O&G: Molar pregnancy with hyperthyroidism

Actually I wrote about this case when I was on my flight back to Sibu from Penang, but I did not save it so everything just gone when I touched down at Sibu Airport.

Nevertheless this is still an interesting case so I rewrite everything to share with you guys.

This case is a 20+ years old lady, G3P1+1A upon admitted in March, LMP on mid December, presented with prolonged PV bleed since January and fever on the day of admission. Patient noted to have passed out some POC-like structure prior to admission, and from scan we noted thickened ET, so the provisional diagnosis in PAC was incomplete or maybe septic miscarriage. The initial HCG level taken is around 1500k, which is insanely high.

But interestingly, patient also found to have enlarged thyroid swelling and tachycardia during her admission. Therefore we referred medical team to rule out thyroid storm. But medical team didn't seem to think she was having thyroid storm, because she still looked quite comfortable despite having fever. However she was still given Lugol's iodine, carbimazole and propranolol as a "thyroid storm prophylaxis".

At first she was just given blood transfusion due to her low Hb around 6. We planned to optimise the Hb first and for watchful observation in case the POC can be passed out spontaneously, KIV for ERPOC after the Hb is replenished and vital signs becomes stable.

During my night shift in gynae ward, she complained of passing out POC in toilet and showed me the photo, it looked like membrane or placenta-like structure. I immediately informed my on-call MO for scan, but noted that the ET still thick despite passing out POC.

Upon further questioning during the next day shift, patient reluctantly informed that she actually passed out POC for 2 times in the ward, but only informed the 2nd one. The first POC photo actually showed some vesicles in the POC, which changed our diagnosis to molar pregnancy.

So we can relate back the high HCG and thyroid part to molar pregnancy, where molar pregnancy typically has high HCG level that can have molecular mimicry effect like TSH, which then triggers the thyroid gland activity, causing hyperthyroid symptoms like tachycardia and neck swelling which was seen on patient.

To further convinced on this diagnosis, my SP even asked for urine FEME to look for raised ketone level. This is because ketosis is suggestive of hyperemesis gravidarum in a pregnancy lady, which is also a clinical feature of molar pregnancy.

Molar pregnancy is definitely a tricky one in cases of early pregnancy bleeding, because it could be subdivided into complete molar, incomplete molar, invasive trophoblastic disease and in worst case scenario choriocarcinoma. Therefore operation was imminent for this patient. We need to get some POC samples for HPE to rule out the malignancy.

But because of the hyperthyroid symptoms that caused the vital signs to go deranged, her operation was delayed for a few times by the anaes team. By the time she was about to go operation, she was already transfused a second pint of packed cell because of her fluctuating low Hb level.

Nevertheless, the suction and curettage went well, vesicles were found during operation and sent for HPE for further investigations. But post-operatively noted patient having transient ST depression after given pitocin 5 unit for uterine contraction. And while in recovery bay, ECG again noted some T wave inversion but no chest pain or SOB complained by patient.

Cardiac enzyme sent was found to be normal. Not sure whether this new cardiac issue has any relation with the thyroid one, but the possibility is there. She was seen by medical again before discharged for her thyroid and cardiac issues. They only asked for TCA in KK with blood test for monitoring. Meanwhile gynae side planned to TCA patient weekly for beta-HCG trend and to review her HPE results once available.

For me, a molar pregnancy case is definitely a rarer one in our settings, compared to intrauterine death which I have seen about 6 to 7 cases since entering this O&G posting. But I have been involved from the diagnosis to management to the discharge of this patient, where I was able to learn something new. 

On the op day itself, this patient almost drove me crazy because I had to call up to so many people like the blood bank MO, medical side, anaes side as well as the lab SP within short time to get everything sorted well, definitely proud of myself.

Anyway I am about to leave O&G posting. But I will still continue to share about some interesting O&G cases that I had seen during my placement. So stay tuned.