Special treatment considerations

• Ischaemic heart disease

Rapid thyroxine replacement can precipitate myocardial infarction, especially in the elderly.

• Pregnancy and postpartum

Continue thyroxine during pregnancy; watch for hypothyroidism (an increased dose of T4 may be required).

• Elective surgery

If euthyroid—can stop thyroxine for one week. If subthyroid—defer surgery until euthyroid.

• Myxoedema coma

Urgent hospitalisation under specialist care is required.

Intensive treatment is required, which may involve parenteral T4 or T3.

Neonatal hypothyroidism

Misdiagnosing this serious condition leads to failure to thrive, retarded growth and poor school performance. If untreated it leads to permanent intellectual damage (cretinism). The clinical features of the newborn include coarse features, dry skin, supra-orbital oedema, jaundice, harsh cry, slow feeding and umbilical hernia. It is detected by routine heel prick blood testing. Thyroxine replacement should be started as soon as possible, preferably before 14 days of age.

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