THYROID DISEASE IN PREGNANCY

THYROID STORM

32 YEAR OLD, consulted at 24 weeks for EASY FATIGUABILITY, EXCERSSIVE SWEATING, FINE TREMORS,
PALPITATIONS and HEAT INTOLERANCE. BP = 120/80, HR 120 bpm, RR 20; No uterine contractions. FHT
– 160, RLQ.
(+) ANTERIOR NECK MASS
IE: cervix closed, long, uneffaced

a. Impression? PU 24 weeks AOG, CNIL; Hyperthyroidism, G1P0

b. Basis for Impression? My basis for the impression is the symptoms that she presented which
includes her EASY FATIGUABILITY, EXCERSSIVE SWEATING, FINE TREMORS, PALPITATIONS and
HEAT INTOLERANCE; And the physical examination findings of Tachycardia and anterior neck
mass.
c. What are the laboratories you will request and what are the expected results?
TSH is expected to be below normal, and elevated FT4
CBC, URinalys, HBsAg, VDRL, Pelvic ultrasound; Ultrasound of Anterior Neck mass/Thyroid
d. What medications will you give? Propylthiouracil; PRopanolol;
Prenatal vitamins, Iron supplements

Handout: She came back at 37 weeks with regular uterine contractions. Patient presented with
CONFUSION, ANXIETY, DIARRHEA. BP-160/100, HR 120, RR 22, temp 40 degrees
IE: cephalic, cevix 3 xm staion -3, 50% effaced

e. Immpresion? PU, 37 weeks AOG, CIL, G1P0; Hyperthyroidism, In Thyroid Storm

f. Meds and the rationale for each. Management

> Admit and Stabilize the patient. Check ABC’s.

> Give propylthiouracil (PTU), 600-800 mg orally followed by 150 mg every 4 to 6 hours
> 1–2 hours after administering PTU, give: Potassium iodide, 2–5 drops orally every 8 hours (or Lugol’s
solution, 8 drops every 6 hours, or Sodium iodide, 0.5–1.0 g intravenously every 8 hours
> Immediately initiate dexamethasone, 2 mg IV or intramuscularly every 6 hours, for 24 hours (4 doses)
> Immediately initiate propranolol, 20–80 mg orally every 4–6 hours, or 1–2 mg IV every 5 minutes, until
a total of 6 mg, then 1–10 mg IV every 4 hours
> Give phenobarbital, 30–60 mg orally every 6–8 hours, as needed for agitation and restlessness
> Aggressively control hyperthermia by applying ice packs and cooling blankets and by administering
acetaminophen (15 mg/kg orally or rectally every 4 h)

PTU – high dose PTU has early onset and inhibits the peripheral conversion of T4 to T3
Potassium Iodide – blocks the release of thyroid hormones (1 hr after PTU)
Propranolol - to minimize sympathomimetic symptoms, bring down the heart rate
Dexamethasone - glucocorticoids to decrease peripheral conversion of T4 to T3. This may also be useful
in preventing relative adrenal insufficiency due to hyperthyroidism.
 Patients with thyroid storm should be treated in an ICU setting for close monitoring of vital signs and for
access to invasive monitoring and inotropic support, if necessary. Initial stabilization and management of
systemic decompensation is as follows:

If needed, immediately provide supplemental oxygen, ventilatory support, and intravenous
fluids. Dextrose solutions are the preferred intravenous fluids to cope with continuously high metabolic
demand.

Correct electrolyte abnormalities.

Treat cardiac arrhythmia, if necessary.

Aggressively control hyperthermia by applying ice packs and cooling blankets and by
administering acetaminophen (15 mg/kg orally or rectally every 4 h).

Promptly administer antiadrenergic drugs (eg, propranolol) to minimize sympathomimetic
symptoms.

Correct the hyperthyroid state. Administer antithyroid medications to block further synthesis of
thyroid hormones (THs).

High-dose propylthiouracil (PTU) is preferred because of its early onset of action and capacity to
inhibit peripheral conversion of T4 to T3. The US Food and Drug Administration (FDA) had added a
boxed warning, the strongest warning issued by the FDA, to the prescribing information for PTU.

Administer iodine compounds (Lugol iodine or potassium iodide) orally or via a nasogastric tube
to block the release of THs (at least 1 h after starting antithyroid drug therapy). If available,
intravenous radiocontrast dyes such as ipodate and iopanoate can be effective in this regard. These
agents are particularly effective at preventing peripheral conversion of T4 to T3.

Administer glucocorticoids to decrease peripheral conversion of T4 to T3. This may also be useful
in preventing relative adrenal insufficiency due to hyperthyroidism.

Treat the underlying condition, if any, that precipitated thyroid storm and exclude comorbidities
such as diabetic ketoacidosis and adrenal insufficiency. Infection should be treated with antibiotics.

Rarely, as a life-saving measure, plasmapheresis has been used to treat thyroid storm in adults.
[11]

Iodine preparations should be discontinued once the acute phase resolves and the patient becomes
afebrile with normalization of cardiac and neurological status. Glucocorticoids should be weaned and
stopped and the dose of thioamides adjusted to maintain thyroid function in the normal range. Beta-
blockers may be discontinued once thyroid function normalizes.

If the patient is given PTU during treatment of thyroid storm, this should be switched to methimazole at
the time of discharge unless methimazole is contraindicated. If there is a contraindication for the use of
methimazole, alternative methods to treat hyperthyroidism should be considered after discharge, such
as radioactive iodine or surgery.

Case. 33 year old G5P4 (4004), 41 1/7 weeks, CIL, consults at the ER for labor pains for the past 6 hours.
She is a diagnosed case of NNTG since 1990 and maintained on ELtroxin. No thyroid function tests done.
She noted passage of watery vaginal discharge 24 hours PTC. BP = 150/90, HR = 100, RR = 18, T = 39.1.
PE: (+) 8 x 6 cm cystic anterior neck mass which moves on deglutition. Chest findings E/N. FH = 34 cm,
EFW = 3.0-3.2 kg, FHT = 164/LLQ. Speculum: (+) pooling of clear, non foul-smelling vaginal discharge, IE:
cervix 5 cm dilated, fully effaced, corpus enlarged to AOG, cephalic presentation, station -1, (-) BOW.
Stat urine albumin = trace.
a. What is your primary working impression?
b. What are the effects of the disease on pregnancy and the pregnancy on the diseases?
c. What work-ups will you request for?
d. What complications do you have to watch out for?
 e. How will manage her case.
PU 41 4/7 weeks AOG, CIL G5P4(4004)

Dx: PU 41 4/7 weeks AOG, CIL, G5P4(4004)

NNTG, Clinically Hyperthyroid
Gestational Hypertension
PROM, Intaamnionic Infection

Hyperthyroidism on Pregnancy:
Pregnancy on Hyperthyroidism:

Labs: CBC with platelet count

Urinalysis; 24 hr urine collection for total protein
TSH, FT4
Cervicovaginal swab GS CS

Possible Complications:
Congestive Heart Failure
Thyroid Storm
Preeclampsia
Sepsis
Postpartum hemorrhage: due to infection from prolonged rupture of membranes
Nonreassuring Fetal Status

Management:
Admit the patient.
Start IV hydration
Accurate I and O
Oxygen Supplementation
Control BP. (Seizure Prophylaxis if Severe Preec)
Anticipate for Thyroid Storm: ready medications (is fever from infection or hypermetabolic
state/thyrotoxicosis?)
Intravenous antibiotics: Ampicillin