1 day PTA: vaginal spotting, LE edema LMP 6 weeks ago. OSH Clinic: distended abdomen, (+) urine pregnancy; sent home with iron

Transcription

1 Anila Bindal, MD

2 1 day PTA: vaginal spotting, LE edema LMP 6 weeks ago OSH Clinic: distended abdomen, (+) urine pregnancy; sent home with iron UCMC ER: abdomen doubled overnight, significant vaginal bleeding, passing large clots and products of conception

3 PMH: Normal vaginal delivery 9 months ago PSH none FH: Brother, maternal aunt: heart disease No known thyroid disease PTA Meds: None NKDA SH: Non-smoker, no alcohol, no illicits Lives with mother and son

4 Constitutional: +slight weight gain; denies fevers, chills CV: +palpitations; denies CP PULM: +SOB ABD: +abdominal cramping, bloating GU: +vaginal bleeding DERM: no rash EXT: +BLE edema MSK: no weakness NEURO: no AMS, no tremor PSYCH: +agitation; denies depression

5 T: 36.5 HR: 148 BP: 130/94 RR: 28 SpO2: 100% (2L) Weight: 56.7kg BMI: 23.6 GEN: mild distress, awake HEENT: conjunctival pallor, slight proptosis, MMM, nontender neck, no palpable thyroid nodules, no thyroid bruit CV: tachycardic, regular rhythm, no murmur PULM: CTA B ABD: soft, distended, TTP diffusely, hyperpigmented vertical stripe on abdomen EXT: 2+ nonpitting BLE edema, no cyanosis/clubbing DERM: no rashes, no bruising NEURO: A&Ox 4, CN grossly intact, strength 5/5 in all ext, no tremor

6 β-hcg: 1,332,

7 Received 4L NS, 2U PRBC s (O neg) Taken to OR for D&C of suspected molar pregnancy In OR, received 1 additional unit PRBC s Shortly after procedure, unable to extubate, required high PEEP and FIO2 Hypotensive after D&C MICU TSH: 0.01 Free T4: 2.57 Total T4: 13.2 T3: 351

8 Thyroid Storm? Meets multiple criteria Unreliable criteria as these may be due to underlying etiologies: severe anemia, TRALI, volume overload, molar pregnancy

9 Thyroid US Diffusely enlarged, heterogeneous thyroid gland with increased vascularity,?consistent with thyroiditis

10 β-hcg mediated thyrotoxicosis Molecular mimicry between hcg and TSH hcg has an α subunit identical to TSH and β subunit that is unique (though still 40% similar) hcg binds to TSH receptors and acts like a weak form of TSH to stimulate thyroid hormone production and release Potency of hcg for TSH receptor is 4000x less

11 Trophoblastic tumors have very high hcg concentrations >>> pregnancy, typically sustained for weeks Trophoblastic tumors secrete less estrogen than normal placental tissue increase in serum TBG concentration is less in molar pregnancy than normal pregnancy Complete moles have highest incidence Trophoblastic tumors have higher serum T4/T3 ratios than Graves Thyroid RAI uptake is greatly increased Prevalence 25-64% of all molar pregnancies (but only 5% symptomatic)

12 Expect hcg to remain elevated for several weeks-months as stimulus for thyroid hormone despite removing molar pregnancy

13 Walkington, L et al. Br J Cancer. 104(11): May 2011.

14 Highest hcg at weeks gestation As high as 300,000 but typically not sustained At the time of peak hcg levels in normal pregnancy, serum TSH levels fall and bear a mirror image to hcg peak Hershman, JM. Best Pract Res Clin Endocrinol Metab. 18(2): Jun 2004

15 Thyrotoxic effect is more dramatic in multiple gestation due to higher and more sustained peak of hcg in twins Association between hyperthyroidism and hyperemesis gravidarum (< 22 weeks)

16 Moderate - Severe thyrotoxicosis PTU 300mg PO q8h Hydrocortisone 100mg IV q8h Hold βb due to CHF symptoms;?esmolol gtt Tachycardia improved

17 Cortisol WNL Hydrocortisone weaned Respiratory failure due to ARDS/TRALI CT-PE neg Bronch WNL Extubated day 4 Weaned off pressors +Rhinovirus AKI

18 Pathology: complete hydatidiform mole TTE: R heart strain, LVEF 42% Diuresed aggressively Repeat TTE Day 3: LVEF 59%, nml RV function Started on MTX

19 8/31 9/1 9/2 9/3 9/5 9/7 TSH < Free T T T B-hCG 1,332, , ,776 60,765 33,846 PTU 300mg q8h TSI neg Thyroglobulin Ab neg TPO Ab neg MMI 10mg bid MMI d/c d

20 TFT s continuing to downtrend Is this due to Nonthyroidal illness with lag of TSH recovery RT3 225 Transient hypothyroid phase after concurrent thyroiditis with lag in TSH recovery Transient central hypothyroidism related to sudden removal of hcg stimulus of thyroid and lag in recovery of TSH Sheehan Syndrome or lymphocytic hypophysitis? Cortisol 26.5, Prolactin 61.67

21 Suspect that thyroid hormones would normalize once able to receive the stimulus from TSH Started on levothyroxine 50mcg

22 9/7/14 9/9/14 9/22/14 10/21/14 TSH Free T T T Levothyroxine 50mcg

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