Peripartum Management of Refractory Graves' Thyrotoxicosis

Graves' disease (GD) is the most common cause of hyperthyroidism, characterized by autoimmune stimulation of the thyroid gland and typically managed with antithyroid drugs (ATDs), radioiodine (RAI) therapy, or surgery. While most patients respond to standard antithyroid therapy, a minority exhibit refractory thyrotoxicosis, posing significant clinical challenges. Pregnancy further complicates management due to immunological shifts, increased risk of adverse maternal and fetal outcomes, and limitations in therapeutic options. We present the case of a 39-year-old woman with severe, persistent Graves' thyrotoxicosis refractory to high-dose propylthiouracil (PTU), whose clinical course was complicated by pregnancy and postpartum deterioration. Despite management with adequate doses of PTU, she remained biochemically hyperthyroid throughout pregnancy, developed gestational hypertension, and delivered a baby with a cleft palate. Postpartum, she suffered from depression and further deterioration of her thyrotoxicosis, with laboratory evidence of markedly elevated thyroid hormones and thyroid-stimulating hormone (TSH) receptor antibodies, despite directly observed high-dose PTU therapy. Definitive management options were limited by a highly vascular thyroid gland, significant myopathy, intolerance to cholestyramine, and psychiatric comorbidities. Surgery was deemed high risk, and RAI therapy was ultimately chosen, with careful pre- and post-treatment using high-dose propranolol to mitigate the risk of thyroid storm. The patient tolerated RAI without major complications and achieved euthyroidism at six months post-treatment, but relapsed at nine months, which may have been influenced by factors such as the long delay between diagnosis and RAI therapy, the presence of a large goiter, and the inability to achieve normal thyroid levels before treatment. This case emphasizes the complexities of managing refractory Graves' thyrotoxicosis in the peripartum period, particularly when conventional therapies fail, and definitive interventions carry elevated risk. It also highlights the importance of a multidisciplinary, patient-centered approach and the need for individualized management strategies in challenging clinical scenarios.