Graves’ disease while planning pregnancy

She has lost 6.5 kg despite increased appetite, with heat intolerance, tremor, regular palpitations, loose stools, proximal weakness, insomnia and oligomenorrhoea. Weight loss with increased appetite is supportive, not specific.

For two months her eyes have felt gritty and relatives think they are prominent. No diplopia, pain, reduced acuity, washed-out colour, field loss or failure of lid closure. No dysphagia, dysphonia or orthopnoea.

She has been trying to conceive for eight months and is not using contraception. No previous pregnancy, thyroid medicine, amiodarone, iodine supplement or recent contrast. No neck pain or recent viral illness. A pregnancy test today is negative.

She smokes ten cigarettes daily and has recently increased. Her priorities are to feel like herself, protect her sight and avoid unnecessary delay to pregnancy. Do not promise that restoring thyroid control guarantees conception.

Pulse 104 and regular, BP 128/68, temperature 37.0°C. Fine tremor, warm moist palms and mild proximal weakness. No heart failure or atrial fibrillation.

Diffuse smooth goitre with a bruit; no discrete nodule, tenderness, retrosternal signs or cervical lymphadenopathy. This supports Graves’ disease but does not replace biochemical confirmation.

Bilateral lid retraction, lid lag, mild proptosis and periorbital swelling. Visual acuity and colour vision are normal, pupils and fields are normal, eye movements are full without diplopia, corneas are covered on lid closure and there is no optic-disc abnormality. Describe this as suspected mild Graves’ orbitopathy pending formal activity and severity assessment, not as a fully staged diagnosis.

TSH <0.01 mU/L, free T4 38 pmol/L, free T3 14.2 pmol/L and TSH-receptor antibodies positive. The diffuse vascular goitre and eye findings support antibody-mediated hyperthyroidism. If antibodies were negative, consider radionuclide scanning; thyroid ultrasound is not a routine cause test without a palpable nodule.

Pregnancy test negative; full blood count and liver tests normal. Record ECG when rhythm is uncertain. Establish baseline eye measurements and arrange thyroid-eye expertise. Reproductive planning requires prompt endocrine/preconception coordination rather than a routine review months later.

This is Graves’ hyperthyroidism with suspected mild orbitopathy and active pregnancy plans. Recommend prompt endocrine and preconception review, achieve stable thyroid control before conception where possible, and agree a written plan for immediate contact and early testing if pregnancy occurs.

Use the lowest effective antithyroid-drug dose. NICE advises considering propylthiouracil when an adult is pregnant or trying to become pregnant within six months. This is a specialist risk–benefit choice because PTU has important hepatic toxicity; it is not permission to continue trying without coordinated monitoring.

Antithyroid medicine is the practical initial option. Radioiodine is unsuitable during pregnancy and near-term conception planning; orbitopathy also requires specialist consideration. Thyroidectomy remains an option when rapid definitive control, relapse, intolerance, compression or patient preference makes it appropriate, with preoperative control and material consent risks discussed by the thyroid team.

Arrange thyroid-eye referral; give lubrication and exposure advice. New reduced acuity, colour desaturation, visual-field change, severe pain, diplopia or inability to close the eye requires urgent ophthalmic assessment. Smoking cessation is part of orbitopathy treatment, offered without blame. A beta-blocker may relieve symptoms after checking contraindications and individual circumstances.

Explain that carbimazole in early pregnancy is associated with congenital-malformation risk and effective contraception is required during treatment when pregnancy is not the agreed plan. For any antithyroid drug, fever, sore throat or mouth ulcers require stopping the drug and an urgent blood count; jaundice, dark urine or significant abdominal symptoms require urgent review. Thyroid tests and drug choice must be reviewed promptly if pregnancy occurs.

Contact endocrine/obstetric medicine promptly; review the antithyroid drug immediately, use the lowest effective dose and monitor maternal thyroid function and fetal risk under the pregnancy pathway. Do not stop treatment or switch drugs without coordinated advice.

Treat as possible dysthyroid optic neuropathy: same-day emergency ophthalmic assessment. Do not wait for routine thyroid-eye clinic.

Reconsider thyroiditis or exogenous hormone. Antithyroid drugs do not treat hormone leakage and expose the patient to avoidable harm; use cause-specific supportive management.

Stop the antithyroid drug and arrange an urgent full blood count and content check for agranulocytosis. Do not advise taking another dose while waiting for a routine appointment.

Strong: Uses antibodies and phenotype to confirm Graves’ and excludes thyroiditis.

Incomplete: Labels all thyrotoxicosis Graves’.

Unsafe: Starts antithyroid medicine without checking the cause or pregnancy.

Strong: Documents acuity, colour, pupils, fields, motility and corneal closure.

Incomplete: Records ‘mild eye disease’ without staging elements.

Unsafe: Misses optic-nerve or exposure warning signs.

Strong: Makes a coordinated preconception recommendation and explains drug trade-offs.

Incomplete: Merely says to discuss pregnancy later.

Unsafe: Offers radioiodine or carbimazole without pregnancy counselling.

Strong: Explains uncertainty and fertility safety without blame or guarantees.

Incomplete: Provides correct drugs but not a usable plan.

Unsafe: Promises treatment will ensure conception.