Journal of Gynecology and Obstetrics

2013; 1(2): 7-10

Published online October 30, 2013 (http://www.sciencepublishinroup.co!/"/"o)
doi:10.11#$%/"."o.20130102.11


Hyperemesis gravidarum and gestational transient
hyperthyroidism: A case report
Cheau Wei, Chin
*
, Aye Aye Myint
&e''re( )he*h +chool o' ,edicine *nd -e*lth +ciences, )linic*l +chool &ohor .*hru, .u/it 01h*, &ohor .*hru, ,*l*(si*
Email address:
che*uwei.1%0%2!*il.co! ()he*u 3ei, )hin), *2!(intster2!*il.co! (0. 0. ,(int)
To cite this article:
)he*u 3ei, )hin, 0(e 0(e ,(int. -(pere!esis 4r*5id*ru! *nd 4est*tion*l 6r*nsient -(perth(roidis!: 0 )*se 7eport. Journal of
Gynecology and Obstetrics. 8ol. 1, 9o. 2, 2013, pp. 7-10. doi: 10.11#$%/"."o.20130102.11

Abstract: 4est*tion*l tr*nsient h(perth(roidis! is o'ten *ssoci*ted with h(pere!esis r*5id*ru!, which is * rel*ti5el(
unco!!on condition in wo!en durin the 'irst *nd second tri!ester o' pren*nc(. :t is * tr*nsient pheno!enon which
resol5es itsel' b( the 20th est*tion*l wee/. 6his is * report o' * c*se o' * pren*nt wo!*n with h(pere!esis r*5id*ru! *nd
est*tion*l tr*nsient h(perth(roidis! who w*s *d!itted to * o5ern!ent hospit*l 'or 1 !onth.
Keywords: -(pere!esis 4r*5id*ru!, 4est*tion*l 6r*nsient -(perth(roidis!, Pren*nc(

1. Introduction
-(pere!esis r*5id*ru! (which occurs in 0.3-1; o'
pren*ncies)
1
*nd est*tion*l tr*nsient h(perth(roidis!
(which occurs in 1-2; o' pren*ncies)
3
*re *ssoci*ted with
ele5*ted h)4 le5els durin pren*nc(
2
. :t is i!port*nt to
distinuish est*tion*l tr*nsient h(perth(roidis! 'ro!
4r*5es< dise*se bec*use the course, 'et*l outco!es,
!*n*e!ent, *nd 'ollow-up *re di''erent
3
. 4r*5es< dise*se
should be suspected i' there is presence o' oitre
1
*nd/or
persistent *bnor!*l th(roid 'unction test result *'ter 20th
est*tion*l wee/
=
. 4est*tion*l tr*nsient h(perth(roidis!
usu*ll( resol5eed b( then, when h)4 le5els decline
3
.
6he *i! o' this c*se report is to hihliht the clinic*l
present*tion *nd tr*nsient pheno!enon o' est*tion*l
tr*nsient h(perth(roidis! with h(pere!esis r*5id*ru!,
*nd *lso to e!ph*si1e on the reco!!ended !*n*e!ent.
. Case !e"ort
0 30 (e*r-old pren*nt :ndi*n l*d(, 1$
th
wee/ o'
pren*nc( (4r*5id* 2, P*r* 1) w*s *d!itted to * hospit*l in
&ohor with 're>uent 5o!itin o' !ore th*n 1= ti!es d*il(,
epi*stric p*in since her 10
th
wee/ o' pren*nc( . 6he
5o!itus w*s !*inl( w*ter *nd s*li5* *s she w*s un*ble to
toler*te or*ll(, but she h*d two episodes o' he!*te!esis in
!id o' 0pril. +he *lso co!pl*ins o' n*use*, di11iness,
leth*r(, loss o' *ppetite *nd weiht, constip*tion, *nd
riht-sided he*d*che. +he denies s(!pto!s suesti5e o'
h(perth(roidis!, such *s 'e5er, p*lpit*tion, *it*tion,


