Fetal Hyperthyroidism with Maternal Hypothyroidism: Two Cases of Intrauterine Therapy

Abstract

Fetal hyperthyroidism can occur secondary to maternal autoimmune hyperthyroidism. The thyroid-stimulating hormone receptor antibody (TRAb) transferred from the mother to the fetus stimulates the fetal thyroid and causes fetal thyrotoxicosis. Fetuses with this condition are difficult to detect, especially after maternal Graves disease therapy. Here, we present two cases of fetal hyperthyroidism with maternal hypothyroidism and review the assessment and intrauterine therapy for fetal hyperthyroidism. Both women were referred at 22⁺ and 23⁺ weeks of gestation with abnormal ultrasound findings, including fetal heart enlargement, pericardial effusion, and fetal tachycardia. Both women had a history of Graves disease while in a state of hypothyroidism with a high titer of TRAb. A sonographic examination showed a diffusely enlarged fetal thyroid with abundant blood flow. Invasive prenatal testing revealed no significant chromosomal aberration. Low fetal serum TSH and high TRAb levels were detected in the cord blood. Fetal hyperthyroidism was considered, and maternal oral methimazole (MMI) was administered as intrauterine therapy, with the slowing of fetal tachycardia, a reduction in fetal heart enlargement, and thyroid hyperemia. During therapy, maternal thyroid function was monitored, and the dosage of maternal levothyroxine was adjusted accordingly. Both women delivered spontaneously at 36⁺ weeks of gestation, and neonatal hyperthyroidism was confirmed in both newborns. After methimazole and propranolol drug treatment with levothyroxine for 8 and 12 months, both babies became euthyroid with normal growth and development.

Keywords: fetal hyperthyroidism; intrauterine therapy; thyroid-stimulating hormone receptor antibody (TRAb).

Figure 1

Ultrasonographic cardiac scan of Case One during the 23rd gestational week. (A) Fetal cardiac enlargement, pericardial effusion, and cardiac hypertrophy; (B) Fetal mild exophthalmos and palpebral oedema; (C) Enlarged thyroid with diffusely abundant blood flow.

Figure 2

(A) Severely enlarged heart with increased cardiothoracic ratio and pericardial effusion at the 23rd gestational week in Case Two; (B) Mild fetal ascites; (C) Mild fetal palpebral oedema; (D) Fetal thyromegaly and congestion; (E) Decreased fetal cardiothoracic ratio at 31 weeks.