Keywords
partial molar pregnancy - partial hydatidiform mole - thyroid storm - gestational
trophoblastic disease - preeclampsia with severe features
Case Report
A 26-year-old woman, gravida 1 para 0 at 14 weeks' 1-day gestation (based on her last
menstrual period and confirmed by an 8-week, 1-day ultrasound), presented to a community
hospital emergency department with new-onset vaginal spotting. She had been experiencing
intermittent heart palpitations, shortness of breath, night sweats, hot flashes, nausea,
and vomiting for 2 weeks. Her medical, surgical, and family history were unremarkable.
She was taking only a prenatal vitamin, had no known allergies, and denied the use
of tobacco, alcohol, or illicit drugs. She had received regular prenatal care, including
a normal first-trimester ultrasound.
On arrival at the outside hospital, her vital signs were as follows: heart rate = 170s
beats/min, blood pressure = 146/63 mm Hg, respiratory rate = 18 breaths/min, temperature = 36.8°C,
SpO2 = 99% on room air. Initial notable laboratory values were beta-human chorionic
gonadotropin (β-hCG) = 2,442,400 mIU/mL, thyroid stimulating hormone < 0.02 mIU/mL,
T4 >24.9 ug/dL, hemoglobin (Hgb) = 9.8 g/dL. Other notable laboratory values included
new-onset proteinuria with a urine protein–creatinine ratio of 0.34.
A transvaginal ultrasound revealed a gestational sac with a fetal pole measuring 80 mm
(14w0d), a fetal heart rate of 137 beats/min, posterior placenta with echogenicity
suggesting a snowstorm appearance, most consistent with partial molar pregnancy ([Fig. 1]). Theca lutein cysts were also noted bilaterally on full surveillance of the pelvis
([Fig. 2]).
Fig. 1 Transvaginal ultrasound of partial hydatidiform mole with classic “snowstorm” appearance.
Fig. 2 Transvaginal ultrasound of theca lutein cysts within ovary at the time of partial
hydatidiform mole diagnosis.
The patient was diagnosed with suspected partial molar pregnancy complicated by thyroid
storm and hypertensive emergency.[4]
[5]
[6]
[7] She was transferred to a tertiary care center for management. She was given propranolol
for heart rate control prior to transport.
The patient received care from a multidisciplinary team, including obstetrics and
gynecology, maternal–fetal medicine, critical care, endocrinology, and gynecologic
oncology specialists. Her notable vital signs on arrival were a heart rate of 110
beats/min and blood pressure of 155/82 mm Hg. Her case was immediately discussed with
maternal–fetal medicine and the critical care team. She was placed on continuous telemetry
and pulse oximetry monitoring and initially had hourly blood pressure monitoring.
A chest X-ray demonstrated no acute findings ([Fig. 3]). Her electrocardiogram revealed sinus tachycardia and an echocardiogram showed
a normal ejection fraction, mild-to-moderate mitral regurgitation, and probable patent
foramen ovale.
Fig. 3 Negative chest X-ray at the time of partial hydatidiform mole diagnosis.
The patient had multiple sustained severe-range blood pressures with a high suspicion
for superimposed preeclampsia with severe features. She was started on intravenous
(IV) magnesium for seizure prophylaxis. Her blood pressures were initially treated
with IV antihypertensive agents followed by long-acting oral agents, including labetalol
and nifedipine XL, which were slowly titrated up throughout her hospital stay. For
the management of thyroid storm, she was started on propylthiouracil (PTU) 1,000 mg
orally followed by 200 mg orally every 6 hours, hydrocortisone 100 mg IV every 8 hours
for three doses, and potassium iodide 0.25 mL orally every 8 hours (2 hours following
PTU).
Given the partial molar pregnancy, thyroid storm, and concern for preeclampsia with
severe features, the decision was made to proceed with medical termination with dilation
and evacuation due to the high risk of maternal morbidity and mortality.[4] Preoperative preparation for surgery included laminaria placement the night before
and preparation for possible postpartum hemorrhage during the procedure.
Dilation and evacuation under ultrasound guidance were performed. She received 200 mg
orally doxycycline for surgical prophylaxis. Her quantitative blood loss was 1,200 mL.
She received TXA 1 g IV, misoprostol 1,000 µg rectally, and 2 units of packed red
blood cells intraoperatively. Otherwise, the procedure was uncomplicated. Her Hgb
remained stable at 8.7 g/dL and higher for the remainder of her admission. She was
transferred to the SICU following the procedure for close monitoring. Endocrinology
and gynecologic oncology were consulted.
