|Year : 2012 | Volume
| Issue : 1 | Page : 31-33
Gestational trophoblastic disease with hyperthyroidism: Anesthetic management
Puneet Khanna, Anil Kumar, Maya Dehran
Department of Anesthesia and Intensive Care, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||4-Aug-2012|
FTA 602, AV Nagar, AIIMS, New Delhi
Source of Support: None, Conflict of Interest: None
The coexistence of hyperthyroidism with gestational trophoblastic disease is a known albeit rare clinical condition. We herein report the successful anesthetic management of such a case in our institute. There are only few case reports in literature of this association. Often, the diagnosis of hyperthyroid state is retrospective one, as it can be missed in the emergency scenario of patient requiring molar evacuation. This case report highlights the perioperative management and optimization of hyperthyroid state prior to surgical evacuation of the invasive hydatidiform mole.
Keywords: Anesthetic management, gestational trophoblastic, hyperthyroidism
|How to cite this article:|
Khanna P, Kumar A, Dehran M. Gestational trophoblastic disease with hyperthyroidism: Anesthetic management. J Obstet Anaesth Crit Care 2012;2:31-3
|How to cite this URL:|
Khanna P, Kumar A, Dehran M. Gestational trophoblastic disease with hyperthyroidism: Anesthetic management. J Obstet Anaesth Crit Care [serial online] 2012 [cited 2019 Jul 19];2:31-3. Available from: http://www.joacc.com/text.asp?2012/2/1/31/99315
| Introduction|| |
Gestational rophoblastic isease (GTD) is a term used for a group of pregnancy-related tumors. Although hyperthyroidism is a rare complication of GTD, when it is present, it can be severe and potentially life-threatening. The clinical scenario may vary from absence of symptoms to thyroid storm.
| Case Report|| |
A 44-year-old female presented to the gynecology OPD with the complaints of irregular menstrual cycle (irregular spotting) for 3 months, with heaviness in the abdomen and increased frequency of micturition for one and a half months. Her last normal menstrual period was three months ago. She was a known hypertensive for twenty years, on irregular medication. She also gave history of having thyrotoxicosis in the post partum period of previous pregnancy for which she underwent subtotal thyroidectomy in 1999. The old documents were not available; however, she was never on any medication for the same complaints and her clinical symptoms resolved after surgery.
On physical examination, she was a thin built anxious looking lady. She was afebrile, with pulse rate of 116/min, blood pressure 120/80 mmHg, and respiratory rate 20/min. Her hands were warm to touch. Thyroid enlargement was not visible and no bruit was heard. There were no tremors and no evidence of ophthalmopathy. On chest examination, normal vesicular breathe sounds were heard bilaterally and heart sounds were normal. On per abdomen examination the height of uterus was 14 weeks and per vaginum examination also showed an enlarged uterus.
Hemoglobin was 13.1 g%, TLC was 6900/mm 3 , platelet count was 2.23 lakh/mm 3 , blood urea was 36 mg/dL, serum creatinine 0.6 g/dL, serum sodium 143 mEq/L, serum potassium 5.3 mEq/L. Prothrombin time was 11.9 s versus 11.4 s control value. Liver function tests showed bilirubin of 0.6 mg/dL, SGOT was 110, SGPT was 150 and ALP was 132 mg/dL. Total protein levels were 6.3 and albumin 3.7 g/dL. Thyroid function tests revealed TSH of 0.03 (0.3-5.5), T3-221 (70-200) and T4-14 (4.5-12.5). In view of raised t3, T4 and decreased TSH levels, endocrine opinion was sought for the treatment of hyperthyroidism. Ultrasound of abdomen revealed a gravid uterus with multiple anechoic cystic spaces with vascularity within, features consistent with hydatidiform mole. There was loss of plane with myometrium at places suggestive of myometrial invasion. The other abdominal organs were normal with no evidence of metastatis. b HCG levels were increased to 8,35,300 mIU/ml. Diagnosis of hydatidiform mole with hyperthyroidism was made. She was put on Tablet neomercazole 15 mg TDS, propranolol 20 mg/BD, Lugols' Iodine 4 drops TDS and dexamethasone 2 mg 6 hourly. She was also started on chemotherapy with methotraxate on alternate days and three cycles were given. In the meantime, herb HCG levels and thyroid function test were closely monitored. She was posted for total abdominal hysterectomy with bilateral salpingo-oophorectomy, but was postponed due to persistent tachycardia, reflecting an uncontrolled hyperthyroid state. The dose and frequency of Tablet propranolol was increased to 40 mg 6 hourly. After about three weeks of chemotherapy and antithyroid treatment, her hyperthyroid state was partly optimized (T4 9.94, T3 0.014) and she was not responding to further treatment with methotrexate. Therefore it was decided to accept her for the planned procedure.
On the night before surgery, she was advised to continue antithyroid medications tablet Pantocid 40 mg with diazepam 5 mg was given the night before and on the day of surgery. Regional anesthesia technique (CSE) was explained to the patient and an informed written consent taken in view of the partially controlled hyperthyroid state.
