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Tanaka Y, Furuya K, Sumi M, Yamashita S, Chang Y, Shikado K, Tsubouchi H, Ogita K. Multidisciplinary perioperative management in dilatation and evacuation for a giant hydatidiform mole: A case report. Case Rep Womens Health 2023; 40:e00556. [PMID: 37954516 PMCID: PMC10637891 DOI: 10.1016/j.crwh.2023.e00556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 10/23/2023] [Accepted: 10/24/2023] [Indexed: 11/14/2023] Open
Abstract
Gestational trophoblastic disease (GTD) is an abnormal pregnancy caused by the placenta, which can potentially metastasise. Suction evacuation is recommended for diagnosis and treatment, and dilatation and evacuation (D&E) is usually performed under intravenous anaesthesia due to the short operation time and minimal blood loss. We refer to the guidelines produced by the Japan Society of Obstetrics and Gynaecology (JSOG), and acknowledge that practices vary globally. However, to the best of our knowledge, there is no evidence on perioperative management and arrangements in D&E required for managing giant hydatidiform moles, such as preventing massive haemorrhage, respiratory dysfunction with a pathogenesis like ovarian hyperstimulation syndrome (OHSS), or intensive care needs. This case report describes perioperative considerations for managing a giant hydatidiform mole using D&E in a uterus enlarged to the third-trimester pregnancy size. A 28-year-old multiparous woman was clinically diagnosed with a hydatidiform mole after a spontaneous miscarriage due to abnormal genital bleeding, systemic oedema, and abdominal distention. Ultrasound and computed tomography showed a ballooning uterus with a third-trimester pregnancy size, a robust intrauterine mass, and ascites. Serum hCG levels were extremely high (>3,000,000 mIU/mL), confirming the clinical diagnosis of a hydatidiform mole. Emergency D&E was safely performed under multidisciplinary perioperative management, with careful preparation and support. This is a rare experience-based case report and valuable documentation detailing multidisciplinary perioperative management under general anaesthesia. To the best of our knowledge, this is the first report describing the considerations, details, and innovations required in the perioperative management of giant hydatidiform moles using D&E.
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Affiliation(s)
| | - Kiichiro Furuya
- Corresponding author at: Department of Obstetrics and Gynaecology, Rinku General Medical Centre, 2-23 Rinku Ourai-Kita, Izumisano, Osaka 598-8577, Japan.
| | - Masanori Sumi
- Department of Obstetrics and Gynaecology, Rinku General Medical Centre, Osaka, Japan
| | - Saya Yamashita
- Department of Obstetrics and Gynaecology, Rinku General Medical Centre, Osaka, Japan
| | - Yangsil Chang
- Department of Obstetrics and Gynaecology, Rinku General Medical Centre, Osaka, Japan
| | - Kayoko Shikado
- Department of Obstetrics and Gynaecology, Rinku General Medical Centre, Osaka, Japan
| | - Hiroaki Tsubouchi
- Department of Obstetrics and Gynaecology, Rinku General Medical Centre, Osaka, Japan
| | - Kazuhide Ogita
- Department of Obstetrics and Gynaecology, Rinku General Medical Centre, Osaka, Japan
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Winchar K, Rosenthal M, Elliott JE, Corbett C. Ovarian Hyperstimulation Syndrome Complicating Spontaneous Molar Pregnancy: A Case Report and Review of the Literature. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 44:71-74. [PMID: 34418560 DOI: 10.1016/j.jogc.2021.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 07/17/2021] [Accepted: 07/20/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ovarian hyperstimulation syndrome (OHSS) is traditionally associated with fertility treatments and results in elevated human chorionic gonadotropin (βhCG) levels and fluid shifts to extravascular compartments. Rarely, spontaneous pregnancies with significant βhCG elevations, such as molar pregnancies, can give rise to OHSS. CASE A 24-year-old woman was diagnosed as having a molar pregnancy at approximately 12 weeks gestation following spontaneous conception. Her initial βhCG was over 1 million IU/L. There was no evidence of metastatic disease. She underwent an uncomplicated dilation and curettage. Three days later, she presented with chest pain, shortness of breath, and abdominal discomfort. Massively enlarged ovaries were identified with bilateral pleural effusions requiring repeated thoracentesis. CONCLUSION This case demonstrates rare sequelae of molar pregnancy. Treatment is mainly supportive, and close observation is required to manage complications. In patients with extremely elevated βhCG levels, clinicians must remain vigilant for signs suggesting OHSS, even following evacuation of the uterus.
