Transient hyperthyroidism in a woman with hydatidiform mole: a case report on unusual clinical presentation and management

Mediatris Labi; Hermina  Novida

doi:10.15562/bmj.v12i3.4762

Transient hyperthyroidism in a woman with hydatidiform mole: a case report on unusual clinical presentation and management

Mediatris Labi ,

Hermina Novida ,

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DOI: https://doi.org/10.15562/bmj.v12i3.4762 |
Published: 2023-10-19

Abstract

Background: Hydatidiform mole (HM) is a genetically abnormal conception involving abnormal growth of placental trophoblast. HM is sometimes accompanied by hyperthyroidism, a rare but potentially life-threatening complication requiring early detection and management. This study aimed to report a case of a woman with HM complicated by transient hyperthyroidism, as well as to analyze some possible pharmacological management before the evacuation of molar tissue.

Case Presentation: A 45-year-old female was referred to Dr. Soetomo Hospital Surabaya with a chief complaint of vaginal bleeding, accompanied by nausea, vomiting, frequent heart palpitations, and hand tremors. The patient had been previously diagnosed with molar pregnancy but refused to undergo curettage. At presentation, physical examination suggested incompatible uterus size with the gestational age, and the vaginal toucher indicated non-palpable ballottement. Vesicles were observed in vaginal discharge. Laboratory findings revealed elevated β-HCG, decreased thyroid stimulating hormone (TSH), and increased free thyroxine (FT4) levels. Abdominal ultrasound exhibited the presence of uterine fibroid and a honeycomb appearance. The patient was then diagnosed with molar pregnancy accompanied by hyperthyroidism; however, Burch-Warsofsky’s (BW) score (25) suggested no thyroid crisis. Before undergoing suction curettage to evacuate the hydatidiform mole, the patient received perioperative treatment for thyrotoxicosis control using methimazole, propranolol, and dexamethasone. After the surgery, hCG levels were regularly followed up until the normal range was reached.

Conclusion: Despite its rarity, hyperthyroidism might become a deadly complication in molar pregnancy. Perioperative treatment to stabilize thyroid levels is prominent to prevent a thyroid storm. Treatment choice depends on the time available for preoperative preparation, the severity of the thyrotoxicosis, and the impact of any current or previous therapies. However, β-blockers should always be used unless absolutely contraindicated. Follow-up of hCG level post-operatively is critical to identify a possible occurrence of gestational trophoblastic neoplasia (GTN).

References

Seckl MJ, Sebire NJ, Berkowitz RS. Gestational trophoblastic disease. Lancet. 2010;376(9742):717-29.
Palmer J. Advances in the epidemiology of gestational trophoblastic disease. The Journal of Reproductive Medicine. 1994;39(3):155-62.
Kurdi MS. Trophoblastic hyperthyroidism and its perioperative concerns. In: Diaz G, ed. Thyroid disorders-focus on hyperthyroidism. Valladolid: IntechOpen; 2014.
Anisodowleh N, Farahnaz K, Nasrin J, Maryam H, Elaheh B. Thyroid hormone levels and its relationship with human chorionic gonadotropin in patients with hydatidiform mole. Open Journal of Obstetrics and Gynecology. 2016;6(1):56-63.
Langley RW, Burch HB. Perioperative management of the thyrotoxic patient. Endocrinology and Metabolism Clinics. 2003;32(2):519-34.
Virmani S, Srinivas SB, Bhat R, Rao R, Kudva R. Transient thyrotoxicosis in molar pregnancy. Journal of Clinical and Diagnostic Research: JCDR. 2017; 11(7):QD01-06.
Samra T, Kaur R, Sharma N, Chaudhary L. Peri-operative concerns in a patient with thyroid storm secondary to molar pregnancy. Indian Journal of Anaesthesia. 2015;59(11):739-746.
Filipescu G, Solomon OA, Clim N, Milulescu A, Boiangiu AG, Mitran M. Molar pregnancy and thyroid storm-literature review. ARS Medica Tomitana. 2017; 23(3):121-5.
Pereira JV-B, Lim T. Hyperthyroidism in gestational trophoblastic disease–a literature review. Thyroid Research. 2021;14(1):1-7.
Yoshimura M, Hershman JM. Thyrotropic action of human chorionic gonadotropin. Thyroid. 1995;5(5):425-34.
Chiha M, Samarasinghe S, Kabaker AS. Thyroid storm: an updated review. Journal of Intensive Care Medicine. 2015;30(3):131-40.
RossDouglas S, BurchHenry B, CooperDavid S, Carol G, Luiza M, RivkeesScott A, et al. 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid 2016.
Walkington L, Webster J, Hancock B, Everard J, Coleman R. Hyperthyroidism and human chorionic gonadotrophin production in gestational trophoblastic disease. British Journal of Cancer. 2011;104(11):1665-9.
Hershman JM. Physiological and pathological aspects of the effect of human chorionic gonadotropin on the thyroid. Best practice & research Clinical endocrinology & metabolism. 2004;18(2):249-65.
De Leo S, Lee SY, Braverman LE. Hyperthyroidism. Lancet. 2016;388(10047): 906-18.
Nugraha GBA, Samodro P. Case study: Thyrotoxicosis on women with complete hydatidiform molar pregnancy. JKKI. 2019;2(1):292-7.
Alisaputri K, Wibisono S. Challenges in The Management of Toxic Multi Nodular Thyroid in Pregnancy who had Crisis Thyroid. Curent Internal Medicine Research and Practice Surabaya Journal. 2021;2(2):56-9.
Noor YA, Mulia EPB, Prajitno JH. Thyrotoxic heart failure: a narrative review of pathophysiology and principle management. Malaysian Journal of Medicine and Health Sciences. 2021;17(2):276-82.
Fatih RR, Novida H. Thyroid storm in a postpartum and uncontrolled graves' disease patient: the challenges of accurate and multidisciplinary disease management. Bali Medical Journal. 2023;12(1):971-5.
Shabrina A, Tjokroprawiro BA, Kurniasari N, Hidayati HB. A profile of Gestational Trophoblastic Neoplasia in a tertiary hospital in Surabaya, Indonesia. Maj Obs Gin. 2023;3(3):1-5.

