Carbimazole-Resistant Graves' Disease in Pregnancy Successfully Managed with the Addition of Steroids in a Rural Kenyan Hospital

Graves' disease (GD) affects 0.1-0.4% of pregnancies and is associated with increased risks of maternal and fetal complications, including fetal hyperthyroidism, low birth weight, stillbirth, maternal hypertension and preeclampsia, atrial fibrillation, and heart failure.To achieve and maintain a euthyroid state, antithyroid drugs (ATDs) are used, specifically propylthiouracil in the first trimester and carbimazole (methimazole) in the later trimesters.Resistant GD happens when hyperthyroidism continues clinically and biochemically despite the maximum ATD doses, often due to poor adherence, drug malabsorption, or rapid drug metabolism.In pregnancy, a euthyroid state must be achieved before definitive treatment by surgery or by use of radioactive iodine much later after pregnancy and lactation in select patients.Steroids, cholestyramine, and iopanoic acid may be added to the ATDs to achieve a euthyroid state in resistant GD.In this study, we report on the successful addition of prednisone 20 mg daily to a carbimazole-resistant GD in a pregnant Kenyan woman in the second trimester.Her thyroid profile normalized in two weeks, and the steroid was withdrawn.She remained euthyroid until a successful vaginal delivery of twin boys.The case highlights the challenges in diagnosing and managing resistant GD in pregnancy.