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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 122-124

Thyroid storm in pregnancy


Department of Anesthesiology, Faculty of Medicine, Udayana University, Bali, Indonesia

Date of Submission29-Sep-2020
Date of Decision14-Dec-2020
Date of Acceptance18-Dec-2020
Date of Web Publication16-Apr-2021

Correspondence Address:
Dr. I Gusti Agung Gede Utara Hartawan
Department of Anesthesiology, Faculty of Medicine, Udayana University, Jl. Kesehatan 1, Denpasar 80114, Bali
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjoa.bjoa_219_20

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  Abstract 


Endocrine emergencies can occur during pregnancy and are associated with the thyroid gland and diabetes. Thyrotoxicosis is a hypermetabolic condition associated with an increase in thyroid hormone in the blood. The manifestations of thyrotoxicosis can range from those without symptoms to a life-threatening condition such as thyroid storm. The diagnosis of thyroid storm can be made based on a history of previous thyroid gland disorders; current signs and symptoms; and laboratory tests of thyroid-stimulating hormone, free thyroxine, and triiodothyronine. The thyroid storm is a rare condition, but the mortality rate on these patients is high. Characteristics of thyroid storms are altered consciousness, hyperpyrexia, tachycardia, and gastrointestinal disturbances. Thyroid storm management focuses on the prevention of thyroid hormone synthesis and its conversion in the periphery, identification, and intervention of the thyroid storm causes and the management of systemic disorders that present during thyroid storm. We present a 24-year-old female who presented with a very high suspicion of thyroid storm based on her Burch and Wartofsky's score criteria had a total score with a very high suspicion of thyroid storm. While pregnancy itself can increase the risk of developing severe thyrotoxicosis, the main management is determined by the presence of emergency manifestations. Our concern was not only for the safety of the mother but also for the fetus. Some drugs need special attention because they cross the blood–placental barrier. Previous patient comorbidities should also receive attention in the management of thyroid storm. The patient was being treated in the intensive care unit and managed to move to a regular ward after 3 days.

Keywords: Intensive care, pregnancy, thyroid storm, thyrotoxicosis


How to cite this article:
Gede Utara Hartawan I G, Agung Senapathi TG, Ryalino C, Pradhana AP, Irawan A, Imannudin R. Thyroid storm in pregnancy. Bali J Anaesthesiol 2021;5:122-4

How to cite this URL:
Gede Utara Hartawan I G, Agung Senapathi TG, Ryalino C, Pradhana AP, Irawan A, Imannudin R. Thyroid storm in pregnancy. Bali J Anaesthesiol [serial online] 2021 [cited 2021 Jun 23];5:122-4. Available from: https://www.bjoaonline.com/text.asp?2021/5/2/122/313886




  Introduction Top


Endocrine emergencies can occur during pregnancy. Endocrine emergencies that often occur in pregnancy are associated with thyroid gland and diabetes.[1] The hypothalamus–pituitary–thyroid axis changed due to fetal growth. The need for thyroid hormones increases during pregnancy, so that abnormalities of the thyroid gland before pregnancy and during pregnancy will affect the mother and her fetus. Uncontrolled thyroid gland abnormalities during pregnancy increase the risk of miscarriage, hypertension in pregnancy, preterm birth, stunted baby growth, low birth weight, thyroid storm, an intellectual decline of the children during their growth period, and congestive heart failure in mothers.[2] Thyroid storm is a rare condition, yet its mortality rate is still high (10%–30%). Characteristics of thyroid storms are altered consciousness, hyperpyrexia, tachycardia, and gastrointestinal symptoms. This thyroid storm is triggered by infection, the use of iodine-containing contrast, pregnancy, surgery, and trauma.[3] The management of a pregnant patient with thyroid storm requires collaboration between the endocrine, obstetric, and intensive care divisions. Thyroid storm management focuses on the prevention of thyroid hormone synthesis and its conversion in the periphery, identification, and intervention of the thyroid storm causes and the management of systemic disorders that present during thyroid storm.


