Thyroid Storm Caused by Hyperemesis Gravidarum

Thyroid storm: hyperemesis and second trimester miscarriage

Thyroid storm is a rare and life-threatening endocrine emergency. This complication is typically seen in women with a history of thyroid disorders triggered by a stressor such as surgery, trauma or severe illness. In pregnancy, there is significant fetal morbidity including preterm birth or fetal death. We present a case of thyroid storm in the second trimester precipitated by hyperemesis gravidarum and gestational transient thyrotoxicosis which was complicated by maternal collapse, miscarriage and cardiomyopathy.

An Unusual and Severe Thyrotoxicosis in a Twin Pregnancy: Fortune Favors the Brave

Graves' disease (GD) and gestational transient thyrotoxicosis (GTT) are the most common causes of thyrotoxicosis during pregnancy, with prevalence ranging from 0.1% to 1% and from 1% to 3%, respectively. Hyperthyroidism during pregnancy can have severe consequences if not promptly recognized and treated. Even more severe, if possible, is the thyroid storm, a life-threatening complication of hyperthyroidism, characterized by severe and dramatic clinical manifestations of thyrotoxicosis. No prior history of thyroid disease, absence of GD stigmata, negative thyrotropin (TSH) receptor antibody levels, serum human chorionic gonadotropin (hCG) higher on average, and symptoms of emesis may lead to the diagnosis of GTT. Few cases of thyroid storm during pregnancy are reported in literature, mainly due to gestational trophoblastic disease. We report a rare and severe case of thyroid storm in a 24-year-old woman at 15 weeks' gestation with twins, likely due to GTT, precipitated by acute myocarditis. Initially presenting with weakness, vomiting, and sinus tachycardia, the patient rapidly deteriorated into a life-threatening condition characterized by hypokalemia, myocardial injury, and severe thyrotoxicosis. Cardiac imaging later revealed acute myocarditis. Thyroid function stabilized at the end of the pregnancy, allowing discontinuation of methimazole. Both fetuses were delivered via emergency cesarean section at 36 weeks, with no significant congenital abnormalities. This case highlights the complexity of diagnosing and managing hyperthyroidism in twin pregnancies, particularly in the context of hyperemesis gravidarum (HG).

From Syncope to Pregnancy: A Case Report of Gestational Transient Thyrotoxicosis

With a multifactorial etiology, syncope is a fairly common clinical presentation in emergency care. During pregnancy, it can result from hemodynamic and hormonal changes. One such rare cause is hyperthyroidism. Although physiological maternal adaptation to fetal requirements can often induce mild, transient, and self-limited thyroid stimulation during the late first trimester, clinically significant thyrotoxicosis can still occur throughout pregnancy. In these cases, the most prevalent causes are gestational transient thyrotoxicosis (GTT) and Graves' disease. We report the case of a 24-year-old woman presenting to the emergency department with recurrent transient syncope, gastrointestinal symptoms, tachycardia, eyelid retraction, and tremor in the upper limbs. Laboratory analysis revealed electrolyte imbalances (metabolic alkalosis, hypokalemia, and hyponatremia), hepatic and kidney dysfunction, and a suppressed thyroid-stimulating hormone with a free thyroxine level of >7.77 ng/dL (reference range: 0.94-1.52 ng/dL), consistent with overt hyperthyroidism. After ruling out the most likely etiologies for syncope and thyroid dysfunction, including autoimmune causes, an abdominal ultrasound revealed the patient was 12 weeks pregnant. Extremely elevated serum human chorionic gonadotropin levels reinforced the presumed diagnosis of a GTT associated with hyperemesis gravidarum (HP). The patient started on fluid support with electrolyte replacement. Due to the uncommon clinical presentation, an antithyroid drug and a beta-blocker were also initiated. The patient showed clinical and biochemical improvement and was discharged after four days, with a close follow-up appointment scheduled with both the endocrinology and obstetrics outpatient care departments. This case report highlights the necessity of considering hyperthyroidism as a potential etiology in cases of recurrent syncope, especially when clinical signs and symptoms are suspicious of excessive thyroid stimulation, while also reminding clinicians to consider pregnancy as a potential trigger in women of childbearing age.

Thyroid storm in pregnancy: a review

BACKGROUND

Thyroid storm is a state of circulating thyroid hormone excess leading to multiorgan dysfunction and systemic decompensation. It typically occurs in the setting of poorly controlled hyperthyroidism and a precipitating illness or event. Management of thyroid storm in pregnancy poses unique diagnostic and therapeutic challenges.

