Journal of Anaesthesia & Critical Care Case Reports

Vol 6 | Issue 3 | September-December 2020 | Page 27-32 | Vennila Rajagopal

Author: Vennila Rajagopal [1]

[1] Department of Anaesthesia, Apollo Womens Hospital, Chennai, Tamilnadu, India.

Address of Correspondence
Dr. Vennila Rajagopal,
Consultant Anaesthesiology and HDU services, Apollo womens Hospital, Chennai, Tamilnadu, India.
E-mail: drrvennila@gmail.com

Gestational Trophoblastic Disease Spectrum: Case Report and Anaesthetic Implications

Abstract

Gestational Trophoblastic Disease (GTD) is a spectrum of tumours with abnormal placental trophoblastic proliferation. They can be benign or malignant lesions. When they invade locally or metastasise, they are called Gestational Trophoblastic Neoplasia (GTN). Clinically, women present with history of amenorrhoea, abdominal pain, mild to severe vaginal bleed with or without symptoms due to metastases. Based on the organ of metastasis, symptoms may vary from breathlessness and cough with chest involvement to lethargy, loss of memory or seizures with brain metastasis. This entity ranges from pre-malignant conditions like hydatidiform mole and partial hydatidiform mole to neoplastic invasive mole, choriocarcinoma or rare type of epitheloid trophoblastic tumour. [1,2] Undetected hyperthyroidism can complicate GTD and present with potential significant complications like cardiac failure and arrhythmias. Manifestations of the disease are attributed to excess secretion of human chorionic gonadotropin (HCG) that has thyrotrophic activity due to its structural similarity. [3,4] The incidence reported in Asian population is as high as 1:400, three times higher. In majority of cases, early diagnosis and treatment provide complete cure in GTD. In 20%, even locally invasive disease, with or without metastasis can be life threatening. [5] Surgical removal is the definitive treatment. Peri-operative anaesthetic management of patients with multiple system involvement as a result of extensive disease can be challenging, hence from anaesthetic perspective it is essential to understand the pathophysiology, clinical presentations and potential complications of molar pregnancy. We hereby report successful management of two cases presenting at different areas of the disease spectrum.
Keywords: Molar pregnancy; Choriocarcinoma; Tropoblastic disease.