  Case Report Top


A 24-year-old female, 60 kg of weight, was sent to intensive therapy at the time of her fourth pregnancy and 26 weeks of gestation, with a major complaint of shortness of breath for 3 days. The patient also had a history of hyperthyroidism for 2 years with occasional palpitations, sweating, and tremors in both hands. She had a history of taking propylthiouracil (PTU) 100 mg three times daily irregularly. The patient also has histories of asthma and increased blood pressure for 24 weeks of gestational age.

From the physical examination, the patient's blood pressure was 168/105 mmHg, pulse rate 128 beats per min (bpm), respiration rate 30 times per min, oxygen saturation 90% with mask oxygen 6 L/min, temperature 37.5°C, and there were also rhonchi and wheezing on both lungs. The thyroid examination showing an enlargement of 1.5 cm in diameter. The chest X-ray showed cardiomegaly and pneumonia. The electrocardiogram was sinus tachycardia with a normal axis and ST-T segment. Echocardiography examination showed normal cardiac chamber dimensions with no left ventricle hypertrophy, ejection fraction was 75%, global normokinetics, tricuspid annular plane systolic excursion 2.33 but accompanied with tricuspid regurgitation, and mild mitral regurgitation. Other tests were as follows: white blood cell, 18.23 × 103/μL; hemoglobin, 10.8 g/dL; hematocrit, 33.7%; platelets, 301 × 103/μL; blood urea nitrogen, 16.4 mg/dL; creatinine, 0.22 mg/dL; Na, 134 mmol/L; K, 2.7 mmol/L; Cl, 96 mmol/L; free thyroxine (FT4), 91.12 mmol/L; and thyroid-stimulating hormones (TSHs), 0.211 IU/mL.

The patient was given a combination of beta-2-agonist and steroid by nebulizer, methylprednisolone 125 mg intravenously (IV), and aminophylline 240 mg IV initially followed by a continuous dose of 40 mg/h. The next day, the wheezing sound reduced on both the lungs, but the rhonchi persisted. After being treated for 12 h, the patient had seizures with a pulse of 138 bpm and a temperature of 40.5°C. The patient was intubated and continued with controlled ventilation using PC BIPAP PS 10 mmHg; PEEP 5 mmHg; FiO2 40%; and sedated using propofol, midazolam, and morphine. Other medications given were PTU 300 mg orally every 6 h, propranolol 20 mg every 8 h, Lugol 8 drops every 6 h, paracetamol 1 g IV every 8 h, salbutamol nebulizer every 8 h, omeprazole 40 mg IV every 8 h, and aminophylline 40 mg/h IV. The methylprednisolone was given 62.5 mg IV every 12 h for 24 h, followed by dexamethasone 5 mg IV every 12 h. Based on Burch and Wartofsky's thyroid storm criteria, the patient had temperature >40°C (score 30), seizures (score 30), pulse 138 bpm (score 20), and with a trigger factor pregnancy (score 10). The total score was 90 with a very high suspicion of thyroid storm. After being treated for 3 days in the intensive care unit (ICU), the patient can be managed to move to a regular ward.


  Discussion Top


Hyperthyroidism is an increase in the amount of thyroid hormone in the blood. Causes of hyperthyroidism include diffuse toxic goiter (Graves' disease), toxic multinodular goiter (Plummer's disease), and toxic adenoma. Thyrotoxicosis is a hypermetabolic condition associated with an increase in thyroid hormone in the blood. The manifestations of thyrotoxicosis can range from those without symptoms to a life-threatening condition, such as thyroid storm. The diagnosis of thyroid storm can be made based on a history of previous thyroid gland disorders; current signs and symptoms; and laboratory tests of TSH, FT4, and triiodothyronine (T3).[4]