di*rrhe*, *nd he*t intoler*nce. +he underwent c*es*re*n
section when i5in birth to her 'irst child due to breech
birth. -owe5er she did not h*5e h(pere!esis r*5id*ru! in
her 'irst pren*nc(. +he h*s no /nown !edic*l illnesses *nd
non-re!*r/*ble '*!il( histor( o' th(roid dise*se.
?pon ph(sic*l e@*!in*tion, the p*tient w*s *'ebrile,
*lert *nd conscious but deh(dr*ted. -er pulse r*te w*s %$
be*ts per !inute with blood pressure o' 117/70 !!-. 9o
h*nd tre!ors were obser5ed. 6here w*s no con"uncti5*
p*llor, but the p*tient w*s "*undiced. :n *ddition, there were
no e(e sins o' 4r*5es< opth*l!op*th( *nd p*lp*ble oiter.
-er luns were cle*r *nd nor!*l he*rt sounds (+1, +2)
were he*rd with no !ur!urs. -er *bdo!en w*s so't but
tenderness *t riht h(pochondriu! *nd epi*stric reion.
6he rest o' the e@*!in*tions were unre!*r/*ble.
-er l*bor*tor( test results showed consistent nor!oc(tic
nor!ochro!ic *ne!i*, ele5*ted bilirubin, 0A6 *nd 0+6,
but low seru! cre*tinine, seru! pot*ssiu!, !*nesiu! *nd
cre*tine /in*se. 6he th(roid 'unction test *lso shows
e5idence o' th(roto@icosis (ele5*ted 6$ *nd low 6+- le5el)
durin 1$
th
est*tion*l wee/, but the 5*lues nor!*li1ed
durin 1=th est*tion*l wee/ *s shown in 6*ble :. -owe5er
the 6+- receptor *ntibodies, *nitinucle*r *ntibod( test,
*ntith(rolobulin *ntibod( test *nd *niti!icroso!*l
*ntibod( test results show ne*ti5e. Burther!ore, the
in5esti*tions 'or hep*titis 0, ., ) *nd the *cid '*st b*cilli
test, *lso show non-re*cti5e.

% )he*u 3ei, )hin et al.: -(pere!esis 4r*5id*ru! *nd 4est*tion*l 6r*nsient -(perth(roidis!: 0 )*se 7eport

Table 1.Thyroid function test of patient

!e#erence
$alue
1%th
&estational
wee'
1(th
&estational
wee'
1)th
&estational
wee'
Bree 6$
(p!ol/A)
10 - 20 $=.00 1%.$0 13.=#
6+-
(!iu/A)
0.2 - $.0 0.0C0 0.030 0.77#
6he p*tient w*s i5en *n intr*5enous drip o' de@trose
s*line with pot*ssiu! chloride throuhout her st*( in the
hospit*l. 0ntith(roid !edic*tion w*s not introduced thouh
her th(roid 'unction showed h(perth(roidis!. -er th(roid
'unction test results nor!*li1e itsel' durin her 1=
th

