Anesthetic management of a pregnant patient with uncontrolled hyperthyroidism for emergency caesarean section - a case report

Document Type : Case Report

Authors

1 Department of Anaesthesia and Critical Care, Pt. B. D. Sharma PGIMS, Rohtak, Haryana, India

2 Department of Anaesthesia, N C Medical College, Panipat, Haryana, India

10.22034/ncm.2023.412332.1112

Abstract

Background and Aims: Uncontrolled hyperthyroid patient in pregnancy for emergency caesarean section under general anaesthesia managed by giving antithyroid agents, beta blockers, dexamethasone preoperatively to inhibit peripheral conversion of T4 to T3 and to control symptoms of hyperthyroidism.
Case presentation: A 20-year-old primigravida, presented at 37 weeks of gestation with complaints of respiratory difficulty, tremors, excessive sweating, prominent eyes, palpitations and anxiety. Patient was given oral propylthiouracil, lugol’s solution, tablet propranolol, injection dexamethasone and injection pantoprazole intravenous preoperatively. Nasogastric tube was inserted for further administration of antithyroid medications. Arterial blood pressure cannula secured and central venous cannulation done in case thyroid storm occurs which may require large volume resuscitation. Patient was managed successfully under general anaesthesia and monitored for thyroid storm in postoperative period.
Discussion: In patients with poorly controlled hyperthyroidism labour, delivery or caesarean section can precipitate life threatening thyroid storm. In case of thyroid storm antithyroid drugs can be administered orally or rectally so Ryle’s tube was inserted preoperatively. General anaesthesia should be considered in patients of uncontrolled hyperthyroidism requiring emergency surgery as it provides less fluctuations in hemodynamic parameters. Sympathetic stimulation should be avoided in perioperative period. Regional anaesthesia can be performed safely if there are no signs of cardiac failure. In the present case there were no signs of cardiac failure but the patient had tachypnoea so a decision to proceed with general anaesthesia with central venous catheterization and invasive blood pressure monitoring was made.

Keywords

Main Subjects

References

  1. Borrow GN. The management of thyrotoxicosis in pregnancy. N Eng J Med 1985; 313:562-5. doi:10.1056/NEJM198508293130907 PMid:2862585
  2. Alexander EK, Pearce EN, Brent GA, Brown RS, Chen H, Do‌siou C, et al. 2017 Guidelines of the American Thyroid Associa‌tion for the diagnosis and management of thyroid disease during pregnancy and the postpartum. Thyroid 2017; 27: 315- 89. doi:10.1089/thy.2016.0457 PMid:28056690
  3. Okosieme OE, Lazarus JH. Hyperthyroidism in Pregnancy. [Updated 2019 Feb 9]. In: Feingold KR, Anawalt B, Blackman MR, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279107/
  4. Rappoport B. Autoimmune mechanisms in thyroid dis-ease. In: The Thyroid. Green WL (Ed.). 1987. Elsevier New York. 47-106.
  5. lnnerfieldR, Hollander CS. Thyroida/complications in pregnancy. Med Clin North Am 1977 6 l: 67-87. doi:10.1016/S0025-7125(16)31349-9 PMid:319314
  6. Hirvonen EA, Niskanen LK, Niskanen MM. Thyroid storm prior to induction of anaesthesia. Anaesthesia 2004; 59: 1020-2. doi:10.1111/j.1365-2044.2004.03838.x PMid:15488064
  7. Fleisher LA, Mythen M. Anesthetic implications of concurrent diseases. In: Miller's anesthesia. 8th ed. Edited by Miller RD, Cohen NL, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Young WL: Philadelphia, Saunders/Elsevier. 2015, pp 1156-225.
  8. Satoh T, Isozaki O, Suzuki A, Wakino S, Iburi T, Tsuboi K, et al. 2016 Guidelines for the management of thyroid storm from The Japan Thyroid Association and Japan Endocrine Society (First edition). Endocr J 2016; 63: 1025-64. doi:10.1507/endocrj.EJ16-0336 PMid:27746415
  9. Cooper DS. Antithyroid drugs. N Engl J Med 2005; 352: 905-17. doi:10.1056/NEJMra042972 PMid:15745981
  10. Hodak SP, Huang C, Clarke D, Burman KD, Jonklaas J, Janic‌ic-Kharic N. Intravenous methimazole in the treatment of re‌fractory hyperthyroidism. Thyroid 2006; 16: 691-5. doi:10.1089/thy.2006.16.691 PMid:16889494
  11. Halpern SH. Anaesthesia for caesarean section in patients with uncontrolled hyperthyroidism. Can J Anaesth. 1989 Jul;36(4):454-9. doi:10.1007/BF03005347 PMid:2758545
  12. Massey DG, Bechlake MR, McKenzie JM et al. Circulat-or)' and ventilatory response to exercise in thyrotoxieo-sis. N Engl J Med 1967; 276:1104-11. doi:10.1056/NEJM196705182762002 PMid:6024164
  13. Devereaux D, Tewelde SZ. Hyperthyroidism and thyrotoxicosis. Emerg Med Clin North Am 2014; 32: 277-92. doi:10.1016/j.emc.2013.12.001 PMid:24766932
  14. Ostman LGP, Chestnut DH, Rollibard JE, Weiner CP, Herrig JE. Assessment of transplacental passage and hemodynamic effects of esmolol in the gravid ewe. Anesthesiology 1987; 67: A635. doi:10.1097/00000542-198709001-00635
  15. Clark SL, Phelan JP, Montoro M, Mestman J. Transient venla'ieular dysfunction associated with cesarean section in a patient with hyperthyroidism. Am J Obstet Gyneeol 1985; 151: 384-6. doi:10.1016/0002-9378(85)90308-4 PMid:3970106
Novelty in Clinical Medicine
Volume 2, Issue 3
August 2023
Pages 163-167

Files

History

  • Receive Date: 05 August 2023
  • Revise Date: 28 August 2023
  • Accept Date: 30 August 2023

Share

How to cite

Statistics