Thyroid hormone production and release is a negative feedback loop involving the hypothalamus, pituitary gland, and the thyroid gland itself. The hypothalamus will release thyroid-releasing hormone (TRH) which will stimulate the pituitary to release TSH and then cause the thyroid gland to release thyroid hormones. Somatostatin will block the hypothalamus from releasing TRH. The increase in T3 will provide feedback to the hypothalamus and pituitary, so that the production of TRH and TSH also decreases. In hyperthyroidism, this feedback mechanism fails. Thyroid hormone production is highly dependent on iodine. The iodide in our daily intake is transported into cells and converted into iodine. Thyroid peroxidase enzymes will bind iodine with thyroglobulin to become monoiodotyrosine and diiodotyrosine. Monoiodotyrosine and diiodotyrosine will combine to form T3 (10%) and T4 (90%). In the peripheral network, T4 will be converted to T3 which is a more active hormone.[4],[5]

Hyperthyroidism in pregnancy can generally be distinguished based on the causes, which are grave disease and gestational thyrotoxicosis. Hyperthyroidism that occurs in Graves' disease is caused by the presence of TSH receptor-stimulating antibodies (TSAb), and gestational thyrotoxicosis occurs due to high concentrations of the hormone human chorionic gonadotropin. In pregnant patients with Graves' disease, TSAb will activate TSH receptors and cause hyperthyroidism. Furthermore, TSAb can cross the placenta, causing Graves' disease in fetuses or neonates.[6]

Thyroid storm is a life-threatening condition in thyrotoxicosis patients. This thyroid storm is triggered by various factors, such as the use of amiodarone drugs, withdrawal from antithyroid medication, aspirin overdoser, chemotherapy, organophosphate intoxication, use of iodine-containing contrast, seizures, trauma, burns, surgery, hypoglycemia, diabetic ketoacidosis, pregnancy, childbirth, and emotional stress. A thyroid storm rarely occurs in thyroid surgery. Thyroid storm is usually anticipated in the perioperative period of thyroid surgery. Sometimes, it occurs in nonoperative thyroid because thyrotoxicosis was not previously diagnosed. A thyroid storm is usually associated with stress, anesthesia, and dehydration.[7]

The diagnosis of thyroid storm can be established based on the clinical condition of the patient. Laboratory evaluation takes a long time, so it is not practical for an emergency. One of the clinical criteria that can be used is Burch–Wartofsky Point Scale (BWPS).[8] Based on the BWPS thyroid storm criteria, this patient was found to have temperature >40°C (score 30), seizures (score 30), pulse rate 138 bpm (score 20), which the management of thyroid storm patients should be performed in the ICU. Treatment in the ICU is not only for thyroid storm with heart failure or organ failure, but all patients diagnosed with thyroid storm must be treated in the ICU to recover the patient's physiological condition.[9] Three things need to be considered in the management of thyroid storm, including antithyroid drugs that will suppress thyroid hormone production and the release of T3 and T4, management to inhibit the effects of the presence of FT3 and FT4 in the circulation, and management of systemic symptoms that arise, such as heart failure, respiratory failure, and shock.[9],[10]

If there is a life-threatening condition, the management is prioritized for the emergency. In this patient, mechanical ventilation was required because the patient had seizures. In addition, it was found tachycardia 138 bpm and hyperthermia 40.5°C. Seizures can occur in patients with thyroid storm; the incidence is 0.2%–4% in both pediatric and adult patients. The incidence of seizures in children is higher than in adult patients.[11] The mechanism of seizures in thyroid storm patients is not clear. The data obtained are only in animal experiments. It possibly relates to hemodynamics, metabolism, and neurotransmittersin the brain, or related to neurotransmitters in the brain.[12] Central nervous system dysfunction manifests as 90% of thyroid storms. The forms of dysfunction include agitation, confusion, paranoia, psychosis, coma, status epilepticus, stroke, and bilateral basal ganglia infarction. Paralysis that occurs in thyroid storm can occur secondary to stroke or can be associated with hypokalemia that often occurs in Asian populations.[13] While the patient was assisted by mechanical ventilation, she was sedated using propofol, midazolam, and morphine to decrease the energy requirements for metabolism in the brain and overall body to the most basal level. We also provided supportive therapy to this patient, such as oxygen, fluids, nutrition, vitamins, and folic acid, given the current patient with pregnancy. For the fever, paracetamol can be given and added with a cooling pad if necessary. Aspirin should be avoided because it releases thyroxine from its protein bonds.

