Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 9  |  Issue : 2  |  Page : 246-249  

Rare complication of uncontrolled hyperthyroidism, "ventricular tachycardia" in patient of severe preeclampsia


1 Department of Anaesthesia, Seth G S Medical College and KEM Hospital, Parel, India
2 Department of Obstetrics and Gynecology, Seth G S Medical College, N Wadia Hospital, Parel, Mumbai, Maharashtra, India

Date of Web Publication1-Mar-2016

Correspondence Address:
Harsha Vasant Mahajan
505 B Wing Olympic CHS Ltd., S D Road, Mulund East, Mumbai - 400 081, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.177676

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  Abstract 

Hyperthyroidism is a rare cause of hypertension during pregnancy with potentially fatal consequences. It should be detected and treated early in pregnancy so as to prevent maternal and perinatal morbidity and mortality. Management requires multidisciplinary approach between the obstetrician, anesthesiologist, pediatrician, and the endocrinologist. Intraoperative and postoperative management for an emergency cesarean section in a parturient with untreated hyperthyroidism are really risky affair. In this case report, we present anesthetic management in such complicated case with ventricular tachycardia with successful maternal and fetal outcome.

Keywords: Hyperthyroidism, preeclampsia, tachycardia ventricular, thyroid crisis


How to cite this article:
Mahajan HV, Narkhede HR, Patel RD. Rare complication of uncontrolled hyperthyroidism, "ventricular tachycardia" in patient of severe preeclampsia. Med J DY Patil Univ 2016;9:246-9

How to cite this URL:
Mahajan HV, Narkhede HR, Patel RD. Rare complication of uncontrolled hyperthyroidism, "ventricular tachycardia" in patient of severe preeclampsia. Med J DY Patil Univ [serial online] 2016 [cited 2024 Mar 29];9:246-9. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2016/9/2/246/177676


  Introduction Top


Ventricular tachycardia is rare in uncontrolled hyperthyroidism. [1] There are only three such cases reported in literature. Overt hyperthyroidism occurs in about 0.2% of pregnancies and subclinical in 2.5%. [2] Usually, the disease is medically controlled at the time of delivery to provide symptomatic relief for the mother, and to reduce the risk of thyroid storm peripartum period. There is a paucity of anesthesia literature on the coexistence of these two conditions. Written consent was obtained from the patient to publish this case report.


  Case Report Top


A 31-year-old primigravida at 32 weeks of pregnancy with twin gestation with severe preeclampsia was referred to our Obstetric Department.

She was unregistered patient in our institute and was admitted in the obstetric ward for anxiety, palpitation, and occasional breathlessness. On examination, she had sweating, staring gaze, lid lag, exophthalmos, and visible thyroid swelling. Her blood pressure was 160/90 mm Hg and heart rate 140 beats/min. Endocrinologist opinion was taken for very low thyroid-stimulating hormone level and clinical presentation of the patient. Ophthalmological examination was done for preeclampsia which was normal.

She was started with tablet methyldopa 250 mg 4 times a day and tablet depin 10 mg 4 times a day. The patient was advised with tablet carbimazole 10 mg once a day which was increased to 15 mg once a day due to persistence of signs and symptoms. On fetal well-being monitoring after 8 days of admission, one intrauterine fetal death was diagnosed by ultrasound examination. Labor pain induced with prostaglandin gel. On detection of meconium stained liquor and fetal heart rate decelerations (heart rate <70 beats/min) immediately, patient shifted for emergency cesarean section.

Following table shows preoperative investigation reports of patient.



Informed written high-risk consent was obtained from the patient in view of recently diagnosed uncontrolled hyperthyroidism, hypertension, and need for a postoperative stay in Intensive Care Unit (ICU). Anti-aspiration prophylaxis was given before shifting to operation theater.

Before induction of anesthesia, heart rate was 164 beats/min and blood pressure was 150/100 mm Hg. Heart rate controlled with intravenous (IV) metoprolol 0.5 mg increments. Induction started when heart rate reduced to 110 beats/min. Preoxygenation was started, anesthesia was induced with thiopentone titrated to loss of eyelash reflex, and succinylcholine 75 mg was given to facilitate tracheal intubation. Anesthesia was maintained with nitrous oxide: Oxygen (50%:50%) and sevoflurane to maintain minimum alveolar concentration 0.6 and atracurium in bolus 7.5 mg was given when patient had respiratory efforts. Intraoperative heart rate was stable between 100 and 110 beats/min, and blood pressure was between 150/100 and 140/90 mm Hg. Twins were delivered after 6 min of induction and after that oxytocin 10 mg was started as slow IV infusion. We were unable to extubate the patient due to poor respiratory efforts after surgery.

