Endocrine Abstracts

We present a case of a young female, who was diagnosed with Graves’ thyrotoxicosis in 2019 with very high TSH Receptor antibody. She had a goitre and mild thyroid ophthalmopathy and was commenced on carbimazole. She was followed up in the Endocrine Clinic and carbimazole was titrated according to the clinical and biochemical picture. Her past medical history included epilepsy, generalised anxiety, and emotionally unstable personality disorder. She had difficult social circumstances with four young children, worsening anxiety and continued to smoke cigarettes. She did not attend numerous clinic appointments and was not diligent with repeat thyroid function tests. In March 2020, her carbimazole dose was increased due to worsening thyroid function and thyrotoxic symptoms. She was also experiencing obstructive symptoms from the goitre. The patient admitted to poor adherence with medication and was therefore given a dosette box. Coincidentally, in the same month she was found to be pregnant with MCMA twin pregnancy. The patient was keen to have thyroidectomy due to ongoing symptoms, swallowing difficulty and poor tolerance to carbimazole due to vomiting. She was admitted to Watford General Hospital for pre-operative optimisation of thyrotoxicosis, planned inpatient thyroidectomy and termination of pregnancy (TOP). She was started on high dose propylthiouracil (PTU) and Lugol’s iodine was considered if the patient consented to TOP. Euthyroidism was achieved with high dose PTU and Lugol’s iodine was not required. She had a successful TOP and thyroidectomy. In early pregnancy, patients can present with gestational thyrotoxicosis, which can worsen the pre-existing Graves’ biochemistry. This is an interesting and complex case involving the multi-disciplinary team. Management of thyrotoxicosis was laborious due to poor compliance, intolerance to high doses of carbimazole, complex social circumstances and unstable decision-making due to patient’s mental health disorder. This situation was further complicated by the unplanned pregnancy.