SAT-399 - Hyperthyroidism in Molar Pregnancy: A Case with Surveillance for Thyroid Storm

Background: Gestational trophoblastic disease is a well-recognized but infrequent cause of hyperthyroidism. Recognition of thyroid dysfunction is critical, particularly when surgical uterine evacuation is planned, as uncontrolled hyperthyroidism increases the risk of perioperative thyroid storm. This case demonstrates the appropriate endocrine evaluation and perioperative management in this setting.

Clinical

Case: A 33-year-old female presented for planned dilation and curettage (D&C) after evaluation for first trimester bleeding revealed ultrasound with no evidence of intrauterine pregnancy and multiple small cystic appearing areas concerning for molar pregnancy. Initial labs consistent with hyperthyroidism and molar pregnancy: β-hCG 1,584,613 mIU/mL (≤ 4 mIU/mL), TSH 0.010 µIU/mL (0.350-4.940 µIU/mL), free T3 8.24 pg/mL (1.58-3.91 pg/mL), and free T4 2.0 ng/dL (0.7-1.5 ng/dL). Etiology of hyperthyroidism suspected to be secondary to elevated levels of β-hCG stimulating the TSH receptor. She denied any personal history of thyroid disease and reported mild insomnia, no palpitations, tremor, or weight loss. Physical examination also did not reveal signs suggestive of Grave’s disease or multinodular goiter. Her Burch-Wartofsky score was 0. Although hyperthyroidism can resolve with surgical evacuation of the uterus, there is high risk for severe complications such as thyroid storm-induced multi-organ failure, ARDS, and pulmonary hypertension (1). Given her untreated hyperthyroidism and planned surgical intervention, treatment was promptly initiated to reduce these risks perioperatively as follows: propylthiouracil 200 mg every 4 hours, potassium iodide 195 mg oral solution every 6 hours (1st dose given 1 hour after propylthiouracil), propranolol 20 mg every 6 hours, and hydrocortisone 100 mg IV every 8 hours. Patient subsequently underwent uncomplicated D&C, medications were weaned off within three days and she was deemed stable for discharge. She had follow up 1 week later which revealed that her thyroid levels had normalized.

Conclusion: This case represents the importance of routine thyroid function testing in patients with molar pregnancy, even in the absence of overt symptoms. Early recognition and aggressive management of hyperthyroidism are essential to mitigate the risk of perioperative thyroid storm and its potentially life-threatening complications.

Reference: (1) Pereira JV, Lim T. Hyperthyroidism in gestational trophoblastic disease - a literature review. Thyroid Res. 2021 Jan 14;14(1):1. doi: 10.1186/s13044-021-00092-3. PMID: 33446242; PMCID: PMC7807451.

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