est*tion*l wee/. -er 're>uent 5o!itin w*s sini'ic*ntl(
reduced *nd w*s *ble to toler*te or*ll(. -er ener*l
condition w*s st*ble *nd she w*s disch*red *'ter $ wee/s o'
hospit*l *d!ission.
*. +iscussion
3.1. Incidence and Prevalence
-(pere!esis r*5id*ru! is de'ined *s intr*ct*ble
e@cessi5e 5o!itin durin pren*nc( with onset be'ore the
13th est*tion*l wee/, usu*ll( the wo!*n is un*ble to
toler*te or*ll( *nd re>uires intr*5enous h(dr*tion
1
. :t is
li/el( to be *ssoci*ted with h(perth(roidis! second*r( to
the hih h)4 le5el. 8*rious studies showed 0.3 D 1;
pre5*lence o' -4 in pren*nc(, with * !e*n onset durin
the 3rd est*tion*l wee/, pe*/s in 11
th
D13
th
est*tion*l
wee/
2
, *nd subsides *'ter 1$
th
-1%
th
est*tion*l wee/
3
.
-(pere!esis r*5id*ru! is possibl( *ssoci*ted with sins o'
disturbed nutrition*l st*tus (*lter*tions in electrol(te b*l*nce,
!ore th*n =; weiht loss, /etosis, *cetonuri*), neuroloic*l
disturb*nces, retin*l he!orrh*e, li5er *nd ren*l d*!*e
2
.
On the other h*nd, the !ost co!!on th(roid dise*se in
*ll pren*ncies is 4r*5es< dise*se (%= D C0;), while the
secondl( !ost co!!on is est*tion*l tr*nsient
h(perth(roidis!, which its incidence is 1D2; in *ll
pren*ncies
3,$
. 4est*tion*l tr*nsient h(perth(roidis! is
de'ined *s 'irstl( di*nosed h(perth(roidis! in e*rl(
pren*nc(, which resol5es spont*neousl( b( the e*rl(
second tri!ester o' pren*nc(, without e5idence o'
*utoi!!une th(roid dise*se *nd ph(sic*l 'indins
*ssoci*ted with 4r*5es< dise*se
$
. 4est*tion*l tr*nsient
h(perth(roidis! occurs up to two-thirds o' wo!en with
h(pere!esis r*5id*ru!
1
.
3.2. Pathophysiology of Gestational Transient
Hyperthyroidism
6he *ctu*l p*thoph(siolo( o' est*tion*l tr*nsient
h(perth(roidis! is still not co!pletel( understood, but it is
stronl( *ssoci*ted with hu!*n chorionic on*dotropin
(h)4) le5el durin pren*nc(. :n nor!*l pren*nc(, h)4
is produced b( the pl*cent* in the 'irst est*tion*l wee/, its
le5el pe*/s *t 10
th
est*tion*l wee/, then decre*ses *nd
re*ches * pl*te*u b( 20
th
est*tion*l wee/
3
. -)4 *nd 6+-
h*5e identic*l E subunit, which !*( le*d to cross re*cti5it(
between the incre*sed le5el o' h)4 *nd 6+- receptor,
le*din to sti!ul*tion o' 63 *nd 6$, in return c*usin
ne*ti5e pituit*r( 'eedb*c/ o' 6+-, resultin in hih 63
*nd 6$ le5el, but low 6+-, especi*ll( in %
th
D1$
th
est*tion*l
wee/, when h)4 le5el pe*/s durin pren*nc(
=
. +e5er*l
clinic*l studies h*5e reported hih h)4 le5el in wo!en
with h(pere!esis r*5id*ru!, *nd there *re e5idences
showin th*t h)4 le5el is positi5el( correl*ted with the
se5erit( o' 5o!itin *nd the deree o' th(roid sti!ul*tion
1
.
:n *ddition, studies *lso showed th*t seru! h)4 is
in5ersel( proportion*te to seru! 6+-
$
. 0 stud( showed
th*t h)4 le5el in wo!en with est*tion*l tr*nsient
h(perth(roidis! re!*ined *bnor!*ll( ele5*ted 'or wee/s
durin the second tri!ester *nd 'ree 6$ le5els nor!*li1es
p*r*llel with the decline o' h)4 le5el, thus supportin the
role o' h)4 in the p*thoenesis o' est*tion*l tr*nsient
h(perth(roidis!
1
, *s shown in Biure 1.Biure 1 shows the
rel*tionship between seru! h)4 *nd 6+-
$
.
0nother e@pl*n*tion 'or est*tion*l tr*nsient
h(perth(roidis! is th*t hih estroen le5el durin
pren*nc( incre*ses hep*tic th(roid-bindin lobulin
(6.4) s(nthesis, which re*ches pl*te*u durin
!id-est*tion. 6he incre*sed 6.4 le5el sti!ul*tes
ele5*tion o' tot*l 63 *nd 6$ le5els. 6he seru! 6$ le5el
incre*ses sh*rpl( between #
th
-12
th
est*tion*l wee/, *nd
st*bili1es *round !id-est*tion
=
.

