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Molar pregnancy and peri-operative thyroid storm
Abstract Number: RF6BI-229
Abstract Type: Case Report Case Series
A 34 yo G3P1011 at 16+4 weeks pregnancy with a history significant for a PDA closure as an infant and previous C-section presented with contractions and heavy vaginal bleeding at an OSH. Prior to transfer, labs were notable for a HCT of 28 and B-HCG of ~1,000,000 mIU/ml. Molar pregnancy was suspected and patient was transferred for further treatment. During transport, the patient was tachycardic into the 120’s and hypertensive with SBP’s in the 140’s. One unit of packed red blood cells was transfused, along with 100 mcg fentanyl, 4 mg ondansetron and 1 g of acetaminophen. On arrival to the ED, labs were notable for a HCT of 22.4 and B-HCG of > 300,000 mIU/ml. Blood pressure was 142/70 with a heart rate of 112. Two large bore IV’s were placed prior to transfer to the OR for emergent dilation and evacuation.
In the operating room, standard ASA monitors were applied and a 20g arterial line was placed. Initial blood pressure was 232/126 mm Hg (MAP 155) with a heart rate of 125. For blood pressure control, general anesthesia was induced with 150 mcg of fentanyl, 1 mg midazolam, 200 mg Propofol, and 50 mg rocuronium with modified rapid sequence. Laryngoscopy with a Macintosh #3 blade revealed a grade 1 view and a 7.5 cuffed endotracheal tube was placed, end tidal CO2 was noted. Transexamic acid 1g and 2g of cefazolin were administered. Blood pressure fell to 152/74 mm Hg. General Anesthesia was maintained with sevoflurane. Two units of uncross matched packed red blood cells were given. A total of 60 mg of esmolol was administered in divided doses, achieving a heart rate of 112 and a blood pressure of 160/80 mm Hg. The patient was extubated after the procedure and transferred to the PACU in stable condition.
In the recovery area blood pressure had dropped to 133/63 without any additional medication. Labs were drawn, revealing a HCT of 20.0. An additional unit of packed red blood cells was given. Post-transfusion HCT was 22.4. There was no evidence of on-going bleeding and vital signs were stable with no vasoactive medications. The patient was stabilized in PACU and transferred to the floor. At discharge, her B-HCG had down trended to 154,900 mIU/ml. Weekly B-HCGs were drawn until this value was 0.
Molar pregnancy occurs at a rate of roughly 1 in 1,000 pregnancies, as a result of genetic error during fertilization. Classically, a “snowstorm” appearance is seen on ultrasound. The B-HCG subunit has a similar structure to TSH. Therefore, exceptionally high levels of B-HCG can produce overt thyrotoxicosis. This can lead to elevated T3 and T4, with a decreased TSH. Thyroid studies of this patient showed an elevated T4 of 24.6 ug/dl (ref 5.5-11.0 ug/dl) and a TSH of < 0.02 uIU/ml (ref 0.47-4.68 uIU/ml). Treatment for molar pregnancy is immediate evacuation of products of conception and treatment with B-blockers for sympathetic symptoms.