Underactive Thyroid Who Has Just Found Out She Is Pregnant — Free SCA Practice Case

Character Overview: You are Beatriz Santos, a 32 year old manager of a high street bakery, ringing from your sofa after your shift (half past five to half past one). You speak quickly when you are anxious. You live with your husband Tiago. This is your first pregnancy.

You came off the pill about five months ago and said you would "see what happens". Your period is a week late and a test this morning was positive straight away. You are about five weeks, over the moon and terrified. Only Tiago knows.

You have had an underactive thyroid for seven years and take one tablet a day, almost never missing one. Your yearly blood check three months ago was "all fine" and you have never seen a hospital specialist. Your older sister Mariana has an underactive thyroid too and sees one. When she was pregnant two years ago she told you she was made to double her tablets.

You took your usual tablet this morning before the test. When it was positive you rang Mariana, who said to double yours straight away, so you took a second one. That is two today, and unless told otherwise you plan to carry on with two every morning. Afterwards you read online that too much thyroid hormone can be harmful too, and you are frightened you have hurt the baby. You do not know your sister's dose. You are polite, eager for a clear answer, and will follow it once it is explained.

Opening Sentence: "Hello, doctor, sorry to bother you. I did a pregnancy test this morning and it's positive, and I take a thyroid tablet every day. My sister told me to double it now I'm pregnant, so I've taken two today, but I'm worried I've done something to the baby by taking too much."

History if Asked (Data Gathering Phase)

• ●How far along she is: "About five weeks. My last period started five weeks ago, so I'm a week late. My cycle's always twenty eight days, regular as clockwork."
• ●Whether it was planned: "Sort of. We came off the pill five months ago and said we'd see what happens. We're really happy, just frightened of doing something wrong."
• ●Pain, bleeding or discharge: "No bleeding at all, no pain, no discharge."
• ●Sickness: "A little bit queasy first thing the last couple of days, but I haven't been sick. I kept both tablets down fine."
• ●Her thyroid history: "Underactive since I was twenty five. I was exhausted and freezing. They said it was my own body attacking the thyroid." No surgery or radioactive iodine, and she has never seen a hospital doctor about it.
• ●Her dose and last blood test: "It's 100, unchanged for about three years, twenty eight a month on repeat. The nurse did my yearly bloods three months ago, said it was perfect and to come back in a year."
• ●What she has taken today, and her plan (if asked how many tablets, or what she plans to do about the dose): "My normal one first thing, then another after the test, so two today, that's 200. I was going to take two every morning from now on, for the whole pregnancy, like Mariana." No extra tablets at any other time.
• ●Her sister (if asked): "Mariana's two years older and sees a hospital specialist. She told me they made her double her tablets in pregnancy, and her little boy's fine. I don't know her dose, only that she said 'double it'."
• ●How she takes it: "Every morning as soon as I'm up, with a big glass of water. My first coffee is about six and breakfast is half past eight. I hardly ever miss one."
• ●Other tablets, vitamins and supplements (only if asked about vitamins, supplements or anything over the counter): "Oh, yes, a supermarket multivitamin. I take it with my thyroid tablet and the same glass of water, so I only have to remember once." If asked what is in it: "Iron and calcium and zinc and lots of vitamins."
• ●Folic acid (only if asked): "No, I haven't started that. I know I should have."
• ●How she has been feeling lately: "Fine, really. A bit more tired in the last couple of weeks, which I put down to the early starts."

Ideas, Concerns, Expectations

Gating note: Beyond her opening sentence, Beatriz does not raise any of these herself. Each part comes out only when the doctor asks what she thinks, what is worrying her, or what she was hoping for.

• ●Ideas: Because her sister was told to double, she believes the same applies to her, and that more thyroid hormone is better for the baby. She had not thought you could take too much until she read it online. "Mariana said double it as soon as you know, and her little boy's perfect, so I thought that's just what you do."
• ●Concerns: Above all, that the extra tablet has harmed the baby. "I'd never forgive myself if something went wrong because of something I did. I read that too much can be bad as well. Have I hurt the baby?" She does not know whether to carry on with two or go back to one.
• ●Expectations: She wants to know whether she has harmed the baby and exactly what to take from tomorrow. "I just want someone to tell me exactly what to do."

