International Journal of Reproduction, Contraception, Obstetrics and Gynecology

Singh S et al. Int J Reprod Contracept Obstet Gynecol. 2016 Mar;5(3):933-936

www.ijrcog.org pISSN 2320-1770 | eISSN 2320-1789

DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20160617
Case Report

A rare case of thyroid storm following caesarean section

Sanjay Singh*, Manash Biswas, Tony Jose, Madhusudan Dey, Monica Saraswat

Department of Obstetrics & Gynaecology, Armed Forces Medical College, Pune, Maharashtra, India

Received: 22 January 2016

Accepted: 15 February 2016

*Correspondence:
Dr. Sanjay Singh,
E-mail: drsanjaysingh@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Thyroid storm in pregnancy is a rare life threatening emergency, with very high maternal and perinatal mortality and
morbidity. Here we present an unusual case of a 30 year-old G2P1L1 woman, a known case of post caesarean
pregnancy with hyperthyroidism who presented with severe preeclampsia and on second post op day developed
thyroid storm. Early recognition and timely institution of appropriate management resulted in good outcome in this
case.

Keywords: Thyroid storm, Thyrotoxic crisis, Pregnancy, Hyperthyroidism, Preeclampsia

INTRODUCTION delivery 01 Jan 2016. She underwent caesarean delivery

in her first pregnancy 4 years ago for thyrotoxicosis with
Generally seen in patients with Graves’ disease, thyroid severe preeclampsia. Patient was registered at 17 weeks
storm also referred to as thyrotoxic crisis is a life 02 days POG. Routine antenatal investigations done were
threatening exacerbation of the hyperthyroid state normal. Her blood group was B positive. Midtrimester
characterized by multisystem involvement.1 Only 1-2% sonography confirmed the correctness of expected date of
hyperthyroid cases during pregnancy manifest as thyroid delivery and ruled out any obvious anomaly. On her first
storm and the mortality range between 20-30% despite antenatal visit only, she was found to be hypertensive
treatment.2 It is abrupt in onset and is usually triggered (BP-150/100mm of Hg) with raised T3 and T4 level
by non-concordance with prescribed antithyroid (T3>800 ng/dl, T4 > 30 µg/dl, TSH – 0.09 µIU/ml).
medication or certain precipitants or stressful situation.3 Diagnosed as a case of chronic hypertension and
In cases of thyroid storm the value of thyroid hormone thyrotoxicosis, she was put on tab labetalol and alpha
remains similar to that of uncomplicated cases of methyl dopa. She was started on tab PTU 50 mg 1-0-1/2
thyrotoxicosis only and treatment is recommended to be for treating thyrotoxicosis (that she had stopped taking
started on strong clinical suspicion, without waiting for one year ago) and tab propranolol 20 mg twice a day, in
lab reports to come.4 Appropriate and timely intervention consultation with physician. In spite of counselling she
reduces mortality and morbidity. remained non-compliant with irregular follow up.

CASE REPORT At our tertiary care centre on evaluation she was found to
have superimposed preeclampsia with severe intrauterine
28 years G2P1L1, a known case of Graves’ disease on growth restriction and severe oligohydramnios. Urine for
tab Propylthiouracil (PTU) was referred from a peripheral protein was 3+ by dipstick test. Inj MgSO4 was started as
hospital at 35 weeks 05 days period of gestation (POG) per Zuspan regimen for seizure prophylaxis and IV
with uncontrolled hypertension (220/120mm of Hg) for labetalol was administered for control of blood pressure.
further management. She was symptomatic with She underwent an emergency LSCS and delivered a
headache on the day of admission. Her last menstrual female new-born baby of 1.8 kg.
period was on 25 Mar 2015 making her expected date of

