A 26-year-old woman comes to the office for a routine visit 6 months after the birth of her first child. Her pregnancy and vaginal delivery were uneventful and her infant is healthy; she breastfed for the first 5 months. The patient reports that during the first 2-3 months after childbirth she had excessive anxiety and worried frequently about her newborn daughter. She also felt unusually fatigued and irritable, which has worsened over the last several weeks. The patient has also experienced constipation, but her appetite is normal and she has gained 2.5 kg (5.5 lb) in the last 3 months. Blood pressure is 130/90 mm Hg and pulse is 60/min. Heart and lung sounds are normal. Mild bilateral lower extremity edema is present. Laboratory results are as follows: Which of the following is the best next step in management of this patient?

Question

A 26-year-old woman comes to the office for a routine visit 6 months after the birth of her first child.  Her pregnancy and vaginal delivery were uneventful and her infant is healthy; she breastfed for the first 5 months.  The patient reports that during the first 2-3 months after childbirth she had excessive anxiety and worried frequently about her newborn daughter.  She also felt unusually fatigued and irritable, which has worsened over the last several weeks.  The patient has also experienced constipation, but her appetite is normal and she has gained 2.5 kg (5.5 lb) in the last 3 months.  Blood pressure is 130/90 mm Hg and pulse is 60/min.  Heart and lung sounds are normal.  Mild bilateral lower extremity edema is present.  Laboratory results are as follows:  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d25a_6900_bc81_714b99dc5e66_MD0003_00 Postpartum thyroiditis occurs in 7%-8% of women after childbirth, usually in the first 6 months. Patients can have a brief hyperthyroid phase due to release of preformed thyroid hormone but frequently have only mild, nonspecific symptoms (eg, anxiety [as seen in this patient], palpitations). The subsequent hypothyroid phase (eg, fatigue, weight gain despite normal appetite, constipation) often brings patients to medical attention. Examination typically shows a nontender goiter, bradycardia, diastolic hypertension, lower extremity edema, and other findings (eg, coarse facies, delayed deep tendon reflex relaxation). In the hypothyroid phase, TSH will be elevated and free T4 levels will be low. Other laboratory findings associated with hypothyroidism include hypercholesterolemia (due to thyroid effects on lipid metabolism) and hyponatremia. Postpartum thyroiditis is similar to painless (silent) thyroiditis, but by convention the latter is not diagnosed within a year of childbirth. Both may be considered variants of chronic lymphocytic (Hashimoto) thyroiditis and are associated with elevated titers of anti-thyroid peroxidase autoantibodies. However, whereas Hashimoto thyroiditis frequently leads to permanent hypothyroidism, postpartum and painless thyroiditis are usually self-limited, and patients return to a euthyroid state over several months. (Choice A) Postpartum thyroiditis and postpartum depression cause overlapping symptoms. Hypothyroidism should be excluded first as it is a reversible cause of depression. In general, postpartum depression is more often associated with weight loss and additional depressive symptoms (eg, anhedonia, feelings of inappropriate guilt). If thyroid function is normal, depression would be more likely. (Choice B) Peripartum cardiomyopathy is characterized by systolic heart failure and occurs in the last month of pregnancy or up to 5 months after delivery. It can lead to edema and hyponatremia but would not occur 6 months after pregnancy and would present with respiratory features (eg, dyspnea, orthopnea, lung crackles) and tachycardia (rather than borderline bradycardia). Hypothyroidism can cause lower extremity edema. (Choice C) Weight gain and hypercholesterolemia in postpartum hypothyroidism usually resolve with restoration of the euthyroid state. Directed lifestyle and pharmacologic interventions are not usually needed. (Choice D) Hypothyroidism and adrenal insufficiency can both cause hyponatremia. However, adrenal insufficiency is unlikely in this patient in light of the associated edema, weight gain, and normal blood pressure. Educational objective: Postpartum thyroiditis is an autoimmune disorder characterized by a possible brief hyperthyroid phase, a self-limited hypothyroid phase, and an ultimate return to a euthyroid state. It is associated with anti-thyroid peroxidase autoantibodies. Painless (silent) thyroiditis is a similar disorder, but by convention is not diagnosed within a year of childbirth. References: Approach to the patient with postpartum thyroiditis. (http://www.ncbi.nlm.nih.gov/pubmed/22312089)

A 26-Year-Old Woman Comes to the Office for a Routine