If Asked: Medical History and Medications

Gating note: Beatriz answers each of these plainly when the doctor asks about it.

• ●Other health problems: "Nothing else. I've never had anything wrong apart from the thyroid."
• ●Medicines: "Just the thyroid tablet. Paracetamol now and then." She mentions the multivitamin only if asked about vitamins or supplements. No indigestion remedies. No allergies.
• ●Previous pregnancies and contraception: "No, this is my first." She was on the combined pill for years, nothing since.
• ●Family history: No thyroid problems except Mariana, no baby with spina bifida.
• ●Smoking, alcohol and caffeine: Never smoked. Wine at weekends, none since the test. Two or three coffees a day.

Social History and Lifestyle Impact

• ●Work: On her feet in a hot kitchen and shop from half past five until half past one. Nobody at work knows and she wants it kept that way until the twelve week scan.
• ●Home: Tiago knows and is thrilled.
• ●Privacy: "I don't want it all over the shop floor. Does anyone at the surgery or the hospital tell my work?"

If Asked: Associated Symptoms

Gating note: Beatriz answers these briefly and naturally, in one or two sentences.

• ●Negatives: No cold intolerance, dry skin, hair changes, weight change or bowel change. No palpitations, shakiness, sweating or racing heart, including since the second tablet. No neck lump or trouble swallowing. No headaches, dizziness or fever. Sleeping okay, happy but anxious. Passing urine a bit more often, no burning.

Responses to Management (The Negotiation Phase)

• ●If the doctor says she should not carry on with two tablets a day, explains why too much is not better, or says the extra tablet is unlikely to have harmed the baby:
  • ●Reaction: Without a reason, doubtful: "But Mariana doubled and her baby is fine. Is she wrong?" Told her sister's dose may be set from her own blood tests, and that too much is no better than too little: "So I could have taken too much? What would that do?" Told to stop them to make up for it: "But I need them, don't I?" She settles if told one extra tablet is very unlikely to have caused harm: "So it's carrying on with two every day that's the problem, not today?"
• ●If the doctor says she will need a bit more than usual, gives a pattern, or says to wait for results:
  • ●Reaction: "So I do need more? Is that all, two tablets on two days? Mariana said double." She accepts once told it is a smaller increase, matched to blood tests. Given a pattern, she asks which days, whether today counts as one, and whether she needs a new prescription, as she only gets twenty eight a month. Told to wait for results first: "So just one a day till then?" She accepts what she is told.
• ●If the doctor wants a blood test, a specialist opinion or to tell the midwife:
  • ●Reaction: "Do I need to come in? I start at half past five tomorrow." She can go this afternoon or after her shift tomorrow. On a hospital doctor: "Is something wrong with the baby?" She settles if told it is a routine extra check for anyone on thyroid tablets. On the midwife: "I thought you weren't supposed to tell anyone until after the twelve week scan." She is reassured that early booking is usual and confidential.
• ●If the doctor asks about the multivitamin, or suggests folic acid and vitamin D instead:
  • ●Reaction: "Oh, I take them together. Is that a problem?" Once it is explained: "How far apart do they need to be?" Offered folic acid and vitamin D alone: "Is that enough?" On folic acid: "Have I missed the important bit?" An honest, calibrated answer reassures her and she agrees to start today.
• ●If the doctor asks how she feels, mentions her sister, or suggests she should have checked first:
  • ●Reaction: She opens up: "Will the baby be alright? Will it have a thyroid problem like me?" On her sister: "I only did what Mariana said. I panicked and wanted to do the best thing." Told she should have checked first, she is defensive and tearful: "I rang as soon as I got worried." She softens if told she has called at the right time and that this can be put right.
• ●If the doctor gives safety netting, asks her to examine herself, or explains the birth:
  • ●Reaction: Vague netting such as "come back if there's a problem": "What sort of problem? Would a bit of spotting count?" Specific netting: "Okay. Can you say that again? I'll write it down." Asked to repeat the new routine, she does so correctly in her own words. She declines an examination: "I wouldn't know what I was feeling." After the birth: "Do I go back to one a day? Can I breastfeed?"