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Thyroid Nodules and Thyroid Cancer 44 Box 6. Management of Uncontrollable Hyperthyroidism and Thyroid Storm in Pregnancy For the treatment of decompensated hyperthyroidism during pregnancy, the same principles would apply as for other emergencies during pregnancy. For any therapeutic decision with a complex fetal/maternal trade-off, the health of the mother should be prioritized to safeguard maternal health and to optimize fetal outcomes considering their interconnected health status. Clinicians should consult with or refer patients to centers experienced in managing thyroid storm during pregnancy and closely collaborate with obstetricians and neonatologists. • Propranolol should be the first beta-blocker of choice to be used to control maternal hyperadrenergic symptoms of hyperthyroidism, while closely monitoring the fetal risks of maternal beta-blockade. • Thyroid surgery may be needed for severe cases. Although there are no data regarding the safety of SSKI therapy for the preparation for thyroidectomy in pregnancy and excess iodine is generally avoided in pregnancy (as iodide crosses the placenta [Figure 2], increasing the risk of neonatal goiter), short-term preoperative use or in the treatment of thyroid storm is unlikely to cause harm to the fetus. From limited data, long-term potassium iodide has been described as an alternative option for the management of Graves' disease in iodine sufficient populations, particularly if there is a higher risk or contraindications (i.e., allergies) to the usual therapies. • Measurement of thyroid function tests may be performed approximately every 2 days to ensure a favorable trajectory. While optimal serum TSH and thyroid hormones concentrations are not well defined in this circumstance, failure of thyroid hormones to decrease and worsening clinical status could be considered indications to increase treatment doses and/or consider additional treatment options. Recommendations Table 20. Autonomous Thyroid Nodules Preconception Strength * Level # Overt hyperthyroidism arising from autonomous thyroid nodules in women desiring pregnancy should be treated preconception, either surgically, with focal ablation, or with I-131. a Good Practice Statement Pregnancy should be avoided for at least 6 months following I-131 treatment of autonomous thyroid nodules. Good Practice Statement During pregnancy Strength * Level # Women with overt hyperthyroidism arising from autonomous thyroid nodules during pregnancy should be treated with ATD therapy, targeting a FT4 concentration at or slightly above the upper third of the reference interval. For T3-predominant secreting thyroid nodules, the treatment target is a total or free T3 at or slightly above the upper limit of the reference interval. Good Practice Statement a e decision regarding surgical or I-131 treatment can depend upon patient preferences including the timing of trying to conceive and risks of complications. Definitive treatment in the preconception phase is important in order to mitigate the risks associated with maternal hyperthyroidism and ATD exposure during pregnancy. * Strength of Recommendation; # Level of Evidence; Good Practice Statement.

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