Authors: Glaser R et al.
Cureus, 18(1): e101614, January 2026 DOI: 10.7759/cureus.101614
Summary
This case report covers anesthetic decision-making for uterine evacuation in a 20-year-old primigravida (16 weeks) with a complete hydatidiform mole complicated by extreme β-hCG elevation, biochemical thyrotoxicosis (suppressed TSH with elevated free T4), and frequent ventricular ectopy (PVC bigeminy). The key clinical point is that she was clinically euthyroid (no tachycardia, tremor, heart failure, or hyperthermia) with preserved ventricular function on echocardiography, despite abnormal thyroid labs and frequent PVCs.
The authors frame the common tension in technique selection: GA provides airway control and rapid escalation capacity if hemorrhage becomes severe, but laryngoscopy/intubation and induction can provoke sympathetic surges that are undesirable with thyrotoxic physiology and ventricular ectopy. Neuraxial anesthesia avoids airway manipulation and volatile-related uterine relaxation, potentially reduces adrenergic stimulation, and may allow earlier recognition of cardiopulmonary deterioration or thyroid storm—at the cost of sympathectomy-related hypotension that must be managed aggressively and in a way that does not provoke tachycardia.
Their solution was spinal anesthesia after structured risk assessment and a clear plan for rapid conversion to GA if needed. They emphasize proactive hemodynamic control: they used a phenylephrine infusion to blunt spinal-induced hypotension while minimizing heart-rate acceleration (a central concern given PVC bigeminy and the catecholamine sensitivity associated with thyrotoxicosis). In their described case, the patient remained hemodynamically stable, the arrhythmia did not escalate intraoperatively, estimated blood loss was modest, and no clinical signs of thyroid storm occurred. Postoperative management included close monitoring and standard GTD follow-up planning (serial β-hCG surveillance).
Bottom line: in carefully selected molar pregnancy patients who are clinically stable (even if “biochemically” thyrotoxic) and who have preserved cardiac function, spinal anesthesia can be a safe alternative to GA when paired with invasive-level vigilance, immediate readiness to convert, blood availability, and a vasopressor strategy designed to preserve blood pressure without driving tachycardia.
Key Points
• Complete molar pregnancy can produce biochemical thyrotoxicosis via β-hCG cross-activation of TSH receptors
• Technique choice is physiology-driven: GA favors airway/hemorrhage control but risks sympathetic stimulation and arrhythmia provocation
• Spinal anesthesia avoids airway manipulation and may blunt catecholamine surges, but sympathectomy hypotension must be anticipated
• Phenylephrine is a logical first-choice vasopressor when tachycardia/ectopy is a concern
• “Biochemical thyrotoxicosis” without clinical hyperthyroid signs can still require high-alert perioperative planning
What You Should Know
If you’re considering neuraxial anesthesia for molar evacuation with abnormal thyroid labs, the go/no-go hinges on the patient’s clinical thyroid status and cardiovascular reserve, not just the lab values. The practical move is to treat hypotension as predictable and preventable (arterial-line-level vigilance if risk is meaningful, early vasopressor infusion, avoid tachycardia-promoting pressors), while maintaining a low threshold and a rehearsed plan to convert to GA if bleeding accelerates, respiratory status changes, or arrhythmias worsen.
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