Thyroid storm patients are given β-blocker drugs, such as propranolol. Propranolol can decrease pulse rate, systolic blood pressure, muscle weakness, and tremors. In addition to reducing sympathetic activity, β-blocker drugs can reduce the conversion of T4 to T3. Glucocorticoid drugs such as dexamethasone can also decrease the conversion of T4 to T3. Even so, the provision of propranolol can affect the baby such as stunted growth, bradycardia, hypotension, hypoglycemia, and hyperbilirubinemia as the β-blocker drugs can cross the placenta.


  Conclusion Top


Pregnancy can increase the risk of developing severe thyrotoxicosis. The main management is determined by the presence of emergency manifestations. Our concern is not only for the safety of the mother but also for the fetus. Some drugs need special attention because they cross the blood–placental barrier. Previous patient comorbidities should also receive attention in the management of thyroid storm.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Khoo CM, Lee KO. Endocrine emergencies in pregnancy. Best Pract Res Clin Obstet Gynaecol 2013;27:885-91.  Back to cited text no. 1
    
2.
Brent GA. Diagnosing thyroid dysfunction in pregnant women: Is case finding enough? J Clin Endocrinol Metab 2007;92:39-41.  Back to cited text no. 2
    
3.
Wang HI, Yiang GT, Hsu CW, Wang JC, Lee CH, Chen YL. Thyroid storm in a patient with trauma – A challenging diagnosis for the emergency physician: Case report and literature review. J Emerg Med 2017;52:292-8.  Back to cited text no. 3
    
4.
Devereaux D, Tewelde SZ. Hyperthyroidism and thyrotoxicosis. Emerg Med Clin North Am 2014;32:277-92.  Back to cited text no. 4
    
5.
Gurvitch DL. Yao & Artusio's Anesthesiology: Problem-Oriented Patient Management. 7th ed. Philadelphia: Lippincott Williams and Wilkins; 2012.  Back to cited text no. 5
    
6.
Cooper DS, Laurberg P. Hyperthyroidism in pregnancy. Lancet Publ Group 2013;1:238-49.  Back to cited text no. 6
    
7.
Klubo-Gwiezdzinska J, Wartofsky L. Thyroid emergencies. Med Clin North Am 2012;96:385-403.  Back to cited text no. 7
    
8.
Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am 1993;22:263-77.  Back to cited text no. 8
    
9.
Bacuzzi A, Dionigi G, Guzzetti L, De Martino AI, Severgnini P, Cuffari S, et al. Predictive features associated with thyrotoxic storm and management. Gland Surg 2017;6:546-51.  Back to cited text no. 9
    
10.
Satoh T, Isozaki O, Suzuki A, Wakino S, Iburi T, Tsuboi K, et al. 2016 guidelines for the management of thyroid storm from the Japan thyroid association and Japan endocrine society (First edition): The Japan thyroid association and Japan endocrine society taskforce committee for the establishment of diagnostic criteria and nationwide surveys for thyroid storm. Endocr J 2016;63:1025-64.  Back to cited text no. 10
    
11.
Ladd JM, Sabsabi, von Oettingen JE. Thyroid storm in a toddler presenting as a febrile seizure. Pediatrics. 2020;145:e20191920. doi: 10.1542/peds.2019-1920.  Back to cited text no. 11
    
12.
Burmeister LA. Coma in thyroid storm: Review of aggregated english-language case reports. J Endocr Soc 2019;3:1261-74.  Back to cited text no. 12
    
13.
Pangtey GS, Baruah U, Baruah MP, Bhagat S. Thyroid emergencies: New insight into old problems. J Assoc Physicians India 2017;65:68-76.  Back to cited text no. 13
    




 

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