[1] Seckl MJ, Sebire NJ, Berkowitz RS. Gestational trophoblastic disease. Lancet. 2010;376(9742):717-29.

[2] Palmer J. Advances in the epidemiology of gestational trophoblastic disease. The Journal of Reproductive Medicine. 1994;39(3):155-62.

[3] Kurdi MS. Trophoblastic hyperthyroidism and its perioperative concerns. In: Diaz G, ed. Thyroid disorders-focus on hyperthyroidism. Valladolid: IntechOpen; 2014.

[4] Anisodowleh N, Farahnaz K, Nasrin J, Maryam H, Elaheh B. Thyroid hormone levels and its relationship with human chorionic gonadotropin in patients with hydatidiform mole. Open Journal of Obstetrics and Gynecology. 2016;6(1):56-63.

[5] Langley RW, Burch HB. Perioperative management of the thyrotoxic patient. Endocrinology and Metabolism Clinics. 2003;32(2):519-34.

[6] Virmani S, Srinivas SB, Bhat R, Rao R, Kudva R. Transient thyrotoxicosis in molar pregnancy. Journal of Clinical and Diagnostic Research: JCDR. 2017; 11(7):QD01-06.

[7] Samra T, Kaur R, Sharma N, Chaudhary L. Peri-operative concerns in a patient with thyroid storm secondary to molar pregnancy. Indian Journal of Anaesthesia. 2015;59(11):739-746.

[8] Filipescu G, Solomon OA, Clim N, Milulescu A, Boiangiu AG, Mitran M. Molar pregnancy and thyroid storm-literature review. ARS Medica Tomitana. 2017; 23(3):121-5.

[9] Pereira JV-B, Lim T. Hyperthyroidism in gestational trophoblastic disease–a literature review. Thyroid Research. 2021;14(1):1-7.

[10] Yoshimura M, Hershman JM. Thyrotropic action of human chorionic gonadotropin. Thyroid. 1995;5(5):425-34.

[11] Chiha M, Samarasinghe S, Kabaker AS. Thyroid storm: an updated review. Journal of Intensive Care Medicine. 2015;30(3):131-40.

[12] RossDouglas S, BurchHenry B, CooperDavid S, Carol G, Luiza M, RivkeesScott A, et al. 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid 2016.

[13] Walkington L, Webster J, Hancock B, Everard J, Coleman R. Hyperthyroidism and human chorionic gonadotrophin production in gestational trophoblastic disease. British Journal of Cancer. 2011;104(11):1665-9.

[14] Hershman JM. Physiological and pathological aspects of the effect of human chorionic gonadotropin on the thyroid. Best practice & research Clinical endocrinology & metabolism. 2004;18(2):249-65.

[15] De Leo S, Lee SY, Braverman LE. Hyperthyroidism. Lancet. 2016;388(10047): 906-18.

[16] Nugraha GBA, Samodro P. Case study: Thyrotoxicosis on women with complete hydatidiform molar pregnancy. JKKI. 2019;2(1):292-7.

[17] Alisaputri K, Wibisono S. Challenges in The Management of Toxic Multi Nodular Thyroid in Pregnancy who had Crisis Thyroid. Curent Internal Medicine Research and Practice Surabaya Journal. 2021;2(2):56-9.

[18] Noor YA, Mulia EPB, Prajitno JH. Thyrotoxic heart failure: a narrative review of pathophysiology and principle management. Malaysian Journal of Medicine and Health Sciences. 2021;17(2):276-82.

[19] Fatih RR, Novida H. Thyroid storm in a postpartum and uncontrolled graves' disease patient: the challenges of accurate and multidisciplinary disease management. Bali Medical Journal. 2023;12(1):971-5.

[20] Shabrina A, Tjokroprawiro BA, Kurniasari N, Hidayati HB. A profile of Gestational Trophoblastic Neoplasia in a tertiary hospital in Surabaya, Indonesia. Maj Obs Gin. 2023;3(3):1-5.

Transient hyperthyroidism in a woman with hydatidiform mole: a case report on unusual clinical presentation and management

Abstract

References

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