Subclinical hypothyroidism unmasked by preeclampsia and ascites
The patient was a 39-year-old G4P2 +1 at GA29 +3 who was referred to our center from a private hospital. She presented on account of poorly controlled hypertension, generalized edema, and deranged thyroid function test (TFT). She was admitted to the Obstetrics Department with a blood pressure (BP) of 210/130 mmHg from the referring hospital. There was a history of headache and generalized body swelling of a month's duration but no history of proteinuria. There was no history of seizures or previous history of pregnancy induced hypertension. The diagnosis at admission was severe preeclampsia with intrauterine growth restriction and anhydraminios. She was commenced on intravenous magnesium sulfate and oral antihypertensives.\nEndocrinology review was requested on the same day on account of a deranged TFT result from the referring hospital []. Patient had a TFT done because she was noticed to have an anterior neck swelling at a gestational age of 24 weeks. There was also a history of anterior neck swelling 6 years before presentation which had resolved spontaneously. There were no symptoms suggestive of hypothyroidism or hyperthyroidism in the past or at the time of review neither was there goiter at presentation.\nExamination revealed a conscious young woman who was not pale, anciteric, and acyanosed with periorbital edema and bilateral pitting pedal edema up to the knee. There was no anterior neck swelling. Pulse rate was 84 beats per min, BP was 140/100 mmHg, jugular venous pulse was not raised, and heart sounds were 1 and 2 only. The abdomen was distended with gross ascites demonstrable and uterus was difficult to palpate.\nObstetric ultrasound scan confirmed maternal ascites and anhydramnios with the fetus compressed. There was gross ascites of 2 litres with kidneys and liver being normal in size and echogenicity. No intra-abdominal mass lesion was seen. Intrauterine fetal death was confirmed and the patient was delivered of a macerated stillbirth following induction of labor. Broad spectrum antibiotics were added while urinary protein, her weight, and vital signs were monitored closely.\nReexamination on the third postpartum day revealed generalized edema, generalized sluggishness, slurred speech, and gross ascites. Blood pressure remained elevated and was managed with oral nifedipine retard and alpha methyldopa while diuretics (frusemide and aldactone) were prescribed for generalized edema and ascites. Investigations in the course of admission are reported in []. Ascitc fluid was exudative.\nShe had a repeat TFT, 6 weeks after the first, which was still in keeping with subclinical hypothyroidism []. She was subsequently commenced on levothyroxine at 100 μg per day. Follow-up reviews showed marked reduction in abdominal girth and weight despite significant reduction in the dosage of diuretics prescribed [].\nShe was discharged home on the 20th day of admission with no pedal edema and minimal ascites. Medications at discharge included oral levothyroxine 100 μg daily, nifedipine 40 mg b.d, alpha-methyldopa 500 mg b.d and slow k on account of persistent hypokalemia.\nShe was reviewed at the medical outpatient clinic 34 days after discharge with history of poor adherence to her medications for a few days prior to that visit and poor BP control. Ascites had completely resolved clinically and radiologically, while TFT result showed reduction in TSH value. She however did not return for follow-up visits.