Graves' disease presenting as bi-ventricular heart failure with severe pulmonary hypertension and pre-eclampsia in pregnancy--a case report and review of the literature.
BACKGROUND
Graves' disease, a well-known cause of hyperthyroidism, is an autoimmune disease with multi-system involvement. More prevalent among young women, it appears as an uncommon cardiovascular complication during pregnancy, posing a diagnostic challenge, largely owing to difficulty in detecting the complication, as a result of a low index of suspicion of Graves' disease presenting during pregnancy. Globally, cardiovascular disease is an important factor for pregnancy-related morbidity and mortality. Here, we report a case of Graves' disease detected for the first time in pregnancy, in a patient presenting with bi- ventricular heart failure, severe pulmonary hypertension and pre- eclampsia. Emphasis is placed on the spectrum of clinical presentations of Graves' disease, and the importance of considering this thyroid disorder as a possible aetiological factor for such a presentation in pregnancy.


METHODS
A 30-year-old Bangladeshi-Bengali woman, in her 28th week of pregnancy presented with severe systemic hypertension, bi-ventricular heart failure and severe pulmonary hypertension with a moderately enlarged thyroid gland. She improved following the administration of high dose intravenous diuretics, and delivered a premature female baby of low birth weight per vaginally, twenty four hours later. Pre-eclampsia was diagnosed on the basis of hypertension first detected in the third trimester, 3+ oedema and mild proteinuria. Electrocardiography revealed sinus tachycardia with incomplete right bundle branch block and echocardiography showed severe pulmonary hypertension with an estimated pulmonary arterial systolic pressure of 73 mm Hg, septal and anterior wall hypokinesia with an ejection fraction of 51%, grade I mitral and tricuspid regurgitation. Thyroid function tests revealed a biochemically hyperthyroid state and positive anti- thyroid peroxidase antibodies was found. (99m)Technetium pertechnetate thyroid scans demonstrated diffuse toxic goiter as evidenced by an enlarged thyroid gland with intense radiotracer concentration all over the gland. The clinical and biochemical findings confirmed the diagnosis of Graves' disease.


CONCLUSIONS
Graves' disease is an uncommon cause of bi-ventricular heart failure and severe pulmonary hypertension in pregnancy, and a high index of clinical suspicion is paramount to its effective diagnosis and treatment.
Department of Cardiology, Dhaka Medical College Hospital, Dhaka, Bangladesh. sabahkmn09@gmail.com.
Khandker Mohammad Nurus
KM
Sabah
Department of Cardiology, Dhaka Medical College Hospital, Dhaka, Bangladesh. drwadud@hotmail.com.
Abdul Wadud
AW
Chowdhury
Department of Cardiology, Dhaka Medical College Hospital, Dhaka, Bangladesh. Shahid.hf09@gmail.com.
Mohammad Shahidul
MS
Islam
Department of Cardiology, Dhaka Medical College Hospital, Dhaka, Bangladesh. aaysha.cader@gmail.com.
Fathima Aaysha
FA
Cader
Department of Microbiology, Dr. Sirajul Islam Medical College, Dhaka, Bangladesh. drshamimak@gmail.com.
Shamima
S
Kawser
Department of Cardiology, Dhaka Medical College Hospital, Dhaka, Bangladesh. md.imam_hosen@yahoo.com.
Md Imam
MI
Hosen
Department of Cardiology, Dhaka Medical College Hospital, Dhaka, Bangladesh. sarahcosis@gmail.com.
Mohammed Abaye Deen
MA
Saleh
Department of Cardiology, Dhaka Medical College Hospital, Dhaka, Bangladesh. dr.shariful31@gmail.com.
Md Shariful
MS
Alam
Department of Cardiology, Dhaka Medical College Hospital, Dhaka, Bangladesh. drjewelk60@gmail.com.
Mohammad Monjurul Kader
MM
Chowdhury
Department of Cardiology, Dhaka Medical College Hospital, Dhaka, Bangladesh. humayara09@gmail.com.
Humayara
H
Tabassum
D000328:Adult; D005260:Female; D006042:Goiter / Q000150:complications / Q000175:diagnosis / Q000503:physiopathology; D006111:Graves Disease / Q000150:complications / Q000175:diagnosis* / Q000503:physiopathology; D006333:Heart Failure / Q000175:diagnosis* / Q000209:etiology / Q000503:physiopathology; D006352:Heart Ventricles / Q000473:pathology; D006801:Humans; D006976:Hypertension, Pulmonary / Q000150:complications / Q000175:diagnosis* / Q000503:physiopathology; D007231:Infant, Newborn; D011225:Pre-Eclampsia / Q000175:diagnosis* / Q000503:physiopathology; D011247:Pregnancy; D011256:Pregnancy Outcome