Background:

Hormonal changes in pregnancy can exacerbate goitre enlargement despite carbimazole therapy,

leading to airway compromise and respiratory failure. Surgical intervention is indicated for

compressive symptoms, potential malignancy, or medical therapy failure. However, factors

such as social isolation, cultural beliefs, and healthcare access disparities must also be

considered, particularly in marginalized or rural communities.

Aim:

To emphasize the need for early surgical intervention in pregnant patients with large goitres,

especially in Indigenous and rural populations, where delayed treatment may lead to lifethreatening

complications.

Case Presentation:

A 35-year-old Indigenous woman at term gestation presented with maternal collapse due to

airway obstruction and severe type 2 respiratory failure from a longstanding multinodular goitre.

She had previously deferred thyroidectomy due to social (breastfeeding her infant) and

geographical (rural residence) constraints, with surgery now planned for postpartum.

Resuscitation included nebulized adrenaline, high-flow oxygen, and airway manoeuvres. Fetal

Doppler and CTG confirmed fetal well-being.

Results:

Perimortem hysterotomy was considered, but the patient stabilized and consented to an urgent

caesarean section and thyroidectomy under general anaesthesia. Both mother and infant had an

uneventful recovery.

Discussion:

The ACOG guidelines state that indicated surgery should never be denied during pregnancy,

regardless of trimester. As clinicians, we must incorporate social, geographical, and cultural

factors into shared decision-making. Early surgical intervention, as a definitive treatment, could

have prevented this airway emergency, highlighting the importance of considering early surgery

in the management of these high-risk pregnancies.

Rushil Sharma (primary author) is an Obstetrics Gynaecology Registrar in Australia

Chaminda Jayalath (supervising author) is an Obstetrics Gynaecology Consultant Staff Specialist in

Australia