Underactive thyroid queries

[Smellyjo]

I've seen a few thyroid threads on here so know there are a few of you knowledgeable that could advise?

I got put up 25mg to 100mg daily at start of my pregnancy. Last bloods in Feb were tsh 0.7 and t4 17.4. I thought I had more bloods at 16wk appt but results at gp read me are only from booking at 9wks.

I'm now 23wks and have felt especially wiped during the last 2 weeks, so asked for more bloods this week. Today got results 0.94 tsh and 13.3 t4. Dr said normal, no action needed.

What does it mean that t4 is dropping, I had a feeling it was better to be at the higher end of the range but not sure where I got that from?

Your t4 is way too low for pregnancy, it should be in higher range. Is the Dr obstetrician? They have no clue, ask for endocrinologist referral and keep repeating how unwell you are feeling with the dose at the moment. I had similar situation and managed to see endo who agreed with me that i should be on higher dose as obstetrician reduced it from 100 to 75/100 every other day (my blood result were showing drop in t4 levels and rise in tsh which is not good in pregnancy).
Just be firm and keep asking to see endo and to have your dose increased.

Thanks for your reply. No dr is gp. I went to consultant clinic at 16 weeks and was seen by a trainee gp! Not to go back to consultant til 34 weeks and booked for an extra growth scan then. Not impressive care but my levels have been fine and I've felt fine until recently. I pushed for an endo referral at the start with no joy but left it as I felt well. Got midwife on Monday so will ask her to refer, hopefully more helpful than gp...

With underactive thyroid during pregnance you should be seen by consultant as this is way beyond gp's expertise and knowledge. I'm surprised your midwife didn't refer you before when she was taking your medical history as i was referred then. Question the midwife why gp is looking after you instead of obstetrician or endocrinologist as you should be classed as higher risk due to thyroid.

Really surprised your not seeing consultant more i also have underactive thyroid I have regular appointments with a consultant currently 32 weeks and seen them 3 times. My GP didn’t know how to correctly read my results in regards to pregnancy which resulted in low dosage from 8-16 weeks until I seen the consultant.

@Smellyjo it's not whether the person treating you is a trainee or not is whether they know the feck what they are doing. In your case the person treating you didn't.

As the others said you should be under consultant care as you are a high risk patient. As the midwife and kick up a fuss as not being treated properly is a risk to your own health as well as the baby's.

btw I'm only saying this as I've had awful treatment pre-pregancy from an experienced GP partner, and it was only because a medical student then a newly qualified nurse practitioner took me seriously did I not end up in A&E. Other people I know haven't been so lucky.

Thanks for the comments. So are you all agreeing from your knowledge that these recent results are not ok? What about Feb results? An obstetrician friend had sent me this pic which says I have been in the correct range for each trimester, even says I am now although I do feel like I shouldn't be this tired.

Because of this I've been content to accept advice that all is well, and going on how I've felt.

At booking at 9wks I asked for an endo and midwife was really reassuring (gp had been patronising about me being anxious about tft levels at 4wks) and when I showed up at 16wk I believed I was coming to an endo clinic. I am on a red/high risk pathway with consultant care apparently. Turned out clinic was consultant rather than endo and this poor trainee gp knew nothing and was running in and out to talk to registrar to answer my questions. They said due to my controlled levels endo not needed.

So if these levels are not right can someone point me in direction of info that makes that clear?

You should be being seen by a consultant at the hospital- has this happened?

Mine were 0.2 around the start of the third trimester with t4 of 17 ig I remember correctly, which is lower than it would usually be at 0.2. I'm not sure why the t4 is a little lower but I didn't take my thyroxine on the day of the test.

Baby started making its own thyroxine at the start of the second trimester, and is unreliant by the roughly middle of the second (I'd have to check exact weeks). So it's more how you feel. You could ask to tweak by adding an extra half of a 25 or taking the extra 25 every other day.

Or it could be some other reason eg iron? I get very low bp during the end of the second trimester.

I'd say the tsh is ok but I'm not sure about the t4 - but it naturally seems to hover at a lower level.

I actually felt a little over replaced when I was 0.2 despite the t4 level and knocked a couple of 25s out each week.

My son was born on Monday at an extremely healthy 7lb 14 and I've doggedly kept the tsh between 0.5 and 1.5, only feeling unwell when it was 3.5 at 10 weeks.

Oh - do you get your test at the same time each day; preferably the morning around 9-10?

Tsh can vary a little during the day as it has a circadian rhythm. T4 doesn't have this but I think it can vary if you're taking thyroxine hence why they often suggest taking that days thyroxine after a blood test.

@Ekphrasis congratulations on your healthy wee boy! That's lovely.

