ABSTRACT
Case Presentation: A 22-year-old primiparous woman presented at 32 weeks gestation with pre-eclampsia and pre-term labour. She underwent an emergency C-section at 33+1 weeks and suffered a cardiac arrest post-delivery. She was transferred to ITU following return of spontaneous circulation and required ventilatory support, magnesium infusion and antihypertensive therapy. She was also found to be hypoxic due to COVID-19 pneumonitis and was started on Dexamethasone and antibiotics. She made a rapid and uneventful recovery. Prior to discharge, she was noted to be thyrotoxic with a Free T4 of 75.3 pmol/L and TSH of less than 0.01 mU/L. She was started on Carbimazole and Prednisolone (to cover for COVID-related thyroiditis). She remained on Labetalol for hypertension management. Outpatient endocrinology follow-up was arranged. Six weeks after discharge, she re-presented moribund in cardiogenic shock and was transferred to a cardiac centre. Investigations: Free T4 > 100 pmol/L, TSH < 0.01 mU/L, TSH receptor Ab 3.33 iU/L. NM thyroid uptake scan: symmetrical and increased uptake consistent with Graves’ disease. CXR: Cardiomegaly with upper lobe diversion. Echocardiogram: Severely dilated left ventricle with severe global dysfunction, increased pulmonary artery pressure and LV thrombus. Cardiac MRI: Moderate-to-severe dilatation of all cardiac chambers with hypertrophy, indicating a degree of chronicity. Progress: She was intubated and ventilated and started on Propylthiouracil, Esmolol and Hydrocortisone infusion. She was also started on prognostic heart failure medication and anticoagulation therapy. She made a good recovery and her thyroid function tests improved rapidly (Free T4 29.2 pmol/L and TSH < 0.01 mU/L) within 1 week of admission. She was weaned off steroids and switched from Propylthiouracil to Carbimazole on discharge. Conclusion: The working diagnosis is that of a multifactorial post-partum cardiomyopathy worsened by concurrent uncontrolled thyrotoxicosis. It is likely that immunomodulation during pregnancy was “protective” against Graves’ thyrotoxicosis and worsened post-partum. Written consent to publish had been obtained from the patient.
ABSTRACT
Introduction: Diabetes is an established risk factor for poor outcome in COVID-19. Additionally, the pandemic has resulted in patients delaying hospital attendance with emergencies such as diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state (HHS). We examined adult admissions for hyperglycaemic emergencies to Newham University Hospital during the first and second COVID-19 waves. Results: 38 adults presented in wave ( March to 3 May 2020): DKA, 4 HHS, 3 mixed DKA/HHS. Median age was 62 years and 58% were male. 63% were Afro-Caribbean,13% Caucasian,11% Asian. 68% had known T2DM, 6% known TDM and 6% newly diagnosed diabetes. Mean BMI was 27.3 kg/m2, mean HbA1c (within one year) was 90.6 mmol/mol. 6 patients (42%) had PCR-confirmed COVID-19 on admission. In wave 2 ( November 2020 to 28 February 202) 59 adults presented: 34 DKA, 2 HHS, 3 mixed DKA/HHS. Median age was 55 years and 6 % were male. 39% were Afro-Caribbean, 27% Caucasian, 7 % Asian. 6 % had known T2DM, 29% known TDM and 0% newly diagnosed diabetes. Mean BMI was 27.9 kg/m2, mean HbA1c was 96 mmol/mol. 8 patients (3%) had PCR-confirmed COVID-19 on admission. In both waves most patients were male, had T2DM with poor pre-admission glycaemic control and most were overweight/obese. Mixed DKA/HHS was unusually prevalent. During wave 2, patients were younger, COVID-19 was less frequent, more patients with TDM were admitted, when DKA predominated and only two patients with TDM had COVID-19. Hyperglycaemic emergency admissions differed between the two waves, with wave 2 seeing increased TDM admissions and more presentations independent of COVID-19 . Discussion: Better understanding of factors underlying these presentations could help to improve patient support during this time.