Thyrotoxicosis and heart failure that complicate pregnancy

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Abstract

Objective

When untreated, Graves' thyrotoxicosis has profound cardiovascular effects, although it rarely causes heart failure in otherwise healthy patients. Preliminary observations suggest that pregnant women are the exception. To further elucidate this association, we studied both immediate and long-term outcomes in women who had thyrotoxicosis and heart failure during pregnancy.

Study design

We reviewed clinical outcomes of pregnant women with Graves' disease and heart failure at our institution from 1974 through 2001. Women with other underlying heart disease were excluded. A standardized antithyroid regimen and serial echocardiography and/or chest radiography were performed.

Results

The 13 women with thyrotoxicosis and heart failure were either noncompliant with antithyroid therapy or had no medical care during pregnancy. Six women had heart failure before fetal viability; decompensation was precipitated by hemorrhage, sepsis, or both. The other 7 women were in the last trimester when heart failure developed; in 4 women, the heart failure was precipitated by severe preeclampsia-eclampsia and in 2 women was precipitated by sepsis. Overall, 11 of 13 women had an underlying obstetric event. In follow-up of 11 women from 2 to 25 years, resolution of cardiomyopathy was confirmed after successful treatment of thyrotoxicosis.

Conclusion

Normal pregnancy mimics and amplifies some of the hyperdynamic cardiovascular changes that are caused by thyrotoxicosis. When they occur simultaneously, there is usually a compensated high-output state. In some women, however, common pregnancy complications that include hemorrhage with associated anemia, sepsis, and severe preeclampsia-eclampsia will precipitate heart failure. The immediate treatment of heart failure and the correction of precipitating pregnancy factors usually results in good outcome. Long-term follow-up confirmed that thyrotoxic cardiac dysfunction is reversible with successful antithyroid therapy.

Section snippets

Material and methods

The pregnant women who are described in this report had uncontrolled thyrotoxicosis that was further complicated by congestive heart failure. They were admitted to the obstetrics service at Parkland Hospital from 1974 through 2001. The diagnosis of Graves' disease was made clinically with laboratory confirmation with the standard criteria.9., 10., 13. All of the women had a diffuse toxic goiter and other variable findings that included peripheral tremor, resting tachycardia, weight loss,

Results

During the 28-year study period, slightly over 300,000 women were delivered at our institution. The recognized incidence of overt thyrotoxicosis averaged approximately 1 in 1500 pregnancies, as determined for three epochs: 1:2000 for approximately 120,000 women who were delivered from 1974 through 19859; 1:1500 for approximately 125,000 women who were delivered from 1991 through 1999; and 1:1000 for 11,000 women who underwent serum thyrotropin screening from 2000 through 2001. From all of

Comment

The incidence of Graves' thyrotoxicosis was approximately 1 in 1700 deliveries during the 28-year period under study. A review of the clinical course of our women with hyperthyroid allows us to make a number of clinical observations. First, we found that 9% of pregnant women with Graves' disease had heart failure. All of these 13 women were untreated and thus were overtly thyrotoxic because they had no medical care during their pregnancy or they were noncompliant with antithyroid therapy. The

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