Critical Care Obstetrics part 45 provides expert clinical guidance throughout on how you can maximize the chances of your patient and her baby surviving trauma. In this stimulating text, internationally recognized experts guide you through the most challenging situations you as an obstetrician are likely to face, enabling you to skillfully:Recognize conditions early-on which might prove life threatening, Implement immediate life-saving treatments in emergency situations, Maximize the survival prospects of both the mother and her fetus | Endocrine Emergencies onset of pregnancy that the free T4 index was increased in the first trimester fell in the second and third trimester and was again increased postpartum. A fall in antimicrosomal antibodies during pregnancy and an increase postpartum was also measured in patients with Graves disease or postpartum thyroiditis 34 . For further information the reader is referred to a recent review of postpartum thyroiditis which occurs in 5-7 of patients 35 . The diagnosis of Graves disease is suggested by the presence of thyrotoxicosis ophthalmopathy a diffuse goiter dermopathy and thyroid receptor antibodies. The diagnosis is clinical and is supported by thyroid function tests thyroid receptor antibody tests are often not necessary but levels of the antibodies at 36 weeks correlate with the risk of neonatal thyrotoxicosis 36 . However pretibial dermopathy is rarely present in pregnant women and active clinical ophthalmopathy is evident in only half of patients with Graves disease 37 38 . Exophthalmos weakness of the extraocular muscles chemosis and impairment of convergence are signs of infiltrative ophthalmopathy and may remain despite normalization of thyroid hormone levels. In pregnancy the signs and symptoms of hyperthyroidism are slightly more difficult to interpret due to the normal changes that occur during gestation. Heart rate and cardiac output increase and heat intolerance nausea and weight loss are common. Thyrotoxicosis is suggested by clinical findings which include a pulse rate persistently greater than 100 that fails to decrease with Valsalva in the presence of a tremor previously mentioned signs thyroid bruit thyromegaly and mild systolic hypertension. The cardiac effects of hyperthyroidism are summarized in Table . An elevated free T4 and low serum TSH confirms the diagnosis. Clinical signs of thyrotoxicosis without elevated total or free T4 should suggest free T3 thyrotoxicosis or deficient TBG states 39 but these are much less common. .