She was continued on PTU 200 mg orally every 4 hours and hydrocortisone 100 mg IV
every 8 hours for thyroid storm management along with labetalol 300 mg orally every
8 hours and nifedipine XL 30 mg orally every 12 hours for blood pressure management.
Due to persistently elevated blood pressures, oral antihypertensive agents were titrated
accordingly. Magnesium sulfate was discontinued after 24 hours.
On postoperative day 1, the patient's laboratories was downtrending appropriately
([Fig. 4]). IV hydrocortisone and orally PTU were discontinued and she was started on methimazole
15 mg daily. The patient was discharged on POD 3 once her tachycardia had resolved,
blood pressures were < 150/< 100 mm Hg, and she was meeting all other postoperative
milestones. She was discharged on methimazole 15 mg orally daily, labetalol 600 mg
orally every 8 hours, and nifedipine XL 30 mg orally every 12 hours. Repeat β-hCG
laboratories were being trended weekly until undetectable, then monthly for 6 months
to monitor for progression to gestational trophoblastic neoplasia.[9] The pathology returned in 1 week and demonstrated hydropic villi tissue mixed with
chorionic villi, decidua, and male fetus, consistent with partial hydatidiform mole.
The patient received a Nexplanon for reliable contraception at her postoperative visit.
Fig. 4 Trend of β-hCG and TSH profile before and after management of partial hydatidiform
mole. β-hCG, beta human chorionic gonadotropin; TSH, thyroid stimulating hormone.
Conclusion
This case highlights the complexity of a partial molar pregnancy and its rare, potentially
fatal complications, including thyroid storm and superimposed preeclampsia, emphasizing
the importance of early recognition and multidisciplinary team coordination to optimize
maternal outcomes.[1] Similar to complete hydatidiform moles, partial molar pregnancies can manifest a
thyroid storm if β-hCG levels are high enough.[8] Early intervention and expertise from a multidisciplinary team at a tertiary care
center were crucial to the successful recovery of this patient. Treatment with antithyroid
medications, corticosteroids, antihypertensive agents, and expedient surgical management
was critical in optimizing outcomes.[7] Postoperative surveillance is essential, including β-hCG monitoring, effective contraception,
blood pressure control, and appropriate follow-up care with specialists.[9] The clinical management of this case is summarized in [Table 1].
Table 1
Clinical management overview
|
Clinical focus
|
Actions and intervention
|
|
Initial evaluation
|
• Vital signs: heart rate, blood pressure, temperature, respiratory rate
• Labs: β-hCG, TSH, T4, CBC, urine protein/creatinine
• Imaging: detailed anatomy ultrasound, chest X-ray
|
|
Diagnosis
|
• Partial molar pregnancy
• Thyroid storm
• Preeclampsia with severe features
|
|
Available services
|
• Transfer to a tertiary center
• Consults: ObGyn, Maternal–Fetal Medicine, SICU, Endocrinology, Gynecology Oncology
|
|
Medical management
|
Thyroid storm
• PTU 1,000 mg orally loading dose, followed by 200 mg orally q6h
• Hydrocortisone 100 mg IV q8h
• Potassium iodide 0.25 mL orally q8h (2-h post-PTU)
• Propranolol 20 mg orally as needed for tachycardia (HR > 100)
Preeclampsia
• Magnesium sulfate IV for seizure prophylaxis
• IV and orally antihypertensives: labetalol, nifedipine, and hydralazine as needed
|
|
Surgical management
|
Dilation and evacuation
Preop: laminaria, doxycycline
Intraop: TXA, misoprostol, blood products
|
|
Postoperative care
|
• SICU monitoring
• Continue antihypertensives and magnesium sulfate
• Transition from PTU to methimazole 15 mg orally daily (continue methimazole outpatient)
• Discontinue steroids
|
|
Surveillance and follow-up
|
• Weekly β-hCG until undetectable, then monthly ×6 mo
• Blood pressure monitoring
• Long-acting reversible contraception (e.g., Nexplanon)
• Close follow-up with ObGyn and endocrinology
|
Abbreviation: β-hCG, beta human chorionic gonadotropin; CBC, complete blood count;
HR, heart rate; IV, intravenous; Intraop, intraoperative; ObGyn, obstetrician–gynecologist;
Preop, preoperative; PTU, propylthiouracil; TXA, tranexamic acid; SICU, surgical intensive
care unit; TSH, thyroid stimulating hormone.
