Neonatal Graves’ disease from high maternal TRAB antibody levels despite definitive therapy

Graves’ disease is an autoimmune thyroid disorder that poses significant risks during pregnancy, affecting both the mother and fetus. We present four cases of neonatal Graves’ disease arising in the offspring of two women treated for Graves’ disease, highlighting the disease's transient but potentially severe impact on newborns. In the first case, the pregnant woman underwent a total thyroidectomy during the second trimester, whereas in the second case, the patient had Graves’ disease and was treated with radioactive iodine six years prior. Both women demonstrated a very high level of thyrotropin receptor antibodies (TRAb) during pregnancy. These cases underline the necessity of vigilant monitoring of TRAb levels in pregnant women with a history of Graves’ disease, regardless of previous treatment or current euthyroid status. This approach aims to facilitate early detection and treatment of neonatal Graves’ disease, mitigating its impact on growth and development. Our findings support recommendations for baseline and mid-gestation TRAb testing in this population, as well as immediate postnatal testing for neonates born to mothers with active or inactive Graves’ disease. Teaching Points: • Elevated TRAb at 20-24 weeks needs a multidisciplinary team for optimal care. • Thyroidectomy/RAI does not eliminate neonatal GD risk if maternal TRAb remains high. • GD pregnancies, even if euthyroid, require careful TRAb level monitoring. • Low maternal TRAb levels lower neonatal GD risk in pregnancy with GD history. • Early NG detection and care are crucial to support growth and development. Clinical Relevance: This paper highlights the importance of TRAb monitoring in pregnant patients with GD post-definitive therapy, even when in euthyroid state. Monitoring can help early detection and management of neonatal GD and improve outcomes. Increased awareness among healthcare providers enhances comprehensive maternal and neonatal management in the setting of maternal history of GD.