Stress-Triggered Graves’ Disease with Multiple Exacerbations in a Pregnant Woman with High Levels of Thyrotropin Receptor Antibodies and No Complicated Delivery: a Case Report

Graves’ disease (GD) is an autoimmune thyroid disease in which stimulation by thyrotropin-receptor antibodies (TRAb) causes thyroid enlargement and hyperfunction. GD is an uncommon condition during gestation, as it occurs in about 0.2% of pregnant women. The typical GD course during gestation is characterized by a progressive reduction of TRAb levels, with associated clinical improvement, but subsequent recurrence after delivery. Instead, gestational GD requires close monitoring, because if inadequately controlled with maternal TRAb levels remaining elevated, it is associated with adverse maternal, fetal, and neonatal outcomes. We describe the case of a 39-year-old woman, who was diagnosed with stress-triggered GD at 1st trimester of her pregnancy. At diagnosis, TRAb levels were very high (30.4 U/L, normal values < 1.5). Five weeks after antithyroid drug (ATD) was started, hyperthyroidism returned, coinciding with an increase of TRAb levels (> 40 U/L). Three additional exacerbations of hyperthyroidism occurred at weeks 28 (TRAb > 40 U/L), 32 (TRAb 36.4 U/L), and 36 (TRAb 26.2 U/L), despite close biochemical monitoring and adjustments of ATD. An uncomplicated spontaneous delivery of a healthy boy occurred at week 37. The neonate had normal weight, length, Apgar score, and was euthyroid (TSH 1.9 mIU/mL). He remained healthy and euthyroid at the last evaluation (9 months of age). This case is unusual because of several exacerbations of GD hyperthyroidism while on ATD during gestation, due to persistently high TRAb levels. Nevertheless, thanks to close maternal and fetal monitoring, neither maternal nor fetal complication occurred.