A CASE OF THYROID STORM IN PREGNANCY
Ritwik Mungara
A CASE OF THYROID STORM IN PREGNANCY
A 22 year old G2 P1 mother at 35 weeks of gestation with previous medical history of Graves disease diagnosed 9 months ago presented with symptoms such as weight loss , heat intolerance , sweating and palpitations. She was compliant with her medicines for the past 9 months.

On examination her BP was 150/110 mm hg , Heart rate of 140 beats per minute, respiratory rate of 26 breaths per minute and low grade fever of 99.2 degrees was recorded

The patient appeared anxious and confused . The thyroid on examination was mildly tender and enlarged. Eye examination revealed bilateral exophthalmoses with proptosis of 24mm right eye and 18 mm of left eye.
The clinician ordered thyroid function tests including Free T4, T3, TSH, anti-TSH receptor antibodies, antithyroglobulin and antithyroid peroxidase antibodies.
The results for the tests follow:
Free thyroxine (FT4) 2.95 ng/dL (Prepubertal 0.73-1.77 Pubertal/Adult 0.73-1.84)
Total triiodothyronine pediatric (T3) 350.00 ng/dL (123-211)
Thyroid-stimulating hormone (TSH) <0.018 uU/ml
Thyroxine (T4) 17.2 ug/dL (5.0-12.0)
Antithyroglobulin antibodies >3000 IU/ml
(Negative <60 IU/mL Equivocal 60-100IU/mL
Positive >100IU/mL)
Antithyroid peroxidase antibodies 2667 IU/mL (<60)
Anti-TSH receptor antibodies 69.6 % Inhibit. (<=16.0 Unit: %)

With the above laboratory reports , the patient was diagnosed with thyroid storm.

As it was a medical emergency,she was treated with a BETA BLOCKER (PROPRANOLOL) and IODINE immediately.

Propranolol 1mg/min IV for 1 hour, then 60mg every 4 hours PO

Her therapy consisted of CORTICO STERIODS AND PROPYL THIOURACIL.

Hydrocortisone 100mg IV every 8 hours for 2 days
Propylthiouracil 1200 mg/day , given in 200mg increments PO

DISCUSSION
Thyroid storm is a potentially fatal, though uncommon condition that affects 1% of individuals with thyrotoxicosis , and accounts for between 1 and 10% of patients hospitalized for thyrotoxicosis . It is an exaggerated state of thyrotoxicosis involving decompensation of one or more organ systems and carries a mortality rate of between 20 and 30% .

CAUSES OF THYROID STORM:
Besides thyroid surgery, thyroid storm is triggered by radioactive iodine therapy, uncontrolled diabetes, emotional stress, abrupt withdrawal of antithyroid medication, excessive palpation of the thyroid gland in hyperthyroid patients, thyroid hormone overdose, pulmonary thromboembolism, toxaemia of pregnancy, labor, trauma, acute infection, severe drug reaction or myocardial infection.

CLINICAL FEATURES
The clinical manifestations of thyroid storm are those consistent with marked hyper metabolism.

PRESENTING COMPLAINTS : chest pain, palpitations, shortness of breath, tremor, nervousness, increased sweating, disorientation, fatigue and fever.

CARDIAC SYMPTOMS : Usually there is marked tachycardia, often with atrial fibrillation and high pulse pressure. On rare occasions symptoms may progress to heart failure in the form of congestive heart failure due to the effects of thyroxin on the myocardium.

CNS SYMPTOMS: marked agitation, restlessness, delirium, psychosis, and coma.

GASTROINTESTINAL SYMPTOMS: nausea, vomiting, diarrhoea and jaundice.
Fatal outcomes, which usually occur in the elderly, are associated with heart failure and shock.

FATE OF HYPERTHYROIDISM IN PREGNANCY
Maternal hyperthyroidism may result in foetal hypo or hyper thyroidism. When identified, antenatal foetus should be treated with either maternal administration of PTU or Injection of intra amniotic thyroxin (in case of foetal hypothyroidism). Failure to identify foetal thyrotoxicosis may result in non immune hydrops or foetal demise
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