We report a case of a female patient who initially presented aged 35 yr with shortness of breath and type 2 respiratory failure at 12 weeks of her pregnancy. She was previously known to have a multinodular goitre under another hospital, which had been stable for several years, and had no other medical problems. Clinically and biochemically she was euthyroid (free T4 12.6 pmol/L [11.023.3], TSH 0.42 mu/L) and there were no signs of obstruction. An ultrasound scan showed a 8.5 cm multinodular thyroid gland with no tracheal compression. She was treated on ITU initially for pulmonary oedema, but then for pneumonia and improved dramatically. It was felt the presentation was unrelated to the goitre and she was discharged four days later with early follow-up at her previous hospital. Twenty-six weeks into pregnancy she presented with a cardiac arrest. A post mortem was performed which showed a benign 9 cm thyroid gland that weighed 210 grams, which was mainly suprasternal. The trachea was narrowed, but unobstructed; size 17 mm anterior to posterior and 9 mm left to right. However, marked pulmonary oedema was found with no focal lung abnormalities and a normal cardiac size. Pulmonary oedema secondary to upper airways compression is a recognised phenomenon related to marked negative intrathoracic pressure, due to forced inspiration against a closed upper airway, resulting in transudation of fluid from pulmonary capillaries to the interstitium1. It has been reported in the context of a thyroid goitre causing significant tracheal compression2, however our case is unusual as there was no significant trachea involvement. In summary we present a 35 yr old female who died in pregnancy from pulmonary oedema which was most likely due to a large thyroid goitre, without an obvious unobstructed trachea. Our case highlights the need to closely monitor large thyroid goitres in pregnancy, even if the trachea is unobstructed.
1 Willms D, Shure D. Pulmonary edema due to upper airway obstruction in adults. Chest 1988;94:10901092.
2 Butterell H, Riley RH. Life-threatening pulmonary oedema secondary to tracheal compression. Anaesthesia and Intensive Care Journal 2002;30:804806.
Declaration of interest: There is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
Funding: No specific grant from any funding agency in the public, commercial or not-for-profit sector.