Table 3 Management of thyroid storm in pregnant patients

General measures

• Admit to ICU

• Continuous cardiac and fetal monitoring^a

• Emergent enteral and intravenous access

• Fluid resuscitation with crystalloids

• Correction of electrolyte abnormalities (e.g., hypokalemia)

• External cooling and antipyretic therapy to target euthermia (acetaminophen preferred over aspirin)

• Search for underlying etiology

• Avoid delivery^a

Urgent

• Antithyroid medications

1st line – PTU 600–1000 mg loading dose followed by 200–250 mg q4h

2nd line – MMI 20 mg q6h

• Steroids

Hydrocortisone (300 mg IV loading dose, then 100 mg IV q8h) (preferred over dexamethasone^a)

• Beta blockers

1st line—Esmolol loading dose of 250–500 μg/kg IV over 30 s, followed by an infusion at 50–100 μg/kg/minute

2nd line – Propranolol enteral (60–80 mg q4-6 h) or IV (1 mg over 10 min)

Avoid atenolol^a

After 1 h

SSKI (5 drops or 250 mg q6-8 h) or Lugol’s iodine (10 drops or 0.5 mL q8h) (lithium carbonate contraindicatedª)

Refractory thyroid storm

• Cholestyramine 4 g q6h

• Plasmapheresis –place patient in left lateral position to avoid IVC compression^a

• Consider emergent thyroidectomy

After resolution

Continue PTU (if in the 1st trimester) or switch to MMI (if in the 2nd trimester)ª

Continue to monitor for antithyroid medication toxicity