A 31-year-old nulliparous woman presented to the respiratory physicians with a 3-month history of abdominal distension, weight loss, increasing shortness of breath and change in bowel habit. On examination she was frail and thin with signs of massive right-sided pleural effusion and ascites. This was confirmed on ultrasound scan and computed tomography (CT) scan which also revealed a simple left adnexal cyst. Tumour markers were negative. As the pleural effusion recurred after drainage, a laparotomy was done to exclude ovarian malignancy and this revealed grade 3 to 4 endometriosis. She declined medical or surgical management of her endometriosis despite recurring pleural effusions.
Description of the case: 25 year old lady with auto-immune hyperthyroidism (TRAb>400) was treated with Propranolol and Carbimazole and referred to the Endocrine clinic. She was started on Block and replace therapy. She was soon moved over to Propylthiouracil as she was contemplating pregnancy. She became hypothyroid within 3 months and anti-thyroid therapy was stopped. In another 2 months she required thyroxine replacement. 3 months later, her TSH started to drop and by 12 months, she was found to be hyperthyroid and Carbimazole was started. 2 months later, she was found to be pregnant and was again changed to PTU. During the rest of her pregnancy, her FT3 remained high, FT4 -normal with TSH undetectable, despite treatment with PTU 300 mg bd with regular counselling. She delivered a healthy but hyperthyroid baby (FT4: 64, FT3: 31.3, TSH<0.001, TRAb > 400) of birthweight 3150 grams at 37 weeks +1 day of gestation. Mum's TFTs 1 day postnatal were still in the hyperthyroid state, but when checked after 5 weeks, showed features of hypothyroidism with TSH 9.11. Her PTU was then reduced to 100 mg/day, but she became grossly hypothyroid in 2 months, needing Thyroxine replacement. Within further 2 months, her hyperthyroidism flared up again and is currently being managed by block & replace regimen. The infant is now being treated with Carbimazole and is euthyroid.
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