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Affiliation(s)
- Kelcey Winchar
- University of Manitoba College of Medicine, University of Manitoba, Winnipeg, MB; Max Rady College of Medicine, University of Manitoba, Winnipeg, MB
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Davies MJ, Fletcher TL, Cox Bauer CM. Spontaneous Ovarian Hyperstimulation Syndrome in a Partial Molar Pregnancy With Early Onset Severe Pre-eclampsia at 15 Weeks Gestation. Mil Med 2020; 185:e1836-e1839. [PMID: 32420602 DOI: 10.1093/milmed/usaa008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/03/2019] [Accepted: 01/09/2020] [Indexed: 11/13/2022] Open
Abstract
Ovarian hyperstimulation syndrome is a well-known entity in assisted reproductive technology. However, it is unusual for this entity to occur without any medications that stimulate follicle stimulating hormone. Herein, we describe a case where a partial molar pregnancy with high human chorionic gonadotropin promiscuously activated follicle stimulating hormone receptors has resulted in spontaneous ovarian hyperstimulation syndrome. There are only eight other cases documented per our literature search of ovarian hyperstimulation syndrome in molar gestations, and this is the third report in partial molar gestation. In our case, it is an unique development of severe early onset pre-eclampsia in the second trimester. Our goal is to discuss the nuances in management of this entity as well as to add the available body of research on this subject.
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Affiliation(s)
- Michael J Davies
- Department of Obstetrics and Gynecology, San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234
| | - Tara L Fletcher
- Department of Obstetrics and Gynecology, San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234
| | - Callie M Cox Bauer
- Department of Obstetrics and Gynecology, San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234
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Tsubokura H, Ikoma Y, Yokoe T, Yoshimura T, Yasuda K. Ovarian hyperstimulation syndrome following surgical removal of a complete hydatidiform mole: a case report. J Med Case Rep 2019; 13:292. [PMID: 31506106 PMCID: PMC6737631 DOI: 10.1186/s13256-019-2181-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 06/27/2019] [Indexed: 11/28/2022] Open
Abstract
Background Generally, ovarian hyperstimulation syndrome develops after superovulation caused by ovulation-inducing drugs in infertile patients. However, ovarian hyperstimulation syndrome associated with natural pregnancy is rare, and most cases of ovarian hyperstimulation syndrome have been associated with a hydatidiform mole. Case presentation We describe a case of a 16-year-old Japanese girl with a complete hydatidiform mole. The patient was referred for intensive examination and treatment of the hydatidiform mole and underwent surgical removal of the hydatidiform mole at 9 weeks, 5 days of gestation. Histopathological examination revealed a complete hydatidiform mole. The patient’s blood human chorionic gonadotropin level decreased from 980,823 IU/L to 44,815 IU/L on postoperative day 4, and it was below the cutoff level on postoperative day 64. Transvaginal ultrasonography on postoperative day 7 revealed a multilocular cyst measuring 82 × 43 mm in the right ovary and a multilocular cyst measuring 66 × 50 mm in the left ovary. Both ovarian cysts enlarged further. Magnetic resonance imaging on postoperative day 24 revealed that the right multilocular ovarian cyst had enlarged to 10 × 12 cm and that the left multilocular ovarian cyst had enlarged to 25 × 11 cm. Blood examination showed an elevated estradiol level as high as 3482 pg/ml. We diagnosed the patient with bilateral giant multilocular cysts accompanied by ovarian hyperstimulation syndrome because of the rapid increase in the size of the cysts. The patient complained of mild abdominal bloating; however, symptoms such as nausea, vomiting, dyspnea, and abdominal pain were not observed. Therefore, we chose spontaneous observation in the outpatient clinic. The cysts gradually decreased and disappeared on postoperative day 242. Conclusion Physicians should be aware that ovarian cysts can occur and can increase rapidly after abortion of a hydatidiform mole. However, the ovarian cyst can return to its original size spontaneously even if it becomes huge.
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Affiliation(s)
- Hiroaki Tsubokura
- Department of Obstetrics and Gynecology, Kansai Medical University, 2-1-1 Sinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Yohei Ikoma
- Department of Obstetrics and Gynecology, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka, 570-8507, Japan
| | - Takuya Yokoe
- Department of Obstetrics and Gynecology, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka, 570-8507, Japan
| | - Tomoo Yoshimura
- Department of Obstetrics and Gynecology, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka, 570-8507, Japan
| | - Katsuhiko Yasuda
- Department of Obstetrics and Gynecology, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka, 570-8507, Japan.
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Unusual Presentation of Hypothyroidism in a Pregnant Woman, Mimicking Gestational Trophoblastic Neoplasm. Case Rep Oncol Med 2016; 2016:3154267. [PMID: 27034864 PMCID: PMC4789410 DOI: 10.1155/2016/3154267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 01/14/2016] [Accepted: 02/01/2016] [Indexed: 11/18/2022] Open
Abstract
Hypothyroidism is a common health issue worldwide with varying clinical manifestations. We report a woman who experienced an incomplete abortion and undiagnosed hypothyroidism who was referred to the oncologist with the suspicion of metastatic gestational trophoblastic neoplasm (GTN). A 29-year-old woman with incomplete abortion was referred to an oncologist for possible GTN due to persistent active vaginal bleeding, an elevated beta human chorionic gonadotropin (hCG), abnormal cervical inspection exam, abnormal liver function tests, ovarian enlargement, ascites, and a pleural effusion. She was found to have hypothyroidism in further work-up. She was managed with thyroid hormone replacement therapy and her condition improved after 6 weeks. Complete resolution of the ovarian mass and pericardial and pleural effusion was achieved. This case describes an important experience; hypothyroidism should be considered in the differential diagnosis of any woman with an incomplete abortion presenting with an ovarian mass. Evaluation and correct diagnosis are important to prevent mismanagement.
