Endocrine Abstracts

29 year old female presented being generally° unwell with vomiting and black outs in Feb 2021. She was 3 weeks postpartum. It was normal vaginal delivery but the baby was small for date but otherwise healthy. She had past medical history of hypothyroidism on levothyroxine. On examination, she looked pale, unwell and tanned. Observations showed BP80/60 PR88/min, RR18/min temp 36.6° c. ABG showed PH 7.34, HCO3 22.3, Na126, k 5.6 cl 93 urea22.9 creat122 glu4.5 lac0.6. other investigations were •Hb 99, WBC 8.2, Neutrophils 5, Platelets 109, Na 132, K 6.1, Urea18.7, Creat 90, GFR74,•Alb 34, Bili 6, ALP 89, ALT 26, Calcium 2.62•CRP 4•Trop: 231 (0-46) •D-dimer: 715 (0-500), Repeat trop: 329, Cortisol: <30 (09:00 am), BNP: 11486 (0 – 299)ECHO - LV upper limit of normal size with reduced systolic function 38%, Basal LV walls contract well, Dyskinetic septum towards apex. Hypokinetic all other LV walls. Normal right heart size and function, no valvular pathology. ECG showed wide spread Twave inversion. Pituitary profile showed prolactin 1194, IGF1 17.5, Oestradiol<70 FSH 8.5 LH 2 TSH0.17 T4 23.8, Synacthen test showed basal cortisol <30, which did not rise in spite of stimulation. Later on adrenal antibodies were positive and ACTH levels were >2000. When did she became adrenal insufficient? Retrospectively she felt well in December 2019 when she had holiday in Turkey. She consulted GP for lethargy, weight loss and head ache a month later and found to have hypothyroidism with raised TPO antibodies. In May 2020, she had hospital admission for head ache, vomiting, dizziness, abdominal pain with recent increase in levothyroxine to 75 mg. The blood tests done during this admission showed sodium 132, potassium 4.5 and the cortisol level was requested. she felt better after iv rehydration and the low sodium was assumed to be due to dehydration due to vomiting. The cortisol level was <30 but was overlooked. In June 2020, she became pregnant and her symptoms were assumed to be due to pregnancy. it was her 2 nd pregnancy and recalled the pregnancy symptoms were much worse than her first pregnancy. She felt much better when she had steroids during pregnancy. She deteriorated further after pregnancy and presented 3 weeks after delivery.