Undiagnosed Hypothyroidism in Pregnancy Leading to Myxedema Coma in labor: Diagnosing and managing this rare Emergency Nilanchali Singh * , Reva Tripathi, Mala YM and Divya Verma Department of Obstetrics and Gynaecology, Maulana Azad Medical College & assoc. Lok Nayak Hospital, New Delhi, India *Corresponding author: Nilanchali Singh, Department of Obstetrics and Gynaecology, Maulana Azad Medical College & assoc. Lok Nayak Hospital, New Delhi, India, Tel: 919811343168, E-mail: nilanchalisingh@gmail.com Received date: Jan 27, 2016; Accepted date: Apr 28, 2016; Published date: Apr 30, 2016 Copyright: © 2016 Singh N, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abstract Myxedema crisis is an extreme complication of uncontrolled hypothyroidism. It is usually seen in elderly women with undiagnosed hypothyroidism and is rare among young. There have been very few reports of myxedema coma in labor. This report pertains to a case of undiagnosed hypothyroidism in a 30 year old lady with twin pregnancy which led to hypothyroidism crisis during labor. Levothyroxine 100 microgram was given by Ryle’s tube followed by 8 hourly doses till total dose of 900 microgram. Rapid and robust correction of hypothyroidism led to successful treatment outcome. Treatment requires a rapidly administered oral or parenteral loading dose and high maintenance doses of levothyroxine. She delivered vaginally and both the babies were fine. Maintenance dose of 100 ugm of levothyroxine was started and patient was discharged after 15 days of delivery with an advice of 100 micrograms of levothyroxine daily. Introduction Myxedema crisis is a potentially fatal complication of uncontrolled hypothyroidism manifesting as progressive mental deterioration like lethargy, stupor, delirium, or coma and multiple organ abnormalities. Diagnosis of this rare phenomenon is hampered by its insidious onset. It usually occurs when precipitating factors like infection, illness, drugs, labour and delivery etc weaken the compensatory responses. Despite appropriate treatment, mortality ranges between 30 to 50 percent; more so in pregnancy. Myxedema coma is usually seen in elderly women with undiagnosed hypothyroidism and is rare among young. Tere have been very few reports of myxedema coma in labor [1] We are reporting a case of hypothyroid crisis during labor in a 30 year old pregnant lady. Case A 30 years old unbooked primigravida with 37 weeks gestation and twin pregnancy presented with gross pedal edema and borderline high blood pressure. She belonged to low socio-economic strata and had no previous antenatal visits. On examination she had facial pufness, dry skin, gross pedal edema, blood pressure of 136/90 mm of Hg. Urine albumin was not detectable. Due to her borderline high blood pressure records and gross pedal edema she was investigated on lines of gestational hypertension. Her kidney and liver function tests were normal. She had mild anemia of normocytic normochromic type. 24-hour urinary protein was 290 mg. She had TSH level of 51.53 µIU/ml, T3 level of 4 ng/dl, T4 level of 4.1 and anti thyroperoxidase antibody > 1300 IU/ml. She had a normal renal ultrasound and venous doppler of lower limbs. Patient was started on levothyroxine 75 microgram daily. Afer six days of admission her blood pressure shoot to 160/106 mm Hg and she was induced with intracervical prostaglandin E2 gel in view of term pregnancy with gestational hypertension. Her blood pressure was within normal limits and urine albumin was nil throughout labor. But the patient’s condition deteriorated and she had altered mental status. Drop in heart rate of frst twin was noted but her relatives did not give consent for cesarean section due to high risk of anaesthetic complications associated with severe hypothyroidism. Te frst twin was delivered by ventouse application and second twin by assisted breech extraction. First twin was kept in neonatal intensive care unit for 15 days in view of birth asphyxia. Both the babies were fne eventually. In the postpartum period the patient deteriorated with altered mental status (Glasgow coma score of 7), bradycardia (PR = 40 to 55/ min), hypotension (Systolic BP 70 mm Hg), hypothermia (95°F), respiratory acidosis (pH = 7.3) and APACHE score II of 15. Patient was resuscitated and started on dopamine drip which was gradually tapered of later. Patient was shifed to High Dependency Unit. Endocrinologist was consulted and diagnosis of myxedema crisis was made. Levothyroxine 100 microgram was given by Ryle’s tube followed by 8 hourly doses till total dose of 900 microgram. She also received prophylactic injectable antibiotics and hydration ensured. Patient gradually responded to the treatment and improved symptomatically. Maintenance dose of 100 ugm of levothyroxine was started and patient was discharged afer 15 days of delivery with an advice of 100 micrograms of levothyroxine daily. She came for regular follow up in endocrinology clinic with signifcant improvement by 12 weeks. Discussion Myxedema coma is rare entity among pregnant women with fewer than 40 cases reported [1]. Although the prognosis of patients with myxedema coma is difcult to determine, the poor predictors of outcome, as reported in the literature, include bradycardia, persistent hypothermia, altered level of consciousness, a high APACHE II score at presentation, hypotension and need for mechanical ventilation. Obstetric guidelines recommend aggressive replacement of thyroid hormone in hypothyroid pregnant women, regardless of the degree of thyroid function, to minimize the time the fetus is exposed to a Singh et al., J Preg Child Health 2016, 3:2 DOI: 10.4172/2376-127X.1000247 Short Communication Open Access J Preg Child Health ISSN:2376-127X JPCH, an open access journal Volume 3 • Issue 2 • 1000247 Journal of Pregnancy and Child Health J o u r n a l o f P r e g n a n c y a n d C h i l d H e a l t h ISSN: 2376-127X