Miscarriage in New York City…Be Thyroid Aware

When I was a girl, my father would sing Frank Sinatra’s song “New York, New York”. He would sing at the top of his lungs, “If I can make it there, I’ll make it anywhere. It’s up to you, New York, New York!” In New York City, one of the greatest cities in the world, I expected the best possible medical care. I trusted my doctors implicitly, never once thinking they might not know everything there was to know about hypothyroidism, especially the dangers of hypothyroidism and pregnancy.

I was diagnosed with hypothyroidism, a low thyroid, following the birth of my first son. When I became pregnant for the second time, I followed my thyroid drug protocol to the letter never once doubting my Ivey League medical school trained and top awarded NYC doctors.

In my first trimester, I was overcome by a sick, tired, weak feeling. I recall the night I told my husband, “I am worried that something is wrong with the baby.” My body was whispering a warning to me, but I trusted my doctors and didn’t question them when they responded that my thyroid levels were safe for pregnancy and that it was normal in early pregnancy to be tired. Somehow this “sick, tired, weak” feeling didn’t seem normal but I disregarded my body’s warning. In hindsight, I was also too sick and exhausted to do the research to help myself. I miscarried at 12 weeks pregnancy.

Frank Sinatra’s song resonates with me now more than ever. If a miscarriage due to hypothyroidism can happen in New York City, it can happen anywhere.

TSH Levels in Pregnancy 

Thyroid Stimulating Hormone (TSH) is a measure taken from a blood sample to test thyroid functioning. High TSH levels above the reference range are interpreted as an underactive thyroid, known as hypothyroidism. Low TSH levels below the reference range are interpreted as an overactive thyroid, hyperthyroidism.

Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and Postpartum were updated in 2011. They recommend the following trimester-specific reference ranges for TSH in pregnancy:[1]

First Trimester, TSH 0.1 – 2.5 mIU/L

Second Trimester, TSH 0.2 – 3.0 mIU/L

Third Trimester, TSH 0.3 – 3.0 mIU/L

As published in The Journal of Clinical Endocrinology & Metabolism in 2010, a study conducted on a large cohort size of 4123 women in Southern Italy revealed that higher TSH levels (between 2.5 and 5.0 mIU/L) increased the risk of miscarriage by 69%. This study provided strong physiological evidence to support defining the TSH upper limit of normal in the first trimester of pregnancy to 2.5 mIU/L.[2]

The European Journal of Endocrinology published a study in 2009 entitled “Higher Maternal TSH levels in pregnancy are associated with increased risk for miscarriage, fetal or neonatal death”. In a cohort of 2497 pregnant Dutch women without overt thyroid dysfunction, the incidence of child loss increased significantly with increasing TSH levels during early pregnancy.[3]

The 2007 Endocrine Society’s clinical guidelines for the Management of Thyroid Dysfunction during Pregnancy and Postpartum includes the following recommendations:[4]

• If hypothyroidism has been diagnosed before pregnancy, thyroid hormone replacement medication dosage should be adjusted to reach a TSH level not higher than 2.5 mIU/L prior to pregnancy.
• If overt hypothyroidism is diagnosed during pregnancy, thyroid function tests should be normalized as rapidly as possible to TSH levels of less than 2.5 mIU/L in the first trimester (or 3 mIU/L in the second and third trimester).”

Throughout my first trimester, my TSH remained higher than the above recommended 2.5 mIU/L, soaring as high as 10.0 mIU/L. My doctor said that everything was fine and that TSH was only a concern in pregnancy above 10.0 mIU/L.

Wait…rewind…yes you read that correctly.

My doctor was not concerned about TSH levels below 10.0 in pregnancy, because she was not aware of the danger to pregnancy with a TSH at that high range, and I wasn’t aware of it either.

According to a study published in Thyroid in 2010, three waves of mail surveys were distributed to 1601 Wisconsin health care providers with a history of providing obstetric care. Survey participants were members of the American College of Obstetricians and Gynecologists or the American Academy of Family Physicians. The study determined that ONLY 11.5% of providers actually read the 2007 Endocrine Society’s “Guidelines on the Management of Thyroid Dysfunction During Pregnancy and Postpartum.”[5]

In another study a survey was distributed to 260 surgeons attending the 2009 American Association of Endocrine Surgeons’ meeting. ONLY 23% had read the 2007 Endocrine Society’s guidelines. Reading the guidelines was associated with a significantly greater likelihood of the doctors informing patients of the TSH guidelines for pregnancy, however I repeat only 23% actually read the guidelines.[6]

If only my doctors had just read the Endocrine Society’s 2007 clinical guidelines, my child would be alive today. What an unnecessary and tragic loss. I can’t go back in time no matter how much I wish it, however I can make sure this never happens to anyone else ever again. I co-authored this book with Mary Shomon, Your Healthy Pregnancy with Thyroid Disease: A Guide to Fertility, Pregnancy, and Postpartum Wellness, so that every woman will know the lab tests, optimal ranges, medications, supplements, dietary recommendations and more so that she will know more than even her doctors about having miracle babies with thyroid disease.

Elie Wiesel said, “Whoever survives a test, whatever it may be, must tell the story. That is his duty.” Hypothyroid Mom is my story. I feel deep within me that it is my duty to share it, so that not one more child will be unnecessarily lost to hypothyroidism. Please take a look at Hypothyroid Mom’s first YouTube video and help build awareness.

References:

1. Stagnaro-Green, A., Abalovich, M., Alexander, E., Azizi, F., Mestman, J., Negro, R., Nixon, A., Pearce, E.N., Soldin, O.P., Sullivan, S., and Wiersinga, W. Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and Postpartum. Retrieved from http://thyroidguidelines.net/pregnancy.

2. Negro, R., Schwartz, A., Gismondi, R., Tinelli, A., Mangieri, T., Stagnaro-Green, A. Increased Pregnancy Loss Rate in Thyroid Antibody Negative Women with TSH Levels between 2.5 and 5.0 in the First Trimester of Pregnancy. The Journal of Clinical Endocrinology & Metabolism 2010; 95(9):44-48.

3. Benhadi, N., Wiersinga, W.M., Reitsma, J.B., Vrijkotte, T.G.M., Bonsel, G.J. Higher Maternal TSH Levels in Pregnancy are Associated with Increased Risk for Miscarriage, Fetal or Neonatal Death. European Journal of Endocrinology 2009; 160:985-991.

4. The Endocrine Society. Management of Thyroid Dysfunction During Pregnancy and Postpartum: An Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology & Metabolism 2007; 92(8)(Supplement):S1-S47.

5. Haymart, M.R. The Role of Clinical Guidelines in Patient Care: Thyroid Hormone Replacement in Women of Reproductive Age. Thyroid 2010 March;20(3):301-307.

6. Haymart, M.R., Cayo, M.A., Chen, H. Thyroid Hormone Replacement in Women of Reproductive Age: Is Surgeon Knowledge Related to Operative Volume? Thyroid 2010 June;20(6):627-631.