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Anesthetic management of hyperthyroid storm with CHF and pulmonary edema in pregnancy
Abstract Number: T 68
Abstract Type: Case Report/Case Series
We present a patient with diagnosis of uncontrolled hyperthyroidism in congestive heart failure (CHF) and pulmonary edema in late pregnancy.
The patient is a 33 year old G2P0 AA female who presented at 33 weeks to an outside hospital (OSH) with 1-week history of dyspnea, palpitations and lower extremity edema. Though symptomatic of hyperthyroidism since 2010, she was not diagnosed until 1/2012 by her ophthalmologist during the work-up of proptosis. While she was started on PTU and propranolol, she was reportedly non-compliant with her medications. She was found to be in severe respiratory distress and her work up was consistent with congestive heart failure complicated by hyperthyroid storm. She was transferred for further management.
On arrival to our institution, review of systems was significant for symptoms of uncontrolled hyperthyroidism and shortness of breath at rest. The physical exam revealed proptosis, diffuse thyromegaly, significant JVD, tachycardia and a loud systolic ejection murmur, wheezing throughout both lung bases and bilateral 3+ pitting lower extremity edema.
Her chest x-ray revealed bilateral hilar congestion, and a prominent cardiomediastinal silhouette with possible left pleural effusion. A transthoracic echo showed left ventricular enlargement, an EF of 50% with high velocity TR and right ventricular systolic pressures of 50-55 mm Hg at rest. T4 was elevated to 39.2 with a TSH of <0.01.
While initially started on IV Labetolol and Magnesium drip, her clinical condition deteriorated and she was urgently taken to the OR for C-section. An arterial line and a right pulmonary artery catheter were placed to assist with hemodynamic monitoring. The decision to intubate was made due to her continued sensation despite epidural anesthesia and high supine pulmonary pressures.
Due to her continued pulmonary hypertension the patient was transported to the MICU and remained intubated. She was diuresed and started on PTU and continued on IV beta blockers overnight. She was able to be extubated late the following day.
She remained in the hospital for 2 weeks due to co-morbidities of her hyperthyroidism. She and her baby were discharged without sequelae by week 3.
Hyperthyroidism is a difficult disease in terms of diagnosis. Uncontrolled Hyperthyroidism due to non-compliance with medications leads to significant cardio-pulmonary morbidity. Successful management of untreated hyperthyroidism in pregnant patients presents as a unique challenge.
1. Clin Obstet Gynecol. 1997 Mar;40(1):45-64.
2. AANA J. 2011 Jun;79(3):249-55.