On the day of surgery, after checking adequate fasting, in the OT routine monitoring including ECG, SpO 2 , temperature, urine output and NIBP were attached and baseline parameters noted. Combined spinal epidural block was given in L3 L4 space with 25 μg fentanyl and 10 mg 0.5 % heavy bupivacaine. When T6 level of sensory block was attained, surgery was allowed to proceed. Patient was given intravenous (IV) sedation with 1.5mg of midazolam and Fentanyl (30 + 20μg). Dexamethasone 4 mg was also given. The patient received 2000ml crystalloids intra operatively and blood loss was 200ml. Surgery lasted for 2 h and 15 min.
At the end of the procedure, she was shifted to the ICU for further management. Tablest neomercazole, propanolol, amlodipin and dexamethasone were continued whereas Lugol's iodine was stopped. Post operatively, epidural analgesia was provided with epidural morphine 3 mg diluted in 10 ml normal saline. After 24 h observation, patient was shifted to the ward. Epidural catheter was removed on the third post operative day. Thyroid function tests at this time showed signifi cant improvement, with T4 of 6.60 IU/m [Figure 1] L and TSH <0.005 [Figure 2]. Repeat b HCG levels showed drastic reduction [Figure 3]. Patient was discharged on the tenth post operative day. By this time both b HCG levels and thyroid function tests had normalized.
| Discussion|| |
The association of hyperthyroidism in molar pregnancy is a rare albeit well recognized clinical entity. There are only few case reports in literature of this association.  Often, the diagnosis of hyperthyroid state is retrospective one, as it can be missed in the emergency scenario of patients requiring molar evacuation. Even if recognized in time, the hyperthyroid state may need to be controlled over a few hours in the emergency setting. This case report highlights the perioperative management and optimization of hyperthyroid state prior to surgical evacuation of the invasive hydatidiform mole.
The thyroid hyper function in molar pregnancy is attributed to excess of human chorionic gonadotropin, which has a weak intrinsic thyroid stimulating activity and molar thyrotropin, which differs from hCG by being larger in molecular size and longer in duration of action.  Serum b human chorionic gonadotrophin (hCG) level is the most specific and sensitive marker for trophoblastic tumors. The value in our patient was 8, 53,000 IU/L (Normal is less than 10 IU/l in the non-pregnant woman). Free b subunit is present in normal pregnancy and averages less than 4% of total b hCG up to the time of hCG peak (peak level of total hCG, 100,000 IU/l after 60-80 days). Although rare, it can lead to significant morbidity if unrecognized.
Hyperthyroid state can range from asymptomatic elevations of thyroid hormones to thyroid storm. It can even be missed in case of emergency surgery, where cardiovascular manifestations may be attributed to hypovolemia. In this patient, a high index of clinical suspicion, as the resting heart rate at preanesthetic checkup was 120/min, anxious face, warm peripheries which led to the preoperative diagnosis and treatment of thyrotoxicosis. The goals of treatment are to prevent the release of T4 and inhibit its conversion to T3, to block the peripheral actions of hormones and to treat the precipitating factors.
The drugs used for treatment of this condition are thyroid hormone synthesis inhibitors, such as propylthiouracil and methimazole, Lugols iodine and b adrenergic blockers. Steroids are also started to prevent peripheral conversion of T4 to T3. This patient was also started on propranolol for heart rate control. As she had extremely high levels of Β HCG hormone, chemotherapy with methotraxate and leucovorin was also started in order to control the thyrotoxic manifestations. Chemotherapy directed against the tumor has been seen to control the symptoms of acute hypermetabolism. It is also well documented that the biochemical markers of choriocarcinoma and of thyroid function parallel the regression of tumor.  After three weeks of chemotherapy, patient's hyperthyroid state was controlled partially and the CVS manifestations were also controlled significantly.
Clinical hyperthyroidism due to trophoblastic disease is cured by surgical evacuation of molar tissue. However, the preoperative management of these patients presents multitude of challenges for the anesthesiologists. High output cardiac failure (secondary to thyrotoxicosis), thyroid storm, hypertension, embolisation of pulmonary arteries by trophoblastic materials, hypovolemia, disseminated intravascular coagulation, and pulmonary edema (secondary to severe anemia) are some of them. ,
In literature both general and regional anesthesia have been described for the management of molar evacuation. ,, In actively bleeding, hypotensive patients general anesthesia has to be used to facilitate evacuation. However, uterine relaxation may increase blood loss and inhaled anesthetics with known tocolytic effect such as halothane, enflurane and isoflurane should therefore only be used in low concentrations.
We decided to use regional anesthesia in this case as it was appropriate for laparotomy with total abdominal hysterectomy and bilateral salpingo oophorectomy, has no tocolytic effect, afforded minimal inteference with the patients cardiovascular status and provided excellent post operative pain relief after surgery.
Intraoperative period was uneventful and no manifestations of thyroid storm were noted. Postoperatively patient was shifted to the intensive care unit as these patients need close monitoring with rapid diagnosis and treatment of thyroid storm. , Thus the perioperative preparation was successful in preventing any complications in this patient.
To conclude, a high index of suspicion for hyperthyroidism must be kept in mind with gestational trophoblastic disease, to diagnose and manage hyperthyroidism. Preoperative optimization with antithyroid and chemotherapeutic drugs are imperative to reduce perioperative morbidity. Combined spinal epidural technique using local anesthetics with opioid provides excellent conditions for lower abdominal surgery.
The hyperthyroid state rapidly resolves after surgical evacuation of hydatidiform mole.
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[Figure 1], [Figure 2], [Figure 3]