stimulating hormone (TSH) (Swaminathan et al 2017). A hCG level greater than 200,000 mIU/ml has been found to suppress TSH (Virmani et al 2017). In our patient, the hCG level was >225000 mIU/ml and it explained the symptomatic hyperthyroidism in the patient.…”

Delivery of Euthyroid Baby following Hyperthyroidism in Twin Gestation with Coexisting Complete Hydatidiform Mole

“…Gestational trophoblastic disease (GTD) is defined as a spectrum of proliferative disorders of trophoblastic cells and includes benign nonneoplastic placental site trophoblastic tumor, HM (complete or partial), gestational trophoblastic neoplasia, and choriocarcinoma [2]. HM is the most common form of GTD and results from errors of fertilization.…”

“…HM is the most common form of GTD and results from errors of fertilization. It can be classified into complete or partial mole on the basis of karyotype, gross morphology of the specimen, histopathologic features, and clinical features [2]. Extreme maternal age (≤15 and >35 years) and previous history of molar pregnancy are considered to be risk factors [3].…”

“…Hyperthyroidism as a complication of HM was first described in 1955 [2]. e prevalence of biochemical hyperthyroidism with HM is relatively common and varies from 25 to 64% with 5% having clinical hyperthyroidism [10].…”

“…Clinically evident hyperthyroidism can manifest with weight loss, heat intolerance, palpitation, tremors, and diaphoresis with severity of symptoms being directly proportional to hCG levels [12]. In patients with uncontrolled hyperthyroidism, surgery and anesthesia may precipitate thyroid storm resulting in increased perioperative mortality [2].…”