Thyroid Disease in Pregnancy

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Thyroid Disease in Pregnancy

Abdelrahman Al-daqqa

 

Physiologic Changes in Thyroid Function During Pregnancy 





Thyroid binding globulin (TBG) increases due to reduced hepatic clearance and estrogenic stimulation of TBG synthesis The test results that change in pregnancy are influenced by changes in TBG concentration Plasma iodide levels decrease due to fetal iodide use and increased maternal clearance -> leads to notable increase in gland sie in !"# of $omen ($ithout abnormal T%Ts)

 

Physiologic Changes in Thyroid Function During Pregnancy Maternal Status

TSH

Free T4

Free Thyroxine Index (FTI)

Total T4

Total T3

Resin Triiodothyronine Uptake (RT3U)

**initial  screening test**

Prenan!y

&o change

&o change

&o change

 Increase

Increase

Decrease

Hyperthyroidis"

'ecrease

ncrease

ncrease

ncrease

ncrease or no

ncrease

change Hypothyroidis"

ncrease

'ecrease

'ecrease

'ecrease

'ecrease or no change

'ecrease

 

The Fetal Thyroid 

Begins concentrating concentrating iodine at !!* $ee+s



,ontrolled by pituitary T. by appro/imately * $ee+s

 

Hyperthyroidism 

0ccurs in 1*# of pregnancies2 Graves3 disease accounts for 4"# of cases

Look for: -&ervousness -Tremor -Tachycardia -%requent stools -$eating -.eat intolerance in tolerance -5eight -5e ight loss -Goiter -nsomnia -Palpitations -.ypertension -6id lag7lid retraction -Pretibial my/edema

 

Fetal & Neona Neonatal tal Effects of Hyperthyroidism 





Associated $ith preterm delivery8 lo$ birth $eight8 fetal loss %etal thyroto/icosis (related to disease itself or treatment) 9is+ of immune-mediated hypo7hyperthyroidism (due to antibodies crossing the placenta8 esp1 in Graves or chronic autoimmune thyroiditis) 



Antibodies in Graves3 disease can be either stimulatory or inhibitory &eonates of $omen $ith Graves3 $ho have been surgically7radioactively surgically7ra dioactively treated are at higher ris+8 b7c not ta+ing suppression

 

Causes & Diagnosis of Hyperthyroidism 

Most common cause of hyperthyroidism is Graves’ disease 





'ocument elevated %T: or elevated %T $ith suppressed T.8 in absence of goiter7mass ;ost patients have antibodies to T. receptor8 antimicrosomal8 or antithyroid pero/idase antibodies8 but measurement of these is not required (though some endocrinologists recommend measuring T8 $hich are stimulatory antibodies to T. receptor)

Other causes: 

</cess T. production8 gestational trophoplastic disease8 hyperfunctioning thyroid adenoma8 to/ic goiter8 subacute thyroiditis8 e/trathyroid source of T.

 

Treatment Treatment of Hyperthyroidism 

Goal is to maintain %T:7%T in high normal range using lo$est possible dose (minimie fetal e/posure)



;easure %T:7%T q*-: $ee+s and titrate Thioamides (PT=7methimaole) -> decrease thyroid hormone synthesis by bloc+ing organification of iodide







PT= also reduces T:->T and may $or+ more quic+ly PT= traditionally preferred (older studies found that methimaole crossed placenta more readily and $as associated $ith fetal aplasia cutis2 ne$er studies refute this)

 

Treatment Treatment of Hyperthyroidism 

<ffect of treatment on fetal thyroid function? 









Possible transient suppression of thyroid function %etal goiter associated $ith Graves3 (usually drug-induced fetal hypothyroidism) hypothyroidism) %etal thyroto/icosis thyroto/icosis due to maternal antibodies is rare -> screen for gro$th and normal %.9 &eonate at ris+ for thyroid dysfunction2 notify pediatrician

Breastfeeding safe $hen ta+ing PT=7methimaole

 

Treatment Treatment of Hyperthyroidism 

Beta-bloc+ers can be used for symptomatic relief (usually Propanolol)





9eserve thyroidectomy for $omen in $hom thioamide treatment unsuccessful odine !! contraindicated (ris+ of fetal thyroid ablation especially if e/posed after ! $ee+s)2 avoid pregnancy7breastfeeding for : months after radioactive ablation

 

Hypothyroidism 

 



ymptoms? fatigue8 constipation8 cold intolerance8 muscle cramps8 hair loss8 dry s+in8 slo$ refle/es8 $eight gain8 intellectual slo$ness8 voice changes8 insomnia ,an progress to my/edema and coma ubclinical hypothyroidism? elevated T.8 normal %T in asymptomatic patient Associated $ith other autoimmune disorders 

Type ! '; -> "[email protected]# ris+ of hypothyroidism2 *"# postpartum thyroid dysfunction

 

Hypothyroidism: Fetal & Neonatal Effects 



.igher incidence of 6B5 (due to medically indicated preterm delivery8 pre-eclampsia8 abruption) odine deficient hypothyroidism -> congenital cretinism (gro$th failure8 mental retardation8 other neuropsychological deficits)

 

Causes & Diagnosis of Hypothyroidism 

,auses? 



