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Postpartum thyroid storm in poorly controlled Grave's Disease: A case report
Abstract Number: F3C-9
Abstract Type: Case Report/Case Series
Hyperthyroidism during pregnancy is a relatively rare event, and is usually best managed medically with thionamide medications.(1) Thyroid storm, a feared sequela of hyperthyroidism, carries a mortality rate of approximately 10 to 30%.(2) We present the anesthetic management for a pregnant woman whose delivery was complicated by signs and symptoms consistent with thyroid storm. Our patient is a 32-year-old G5P0 with a history of Graves' disease on methimazole and type two diabetes mellitus who presented to labor and delivery in spontaneous labor at 25 weeks gestation. On admission, maternal vitals were notable for sinus tachycardia in the 120s, mildly elevated blood pressures, and normothermia. Given her history of poor compliance with her antithyroid therapy, thyroid laboratory studies were sent and revealed a decreased TSH of 0.02 uIU/mL, increased free T4 of 2.6 ng/dL, increased T3 of 272 ng/dL, but normal total T4. Patient's dose of methimazole was increased, and she was treated with betamethasone to accelerate fetal lung maturity. Two days later, after fetal heart tracing revealed persistent fetal tachycardia with recurrent late and variable decelerations, decision was made to proceed with urgent caesarean delivery. Surgery was uncomplicated, with expected blood loss. Upon arrival to PACU, patient's temperature was 99.2F, heart rate was 109 bpm, and blood pressure was 157/70 mmHg. Thirty minutes later, the anesthetic team was notified of an increase in temperature to 101.8F, heart rate of 143 bpm, and blood pressure of 171/84 mmHg. Patient noted shortness of breath but her SpO2 was 100% on room air. Patient was given several esmolol boluses with transient decrease in heart rate, and started on an esmolol drip. An arterial catheter was placed. Patient was started on antibiotic therapy for possible chorioamionitis, but given the rapidity of her symptoms, the intensive care and endocrinology teams were consulted for concern of thyroid storm. Patient was also started on corticosteroids and saturated solution of potassium iodide. Patient's clinical condition improved in the intensive care unit and her thyroid hormone levels began to normalize (see figure). Endocrine surgery was consulted for thyroidectomy, however, patient refused surgery and was discharged on medical management.
(1) John H. Lazarus. (2014) Thyroid 12(10): 861-865.
(2) Maguy Chiha. (2015) Journal of Intensive Care Medicine 30(3): 131-140.