The patient then shifted to intensive cardiac unit on ventilator volume-assist control mode. In intensive cardiac unit, patient had cardiac arrest. Cardiopulmonary cerebral resuscitation was given for 2 min. After which electrocardiogram (ECG) rhythm was found to be ventricular tachycardia which then reverted by direct current (DC) shock. When investigated in detail mild bilateral pleural effusion and hyperkalemia was detected and successfully treated in the postoperative period. Patient's extubation was done after 36 h when she followed all standard extubation criteria. She was started on a preoperative dose of carbimazole 15 mg once a day. Until the 3 rd postoperative day, her blood pressure was around 130/90 mm Hg, and pulse rate was around 110 beats/min. On the 4 th postoperative day, she developed severe breathlessness and tachycardia increased up to 160 beats/min. She was unable to maintain saturation with supplementary oxygen. Thyroid storm was diagnosed by an endocrinologist. Thyroid storm was controlled with Lugol's iodine 4-6 drops 8 hourly and propranolol 60 mg given 4 hourly. Her heart rate and blood pressure came to normal. Noninvasive ventilation was given for 3 days to reduce respiratory efforts. Patient was shifted in the ward from ICU after 7 days. Postoperatively, facial edema and thyroid swelling were reduced. Patient discharged from hospital with a male baby on day 21.


  Discussion Top


Overt thyrotoxicosis affects approximately 0.2-2/1000 pregnancies and subclinical in 1.6%. [3] The prevalence of overt hyperthyroidism in iodine-sufficient areas is 1.3%, and that of subclinical hyperthyroidism is 1.6% in community survey in epidemiology study in Cochin. [4] However, in 90-95% of cases, the main cause of hyperthyroidism in pregnancy is Graves' disease. [5] Thyroid storm occurs in 1-2% of pregnant patients with hyperthyroidism. [6],[7]

If left untreated, hyperthyroidism is associated with a high-risk of fetal demise. [8] In addition, labor and delivery or cesarean section may lead to life-threatening thyroid storm [9] particularly in a patient with previously poorly controlled hyperthyroidism.

The anesthetic management of the hyperthyroid parturient must take into consideration the metabolic changes in the mother, the possibility of postoperative thyroid storm and the effects of both hyperthyroidism and antithyroid medication on the fetus. If time permits, the mother should be rendered euthyroid prior to delivery. The mainstay of treatment is antithyroid drugs, and either propylthiouracil or methimazole are safe in pregnancy. [10]

There are a few reports on the management of anesthesia for cesarean section in patients with antenatal diagnosed hyperthyroidism after adequate control of thyroid hormone status. Regional anesthesia can be accomplished safely if the patient has no signs of high output cardiac failure. [11] Since thyroid storm always alters the sensorium, this technique has the advantage, compared with general anesthesia, of maintaining consciousness and, therefore, making the patient's level of consciousness easier to assess postoperatively. Patient in our case report was diagnosed with unoptimized preeclampsia and hyperthyroidism. Emergency cesarean section for fetal distress ruled out the possibility of rapid preoperative preparation with antihypertensive and antithyroid drugs. Inside operation theater, our patient had severe anxiety, palpitation, and breathlessness.

We preferred general anesthesia in our case because first, patient could not have tolerated spinal anesthesia due to increased work of breathing and severe maternal tachycardia. Second, it was obstetrician's insistence of rapid induction of anesthesia due to severe fetal bradycardia <70 beats/min. Third, it was early disseminated intravascular coagulation according to pathological investigations, may be due to one intrauterine fetal demise and severe preeclampsia. Hence, we preferred general anesthesia over spinal to attain a stable hemodynamic and respiratory condition.

Dyspnea on exertion is common in hyperthyroidism for several reasons. Our patient had dyspnea at the time of admission. Reduced vital capacity, decreased pulmonary compliance, and increased minute ventilation have been described. Increased CO 2 production leads to hyperpnoea. Rarely, tracheal compression is severe enough from the goiter to restrict air flow. Occasionally, dyspnea is due to cardiac failure.

Induction of anesthesia is best accomplished with thiopentone as this drug has antithyroid action because of its thiocarbamate structure. [12] N ketamine is relatively contraindicated because of its sympathomimetic effect. Antimuscarinic agents should be used with caution when neuromuscular blockade is reversed as severe tachycardia may result. Succinylcholine administered by infusion or by intermittent bolus may be indicated since reversal of this agent is not required.

To prevent the dreaded complication of "thyroid storm" was our primary goal in this case. This is achieved by the use of antithyroid medication propylthiouracil. We had given metoprolol 5 mg in graded dosage to our patient preoperatively to control hypermetabolic state and 100 mg hydrocortisone [13] to prevent complication such as thyroid storm.

