Case Report Gestational trophoblastic disease with ...

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partum period of previous pregnancy for which she underwent subtotal .... DISCUSSION. The association of hyperthyroidism in molar pregnancy is a rare.
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Case Report Gestational trophoblastic disease with hyperthyroidism: Anesthetic management Puneet Khanna, Anil Kumar, Maya Dehran

ABSTRACT

Department of Anesthesia and Intensive Care, All India Institute of Medical Sciences, New Delhi, India Address for correspondence: Mr. Puneet Khanna, FTA 602, AV Nagar, AIIMS, New Delhi, India. E-mail: [email protected]

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. Key words: Anesthetic management, gestational trophoblastic, hyperthyroidism

INTRODUCTION

G

estational trophoblastic disease (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. Access this article online Quick Response Code:

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DOI: 10.4103/2249-4472.99315

Journal of Obstetric Anaesthesia and Critical Care / Jan-Jun 2012 / Vol 2 | Issue 1

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/mm3, platelet count was 2.23 lakh/mm3, blood urea was 36 mg/dL, serum creatinine 0.6 mg/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 31

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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, SpO2, 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 1.5 mg of midazolam and Fentanyl (30 + 20 µg ). Dexamethasone 4 mg was also given. The patient received 2000ml crystalloids intra operatively and blood loss was 200 ml. 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