Learning Objectives
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Recognize clinical presentation of thyrotoxicosis.
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Describe management of thyrotoxicosis in pregnancy.
Thyroid storm and thyrotoxic heart failure are life-threatening hypermetabolic states in pregnancy. Thermoregulation, cardiovascular, nervous, and gastrointestinal systems can be affected, typically leading to multisystem failure ( Fig. 23.1 ). The key to management is to have a high index of suspicion.
Materials Needed
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Volunteer to act as standardized patient
Key Personnel
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Attending obstetrician
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Resident physician (if available in your institution)
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Nurse
Sample Scenario
A 34-year-old G2P1 female at 32 weeks gestation presents with fever, vomiting, and “feeling like [her] heart is racing.” On exam, her pulse is 154. BP is 176/98. Temperature is 104.1. She appears agitated. You note marked exophthalmos. Fetal heart rate tracing shows baseline of 180 with minimal variability, no accelerations, and no decelerations.
– Discuss your differential diagnosis. What would be your initial work-up and management for this patient?
– As you are waiting for other lab results, her TSH results as <0.01. How do you continue to manage this patient?
Debriefing and Documentation
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Suspected precipitating factor for thyroid storm
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Medications received
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Fluids received
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Current vital signs
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Fetal status
Precipitating Factors
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Labor and delivery
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Surgery
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Trauma
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Preeclampsia
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Anemia
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Sepsis
Diagnosis
Signs and symptoms of thyroid storm are frequently nonspecific. They include the following:
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Hyperthermia
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Nausea
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Abdominal pain
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Vomiting
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Agitation
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Diaphoresis
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Dehydration
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Tachycardia
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Congestive heart failure
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Arrhythmia
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Confusion
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Cardiovascular collapse
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Malignant exophthalmos
The diagnosis is confirmed by low TSH and elevated T4 .
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