Ventricular tachycardia does not appear to be a recognized arrhythmia in thyrotoxicosis. [14] No recognized cause of ventricular tachycardia could be found in this case. Ischemic heart disease appears unlikely in view of the patient's age, sex, and normal ECG after DC shock. There was no clinical evidence of rheumatic or congenital heart disease. Hence, after stabilization of the rhythm, all investigations were done.

Her potassium was 7.1 mEq/L. Arterial blood gas analysis was suggestive of acidosis. It was treated with K resins. In this case, hyperkalemia may be due to muscle trauma during chest compression. She was extubated after elective ventilation of 36 h. Next day, she again went into hypermetabolic state with breathlessness and severe tachycardia. Chest X-ray had a picture of bilateral mild pleural effusion superimposed on consolidation in both basal regions, which could be because of ventilation for 36 h. At that time, we postponed reintubation and maintained her oxygenation with noninvasive ventilation and heart rate on IV metoprolol.

The diagnosis of thyroid storm is usually made on the basis of the clinical features alone since it is difficult to obtain rapid laboratory or nuclear medicine tests confirming hyperthyroidism. Supportive management of thyroid crisis involves symptomatic treatment of dehydration and high temperature. Inotropic drugs and steroid are needed in some. Beta-blockade, using propranolol and antithyroid drugs, is used as the first-line of treatment.


  Conclusion Top


Ventricular tachycardia can occur as arrhythmia in thyrotoxicosis even though it is rare as compared to atrial fibrillation. The aim of preoperative management is to normalize the thyroid level keeping in mind the effect of antithyroid drugs on the fetus and the duration for stabilization. Regional or general anesthesia can be used safely depending on the clinical situation. The patient should be closely monitored postoperatively for signs of thyroid storm.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Jao YT, Chen Y, Lee WH, Tai FT. Thyroid storm and ventricular tachycardia. South Med J 2004;97:604-7.  Back to cited text no. 1
    
2.
Krassas G, Karras SN, Pontikides N. Thyroid diseases during pregnancy: A number of important issues. Hormones (Athens) 2015;14:59-69.  Back to cited text no. 2
    
3.
Casey BM, Dashe JS, Wells CE, McIntire DD, Leveno KJ, Cunningham FG. Subclinical hyperthyroidism and pregnancy outcomes. Obstet Gynecol 2006;107(2 Pt 1):337-41.  Back to cited text no. 3
    
4.
Usha Menon V, Sundaram KR, Unnikrishnan AG, Jayakumar RV, Nair V, Kumar H. High prevalence of undetected thyroid disorders in an iodine sufficient adult south Indian population. J Indian Med Assoc 2009;107:72-7.  Back to cited text no. 4
    
5.
Mathew J. Burden of thyroid diseases in India. Need for aggressive diagnosis. Med Update 2008;18:334-41.  Back to cited text no. 5
    
6.
Rashid M, Rashid MH. Obstetric management of thyroid disease. Obstet Gynecol Surv 2007;62:680-8.  Back to cited text no. 6
    
7.
Belfort MA. Navigating a thyroid storm. Contemporary OB/GYN; 2006. p. 38-46. Publisher: Medical Communications Group 24950 Country Club Drive, Suite 200 North Olmsted, Ohio 44070.  Back to cited text no. 7
    
8.
Mestman JH. Hyperthyroidism in pregnancy. Clin Obstet Gynecol 1997;40:45-64.  Back to cited text no. 8
    
9.
Sheffield JS, Cunningham FG. Thyrotoxicosis and heart failure that complicate pregnancy. Am J Obstet Gynecol 2004;190:211-7.  Back to cited text no. 9
    
10.
Stagnaro-Green A, Abalovich M, Alexander E, Azizi F, Mestman J, Negro R, et al. Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and postpartum. Thyroid 2011;21:1081-125.  Back to cited text no. 10
    
11.
Clark SL, Phelan JP, Montoro M, Mestman J. Transient ventricular dysfunction associated with cesarean section in a patient with hyperthyroidism. Am J Obstet Gynecol 1985;151:384-6.  Back to cited text no. 11
    
12.
Halpern SH. Anaesthesia for caesarean section in patients with uncontrolled hyperthyroidism. Can J Anaesth 1989;36:454-9.  Back to cited text no. 12
    
13.
Tay S, Khoo E, Tancharoen C, Lee I. Beta-blockers and the thyrotoxic patient for thyroid and non-thyroid surgery: A clinical review. OA Anaesthetics 2013;1:5.  Back to cited text no. 13
    
14.
Nadkarni PJ, Sharma M, Zinsmeister B, Wartofsky L, Burman KD. Thyrotoxicosis-induced ventricular arrhythmias. Thyroid 2008;18:1111-4.  Back to cited text no. 14
    




 

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