Figure 1. Relationship between serum hCG and TSH
4
3.3. linical Features
P*tients with h(pere!esis r*5id*ru! co!plic*ted with
est*tion*l tr*nsient h(perth(roidis! usu*ll( co!pl*int o'
n*use*, 5o!itin *nd weiht loss b( est*tion*l wee/ $-C,
*nd present with t*ch(c*rdi* (second*r( to deh(dr*tion),
'ine tre!ors *nd !ild pro@i!*l we*/nesses. :n p*tients
with hih seru! 63, the( !iht present with shortness o'
bre*th, he*t intoler*nce *nd p*lpit*tions. -owe5er, sins
*nd s(!pto!s suesti5e o' 4r*5eFs dise*se *re *bsent
=,#
. 0
stud( showed th*t bioche!ic*l in5esti*tions in the e*rl(
&ourn*l o' 4(necolo( *nd Obstetrics 2013; 1(2): 7-10 C

present*tion o' wo!en with est*tion*l tr*nsient
h(perth(roidis! *nd h(pere!esis r*5id*ru! re5e*l
h(pon*tre!i*, h(po/*le!i*, !ild h(perbilirubine!i*, *nd
!ild to !oder*te ele5*tion o' *sp*rt*te *!inotr*ns'er*se
(0+6) *nd/or *l*nine *!inotr*ns'er*se (0A6) le5els.
-owe5er, 5ir*l hep*titis screenin shows ne*ti5e results
*!on those with *bnor!*l li5er 'unction test results. 6he
'ree 6$ le5el is 'ound to be ele5*ted in the 'irst tri!ester,
but nor!*li1ed b( 1=
th
est*tion*l wee/
1
*nd seru! 6+- in
the 'irst tri!ester could be *s low *s 0.03D0.0% !:?/A
second*r( to the th(rotropic *cti5it( o' h)4
=
.
Table 2.Clinical presentations and inestigation results of patients with hyperemesis graidarum complicated with gestational transient hyperthyroidism
4
Medical ,istory
-hysical
E.amination
/aboratory Tests
- 0bsence o' h(perth(roid s(!pto!s prior
conception
- +i!il*r histor( o' 5o!itin in pre5ious
pren*ncies
- B*!il( histor( o' -(pere!esis 4r*5id*ru!
- 9o pre5ious histor( o' th(roid dise*se
-9o oiter
-0bsence o' 4r*5es< ophth*l!op*th( or
der!op*th(
-9o other ph(sic*l 'indins such *s 5itilio
*nd Plu!!er<s n*ils
-+ins o' deh(dr*tion
- Gle5*ted 'ree 6$
- +uppressed or undetect*ble 6+-
- 9e*ti5e th(roid *ntibodies: 6PO *nd
670b,
- 6r*nsient electrol(te *bnor!*lities
- 0bnor!*l li5er 'unction test results

3.!. "anagement
3o!en with h(pere!esis r*5id*ru! should be i5en
supporti5e ther*p( with *ntie!etics, h(dr*tion, electrol(te
repl*ce!ent, *nd nutrition
#
. Bor those with h(pere!esis
r*5id*ru! *nd est*tion*l tr*nsient h(perth(roidis!,
*nti-th(roid drus (06H) tre*t!ent is not reco!!ended, *s
no bene'it w*s supported b( c*se reports *nd c*se studies.
4est*tion*l tr*nsient h(perth(roidis! *ssoci*ted with
h(pere!esis r*5id*ru! is o' * tr*nsient n*ture where 'ree
6$ le5els nor!*li1ed b( itsel' without 06H tre*t!ent
1
.
0lso, 06H tre*t!ent is poorl( toler*ted b( p*tients, li/el(
due to the persistent 5o!itin *nd !et*llic t*ste o' 06H
$
.
-owe5er, 06H tre*t!ent should be st*rted i' there is *
persistence o' h(perth(roid s(!pto!s *nd th(roid 'unction
*bnor!*lities *'ter 1%
th
-20
th
est*tion*l wee/s *s this !iht
indic*te 4r*5es< dise*se
#,7
.
3.#. $ature linical ourse of Gestational Transient
Hyperthyroidism
:n wo!en with h(pere!esis r*5id*ru! *nd est*tion*l
tr*nsient h(perth(roidis!, the onset o' n*use* is usu*ll(
within the $ est*tion*l wee/s, worsens b( the Cth
est*tion*l wee/ *nd co!pletel( resol5es b( 20
th

