Therapeutic plasma exchange for Graves’ disease in pregnancy

2021 ◽  
pp. 1753495X2110313
Author(s):  
Matthew Lumchee ◽  
Mimi Yue ◽  
Josephine Laurie ◽  
Adam Morton
Keyword(s):  
Plasma Exchange ◽  
Thyroid Function ◽  
Therapeutic Plasma Exchange ◽  
Graves Disease ◽  
Close Monitoring ◽  
Optimal Management ◽  
Rapid Control ◽  
Preconception Counselling ◽  
Definitive Management ◽  
In Pregnancy

Graves’ disease in pregnancy may be associated with maternal, fetal and neonatal complications, which are proportionate to the severity of hyperthyroidism. Optimal management is detailed preconception counselling, achievement of an euthyroid state prior to conception, and close monitoring of thyroid function and thyroid-stimulating antibodies together with judicious use of anti-thyroid medications during pregnancy. A case of Graves’ disease in pregnancy, complicated by pancytopenia, with a deterioration in thyroid function following cessation of thionamide therapy is described here. Therapeutic plasma exchange was subsequently used to achieve rapid control prior to thyroidectomy. Therapeutic plasma exchange is an effective treatment for hyperthyroidism where thionamides are ineffective or contraindicated, as a bridge to definitive management.

scholarly journals Therapeutic plasma exchange for the management of severe gestational hypertriglyceridaemic pancreatitis due to lipoprotein lipase mutation

2020 ◽  
Vol 2020 ◽  
Author(s):  
Albert S Kim ◽  
Rashida Hakeem ◽  
Azaliya Abdullah ◽  
Amanda J Hooper ◽  
Michel C Tchan ◽  
...  
Keyword(s):  
Plasma Exchange ◽  
Lipoprotein Lipase ◽  
Therapeutic Plasma Exchange ◽  
Placental Lactogen ◽  
Pharmacological Intervention ◽  
List Type ◽  
Hormonal Changes ◽  
Changes In Pregnancy ◽  
Preconception Counselling ◽  
In Pregnancy

Summary A 19-year-old female presented at 25-weeks gestation with pancreatitis. She was found to have significant hypertriglyceridaemia in context of an unconfirmed history of familial hypertriglyceridaemia. This was initially managed with fasting and insulin infusion and she was commenced on conventional interventions to lower triglycerides, including a fat-restricted diet, heparin, marine oil and gemfibrozil. Despite these measures, the triglyceride levels continued to increase as she progressed through the pregnancy, and it was postulated that she had an underlying lipoprotein lipase defect. Therefore, a multidisciplinary decision was made to commence therapeutic plasma exchange to prevent further episodes of pancreatitis. She underwent a total of 13 sessions of plasma exchange, and labour was induced at 37-weeks gestation in which a healthy female infant was delivered. There was a rapid and significant reduction in triglycerides in the 48 h post-delivery. Subsequent genetic testing of hypertriglyceridaemia genes revealed a missense mutation of the LPL gene. Fenofibrate and rosuvastatin was commenced to manage her hypertriglyceridaemia postpartum and the importance of preconception counselling for future pregnancies was discussed. Hormonal changes in pregnancy lead to an overall increase in plasma lipids to ensure adequate nutrient delivery to the fetus. These physiological changes become problematic, where a genetic abnormality in lipid metabolism exists and severe complications such as pancreatitis can arise. Available therapies for gestational hypertriglyceridaemia rely on augmentation of LPL activity. Where there is an underlying LPL defect, these therapies are ineffective and removal of triglyceride-rich lipoproteins via plasma exchange should be considered. Learning points: Hormonal changes in pregnancy, mediated by progesterone,oestrogen and human placental lactogen, lead to a two- to three-fold increase in serum triglyceride levels. Pharmacological intervention for management of gestational hypertriglyceridaemia rely on the augmentation of lipoprotein lipase (LPL) activity to enhance catabolism of triglyceride-rich lipoproteins. Genetic mutations affecting the LPL gene can lead to severe hypertriglyceridaemia. Therapeutic plasma exchange (TPE) is an effective intervention for the management of severe gestational hypertriglyceridaemia and should be considered in cases where there is an underlying LPL defect. Preconception counselling and discussion regarding contraception is of paramount importance in women with familial hypertriglyceridaemia.

scholarly journals THERAPEUTIC PLASMA EXCHANGE AS A BRIDGE TO TOTAL THYROIDECTOMY IN PATIENTS WITH SEVERE THYROTOXICOSIS

2020 ◽  
Vol 6 (1) ◽  
pp. e14-e18
Author(s):  
Kelsey Tieken ◽  
Ameena Madan Paramasivan ◽  
Whitney Goldner ◽  
Ana Yuil-Valdes ◽  
Abbey L. Fingeret
Keyword(s):  
Total Thyroidectomy ◽  
Plasma Exchange ◽  
Medical Management ◽  
Response To Therapy ◽  
Therapeutic Plasma Exchange ◽  
Thyroid Storm ◽  
Antithyroid Drugs ◽  
Average Percentage ◽  
The Mean ◽  
Definitive Management