 

.ashimoto3s (chronic thyroiditis2 most common in developed countries)  iodine deficiency -> both associated $ith goiter ubacute thyroiditis -> not associated $ith goiter Thyroidectomy8 radioactive iodine treatment odine deficiency (most common $orld$ide2 rare in =)

 

Treatment eatment of Hypothyroidism Tr 

 

Treat $ith $it h 6evot 6evothyro/ine hyro/ine in sufficient dose to return T. to normal Adust dosage every : $ee+s ,hec+ T. every trimester

 

 ACO !ecommendations 

creening of all pregnant $omen $ith a personal history8 physical e/amination8 or symptoms of a thyroid disorder1

 

Rheu"atoid #rthritis

 

Rheu"atoid #rthritis in Prenan!y 

 Affects !-*# of the general population  ;ore common in $omen  9A in pregnancy is a common challenge  e/ hormones have effects on disease activity  C[email protected]# of cases improve during pregnancy  Post-partum flare common

  

 

 

$%%e!t o% Prenan!y on R#

 ;inimal effects on fetal morbidity and mortality  teroids may increase ris+ of =G9 and PP90; 





 Active disease correlates $ith lo$er birth $eights

 

Treat"ent o% R# in Prenan!y

 Avoid &A' and high dose aspirin  6o$-dose aspirin safe  =se lo$est doses of prednisone









 ulfasalaine8 refractory cases hydro/ychloroquine in

 

R# Medi!ations and &reast-%eedin ' #oid

 Aspirin  Aathioprine  ,yclosporin  ,yclophosphamide  ;ethotre/ate

     

 ,hlorambucil  .igh dose prednisone



 

I""une Thro"*o!ytopeni! Purpura ITP

 

"mmune throm#ocytopenic purpura $"TP% 

is a clinical syndrome in $hich a decreased number of circulating platelets (thrombocytopenia) manifests as a



 bleeding tendency8 easy bruising (purpura)8 or e/trava e/travasation sation of blood from capillaries into s+in and mucous membranes (petechiae)1 Although most cases of acute TP8 particularly in children8 are mild and self-limited8



intracranial hemorrhage may occur $hen the intracranial platelet count drops belo$ ! D !476 (E ! D !7F6)2!HH this occurs in 1"-!# of children8 and !7F6)2! half of these cases are fatal1*H

 

ITP ' +ianosti! ,riteria



solated   &o drugsthrombocytopenia or other conditions that may affect platelet count 

 </clude .I8 .ep ,8 6<



 

ITP ' Patholoy

 ncreased platelet destruction  nhibition of platelet production at mega+aryocyte level







 ;ediated by gG Abs against platelet membrane glycoproteins  =sually a chronic condition



 

ITP ' ,lini!al Features

 Petechiae8 purpura8 easy bruising

 

<pista/is8 menorrhagia8 from gums   GT bleeding8 hematuria?bleeding rare  ntracranial hemorrhage J very rare

 

 

ITP and Prenan!y

 ;ay affect fetus in up to !"# of cases  &eonatal count may drop sharply several days after

 

birth  'ifficult to differentiate from gestational thrombocytopenia  <pidurals safe if count > "  Prednisone K7- IG if count E " 

  

 ;anage delivery according to standard obstetric practice  Avoid &A' post-partum 

 

estational Thro"*o!ytopenia

 ncidence about "#  0ccurs late in pregnancy  ;ild (>C )  &o fetal neonatal

   

thrombocytopenia  Postpartum resolution 

 

Myasthenia rais

 

Myasthenia rais



 Typically presents $ith fluctuating s+eletal muscular $ea+ness  ;ay be ocular or generalised  ;ay have antibodies to the A,h9  !-!"# have a thymoma  9espiratory muscle involvement may lead to respiratory failure 







 

Myasthenia rais in Prenan!y

 Pregnancy has a variable effect on the course of ;G  Post-partum e/acerbations in #  nfections can trigger e/acerbations



  

 teroids can cause transient $orsening  ;g0: is contraindicated



 

Myasthenia rais ' $%%e!t on the Fetus

 Transplacental passage of gG anti-A,h9  &euromuscular unction disorders Transient neonatal neonatal ;G in !-*#



 



 'ecreased %;3s and breathing  Polyhydramnios  Arthrogryposis multiple/ congenita

 

 

Myasthenia rais ' .a*our / +eliery

 %irst stage of labour not affected  econd stage? e/pulsive efforts may $ea+en







 Assisted vaginal delivery may be indicated  Pre-labour anaesthetic assessment indicated 

 

Syste"i! .upus $rythe"atosus $rythe"atosus

 

S.$ %eatures asso!iated 0ith hih "aternal and %etal risks ' prenan!y relatiely r elatiely !ontraindi!ated !ontraindi!ated

     

 evere pulmonary hypertension  9estrictive lung disease  .eart failure  .istory of severe .<66P or P<T   tro+e $ithin previous L7!*L7!* 6upus flare $ithin previous

 

S.$ !o"pli!ations in prenan!y



 'isease e/acerbation  ;iscarriage8 stillbirth  =G98 preterm labour  &eonatal lupus  'rugs and breast-feeding

   

 

1eonatal .upus

 0ccurs in up to *# of mothers $ith 6<

 

 Targets s+in a and nd cardiac tissue8rarely other tissues  ,ongenital partial or complete heart bloc+  .eart bloc+ detected in utero  ,omplete heart bloc+? P&; of ::#  9ash? erythematous annular lesions



   

 9ash clears $ithin L7!*  ;aternal de/amethasone may prevent progression of heart bloc+  &eonatal pacema+er if .9E"" 



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