Table 3.

Management of thyroid storm in pregnant patients

	Management of thyroid storm in pregnant patients
General measures	• Admit to ICU
	• Continuous cardiac and fetal monitoring^a
	• Emergent enteral and intravenous access
	• Fluid resuscitation with crystalloids
	• Correction of electrolyte abnormalities (e.g., hypokalemia)
	• External cooling and antipyretic therapy to target euthermia (acetaminophen preferred over aspirin)
	• Search for underlying etiology
	• Avoid delivery^a
Urgent	• Antithyroid medications
	1st line – PTU 600–1000 mg loading dose followed by 200–250 mg q4h
	2nd line – MMI 20 mg q6h
	• Steroids
	Hydrocortisone (300 mg IV loading dose, then 100 mg IV q8h) (preferred over dexamethasone^a)
	• Beta blockers
	1st line—Esmolol loading dose of 250–500 μg/kg IV over 30 s, followed by an infusion at 50–100 μg/kg/minute 2nd line – Propranolol enteral (60–80 mg q4-6 h) or IV (1 mg over 10 min)
	Avoid atenolol^a
After 1 h	SSKI (5 drops or 250 mg q6-8 h) or Lugol’s iodine (10 drops or 0.5 mL q8h) (lithium carbonate contraindicatedª)
Refractory thyroid storm	• Cholestyramine 4 g q6h
	• Plasmapheresis –place patient in left lateral position to avoid IVC compression^a
	• Consider emergent thyroidectomy
After resolution	Continue PTU (if in the 1st trimester) or switch to MMI (if in the 2nd trimester)ª
After resolution	Continue to monitor for antithyroid medication toxicity

PTU Propylthiouracil, MMI Methimazole, SSKI Saturated Solution of Potassium Iodide; q every, IVC Inferior vena cava, IV Intravenous, h hours

^aSteps marked indicate the steps which are different from conventional management of thyroid storm in non-pregnant patients