|LETTER TO THE EDITOR
|Year : 2015 | Volume
| Issue : 6 | Page : 841-842
Hydatiform mole and its anesthetic implications
Alka Chandra, Vijay Thakur, Rashmi Duggal, Sunil Pawar
Department of Anaesthesiology and Critical Care, Hindu Rao Hospital, New Delhi, India
|Date of Web Publication||19-Nov-2015|
802, South Delhi Apartment, Sector 4, Dwarka, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chandra A, Thakur V, Duggal R, Pawar S. Hydatiform mole and its anesthetic implications. Med J DY Patil Univ 2015;8:841-2
Hydatidiform mole is best regarded as a benign neoplasm of the chorion with malignant potential. In India, the prevalence is 1 in 400 pregnancies.  Anemia, hyperthyroidism, and acute cardiopulmonary distress are significant complications of complete molar pregnancy. 
A moderately built 19-year-old female with 11 weeks of complete molar pregnancy was brought to the emergency operation theater for suction and evacuation. The preoperative anesthesia assessment revealed an anxious 48 kg female with complaints of pelvic pain, excessive nausea and vomiting since 1-month, and vaginal bleeding for last 24 h. The medical and surgical history revealed no other positive findings. She was moderately pale with the pulse rate of 130 beats/min, blood pressure of 128/76 mm of Hg, respiratory rate of 20 breaths/min. Her hemoglobin level was 9.4 g%. Her thyroid function tests were markedly deranged, free T3 - 7.96 pg/ml (2-4.4), free T4 - 3.99 ng/dl (0.93-1.7), and thyroid stimulating hormone 0.010 IU (0.27-4.2). The serum beta human chorionic gonadotropin (HCG) levels were 678724 mIU/ml, which was markedly raised. An ultrasonography of abdomen showed features of complete molar pregnancy. Rest of the investigations were within normal limits.
The patient was given tablet methimazole 20 mg and tablet propranolol 20 mg 1 h before taking up the patient to the operation theater. In operation theater, standard monitoring with five lead Electrocardiogram, SpO 2 , noninvasive blood pressure, and end-tidal CO 2 were established. She was given intravenous dexamethasone 4 mg, fentanyl 100 mcg, thiopental 250 mg, and then maintained on oxygen, nitrous oxide, and sevoflurane 2%. Injection esmolol and tablet propylthiouracil were arranged and kept ready. Intraoperatively, vitals were stable throughout the procedure which lasted for 25 min. The intraoperative blood loss was approximately 250 ml which was replaced with crystalloids. She was given injection oxytocin 20 units in a slow infusion, and injection methergine 0.2 mg intravenously toward the completion of the procedure which was uneventful. She was then shifted to the high dependency unit for monitoring of vitals. After 48 h, the beta HCG levels were repeated which came down to 65,000, and the thyroid hormones also showed a downfall. She was discharged from the hospital with instructions to continue tablet methimazole and propranolol with follow-up after 1-week.
Of molar pregnancies, 80% are uncomplicated and follow an unremarkable course. However, for the remaining 20%, complication can be severe and may lead to substantial morbidity and mortality in otherwise healthy women. 
Human chorionic gonadotropin bears structural homology to pituitary thyrotropin. The extremely elevated levels of HCG in patients with molar pregnancy or other trophoblastic diseases can lead to hyperthyroidism. Plasmapheresis has been done to decrease the serum T3 and T4 concentrations for emergency evacuation.  Since there was no provision for plasmapheresis in our institute, it could not be instituted in spite of very high levels of thyroid hormones in our patient. Clinical hyperthyroidism is found in approximately 5% of women, and it is biochemical in 50% of the cases. Surgical evacuation is indicated for significant hemorrhage or eclampsia. Perioperative management in the presence of hyperthyroidism may be complicated by a thyroid storm.  The thyroid storm is associated with mortality rates of up to 30%. It may be induced by infection, surgery, iodine exposition, trauma, pregnancy, and metabolic disorders.  Acute respiratory distress syndrome has also been reported in a case of vesicular mole with secondary hyperthyroidism. 
Anemia in molar pregnancy is secondary to chronic occult per vaginal bleeding and from massive blood loss during surgery.  Severe anemia can lead to left ventricular failure and pulmonary congestion, leading to cardiopulmonary distress. 
Inadvertent fluid overload can occur in regional anaesthesia. The patient was also bleeding vaginally and hence the decision for short general anaesthesia was taken with thiopental sodium, oxygen, nitrous oxide and sevoflurane.
As anesthesiologists, we should be aware of the complications associated with molar pregnancy. Proper anesthesia work up, optimization of the patient, and preparedness to deal with its complications can lead to successful management thus preventing the morbidity and mortality.
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