Endocrine Abstracts

We report the case of a 22-year old woman with aggressive Graves disease. She was initially found to be clinically and biochemically thyrotoxic in June-2001 when she presented with severe thyroid eye disease. Treatment was commenced with carbimazole but she failed to adequately comply with therapy and follow-up appointments. She fell pregnant whilst thyrotoxic and was converted to propylthiouracil (dose gradually increased due to poor response). She then left the area and had a premature delivery at 27-weeks in another hospital complicated with severe IUGR. She moved back to the area and was referred back to our endocrine team in January-2003 again pregnant with persistent severe thyrotoxicosis. Propylthiouracil was commenced by her GP but unfortunately she miscarried at 5-weeks gestation. Her dose of antithyroid drugs was immediately optimised but while more definitive ablative treatment was being organised, she fell pregnant again also complicated by severe uncontrolled thyrotoxicosis unresponsive to full dose propylthiouracil (compliance enforced by inpatient care). Lugol’s Iodine was therefore given with rapid improvement in thyroid function tests prior to intrapartum thyroidectomy at 24-weeks gestation. Biochemical euthyroid status was achieved within 4-days post-operatively, and she is currently on thyroid replacement therapy. Significant fluctuations in her thyroid receptor antibody titres are postulated, which is recognised to be associated with poor pharmacological response. Interestingly the thyroid overactivity also affected her mental status quite considerably leading to alteration in her personality and forgetfulness perhaps responsible for non-compliance. Her mental health improved dramatically upon restoration to euthyroid status. This case illustrates the challenges of managing aggressive thyrotoxicosis in pregnant patients.