MAIN BODY

Thyroid storm is a clinical diagnosis characterized by hyperpyrexia, tachyarrhythmias, congestive heart failure, gastrointestinal and neuropsychiatric disturbances. However, diagnostic scoring systems have not been validated in pregnancy. Treatment involves specialist consultation, supportive care, and pharmacological options such as anti-thyroid medications, beta blockers, iodine solutions, glucocorticoids, and cholestyramine. These must be adapted and modified in pregnancy to prevent fetal and maternal complications.

CONCLUSION

There is a critical need to recognize thyroid storm during pregnancy and initiate proper medical interventions promptly.

Correlation between serum beta-human chorionic gonadotropin levels and thyroid metabolic function in pregnant women with hyperemesis gravidarum

As previously demonstrated, serum beta-human chorionic gonadotropin (β-hCG) is linked to identifying early gestational abnormalities. This research was aimed at investigating the correlation between serum β-hCG levels and thyroid metabolic function in pregnant women with hyperemesis gravidarum (HG). Ninety-one pregnant women with HG were selected as the study group and divided into early pregnancy (EP), mid-pregnancy (MP), and late pregnancy (LP) groups according to their gestational weeks, while 84 normal pregnant women were selected as the control group. Venous blood was collected from pregnant women in both groups and serum β-hCG levels were measured by chemiluminescent immunoassay. The levels of free thyroxine (FT4), free triiodothyronine (FT3), thyroid-stimulating hormone (TSH), thyroid peroxidase antibody (TPOAb), thyroid-stimulating hormone receptor antibody (TRAb), and thyroglobulin antibody (TgAb) were tested by chemiluminescent microparticle immunoassay. Visual analog scale (VAS) scores were utilized to assess the degree of HG. Pearson analysis was implemented to measure the correlations between serum β-hCG levels and serum FT3, FT4, TSH, TPOAb, TRAb, TgAb, as well as VAS scores and the correlations between β-hCG, FT3, FT4, TSH, TPOAb, TRAb, TgAb, as well as VAS scores and gestation period. The receiver operating characteristic (ROC) curve was plotted to analyze the diagnostic values of thyroid hormones, thyroid-related antibodies, and β-hCG levels for HG. Versus those in the control group, β-hCG, FT3, FT4, TPOAb, TRAb, TgAb levels, and VAS scores were higher and TSH levels were lower in the study group. Versus those in the EP group, β-hCG, FT3, FT4, TPOAb, TRAb, TgAb levels, and VAS scores of pregnant women in the MP and LP groups were decreased, and TSH levels were increased. Serum β-hCG levels of pregnant women with HG were positively correlated with FT3, FT4, TPOAb, TRAb, TgAb, and VAS scores and negatively correlated with TSH levels. Serum β-hCG, FT3, FT4, TPOAb, TRAb, TgAb levels, and VAS scores of pregnant women with HG had a negative correlation with the gestation period, while TSH levels had a positive correlation with the gestation period. The ROC curve analysis showed that β-hCG and thyroid function-related indicators were of high clinical values in the diagnosis of HG. Collectively, our article suggests that serum β-hCG expression of pregnant women with HG is abnormally elevated and closely related to the degree of HG and hyperthyroidism. In addition, β-hCG and thyroid function-related indicators have certain diagnostic efficacy for HG.

Gestational Transient Thyrotoxicosis Complicated by Thyroid Storm in a Patient With Hyperemesis Gravidarum

We describe a patient with gestational transient thyrotoxicosis (GTT) associated with hyperemesis gravidarum (HG) in a twin gestation complicated by thyroid storm resulting in intrauterine fetal demise. GTT is a well-documented complication of the first trimester of pregnancy that may affect up to 60% of pregnancies with HG. Typically, GTT is not associated with unfavorable maternal or fetal outcomes and has a spontaneous resolution. Aside from supportive care, the use of antithyroid drugs (ATD) in GTT is not regularly recommended. Although to our knowledge one similar case has been reported in the literature, the incidence of thyroid storm in GTT has not yet been established. Our case highlights that, although rare, GTT may be complicated by thyroid storm resulting in adverse maternal and fetal outcomes. Our case further suggests that consideration of ATD use in GTT should be given in pregnancies with higher serum human chorionic gonadotropin (hCG) concentration as occurs in HG and multiple pregnancies.