Thyroid storm in a postpartum and uncontrolled graves' disease patient: the challenges of accurate and multidisciplinary disease management

Abstract

Background: Graves' disease is an immune system disorder that results in the overproduction of thyroid hormones (hyperthyroidism). Although pregnancy hyperthyroidism is a relatively uncommon, thyroid crisis is a medical emergency caused by hyperthyroidism exacerbation with symptoms of organ decompensation in one or more organs. Therefore, managing this disease in pregnant women is critical as well as the safety of using antithyroid drugs for pregnant women and the foetus. Case presentation: A 26-year-old woman presented to the Dr Soetomo General Academic Hospital Surabaya, Indonesia with complaints of shortness of breath that had worsened one hour before the admission as well as sudden fever, diarrheal, anxiety, and decreased consciousness. The patient had hyperthyroidism for three years, and the controls were inconsistent. The patient was diagnosed with P1101 postpartum day 1, thyrotoxicosis due to Graves' disease, thyroid crisis, hypertension, microcytic hypochromic anemia, hypoglycemia, hypoalbuminemia, keratitis, and lagophthalmos. The patient was treated with supportive therapy with an oxygen mask 8 liters per minute (lpm), intravenous fluids, and antipyretic acetaminophen 500 mg every 8 hours. Propylthiouracil 400 mg loading dose followed by maintenance 6x100 mg, 8 drops of Lugol's solution after propylthiouracil administration, intravenous (IV) dexamethasone 2 mg every 6 hours, and oral propranolol 20 mg every 6 hours. The patient was discharged from the hospital after presented favorable improvement. Conclusion: This case demonstrates that the stage of the disease determines the management of Grave's disease during pregnancy, and that multidisciplinary involvement could improve the success and reduce the patient mortality.