Endocrine Abstracts

Background: Hypothyroidism, if overt and untreated during pregnancy, is linked to both adverse maternal outcomes, including increased risk of miscarriage, pre-eclampsia and post-partum haemorrhage, but also to poor neonatal outcomes, including respiratory distress, low birth weight and impaired cognitive development.

Case presentation: 32-year-old diagnosed with hypothyroidism in 2007, first seen by endocrinology after her 5th pregnancy where TSH remained >130mu/l. The patient has experienced complications attributed to hypothyroidism, including pericardial effusion, renal impairment, constipation and gestational diabetes. Her eldest children require additional educational support, and her twins (born 37+5) were assessed to have developmental delay. Furthermore, one of her twins who was borderline low birth weight required NICU admission with respiratory distress and neonatal jaundice. There are complex social circumstances compounding this case, with safeguarding concerns regarding possible child neglect. She has represented during her eighth pregnancy after failed sterilisation, despite TSH 89mu/l, T4 7.0 pmol/l and T3<1.5 pmol/l. She was only taking 100 mg of expired levothyroxine once a week. Complications to her unborn child’s health were discussed, and she had capacity. Her levothyroxine dose was increased to 150mcg, with 2 months supply given directly to her. However, TSH remained raised and she was offered further support to aid compliance. A subsequent echocardiogram reported left ventricular global systolic impairment, with cardiology additionally concerned about right ventricle non-compaction due marked trabeculation. After this review, compliance improved and at 32 weeks her TSH was 6.34mu/l, T4 15.6 pmol/l and T3 3.4 pmol/l.

Discussion and learning points: This case highlights the relationship between maternal and foetal health and emphasises the importance of medication adherence and control of hypothyroidism during pregnancy. Unfortunately, this case encompasses complex medical and ethical challenges that the endocrinology team have managed with input from multiple specialties, and given the patient’s grand multiparity, the concerns extend to the impact on her unborn child’s health.