Hi. I'm an ARNP who will be starting with a pt who also happens to be my best friend. I'm very concerned for her. A few years ago she had RAI for hyper and then when severely hypo. It took a couple of years to get her TSH under control. She has been unable to get pregnant for years. In jan she finally got her TSH under 1 with the previous lowest at around 4 of 5. She was pregnant in 2 months. She just miscarried at 15 weeks. Her TSH when she delivered her dead fetus after induction was over 7. I've asked a few questions and found that her TSH at initial OB visit was greater than 2.5! Her OB told her that level was fine and never even increased her meds. She was on 150 or 175 mcg of synthroid and 5mcg of cytomel. Her endo told her prior to pregnancy she couldn't take cytomel if pregnant so she quit her cytomel. Anyway she feels its not safe to get pregnant or that she won't be able to carry to term. I feel that she could! Am I wrong? If her thyroid is managed appropriately such as continuing all of her meds, immediate increase in meds and frequent level checks with adjustments, she could right? By the way in the entire 15 weeks she had one TSH check and I don't believe her free T's were ever checked! Also would you recommend in the mean time while getting her thyroid back under control decreasing her synthroid and increasing her cytomel as long as the free T's permit to allow more adjustment room in the future if she chooses to become pregnant again? Thank you for your help. I'm actually hoping to convince her to join your group as my twin with hashimotos did and was monitored well during pregnancy :)
Would manage with brand T4 only without cytomel while trying to conceive or pregnant. Target TSH is 0.3-2.5 usually during this time. Free or Total T4 can be followed (perhaps total is more accurate and the reference range should be adjusted upwards by 50% if the lab does not list pregnant T4 ranges -- this is due to TBG increase) however TSH is most important. With h/o what sounds like Graves, TSH-Receptor antibodies should be tested at 24-28 weeks to assess risk for neonatal graves (increased if >3-5x upper normal). From thyroid standpoint, she should be able to decrease her miscarriage (etc) risks signficantly w/ proper management.
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