So the 16wk appt I mentioned was a consultant appointment- but I was seen by a trainee gp on rotation as an obstetrician. Very frustrating, especially as I waited nearly 2hrs over my appointment time. All my questions for him he couldn't answer and had to run back and forward to ask someone senior. And they still didn't get answered satisfactorily. So while I am technically under a consultant I've never seen one face to face. Monday is first appt since then, with community midwives.

I was discussing it with DH earlier and am thinking I'll tell midwife I'm feeling shit and I don't feel I'm really being looked after either, and also seek full bloods to look at iron, vit d to make sure nothing else causing tiredness. Iron levels were great in my last pregnancy, I wasn't underactive then though. But my instinct is a bit more tweaking is needed like you say.

Are you positive for TPO antibodies? I am but I can't seem to get info from them as to what this actually means, they only tested this when I asked for it.

Thanks for your help

Thank you!

It is within range and consultant would probably say it's fine, I found my gps were willing (wanted to) double check with the consultants at the hospital and would ring to clarify any queries, so you could try that. Ime the mws aren't as involved in this bit you could certainly ask them and as you say get other things tested. The thing is symptoms could be due to other things eg hormones, however as you say t4 seems low. They (gp and hospital) were certainly happy for me to be at 0.2 tsh as my t4 was within range. The consultants were also happy for me to tweak doses a little though I went down a little as felt too buzzy.

I had antibodies tested in my first pregnancy but don't remember what that was or meant; I'd ask gp or midwife to clarify this with the hospital. It's ringing bells a little in the back of my mind. They didn't test this time.

I think antibodies can cross the placenta but haven't had a straight answer about what this means. I feel even worse today, so wiped out, after a couple of good nights sleep so I'm now thinking more likely it is anaemia or something like that.

What happens post birth, do you get your thyroxine put down again?

Yes back to original dose unless your original dose was relatively low eg 50 - you might need more. The usual advice is to check tsh 6 weeks post partum. I had my son a week ago.

My only query is that I'm 2 stone heavier at the mo. And don't know if that makes a difference. I've decided to take a couple of extra 25s a week for the next few weeks and then test. I may ask for it to be after a month as last time I'd become underactive by 4 months (not sure why I hadn't had a test) and was really quite poorly, but possibly also due to forgetting tablets. I took an extra 25 then later dropped to extra 25 on alternate days. I'm being ultra careful this time.

If your TPO antibodies are positive and quite high levels, ask for thyroid scan as you might have hashimoto thyroiditis (autoimmune disease, basically your body thinks thyroid is enemy and tries to destroy it). Unfortunately doctors here are not trained on this one, most of them never heard of it.... If you have hashimoto your T4 levels definitely should be in higher range and how you are feeling is very good indication they are too low at the moment.

Hi @Sreberko, thanks that is helpful. Do you know what the range is or where I can see a reliable reference for that? I did find out this week that I am low in iron so am glad there is something being done to help how I am feeling, although that's not to say that thyroid isn't playing a part. Midwife was helpful but focusing on tsh being below 1 so suggesting all is well and not seeing a need to refer to endocrinologist. Thought I'd wait and see blood results before deciding what to do. I asked about antibodies and she didn't seem to know much. I remember my tpo results when I booked in were 230 but I don't know if that is high or not. As I write this I think I should just be pushing for endo referral shouldn't I, to get these queries answered properly.

This is an old set of guidelines by the endocrinologist who wrote the current BMA family medical guide to thyroid disorders:

www.thyroiduk.org.uk/tuk/guidelines/Lothian%20Guidance%20for%20Diagnosis%20and%20Management%20of%20thyroid%20function%20in%20pregnancy.pdf

The problem can be that there may be slight variation in local guidelines as testing may be slightly different.

Page 13 in this document for an nhs area in the north east (by v good endocrinologist) doesn't mention t4 but highlights tsh can be as low as 0.3. It mentions antibodies in relation to hyperthyroidism but not TPO ones.

It may be worth looking for any local nhs documents for your area.

I have wondered if t4 is a bit lower later in pregnancy simply due to the increased fluid/ blood in your body? As I said I noticed mine was relatively low compared to what it would be at that tsh outside pregnancy. T4 results may also depend on when you took your thyroxine and when the test was.

The latter doc does say you could go a bit lower on tsh as long as t4 in range.

What was iron level? Don't underestimate how rubbish that can make you feel.

Oops: www.northoftyneapc.nhs.uk/wp-content/uploads/sites/6/2012/03/Thyroid-guidelines-North-of-Tyne-Area-Sept2016.pdf

Thanks for that. I was 2.94 tsh when first tested at 4wks preg, so according to that should've gone up 50 then rather than 25. But tsh now is well within range so not overly worried about that. My haemoglobin was fine but ferratin 14 when normal range is 12-150. So v low end of normal. Am feeling a little better already after 3 days on it so will give it a few weeks and ask for more thyroid bloods as well as iron etc at routine bloods at 28wks. Thanks so much for all your help and to everyone else x