Introduction: Molar pregnancy is more commonly seen in South East Asia, women in extreme age group and those with previous history of molar. The local incidence of molar is around 2-3 per 1,000 deliveries. Complications include thyrotoxicosis, persistent gestational trophoblastic disease (GTD), choriocarcinoma and thyroid storm. Complete moles have the highest incidence of thyrotoxicosis and predominantly affect younger women.

Case Illustration: Madam Y 42 years-old Para 8 had intermittent spotting for past 1 month.  Her abdomen is 20 weeks size with a beta human chorionic gonadotrophin level of 1.1 Million IU.  Blood pressure is on the higher side and she’s anaemic hence was transfused and planned for suction. However the operation was delayed due to social reason and uncontrolled blood pressure despite on 3 antihypertensive agents.  The thyroid gland was of normal size. She later complained of severe epigastric pain not responding to H2 blocker. Investigations showed thrombocytopenia, free T4 133, TSH 0.01 and proteinuria. Liver and renal function remains normal. Magnesium Sulphate was commenced and proceeded with surgery where 800 mls of product of conception with vesicles removed. Post evacuation, drastic clinical improvement was seen with normalisation of blood pressure without requiring any antihypertensive. Beta HCG level dropped to 1,000 iu, Free T4 to 58 and platelets increased to 115.

Discussion: GTD with thyrotoxicosis is a rare clinical scenario but it causes severe clinical consequences. Even though symptoms may not be obvious and urine pregnancy test may be negative, clinician should consider GTD as their differential diagnosis. Early diagnosis and prompt evacuation is the cornerstone of treatment to avoid complications such as massive hemorrhage, thyrotoxicosis and preeclampsia.  Thyroid storm is associated with high morbidity and mortality. Physiological changes and symptoms in early pregnancy such as nausea, vomiting, palpitation, dyspepsia and epigastric pain might mask the symptoms of impending thyroid storm secondary to a molar pregnancy. Hence clinicians need to have high index of suspicion and prompt action in managing GTD. With the availability of ultrasound machine more common in modern medicine diagnosis should not be missed and need to be confirmed histopathologically.

Conclusion: Malaysian population and also clinician should be made more aware with the complications following molar and persistent GTD. It can recur in subsequent pregnancy regardless the outcome of the pregnancy. Importance of proper follow up, monitoring and contraception should be enforced as GTD may lead to cancerous changes.