Objective: Graves disease is the most common cause of thyrotoxicosis. Medical management is the first-line treatment but may be contraindicated or ineffective. In patients with severe, refractory thyrotoxicosis therapeutic plasma exchange (TPE) may be indicated as a bridge to thyroidectomy. Methods: We present 3 cases of thyrotoxicosis refractory to medical management that were successfully treated with TPE and subsequent total thyroidectomy, and provide an analysis of the response to therapy via a change in free thyroxine (fT4) levels throughout their treatment course. Results: The average change in fT4 per liter of fluid exchanged was 0.37 ng/dL (SD = 0.08) and the average percentage change of fT4 after each treatment was 20.7% (SD = 8.28). The mean decrease in fT4 after 4 TPE treatments was 57.4%. All patients successfully underwent total thyroidectomy without complication and were discharged from the hospital. Conclusion: TPE should be considered for thyrotoxic patients with severe hyperthyroidism or thyroid storm refractory to medical management or contraindications to antithyroid drugs who need a bridge to total thyroidectomy. In these cases, TPE was a safe and effective treatment that enabled definitive management with thyroidectomy and may be considered in other patients with severe refractory hyperthyroidism or thyrotoxicosis.

scholarly journals A case of D alloimmunization in pregnancy: successfully treated solely with therapeutic plasma exchange (TPE)

2019 ◽  
Vol Volume 10 ◽  
pp. 251-253
Author(s):  
Fatemeh Tara ◽  
Asieh Maleki ◽  
Nayereh Taheri ◽  
Somayeh Moein Darbari
Keyword(s):  
Plasma Exchange ◽  
Therapeutic Plasma Exchange ◽  
In Pregnancy

scholarly journals ENDOCRINOLOGY IN PREGNANCY: Pregnancy and the incidence, diagnosing and therapy of Graves’ disease

2016 ◽  
Vol 175 (5) ◽  
pp. R219-R230 ◽  
Author(s):  
Peter Laurberg ◽  
Stine Linding Andersen
Keyword(s):  
Thyroid Function ◽  
Birth Defects ◽  
Early Pregnancy ◽  
Graves Disease ◽  
Thyroid Function Tests ◽  
Developmental Factors ◽  
Normal Thyroid Function ◽  
Important Concern ◽  
And Control ◽  
In Pregnancy

Thyroid hormones are essential developmental factors, and Graves’ disease (GD) may severely complicate a pregnancy. This review describes how pregnancy changes the risk of developing GD, how early pregnancy by several mechanisms leads to considerable changes in the results of the thyroid function tests used to diagnose hyperthyroidism, and how these changes may complicate the diagnosing of GD. Standard therapy of GD in pregnancy is anti-thyroid drugs. However, new studies have shown considerable risk of birth defects if these drugs are used in specific weeks of early pregnancy, and this should be taken into consideration when planning therapy and control of women who may in the future become pregnant. Early pregnancy is a period of major focus in GD, where pregnancy should be diagnosed as soon as possible, and where important and instant change in therapy may be warranted. Such change may be an immediate stop of anti-thyroid drug therapy in patients with a low risk of rapid relapse of hyperthyroidism, or it may be an immediate shift from methimazole/carbimazole (with risk of severe birth defects) to propylthiouracil (with less risk), or maybe to other types of therapy where no risk of birth defects have been observed. In the second half of pregnancy, an important concern is that not only the mother with GD but also her foetus should have normal thyroid function.

scholarly journals Crash Landing of Thyroid Storm: A Case Report and Review of the Role of Extra-Corporeal Systems

2021 ◽  
Vol 12 ◽  
Author(s):  
Shir Lynn Lim ◽  
Kangjie Wang ◽  
Pak Ling Lui ◽  
Kollengode Ramanathan ◽  
Samantha Peiling Yang
Keyword(s):  
Plasma Exchange ◽  
Case Series ◽  
Therapeutic Plasma Exchange ◽  
Thyroid Storm ◽  
Organ Support ◽  
Beta Blockade ◽  
Close Monitoring ◽  
Extra Corporeal Membrane Oxygenation ◽  
First Line ◽  
Membrane Oxygenation

Thyroid storm is a rare but life-threatening endocrinological emergency with significant mortality ranging from 10-30% with multi-organ involvement and failure. In view of the rarity of this condition and efficacy of established first line medical treatment, use of extra-corporeal treatments are uncommon, not well-studied, and its available evidence exists only from case reports and case series. We describe a 28-year-old man who presented with an out-of-hospital cardiac arrest secondary to thyroid storm. Despite conventional first-line pharmacotherapy, he developed cardiogenic shock and circulatory collapse with intravenous esmolol infusion, as well as multi-organ failure. He required therapeutic plasma exchange, concurrent renal replacement therapy, and veno-arterial extra-corporeal membrane oxygenation, one of the few reported cases in the literature. While there was clinical stabilization and improvement in tri-iodothyronine levels on three extra-corporeal systems, he suffered irreversible hypoxic-ischemic brain injury. We reviewed the use of early therapeutic plasma exchange and extra-corporeal membrane oxygenation, as well as the development of other novel extra-corporeal modalities when conventional pharmacotherapy is unsuccessful or contraindicated. This case also highlights the complexities in the management of thyroid storm, calling for caution with beta-blockade use in thyrocardiac disease, with close monitoring and prompt organ support.

