Obstetric difficulties due to Graves' disease

A 14 year old girl was referred to the paediatricians with symptoms of hyperthyroidism. She had a smooth diffuse goitre with dysthyroid eye disease (proptosis, lid lag, and lid retraction). Hyperthyroidism was confirmed biochemically (protein bound iodine 18.8, normal 5–8 μg). She was treated with carbimazole, 30 mg/day. Poor compliance resulted in inpatient care for treatment with carbimazole followed by subtotal thyroidectomy, two years later. Two years later she presented with a self limited episode of hyperthyroidism. Aged 22 years she was referred with eight weeks amenorrhoea when pregnancy was confirmed and terminated. She was floridly hyperthyroid (free thyroxine 36.6, normal 10–23 pmol/l, free triiodothyronine 14, normal 3–9 pmol/l; …