Thyroid Storm In Pregnancy
Audio File
- Describe the effects of pregnancy on the thyroid.
- Identify the signs and symptoms of thyroid storm.
- Describe the treatment for thyroid storm.
Background: We describe the multidisciplinary management of a pregnant patient with Thyrotoxicosis (Thyroid Storm), admitted at 33 weeks to our OB High Risk Unit after elevated blood pressures were found during a routine visit.
Case: Ultrasound diagnosed oligohydramnios and uterine artery notching. She had a history of chronic hypertension, and BP on admission was 150s/90s, pulse was 100s-130s. Cardiac monitoring was ordered. An EKG, CBC, electrolytes and thyroid studies were ordered. Her TSH and free T4 levels were elevated, so an endocrinology consult was ordered. Thyrotoxicosis was diagnosed and Antithyroid drugs (ATDs) were ordered.
Suddenly there were signs of altered mental status and pulmonary edema. Her systolic blood pressure rose to the 200s. Fetal tachycardia with prolonged decelerations was noted on the fetal monitor. She required IV propranolol and antihypertensives to correct her pulse and blood pressure. She had consults with a pulmonologist and a physician from Maternal Fetal Medicine. She was given betamethasone for fetal lung maturity, and a neonatology consult.
Maternal Fetal Medicine recommended delivery, because of inadequate fetal growth and thyrotoxicosis. She had a repeat C-Section to deliver a baby weighing 2637 grams, with Apgars of 3 and 7. The newborn was transferred to the Neonatal Intensive Care Unit, and a pediatric endocrinology consult was ordered. Thyroid studies done on the newborn showed hyperthyroidism, so ATDs were ordered for him as well. She wanted to breast feed, and it was determined that her medications were not contraindicated for breast feeding. She was seen by a lactation consultant.
She was discharged four days after delivery with a prescription for ATDs, an appointment with the endocrinologist, and a breast pump. Her baby was discharged from the NICU forty days after birth, with a prescription for ATDs and an appointment with the pediatric endocrinologist.
Conclusion: Thyrotoxicosis is a rare complication that can be life-threatening if not treated promptly. It occurs in 1% of pregnant patients with hyperthyroidism, and can end in maternal heart failure. It is diagnosed by signs and symptoms such as elevated thyroid levels, fever, tachycardia, confusion, seizures and cardiac arrhythmias. Thyroid storm is treated with antithyroid drugs such as propylthiouracil (PTU) and iodine drops to inhibit the synthesis of thyroid hormones. Hypertension is also associated with hyperthyroidism, so ruling out preeclampsia is important. A multidisciplinary team is essential to the favorable outcome of both mother and baby.
Keywords: Thyroid Storm, Thyrotoxicosis, hyperthyroidism
