Myxedematous coma in a laboring woman suggested a pre-eclamptic coma: a case report

Acta Obstet Gynecol Scand 2004: 83: 1089--1096 Printed in Denmark. All rights reserved

Copyright # Acta Obstet Gynecol Scand 2004

Acta Obstetricia et Gynecologica Scandinavica

CASE REPORT

Myxedematous coma in a laboring woman suggested a pre-eclamptic coma: a case report ¨ . TURHAN1, MUHAMMET C. KOC¸KAR AND ´ILKNUR NILGU¨N O 2 ´INEGO¨L From the Departments of 1Obstetrics and Gynecology and 2 Internal Medicine, Fatih University School of Medicine, Ankara, Turkey Acta Obstet Gynecol Scand 2004; 83: 1089–1091. # Acta Obstet Gynecol Scand 83 2004 Myxedematous coma in pregnancy is a rare incident. We present a case of Myxedematous coma in a laboring woman that suggested a pre-eclamptic coma and finalized with a healthy baby. Key words: Myxedematous coma, pre-eclampsia, pregnancy Submitted 24 June, 2002 Accepted 21 November, 2002

Myxedema in pregnancy is rare, as it is often accompanied by menstrual disorders and loss of libido, which lower fertility and a high rate of fetal loss in the first trimester (1). In 1963, Echt and Doss (2) reviewed the literature from 1897 to 1960 and found 29 cases, adding three of their own. Searching the literature from 1963 to 2001, we found only six cases of myxedema in association with pregnancy (3–7). Awareness of the differential diagnosis of myxedematous coma with other comateous conditions in pregnancy is an inevitable necessity both for maternal and neonatal wellbeing.

Case report A 26-year-old spontaneously laboring primigravid woman was admitted to our hospital in lack of consciousness. A more thorough evaluation revealed dry and cool skin, coarse hair, swelling of both hands and face, periorbital edema, large tongue, clear prolongation of the recovery phase of the knee, and ankle jerks. Blood pressure was 110/70 mmHg, pulse 60/min and temperature 350
. Hypoventilation was present (10 breaths/min).

She was in the 40th week of gestation according to her last menstruation. Her pelvic examination revealed a cervical dilatation of 3 cm and percentage 60 effacement. On ultrasonographic control, the fetus was in concordance with the 37th gestational age. Ablatio placentae and/or placentae previa were not observed. One hour later, after close monitorization of vital functions, strict bed rest, hydration and nasal oxygen therapy, the patient was conscious and had an uncomplicated delivery of a 2565-g 47-cm living female infant. Apgar scores were 8–9 at the 1st and 5th minutes, respectively. No congenital abnormality, goiter or any thyroid dysfunction was observed in the newborn infant. After delivery, history revealed that she had been taking L-thyroxine for a ‘goiter’ since 1996 and had not received any prenatal care in her pregnancy. She stated that she had taken the medication before but not during her pregnancy. Discontinuation of the medication was voluntary. She stated that the last time she had taken any thyroid medication was 9 months previous, and during her pregnancy she had noticed lassitude and weakness. Laboratory studies at the time of the admission included hemoglobin 10.5 g/dl, hematocrite 32.3%, mean corpuscular volume 91.2 fl, white blood cell count 8.5  109/l, platelet count 189  109/l, total serum protein 6.2 g/dl albumin 3.14 g/dl, and the urine specimen was found to be normal [urinary protein in 24 h was 15 pg/dl (normal ranges: 10–1001, density was 1016 and free cortizol was in the normal range)]. Electrolytes, blood glucose level, SGOT, SGPT, ACTH levels and urea were in normal ranges. Serum iron level and serum iron binding capacity were normal at 101 mg/dl and 321 mg/dl, respectively. The ferritin level was depressed at 9.25 ng/ml. Serum folate and B12 levels were normal. Maternal thyroid hormone and thyroid antibody levels are given in Table I. The thyroid ultrasonography revealed that the gland was heterogen, no nodule was established and the dimensions were 33  11  18 mm. In the fine needle aspiration, Hurthle cells were seen that were related to Hashimoto thyroiditis. Laboratory studies of the infant included a FT3 (free T3) level of 4.4 pg./dl, a FT4 (free T4) level of 3.7 pmol/l and a TSH level of 2.9 mU/ml, which were all in normal ranges. There was no thyroid antibodies demonstrable (AntiM: 0.15 IU/ml, AntiTg: 30 IU/ml). The infant required no thyroid medication. Nine months after the delivery, the mental and physical development of the child was found to be normal.

Conclusions Clinical hypothyroidism is a rare complication of pregnancy, as most untreated hypothyroid women are infertile as a result of a high prevalence of anovulatory cycles (> 70%). Untreated hypothyroid women have increased risk for

Table I. Maternal thyroid hormone levels and thyroid antibodies FT3 pgr/ml (1.5–4.1) Initial examination 6 months after admission