References

1. Dave N, Fernandes S, Ambi U, Ayer H. Hydatidiform mole with hyperthyroidism – perioperative challenges. J Obstet Gynaecol India 2009; 59: 356-7
2. Dutta DC. Haemorrage in early pregnancy. In Hiralal Konan, editor. Textbook of Obstetrics. 6th edition. Kolkatta:New Central Book Agency;2004.p.159-202
3. Yoshimura M, Hershman JM. Thyrotropic action of human chorionic gonadotropin. Thyroid 1995; 5: 425-34.
4. Swaminathan S, James RA, Chandran R, Joshi R. Anaesthetic implications of severe hyperthyroidism secondary to molar pregnancy: A case report and review of literature. Anesth Essays Res 2017; 11: 1115-7
5. Lurain, JR. Gestational trophoblastic disease I: epidemiology, pathology, clinical presentation and diagnosis of gestational trophoblastic disease, and management of hydatidiform mole. American Journal of Obstetrics and Gynecology 2010; 203(6):531– 539.
6. John R Lurain Gestational trophoblastic disease II: classification and management of gestational trophoblastic neoplasia JANUARY 2011 American Journal of Obstetrics & Gynecology. Oncology Reviews. P 12-18.
7. Tidy J, Seckl M, Hancock BW, on behalf of the Royal College of Obstetricians and Gynaecologists. Management of Gestational Trophoblastic Disease. BJOG 2020;
8. Ngan, H.Y., Seckl, M.J., Berkowitz, R.S., Xiang, Y., Golfier, F., Sekharan, P.K., Lurain, J.R. and Massuger, L. (2018), Update on the diagnosis and management of gestational trophoblastic disease. Int J Gynecol Obstet, 143: 79-85.
9. Collins PW, Bell SF, de Lloyd L, Collis RE. Management of postpartum haemorrhage: from research into practice, a narrative review of the literature and the Cardiff experience. Int J Obstet Anesth. 2019 Feb; 37:106-117.
10. Khanna P, Kumar A, Dehran M, Gestational trophoblastic disease with hyperthyroidism: Anesthetic management. Journal of Obstetric Anesthesia and critical care 2012; 2:31-3
11. Seckl MJ, Sebire NJ, Berkowitz RS. Gestational trophoblastic disease. Lancet 2010; 376:717-729.
12. M J Seckl, N J Sebure, R A Fisher, F Golfeir, L Massuger, C Sessa Gestational trophoblastic disease. ESMO clinical practice guidelines. Ann Oncol 2013;0240(Suppl 6: vi39-vi50
13. Erturk E, Bistan H, Geze S, Saracoglu S, Erciyes N, Eroglu A. Total Intravenous Anaesthesia for evacuation of a hydatidiform mole and termination of pregnancy in a patient with thyrotoxicosis. Int J Obster Anaesth 2007; 16:363-6
14. Nikoletta Proudan, DO, Kersthine Andre, MD, SUN-513 Severe Hyperthyroidism in a Complete Molar Pregnancy, Journal of the Endocrine Society, Volume 4, Issue Supplement 1, April-May 2020, SUN–513,
15. Ramprasad M, Bhattacharyya SS, Bhattacharyya A. Thyroid disorders in pregnancy. Indian J Endocrinol Metab. 2012;16(Suppl 2):167–70.
16. Rajata Rajatanavin, La-Or Chailurkit, Somkeart Srisupandit, Somsak Tungtrakul, Sukhum Bunyaratvej, Trophoblastic hyperthyroidism: Clinical and biochemical features of five cases, The American Journal of Medicine,Volume 85, Issue 2,1988; 237-241,
17. Virmani S, Srinivas SB, Bhat R, Rao R, Kudva R. Transient Thyrotoxicosis in Molar Pregnancy. J Clin Diagn Res. 2017;11(7)
18. Erbil Y, Tihan D, Azezli A. Severe hyperthyroidism requiring therapeutic plasmapheresis in a patient with hydatidiform mole. Gynecol Endocrinol. 2006; 22:402
19. Kim JM, Arakawa K, McCann V. Severe hyperthyroidism associated with hydatidiform mole. Anesthesiology. 1976; 44:445–48.
20. Samra, et al.: Thyroid storm secondary to molar pregnancy Indian Journal of Anaesthesia | Vol. 59 | Issue 11 | Nov 2015 741 24–48
21. Chiniwala NU, Woolf PD, Bruno CP, Kaur S, Spector H, Yacono K. Thyroid storm caused by a partial hydatidiform mole. Thyroid 2008; 18:479 81.
22. Adali E, Yildizhan R, Kolusari A, Kurdoglu M, Turan N. The use of plasmapheresis for rapid hormonal control in severe hyperthyroidism caused by a partial molar pregnancy. Arch Gynecol Obstet. 2009; 279:569–71.
23. Tetsurou Satoh, Osamu Isozaki, Atsushi Suzuki, Shu Wakino, Tadao Iburi, Kumiko Tsuboi, Naotetsu Kanamoto , Hajime Otani, Yasushi Furukawa, Satoshi Teramukai and Takashi Akamizu. 2016 Guidelines for the management of thyroid storm from The Japan Thyroid Association and Japan Endocrine Society (First edition) Endocrine Journal 2016, 63 (12), 1025-1064
24. Azezli A, Bayraktaroglu T, Topuz S, Kalayogly-Besisk S. Hyperthyroidism in molar pregnancy: Rapid preoperative preparation by plasmapheresis and complete improvement after evacuation. Transfus Apher Sci 2007, 36:87-9
25. Celeskj D, Micho J, Walers L Anaesthetic implications of a partial molar pregnancy. and associated complications. AANA J 2001; 69:49-53
26. Wonjung Hwang, Daehwan Im, Eunsung Kim, Persistent perioperative tachycardia and hypertension diagnosed as thyroid storm induced by a hydatidiform mole. Korean Journal of anaesthesiology 67(3):205-8

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