Hyperthyroidism secondary to Graves? or Gestational thyrotoxicosis?

A Naqvi, M Martineau, West Middlesex University Hospital.


1. Thyrotoxicosis

2. G2 P1; Currently 14 weeks pregnant

3. Hyperemesis (in both pregnancies)

Blood tests January 2015,

TSH 0.1, FT4= 49, FT3= 15.5, TPO Ig 206 & TSH Rc Ig  7.5 K 4.0, Na 136, Ur 3.0, ALT 18, Ca 2.4, Mg 0.65, Hb 13.1, MCV 81,& albumin 33 Urinalysis NAD, no ketones.

Current Medications

1. Propranolol 40 mg qds (commenced 23/1/15).

2. Metoclopramide 10 mg tds (commenced 23/1/15).

3. Thiamine  100 mg daily (commenced 23/1/15).

4. Carbimazole 30 mg bd (under consideration).


Examination: Blood pressure 120/83, pulse 102 (SR), mild resting tremor. Lid lag with minimal proptosis & normal optic saccades. No additional extrathyroidal manifestations of Graves' disease.This 38 years old lady presented to Accident and Emergency with regard to an incidental finding of raised free T4 and T3. She was 14 weeks pregnant and had significant symptoms in keeping with hyperemesis (nausea, vomiting, dry retching, ptyalism and spitting from approximately 6-7 weeks gestation). Her symptoms had been persistent and she was unable to tolerate food or fluid during the day, although had some relief in the evening.  She reported loosing approximately 9 kg over the past two months, although reassuringly her BMI was currently normal. She had similar symptoms during her first pregnancy, which lasted for about six weeks. She reported no neck or occipital discomfort and no recent viral illness suggestive of thyroiditis. She did complain of excessive lethargy, but had no palpitations. There was no personal or family history of autoimmune disease.

Given her mild proptosis, significantly elevated T4 and T3 and +ve anti thyroid antibodies, on balance we treated her Graves’ disease, rather than β-HCG induced thyrotoxicosis associated with hyperemesis.


Conclusions: Graves disease accounts for 80-85% of cases of hyperthyroidism.

It is difficult to differentiate Graves and Gestational hyperthyroidism clinically.

Physiological symptoms of normal pregnancy and hyperemesis gravidarum are very similar to Graves.


There is transient hyperthyroidism in gestational hyperthyroidism (hyperemesis gravidarum) It can be differentiated from Grave’s by anti-thyroid antibodies, family history of graves and auto immune disease and absence of goitre.