Graves thyrotoxicosis presenting late in pregnancy: Additional challenges, considerations and multidisciplinary teammates
S Gleeson, S Jarvis, K Meeran, V Lee, A Aziz, B Jones, C Frise, C Nelson-Piercy, N Martin N, all authors in Imperial Healthcare NHS Trust: Queen Charlottes (obstetric medicine and obstetricians), endocrinology, ophthalmology
Abstract: A 35-year-old G4P3 woman presented at 29+4 weeks with chest pain, neck swelling and abdominal tightenings. She had similar previous presentations. On further questioning she had been unwell for months feeling anxious, tremulous and excessively sweaty. Examination revealed tachycardia, a tremor and a goitre with a thyroid bruit. Eye examination revealed normal eye movements with reported pain and diplopia in all directions of gaze, lid lag and exophthalmos. Investigations revealed fT4 59.5 (9-23) pmol/L, T3 >46.1 (2.5 – 5.7) pmol/L and Thyroid Stimulating hormone <0.01 (0.3-4.2 milliunit/L. Her TSH receptor antibodies later came back positive. She was diagnosed with thyrotoxicosis, secondary to Graves’ disease and threatened pre term labour. She started carbimazole 20mg tds and propranolol 40mg tds. She was switched to propylthiouracil 100mg TDS after developing a blistering rash. She remained thyrotoxic throughout pregnancy, complicated by non-compliance, inability to attend ophthalmology clinic and repeat admissions with threatened preterm labour. She delivered a healthy 2150g baby at 33+4 weeks. 19 days postnatally she attended ophthalmology clinic) where vision threatening thyroid eye disease was diagnosed. Despite receiving 3 days of 1g IV methylprednisolone her vision deteriorated and she required an emergency endoscopic bilateral orbital decompression. In view of ongoing difficulties with compliance and unsuitability for radioactive iodine due to both her thyroid eye disease and her young children, a thyroidectomy is planned.
Discussion: Thyroid disease is relatively frequently encountered in pregnancy; however, this is often in the context of pre-existing thyroid disease or mildly abnormal thyroid function tests. It is much less common for Graves to present in pregnancy and it is unusual for Graves thyrotoxicosis to be this severe in the third trimester. In this case her severe disease and difficulty controlling her Graves led to adverse obstetric (preterm delivery) and ophthalmological (vision threatening disease requiring surgery) outcomes. During pregnancy and postnatally she has required input from a large multidisciplinary team which included obstetric physicians, obstetricians, endocrinologists, ophthalmologists, ENT and endocrine surgeons. This medically complex patient presenting late in pregnancy with symptomatic thyrotoxicosis and threatened pre term labour demonstrates the importance of the multidisciplinary team and good communication and teamwork.