A 32-year-old Caucasian was admitted at 14 weeks of gestation with
hypotension and
weight loss. Family members noted that she appeared "tired" prior to pregnancy Past medical history included
primary hypothyroidism treated with
thyroxine (100 microg/day). She had a healthy daughter aged 2.5 years who had been born small for gestational age. At about 8 weeks of gestation she started to vomit several times a day. She was treated with
antiemetics and intravenous fluids. Following discharge she remained nauseated, weak and lightheaded and lost about 8 kg of weight. After readmission she appeared ill and dehydrated, BMI 16.6 kg/m2, BP 90/60 mmHg supine, 70/50 mmHg upright (with faint-like sensation), normal heart sounds, chest clinically clear, abdomen soft and not tender Investigations revealed severe hyponatraemia (
sodium 112 mmol/L), normal
potassium level 4.3 mmol/L, normal renal function, TSH 1.31 microIU/mL (reference range (RR): 0.27-4.2), freeT4 1.99 ng/dL (RR: 0.93-1.7), freeT3 3.29 pg/mL (RR: 2.57-4.43), anti-TPO
antibodies 467 IU/mL (RR: <34)). She was hyperpigmented, hypotensive and hyponatraemic despite
rehydration.
Cortisol &
ACTH, followed by a 250 microg short Synacthen test were requested and revealed peak
cortisol response of 17 nmol/L (RR: above 550 nmol/l) as well as high baseline
ACTH (969 pg/mL, RR: 0-46 pg/mL). She was started on
hydrocortisone and felt tremendously better A diagnosis of
Addisons disease was made (in view of
hypothyroidism as a part of
Autoimmune Polyglandular Syndrome type II). She was discharged on
hydrocortisone and
fludrocortisone replacement. Further during her pregnancy there was about two-week foetal growth delay. She, however delivered a healthy female infant at 36 weeks of gestation.
CONCLUSIONS: