The relationship between maternal Graves’ disease and neonatal hyperthyroidism is well established. Maternal Thyroid Receptor Antibodies (TRABs) over 3 times the upper limit of normal can result in fetal and subsequent neonatal hyperthyroidism, causing significant morbidity and mortality. As this is not detected on Guthrie testing (which, being designed for congenital hypothyroidism, tests only Thyroid Stimulating Hormone), complete thyroid function testing (TFTs) is imperative for at-risk neonates.
In 2016 at the ESA ASM, we presented a case of missed neonatal hyperthyroidism after such testing was not undertaken.
This case prompted our implementation of a Graves’ disease alert sticker in January 2015, to highlight relevant medical files where complete neonatal TFTs are indicated. We audited this intervention and now present the results.
Obstetric patients with Graves’ disease attending our Endocrinology in Pregnancy Clinic between January 2011 and June 2016 were identified from medical records. Neonates of patients with TRAB titres above 5 IU/L after 16 weeks were evaluated for whether follow-up TFTs were performed at birth, day 2-7 and day 10-14. Comparison was made of data before and after the intervention.
Prior to implementing the Graves’ disease alert sticker, of three patients with TRAB titres above 5 IU/L, only one neonate received full TFTs at birth, 2-7 days and 10-14 days post-delivery. Another had TFTs done at birth, while the remaining neonate did not have any TFTs performed. Post implementation, of three patients with TRAB titres above 5 IU/L, three neonates had complete TFTs at birth, 2-7 days and 10-14 days post-delivery.
Following introduction of a Graves’ disease alert sticker all at-risk neonates have undergone complete TFTs. We appeal to other centres to trial a similar approach. Looking forward, introduction of the electronic medical record may facilitate such endeavours; and will require auditing in due course.