Recurrent Abortion in Multigravid Type 1 Diabetes Mellitus Woman With Subclinical Hypothyroidism Hashimoto’s Thyroiditis and Antiphospholipid Syndrome as a Manifestation of Type III Autoimmune Polyglandular Syndrome: A Case Report

Abstract

Recurrent Abortion in Multigravid Type 1 Diabetes Mellitus Woman With Subclinical Hypothyroidism Hashimoto’s Thyroiditis and Antiphospholipid Syndrome as a Manifestation of Type III Autoimmune Polyglandular Syndrome: A Case Report Background: Type 1 Diabetes Mellitus, Antiphospholipid Syndrome, and autoimmune thyroid disease such as Hashimoto’s Thyroiditis had been reported for increasing risk of miscarriages. Meanwhile, the type III Autoimmune Polyglandular Syndrome comprises of autoimmune hypothyroidism and immune mediated diabetes mellitus. Here we report a manifestation of the syndrome presented as a recurrent pregnancy loss in newly diagnosed subclinical hypothyroidism phase of Hashimoto’s Thyroiditis and Antiphospholipid Syndrome, in multigravid woman with long standing Type 1 Diabetes Mellitus. Clinical Case: A 31 years old woman, 20 weeks pregnant, with previously known Type 1 Diabetes Mellitus since the age of 11 years old, came to the Emergency Room with diabetic ketoacidosis. She complained of having nausea, vomiting, and diarrhea two days before hospital admission. She also had history of six spontaneous abortions which all occurred at below 20 weeks of gestation, but no further examination was done to find the cause. The patient was examined with fetal ultrasound and showed good fetal condition, fetal heart rate 143 bpm, estimated fetal weight 562 grams, polyhidramnion, and single umbilical artery. The patient denied any symptoms regarding hair loss, cold intolerence, slow movement, slow speech, or constipation. From physical examination, we found normal vital signs, no abnormalities in thyroid physical examination, but dry hyperpigmented skin in both legs. The patient was examined for thyroid function and found elevated TSH (5.625 IU/mL, n = 0,48 - 4,17 mIU/L) and normal free T4 (1,3 ng/dL, n = 0,89 - 1,76 ng/dL). The TPO antibody was 549,59 IU/mL (n<5.61 IU/mL) and lupus anticoagulant was weakly positive (1.2 - 2.5, n<1.2). The patient was finally diagnosed as Hashimoto’s Thyroiditis and Antiphospholipid Syndrome, which was unrecognized at previous medical care, and in addition to previously known Diabetes Mellitus Type 1 could be manifested as Type III Autoimmune Polyglandular Syndrome. The likely cause of recurrent pregnancy loss in this case could be the Hashimoto’s Thyroiditis and Antiphospholipid Syndrome. Conclusion: Type III Autoimmune Polyglandular Syndrome could be manifested as recurrent pregnancy loss in patient with Type 1 Diabetes Mellitus, therefore the examination of thyroid function and other autoimmune disease such as Antiphospholipid Syndrome should be conducted.