scholarly journals A Rare Phenomenon of Hashimotos Thyroiditis Converting to Graves Disease

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A917-A917
Author(s):  
Ahl Jeffrey Caseja ◽  
Samer Nakhle
Keyword(s):  
Thyroid Function ◽  
Thyroid Function Test ◽  
Primary Care Providers ◽  
Deficiency Anemia ◽  
Graves Disease ◽  
Close Monitoring ◽  
Thyroid Function Tests ◽  
Care Providers ◽  
History Of

Abstract Introduction: Hashimotos thyroiditis and Graves disease are two distinct autoimmune disorders of the thyroid. Conversion of hypothyroidism to hyperthyroidism is even more rare. We report a case of an established Hashimotos thyoiditis patient who converted into Graves disease. Case Description: 67-year old female with a past medical history of iron-deficiency anemia, dyslipidemia, and depression presented with a six-month history of fatigue, cold-intolerance, hair loss, and weight gain in September of 2015. Laboratory tests confirmed diagnosis of Hashimotos thyroiditis with an elevated TSH 80.7 (0.40-4.50 mIU/L), FT4 0.2 (0.8-1.8 ng/dL), and positive thyroid antibodies TPO 24 (0.0-8.9 IU/mL). She was started on Levothyroxine 88 mcg daily. Gradually she had a decreased requirement of Levothyroxine; from February 2016 to March 2017 she maintained a normal TSH range while on 50 mcg/day with resolution of her symptoms. The patient was then lost to follow-up until she presented in the clinic in September 2018 with complaints of several weeks of easy fatigability, 10lb-weight loss, and periorbital edema. She was found to have a suppressed TSH 0.01, and elevated FT4 2.3, and FT3 8.4 (2.3-4.2 pg/mL). Her Levothyroxine 50 mcg/day was discontinued for four days and labs were repeated which still showed suppressed TSH and elevated FT4 and FT3. She was found to have a positive TRAB and a positive TSI which are consistent with hyperthyroidism. Thyroid ultrasound was performed which showed a heterogeneous thyroid gland with increased vascularity, confirming the diagnosis of Graves disease. She was started on Methimazole 10 mg daily. Her Methimazole dose was adjusted according to her thyroid function test until she had a total thyroidectomy in October 2019. She was started on levothyroxine post-operatively and as of March 2020 is on Levothyroxine 50 mcg/daily. Conclusion: Despite the rarity of Hashimotos thyroiditis converting to Graves disease, it is possible that those affected can be encountered by primary care providers and hospitalists and could easily be mistaken for over-replacement of levothyroxine. Close monitoring of the patient along with regular thyroid function tests will be required for ongoing follow-up.

scholarly journals Hypertriglyceridemia-induced pancreatitis in pregnancy: case review on the role of therapeutic plasma exchange

2021 ◽  
Vol 2021 ◽  
Author(s):  
Sarah Ying Tse Tan ◽  
Swee Ping Teh ◽  
Manish Kaushik ◽  
Tze Tein Yong ◽  
Shivani Durai ◽  
...  
Keyword(s):  
Plasma Exchange ◽  
Case Reports ◽  
Therapeutic Plasma Exchange ◽  
Team Approach ◽  
High Morbidity ◽  
List Type ◽  
Low Fat ◽  
Management Options ◽  
Low Fat Diet ◽  
In Pregnancy

Summary Gestational hypertriglyceridemia-induced pancreatitis is associated with significant maternal and fetal morbidity and mortality. We report a case of gestational hypertriglyceridemia-induced pancreatitis in a primigravida at 31-weeks gestation, complicated by impending preterm labor and metabolic acidosis requiring hemodialysis. This was successfully managed with therapeutic plasma exchange (TPE), followed by i.v. insulin, low-fat diet, and omega-3. Triglyceride levels stabilized after TPE and the patient underwent an uncomplicated term delivery. In pregnancy, elevated estrogen and insulin resistance exacerbate hypertriglyceridemia. Management is challenging as risks and benefits of treatment options need to be weighed against fetal wellbeing. We discuss management options including a review of previous case reports detailing TPE use, dietary optimization, and delivery timing. This case emphasizes the importance of multidisciplinary care to optimize maternal and fetal outcomes. Learning points Gestational hypertriglyceridemia-induced pancreatitis has high morbidity. A multidisciplinary team approach is a key as maternal and fetal needs must be addressed. Rapid lowering of triglycerides is crucial and can be achieved successfully and safely with plasma exchange. A low-fat diet while ensuring adequate nutrition in pregnancy is important. Timing of delivery requires consideration of fetal maturity and risk of recurrent pancreatitis.

Sign in / Sign up

Export Citation Format

Share Document