OME degree of stimulation of the thyroid gland by human chorionic gonadotropin is common during early pregnancy. 1-3 When serum chorionic gonadotropin concentrations are abnormally high -for example, in women with molar pregnancies -overt hyperthyroidism may ensue. The pathophysiologic mechanism is believed to be promiscuous stimulation of the thyrotropin receptor by the excess chorionic gonadotropin. 4,5 The explanation for this stimulation is the close structural relations between chorionic gonadotropin and thyrotropin and between their receptors. 6 Hyperemesis gravidarum is characterized by excessive vomiting in early pregnancy, leading to the loss of 5 percent or more of body weight. 4 It is usually self-limited and therefore of little clinical consequence. 5,7 Some women with the disorder have high serum thyroid hormone concentrations, and a few have sufficient clinical manifestations of hyperthyroidism to warrant short-term treatment with antithyroid drugs. 8,9 Many but not all women with hyperemesis gravidarum and hyperthyroidism have high serum chorionic gonadotropin concentrations, raising the possibility that other factors contribute to the hyperthyroidism. 3,8,9 We describe a woman and her mother who had S recurrent gestational hyperthyroidism and normal serum chorionic gonadotropin concentrations. Both women were heterozygous for a missense mutation in the extracellular domain of the thyrotropin receptor. The mutant receptor was more sensitive than the wild-type receptor to chorionic gonadotropin, thus accounting for the occurrence of hyperthyroidism despite the presence of normal chorionic gonadotropin concentrations.
CASE REPORTThe proband was a 27-year-old woman who was 10 weeks' pregnant when referred for the evaluation and treatment of hyperthyroidism. This was her third pregnancy, the first and second having resulted in early miscarriage accompanied by severe nausea and vomiting. She again reported severe nausea and vomiting and had recently lost 5 kg in weight. Physical examination revealed persistent tachycardia (heart rate, 120 beats per minute), excessive sweating, and tremor of the hands. There was a small, diffuse goiter and no ophthalmopathy. Laboratory studies revealed the following values: serum thyrotropin concentration, <0.07 µU per milliliter (normal, 0.2 to 6); serum free thyroxine concentration, 4.7 ng per deciliter (60 pmol per liter; normal, 0.8 to 1.9 ng per deciliter [11 to 24 pmol per liter]); and serum triiodothyronine concentration, 605 ng per deciliter (9.77 nmol per liter; normal, 65 to 170 ng per deciliter [1.05 to 2.75 nmol per liter]). No antibodies to thyroid peroxidase or the thyrotropin receptor were detected in serum.The patient was treated with 450 mg of propylthiouracil per day for eight weeks, and the dose was then tapered to 150 mg per day. Her condition improved rapidly, and she remained clinically and biochemically euthyroid for the rest of her pregnancy. She delivered a normal girl at 38 weeks of gestation, at which time the propylthiouracil was discontinued....