est*tion*l wee/. 6he seru! 6$ is usu*ll( nor!*li1ed b(
1=
th
est*tion*l wee/, but seru! 6+- !*( re!*in
suppressed until the end o' second tri!ester
1,$
. 9o
sini'ic*nt obstetric*l co!plic*tions h*d been 'ound *!on
these wo!en, but the in'*nts born h*5e lower birth weiht
co!p*red to nor!*l in'*nts
#
.
%. Conclusion
:n conclusion, est*tion*l tr*nsient h(perth(roidis! is *
tr*nsient pheno!enon which resol5es itsel' b( 20
th

est*tion*l wee/. 6here'ore, 06H tre*t!ent is not indic*ted
unless the di*nosis is uncert*in. +upporti5e !*n*e!ent
is the reco!!ended tre*t!ent 'or h(pere!esis r*5id*ru!,
*nd hospit*li1*tion !*( be re>uired in se5ere c*ses. 6he
!*in !ess*e o' this c*se report is th*t the reco!!ended
!*n*e!ent o' p*tients with h(pere!esis r*5id*ru!
co!plic*ted with est*tion*l tr*nsient h(perth(roidis!
should be supporti5e !*n*e!ent onl( *nd 06H tre*t!ent
is unnecess*r( *s the tr*nsient pheno!enon o'
h(perth(roidis! in pren*nc( resol5es itsel'.
Author0s Contribution
6his c*se report w*s co!pleted in coll*bor*tion between
both *uthors: )he*u 3ei )hin *thered in'or!*tion
re*rdin the p*tient, obt*ined consent 'ro! the p*tient *nd
written the 'irst *nd 'in*l dr*'t o' the c*se report, while Hr.
0(e 0(e ,(int sh*red the liter*ture re5iews *nd *d5ised on
proo're*din. .oth *uthors h*5e *ppro5ed the 'in*l dr*'t. 3e
would *lso li/e to th*n/ the Hirector 4ener*l o' -e*lth
,*l*(si* 'or per!ission to publish this p*per.
Consent
)onsent 'or public*tion h*s been obt*ined 'ro! the
p*tient.
Com"etin& Interests
.oth *uthors h*5e decl*red th*t no co!petin interest w*s
present.

!e#erences
I1J 6*n, K.A, Aoh, L.)., Keo, +.-. et *l. 6r*nsient
h(perth(roidis! o' h(pere!esis r*5id*ru!. .&O4: *n
:ntern*tion*l &ourn*l o' Obstetrics *nd 4(n*ecolo(. &une
2002; 10C: #%3D#%%.
I2J 9*use* *nd 5o!itin in pren*nc(. G.+)O H(n*,ed
website. 05*il*ble *t: https://d(n*!ed.ebscohost.co!.
?pd*ted 100pr 2013. 0ccessed &une 20, 2013.
10 )he*u 3ei, )hin et al.: -(pere!esis 4r*5id*ru! *nd 4est*tion*l 6r*nsient -(perth(roidis!: 0 )*se 7eport

I3J 4old!*n, 0.,., *nd ,est!*n, &.-. 6r*nsient
9on-0utoi!!une -(perth(roidis! o' G*rl( Pren*nc(.
&ourn*l o' 6h(roid 7ese*rch. 2011; 2011: 1$2$13.
I$J &ore -. ,est!*n. 6h(roid *nd P*r*th(roid Hise*ses in
Pren*nc(. 4*bbe: Obstetrics: 9or!*l *nd Proble!
Pren*ncies, #th ed. )-0P6G7 $0;C2C-C33
I=J K*1bec/, ).B. *nd +ulli5*n, +.H. 6h(roid Hisorders durin
Pren*nc(. ,edic*l )linics o' 9orth 0!eric* 2012; C#:2,
23=-2=#.
I#J Bit1p*tric/ H.A., *nd 7ussel ,.0. Hi*nosis *nd
!*n*e!ent o' th(roid dise*se in pren*nc(. Obstet
4(necol )lin 9orth 0! 2010; 37:173-C3.
I7J )(nthi*B. K*1bec/, ,H, +h*nnon H. +ulli5*n, ,H,
PhH.6h(roid Hisorders Hurin pren*nc(.,edic*l )linics
o' 9orth 0!eric* - 8olu!e C#, :ssue 2 .