I found out this week I am pregnant (very early around 4 weeks). I had bloods tested in August and my TSH was 5.33, T3 and T4 normal.
They were going to repeat blood end of October. After speaking to 3 different GPs and a nurse they all say it's nothing to worry about as I haven't got the diagnosis of hypothyroidism (it just means i may get it in future. They also don't think it's necessary to repeat the test until October.
But am I right in saying that this would be classed as subclinical hypothyroidism? If so, I know the NICE guidelines state that I should be referred to an endocrinologist, prepregnancy or at least now that I'm pregnant.
I've had multiple miscarriages in the past and I don't know where to turn.
Thanks
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Lamyss
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I would definitely contact your GP now that you are pregnant to discuss your previous results. I would also want to be re-tested as there are recommended ranges for TSH leveks in each trimester of pregnancy, I think it is less than 2.5 for the first trimester.
I have spoke to 3 GPs since I got pregnant but all refuse to test sooner as "there's nothing to worry about". I mentioned the nice guidelines but they stated they only refer or test with diagnosed hypothyroidism.
I feel as though nobody is listening. Yesterday I was told to stop reading things online, even though the information is on guidance they should be following.
If you can afford a Private Blood Test and get a Full One, and they are home pin-prick tests. Make sure you are well-hydrated a couple of days before blood draw.
Blood draw should be at the earliest possible, fasting (you can drink water).
The fact that you've had previous miscarriages should be a red flag to doctors (you'd think so anyway) but they seem to have no knowledge except to look at the TSH result alone.
The TSH is at its highest early a.m. and drops throughout the day and can mean the difference between getting a diagnosis or not. Unfortunately, if you're in the UK, doctors have been told not to diagnose until TSH is 10+ but in other countries we'd be diagnosed if it goes above 3+ with symptoms.
You need:
TSH, T4, T3, Free T4, Free T3 and thyroid antibodies.
I think anyone who was pregnant and hypo would have the same anxiety. I have changed the sentence below to draw your attention to a particular paragraph.
1.1.2. If hypothyroidism has been diagnosed before pregnancy, we recommend adjustment of the preconception T4 dose to reach a TSH level not higher than 2.5
U/ml before pregnancy. USPSTF recommendation level is I; evidence is poor (QEEE).
1.1.3. The T4 dose usually needs to be incremented by 4–6 wk gestation and may require a 30–50% increase in dosage.USPSTF recommendation level is A; evidence is good (GRADE 1 QQQQ).
1.1.4. If overt hypothyroidism is diagnosed during pregnancy, thyroid function tests should be normalized as rapidly as possible.
The T4 dosage should be titrated to rapidly reach and thereafter maintain serum TSH concentrations of less than 2.5 U/ml in the first trimester (or 3 U/ml in the second and third trimesters) or to trimester-specific normal TSH ranges. Thyroid function tests should be remeasured within 30–40 d. USPSTF recommendation level is A; evidence is good (GRADE 1QQQQ).
1.1.5. Women with thyroid autoimmunity who are euthyroid in the early stages of pregnancy are at risk of developinghypothyroidism and should be monitored for elevation of TSH above the normal range. USPSTF recommendation level
I believe that in the USA they diagnose at a lower number than the UK, which states that doctors don't diagnose hypo until the TSH is 10 before we're diagnosed
The guidance is based on research into patients diagnosed with hypothyroidism and it is these patients that the research shows are at increased risk if their TSH is above 2.5. There's no evidence that the healthy population is at any risk if their TSH should go a little above 2.5 during pregnancy, presumably their thyroid is robust enough to cope with any minor challenges.
However, in your case you have had multiple miscarriages. Additionally patients can have impaired thyroid function before the TSH rises, for example when high antibody levels are leading to thyroid damage. Also, some patients are hypothyroid in spite of 'normal' blood tests. There are cases of women with 'normal' thyroid function tests who have only managed to conceive after receiving thyroid hormone.
Given all of the above it seems reasonable, indeed appropriate to give you some levothyroxine to bring your TSH down to around 1.0. It might make no difference, it might make the world of difference. The cost of treating you throughout your pregnancy will be less than £20 and the risk to you is virtually zero. If I were in your shoes I would press very hard for levothyroxine during your pregnancy pointing out your previous miscarriages and the distress it causes and cost to the NHS (they are concerned about money). Make sure you take your partner along for support.
I honestly don't know what your can do to convince these doctors/nurses that you are at risk. I say you are at risk as the grandmother of 4 babies who never took breath. My daughter-in-law had multiple miscarriages with no explanation until one day I recognised the signs of hypothyroidism. The GP didn't, she was referred to hospital and they wanted to put her on a trial of epilepsy drugs (!) which my d-i-l refused. Eventually she was seen by a private doctor who started her on Levothyroxine. GP didn't agree but whatever, she was paying the private doctor.