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Ovary hyperstimulation syndrome accompanying molar pregnancy: case report and review of the literature. Arch Gynecol Obstet 2014; 290:803-6. [PMID: 24966119 DOI: 10.1007/s00404-014-3319-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 06/11/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE To describe a naturally conceived woman with ovary hyperstimulation syndrome (OHSS) accompanying molar pregnancy and review the literature on this condition. METHODS We report a 31-year-old 2 parous naturally conceived woman with OHSS accompanying partial molar pregnancy. Dilatation and evacuation (D&E) were performed at 10 weeks of gestation. The signs and symptoms of OHSS were the severest on day 8 after D&E, when hCG had already decreased. This case is reported in detail. We also review the literature. RESULTS A literature search yielded seven cases of this condition. Any type of molar pregnancy, i.e., complete, partial, or invasive, can accompany OHSS. The initial manifestation of OHSS occurred at a median of the 12th week of gestation (range 7-16), which may be later compared with OHSS caused by ovulation induction. In all cases, OHSS aggravated after D&E. CONCLUSIONS We must be aware that OHSS can occur during molar pregnancy, and can be exacerbated after D&E.
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Ovarian Hyper Stimulation Syndrome in Two Spontaneous Pregnancies. RAZAVI INTERNATIONAL JOURNAL OF MEDICINE 2014. [DOI: 10.5812/rijm.14245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Panagiotopoulou N, Byers H, Newman WG, Bhatia K. Spontaneous ovarian hyperstimulation syndrome: case report, pathophysiological classification and diagnostic algorithm. Eur J Obstet Gynecol Reprod Biol 2013; 169:143-8. [PMID: 23561021 DOI: 10.1016/j.ejogrb.2013.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Revised: 03/04/2013] [Accepted: 03/06/2013] [Indexed: 01/04/2023]
Abstract
Spontaneous ovarian hyperstimulation syndrome is an extremely rare condition that occurs in the absence of ovarian hyperstimulation treatment. It can lead to significant morbidity and mortality, and therefore early diagnosis and supportive treatment are essential. We report an affected mother and her daughter with a previously reported heterozygous activating mutation in the FSHR gene. We performed a literature review with particular regard to pathogenesis, with a view to suggesting a pathophysiological classification system and a diagnostic algorithm to assist in the management of this rare condition.
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Affiliation(s)
- Nikoletta Panagiotopoulou
- O&G Department, Burnley General Hospital, East Lancashire Hospitals NHS Trust, Casterton Avenue, Burnley, UK.
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Zhou X, Duan Z. A case of ovarian hyperstimulation syndrome following a spontaneous complete hydatidiform molar pregnancy. Gynecol Endocrinol 2012; 28:850-2. [PMID: 22587660 DOI: 10.3109/09513590.2012.683063] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION To present a rare case of ovarian hyperstimulation syndrome (OHSS) following a spontaneous complete hydatidiform molar (CHM) pregnancy. CASE A 38-year-old woman underwent vacuum curettage for a CHM pregnancy. Seven days later, she was admitted to our hospital with the symptoms of OHSS. Transvaginal ultrasonography demonstrated enlarged multicystic ovaries, marked ascites and large pleural effusions that required abdominocentesis and thoracocentesis, respectively. She was treated with intravenous fluid, exogenous colloid supplementation, prophylaxis for deep vein thrombosis, and drainage of the ascites and bilateral pleural effusions. She recovered by day 14 of admission. CONCLUSION OHSS may develop in older women who undergo treatment for CHM pregnancies. Serious complications may develop rapidly and therefore the prompt diagnosis of OHSS is very important.
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Affiliation(s)
- Xi Zhou
- Department of Obstetrics and Gynecology, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, P.R. China
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[Ovarian hyperstimulation syndrome: pathophysiology, risk factors, prevention, diagnosis and treatment]. ACTA ACUST UNITED AC 2011; 40:593-611. [PMID: 21835557 DOI: 10.1016/j.jgyn.2011.06.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 06/07/2011] [Accepted: 06/14/2011] [Indexed: 12/26/2022]
Abstract
The ovarian hyperstimulation syndrome is a major complication of ovulation induction for in vitro fertilization, with severe morbidity and possible mortality. Whereas its pathophysiology remains ill-established, the VEGF may play a key role as well as coagulation disturbances. Risk factors for severe OHSS may be related to patients characteristics or to the management of the ovarian stimulation. Two types of OHSS are usually distinguished: the early OHSS, immediately following the ovulation triggering and a later and more severe one, occurring in case of pregnancy. As no etiologic treatment is available, the therapeutic management of OHSS should focus on its related-complications. Thrombotic complications that can occur in venous or arterial vessels represent the major risk of OHSS, possibly conducting to myocardial infarction and cerebrovascular accidents. Once the OHSS is diagnosed, prevention of thrombotic accidents remains the major issue.
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