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Obstructive Goiter and Urgent Thyroidectomy in a Pregnant Patient
Abstract Number: 202
Abstract Type: Case Report/Case Series
Thyroid disease is fairly common in pregnancy although obstructive goiter requiring surgical intervention during pregnancy has not been frequently reported. We present a 34 year old P2022 in her 30th week of pregnancy, with a previously undiagnosed thyroid goiter, and history of morbid obesity (BMI=51.7) and chronic hypertension, admitted complaining of severely worsening dyspnea and orthopnea. Her symptoms began 3 months prior to admission but was attributed to her morbid obesity and pregnancy. Clinical examination revealed an obese patient with inspiratory stridor and a large anterior neck mass with tender nodules. The patient was unable to tolerate the supine position but had stable vital signs with an oxygen saturation of 99% on room air while sitting upright. Fetal heart tones ranged from 130-150 bpm and her tracing was reassuring. A bedside flexible fiberoptic exam by the otolaryngologist revealed marked naso- and oro-pharyngeal edema with adequate visualization of the vocal cords. Thyroid function tests were within normal limits. Initial workup included CT of the chest which revealed an enlarged goiter which enveloped the trachea at the thoracic inlet. The trachea measured 6mm in diameter. Subsequent ultrasound of the thyroid gland was performed revealing a diffusely enlarged gland measuring 10.8cm x 4.9cm x 5.6cm on the right and 10.4cm x 4.7cm x 4.4cm on the left with an isthmus thickness of 2.3cm. The patient also had a right lobe nodule measuring 6.4cm and a left lobe nodule measuring 4.4cm.
Given her rapidly deteriorating symptoms she was scheduled for an urgent thyroidectomy under general anesthesia. Plans for an awake nasal fiberoptic intubation with spontaneous ventilation were made. Serial dilation of the left nares with 2% lidocaine and phenylephrine was performed with concurrent pre-oxygenation. Examination with a flexible bronchoscope by the otolaryngologist revealed worsening nasopharyngeal, oropharyngeal, and supraglottic edema. A size 7.0 endotracheal tube was advanced through the vocal cords under fiberoptic guidance. General anesthesia was induced after verification of the presence of end tidal CO2 and bilaterally equal breath sounds. The patient was positioned supine with left uterine displacement for the procedure. Continuous fetal monitoring was performed throughout.
The patient was extubated to 10L of oxygen via face mask in the operating room at case end. She received ICU level monitoring for 24 hours post-op as well as continuous fetal monitoring. Her post-operative course was uneventful and she was discharged on post-op day #2. The patient continued on levothyroxine 250mcg daily for the remainder of her pregnancy. She returned at 39 weeks for a scheduled repeat cesarean section with bilateral tubal ligation at which time she was asymptomatic and had a normal airway exam. The patient delivered a term infant via cesarean section under epidural anesthesia.