A case of resistant Graves’ in pregnancy – A clinical challenge

A 29-year-old lady presented at 16 weeks of gestation, a case of Graves’ disease on anti-thyroid drug with uncontrolled thyrotoxic symptoms despite regular medication. Therapy with methimazole and propranolol was started at 12 weeks of gestation didn’t show clinical and biochemical normalization even with the maximum dose of antithyroid drug permissible at pregnancy. At gestational week 20, T4 and T3 remained elevated with suppressed serum TSH and high levels of TSH receptor antibody levels (TRAb =39.5 U/L, Normal value <1.7U/L). Anomaly scan at 20 weeks showed normal fetal study. Definite management of surgery was considered at second trimester in view of resistant Graves’ disease not responding to medical therapy. As the patient and her family refused surgical procedure, the patient had to be followed up medically with guarded prognosis. Subsequently on follow up patient didn’t show any clinical or biochemical remission. TSH receptor antibody levels estimated at 34 weeks also showed higher values (38U/L). Fetal well-being was monitored on a regular basis. Despite high thyroid hormones levels and higher anti-TSH receptor antibody levels all throughout the gestation and with maximum dose of methimazole the patient delivered a healthy baby with no clinical symptoms of thyrotoxicosis, goitre or any stigmata of methimazole fetopathy in the neonate. Mother’s TFT was closed monitored and anti-thyroid medication was titred. Here we present a rare case of resistant Graves’ in pregnancy where we encountered many challenges to manage the case at different stages