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On the second post op day she developed sudden onset Table 1: Burch and Wartofsky’s scoring system: A
breathlessness with wheeze, vomiting, agitated and score of 45 or more is highly suggestive of thyroid
delirious behaviour, profuse sweating, tachycardia (140- storm, a score of 25 - 44 supports the diagnosis and a
160 BPM), severe hypertension (BP-220/120 mm Hg), score below 25 makes thyroid storm unlikely.9
tachypnea (RR- 28/min) and hyperpyrexia (104 ).
Applying the Burch Wartofsky score she was diagnosed Parameters Scoring
as a case of thyroid storm with a score of 100 (> 25 is Thermoregulatory dysfunction
diagnostic). Patient was shifted to ICU where she was Oral temperature (°F)
managed in consultation with endocrinologist and 99-99.9 5
intensivist with moist O2 inhalation, cooling by tepid 100-100.9 10
water sponging, IV fluid, Inj labetalol, Inj lasix, Inj
101-101.9 15
hydrocortisone, tab propranolol, increased dosage of tab
102-102.9 20
PTU (200 mg three times a day) and nebulization.
Antibiotic was augmented. Patient responded to this 103-103.9 25
management. The acute phase was controlled. Thyroid 104 30
profile done on the same day was found to be normal Cardiovascular dysfunction
(T3-1.34 mg/dl, T4-7.21µg/dl, TSH 0.01µIU/ml). Tachycardia
Detailed history taken from the patient after recovery 90-109 5
revealed that she had not been taking PTU since last 110-119 10
seven days. 120-129 15
130-139 20
After the acute phase was over she was put on tab >140 25
amlodipine 10 mg twice a day and tab minipress XL
Congestive heart failure
(prazosin) 1mg once a day. She was continued with tab
PTU 100 mg three times a day and planned for review Absent 0
after 3 weeks with repeat thyroid profile by Mild (pedal oedema) 5
endocrinologist. Moderate (Bibasal rales) 10
Severe (pulmonary oedema) 15
DISCUSSION Atrial fibrillation
Absent 0
The prevalence of hyperthyroidism during pregnancy is Present 10
ranges from 0.1% to 0.4%. Graves’ disease accounts for Central nervous system symptoms
around 85% cases of hyperthyroidism during pregnancy.5 Absent 0
Maternal hyperthyroidism is associated with an increased Mild agitation 10
risk of pre-eclampsia, maternal heart failure, maternal
Moderate (Delirium, psychosis, extreme
death, spontaneous abortion, preterm delivery, low birth 20
lethargy)
weight, stillbirth and perinatal mortality (6-12%).6 Our
Severe (Seizure, coma) 30
case was associated with preeclampsia, preterm delivery,
and low birth weight. The risk of complications for both Gastrointestinal /hepatic dysfunction
the mother and the fetus is related to the duration and Absent 0
control of maternal hyperthyroidism. Our non-compliant Moderate (Diarrhoea, nausea, vomiting,
10
patient is a good example. Because normal pregnancy abdominal pain)
simulates some clinical findings similar to thyroxine (T4) Severe (Unexplained jaundice) 20
excess, clinically mild thyrotoxicosis may be difficult to Precipitating event
diagnose. Some important symptoms and signs include - Absent 0
failure in non-obese woman to gain weight despite Present 10
normal or increased food intake, heat intolerance,
irritability, tachycardia, thyromegaly and exophthalmos. Precipitants of thyroid storm in a previously compensated
All these symptoms and signs except exophthalmos were thyrotoxicosis case include abrupt cessation of
present in our case. Overt thyrotoxicosis, is characterized antithyroid drugs, thyroid, or nonthyroidal surgery and a
by excess thyroid hormones in serum and suppressed number of acute illnesses unrelated to thyroid disease
TSH (<0.01 mU/L).7 such as severe infection, anaemia, severe pre-eclampsia,
labour and several others.3,8 In our case the probable
Thyroid storm is an acute and life threatening endocrine precipitants were abrupt cessation of PTU, severe
emergency. Though the exact prevalence of thyroid storm preeclampsia and caesarean section. Thyroid storm also
is not known, because of variability in diagnostic criteria, occurs rarely following radioactive iodine therapy.
it may account for <1-2% hyperthyroid cases. The
mortality of this condition is still high, ranging from 20 to Thyroid storm is not an entity distinct from
30%, despite treatment.2 thyrotoxicosis, but rather one end of a spectrum of
severity of hyperthyroidism. Patients with thyroid storm