After being in hospital for a successful birth, blood tests were obviously done and beside the results for thyroid were the words "Satisfactory result for someone on Levothyroxine". At that point her GP accepted she was hypothyroid and she got her official diagnosis on the NHS and was then able to get NHS prescriptions for Levo.
This is something very close to my heart because I've seen the heartbreak that multiple miscarriages can bring.
And yes, I agree that with an over range TSH, in range FT4 and FT3, and symptoms of hypothyroidism, you should have a diagnosis of subclinical hypothyroidism, it's in the NICE Clinical Knowledge Summary
If TSH is between 4 and 10 mU/L and FT4 is within the normal range
◾In people aged less than 65 years with symptoms suggestive of hypothyroidism, consider a trial of LT4 and assess response to treatment 3–4 months after TSH stabilises within the reference range — see the section on Prescribing information for further information on initiation and titration of LT4. If there is no improvement in symptoms, stop LT4.
Refer to an endocrinology specialist all women with overt or subclinical hypothyroidism who are:
◦Planning a pregnancy
◾Check thyroid function tests (TFTs) before conception if possible.
◾If TFTs are not within the euthyroid range, advise delaying conception, until stabilised on levothyroxine (LT4) treatment — discuss with an endocrinologist if there is any uncertainty about initiation of treatment or what dose to prescribe while waiting for review.
◾Check that the woman understands that her dose of LT4 must be adjusted as early as possible in pregnancy to reduce the chance of obstetric and neonatal complications.
◾Advise the woman to seek medical advice immediately if pregnancy is suspected or a menstrual period is missed.
◦Pregnant
◾Check TFTs immediately once pregnancy is confirmed.
◾Discuss urgently with an endocrinologist regarding initiation of, or changes to, dosage of LT4 and TFT monitoring while waiting for review — trimester-specific TFT reference ranges may vary locally.
..........
Basis for recommendation
The recommendations on management of subclinical or overt hypothyroidism for women who are planning a pregnancy or pregnant are based on the clinical guidelines Management of Thyroid Dysfunction during pregnancy and postpartum
[De Groot et al, 2012]
, Clinical practice guidelines for hypothyroidism in adults
[Garber et al, 2012]
, European Thyroid Association (ETA) Guidelines for the management of subclinical hypothyroidism in pregnancy and in children
[Lazarus et al, 2014]
, Subclinical hypothyroidism in the infertile female population: a guideline
[Practice Committee of the American Society for Reproductive Medicine, 2015]
, and expert opinion in review articles
[Gaitonde et al, 2012; So et al, 2012; BMJ Best Practice, 2015a]
I think you need to take your partner to see your GP and be very assertive. Push for a referral of at the very least your doctor telephones a thyroid specialist who understands about pregnancy. I wouldn't leave the room until this was done.
Is it not scandalous that if someone has several miscarriages there's no further investigation as to the reason? It is really awful. The trepidation, too, of the next pregnancy if whether it will be a successful outcome or not so the mother-to-be has a very stressful time throughout.
Not only scandalous Shaws, but so heartbreaking for the parents. I'm going back a good few years, first miscarriage would have been 1993/94, last miscarriage was 2002. They did have 3 full term pregnancies but one of the children is on the autism spectrum which I think can be linked somehow.
The baby from the last miscarriage was carried longer than any of the others (4 and 1/2 months) and a perfect miniature baby was delivered after she'd died in the womb. To my dying day I'll never forget seeing my son carry a tiny white coffin into church to Eric Clapton's Tears in Heaven for the most heartbreaking funeral ever
It would have been heartbreaking especially when we think it could have been avoided and am sorry your other grandchild is in the autism spectrum. This is a link to a study - excerpt:
Severe hypothyroidism in the mother is associated with possible autism in their babies
Thank you so much to everyone that's replied. I have spoken to a nurse in the early pregnancy unit who didn't share my concerns but after a 30 minute phone call agreed to contact the recurrent miscarriage consultant to get some advice.
I just pray this consultant knows what they're talking about!
Waiting to get a call back this afternoon so will update then.
I do hope the doctor who deals with recurrent miscarriages will be able to help you. Sometimes our instincts work well but many professionals may think we're a bit overwrought. I hope you have success with the specialist.
hi! Congratulations on your pregnancy! I wouldn't trust a consultant or a so called thyroid specialist to know what they are talking about. This is definatley something you need to take into your own hands. I would get aprivate blood test as per the previous comments. And look at Dana trentinis website, hypothyroid mom. Xxx
So pleased you seem to be getting the care you need now Lamyss. I am sending my very best wishes for a happy, healthy pregnancy and that you deliver a healthy, beautiful baby
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