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have an exaggeration of the usual symptoms of the first trimester followed by methimazole beginning in
hyperthyroidism. This may be easily confused with the second trimester.
hypertensive encephalopathy, CNS infections, heart
failure, sepsis, panic disorder and pheochromocytoma. An hour or two after initial thionamide administration,
Precise criteria for thyroid storm have been defined by iodide is given to inhibit thyroidal release of T3andT4. It
Burch HB, Wartofsky (Table 1).9 This includes can be given intravenously as sodium iodide (500-100mg
tachycardia, arrhythmias, congestive heart failure, IV every 8 hr) or orally as saturated solution of potassium
hypotension, hyperpyrexia, agitation, delirium, psychosis, iodide (5gtt PO every 8 hr) or lugol solution 10 gtt PO
stupor and coma as well as nausea, vomiting, diarrhoea every 8 hr).With a history of iodine induced anaphylaxis ,
and hepatic failure. A score of 45 or more is highly lithium carbonate , 300mg every 6 hours may be given.
suggestive of thyroid storm, a score of 25 - 44 supports
the diagnosis and a score below 25 makes thyroid storm Beta blockers like propranolol, labetalol or more specific
unlikely. Our patient achieved a score of 100 which was short acting beta blocker - esmolol are used to inhibit the
highly suggestive of a thyroid storm. Laboratory test are adrenergic effects of excessive thyroid hormone on the
not helpful in making the diagnosis of a thyroid storm, cardiovascular system. 10-40mg of propranolol may be
because the serum thyroxin and thyroid stimulating given PO every 4-6 hours. It is to be noted that b-blockers
hormone levels are the same as those of uncomplicated are contraindicated in presence of severe heart failure and
hyperthyroidism, as can be seen in our case. shock. Supraventricular arrhythmias should be managed
with current antiarrhythmic therapy (adenosine, overdrive
A high index of suspicion for thyroid storm should be pacing) if not responsive to b-adrenergic blockade.
maintained in patients with thyrotoxicosis for its early Treatment of congestive heart failure if present, also need
diagnosis and aggressive management. The diagnosis is attention.
usually made on the basis of the clinical features alone.
Treatment should be started immediately and should not Corticosteroid therapy for 24 hours (hydrocortisone
be delayed for want of lab reports as we did. A 100mg IV every 8 hr or dexamethasone 2 mg every 8 hr)
multimodality treatment approach to patients with thyroid is recommended to further block peripheral conversion of
storm should be used, including beta-adrenergic T4 to T3.
blockade, antithyroid drug therapy, inorganic iodide,
corticosteroid therapy, aggressive cooling with Appropriate supportive management as mentioned above
acetaminophen and cooling by tepid water sponging, and treatment of precipitating factors e.g. infection, pre
volume resuscitation, correction of electrolyte imbalance eclampsia, anaemia or any other factor present, is equally
if any, respiratory support, treatment of the underlying important. Close assessment and continuous maternal
precipitating event and monitoring in an intensive care cardiac monitoring in an intensive care setting is
unit.7,10,11 We could not use inorganic iodide in our case required.10
because of its nonavailability.
CONCLUSIONS
The therapeutic options for thyroid storm are the same as
those for uncomplicated hyperthyroidism, except that the Thyroid storm is an acute, life-threatening, hyper
drugs are given in higher doses and more frequently. metabolic state in individuals with thyrotoxicosis.
Safety of the drugs during pregnancy is also given due Diagnosis is primarily clinical, and no specific laboratory
consideration. The antithyroid drugs available are the tests are available. Several factors may precipitate the
thionamides that includes propylthiouracil (PTU), progression of thyrotoxicosis to thyroid storm. Because
methimazole and carbimazole (which is metabolised to thyroid storm is almost invariably fatal if left untreated,
methimazole). All are effective and all have been used rapid diagnosis and aggressive treatment is fundamental
during pregnancy, whereas methimazole blocks new in limiting the maternal, fetal and neonatal morbidity and
hormone synthesis, PTU also blocks T4 to T3 conversion. mortality associated with this condition.
The recommended doses for PTU are 1000mg followed
by 200 mg every 6 hours (hr) and for methimazole 20-25 Funding: No funding sources
mg every 6 hours orally or via nasogastric tube. Transient Conflict of interest: None declared
leukopenia (10%) and agranulocytosis (0.3-0.4%) are Ethical approval: Not required
known complications with thionamide treatment. It has
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