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Thyroid disorders in pregnancy
Thyroid disorders are common in pregnancy and can impact both mother and baby if not properly managed. Hyperthyroidism, hypothyroidism, and postpartum thyroid disease are the main thyroid conditions seen. Treatment involves medication like antithyroid drugs, levothyroxine, and beta blockers with careful monitoring of thyroid levels throughout pregnancy. Screening high-risk women and optimizing thyroid function is important for achieving good pregnancy outcomes.
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Introduction to thyroid disorders in pregnancy, highlighting prevalence and management.
Increased iodine requirements during pregnancy due to hormonal changes and fetal demands.
Physiological modifications during pregnancy affecting thyroid hormone levels and metabolism.
Recommended trimester-specific TSH reference ranges for monitoring thyroid function.
Guidelines on screening for thyroid dysfunction, emphasizing high-risk factors and universal testing.
Overview of hyperthyroidism prevalence, causes with emphasis on Graves’ disease and associated risks.
Methods for diagnosing hyperthyroidism and treatment options, including anti-thyroid drugs.
Discussion on hypothyroidism in pregnancy, highlighting causes, symptoms, and maternal effects.
Strategies for managing hypothyroidism, especially with Levothyroxine dosage recommendations.
Monitoring protocols for hypothyroidism management focusing on TSH and FT4 levels.
Risks associated with euthyroid pregnancy state, including the likelihood of postpartum thyroiditis.
Characteristics and management of postpartum thyroiditis, including diagnosis and potential recurrence.
Challenges in diagnosing and managing thyroid cancer during pregnancy, including necessary assessments.
Safety and protocol for fine needle aspiration in pregnant women with thyroid nodules.
Reference to guidelines and literature used for managing thyroid disorders in pregnant women.
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Thyroid disorders in pregnancy
- 1. THYROID DISORDER IN PREGNANCY Presentedby Dr. Syeda Trina Intern Doctor Department of medicine Unit blue M Abdur Rahim Medical College
- 2. Outline •Changes during pregnancy •Hyperthyroidism •Hypothyroidism •Postpartum thyroid disease •Euthyroid with autoimmune thyroid disease
- 3. Introduction • Most commonendocrine disorder in pregnancy. • Affects 1-2% pregnant women. • Pregnancy may modify course of thyroid disease. • Pregnancy outcome can depend on optimal management of thyroid disorders.
- 4. Iodine requirement inpregnancy Iodine requirement increases in pregnancy due to – • Increase thyroid hormone production • Increase renal excreation • Increase demand of fetus
- 5. Continue ATA 2017- •150 mcg/dayduring planing for pregnancy •220 mcg/day during pregnancy •290 mcg/day during lactation WHO – •250 mcg/day during pregnancy & lactation
- 7. Physiological changes during pregnancy •Increase TBG – • 2nd ary to increase estrogenic stimulation & reduced hepatic clearance of TBG. • TT3,TT4 increases. • FT3, FT4 increase in 1st trimester in response to elevated HCG
- 8. • hCG – •Intrinsic thyrotropic activity • Begins shortly after gestation, peaks at 10 wks, declines at 20 wks • Activates thyroid receptor • Transient decrease of tsh during 8-11 wks due to peak in hCG
- 10. PHYSIOLOGICAL CHANGES CONSEQUESCES IncreaseTBG Increase TT3, TT4 ; Increase production Increase plasma volume Increase T3,T4 pool Increase hCG in 1st trimester Increase FT4, T4 production, decrease basal thyrotropin Increase renal Iodine clearance Increase T4 production Increase fetal demand Increase iodine requirement
- 11. Trimester specific TSHlevel If trimester specific referance range is not available in laboratory following referance range is recommonded. •1st trimester : 0.1 – 2.5mIU/L •2nd trimester : 0.2 – 3.0 mIU/L •3rd trimester : 0.3 – 3.5 mIU/L
- 12. Who should testfor TFT during pregnancy? Targeted case finding vs Universal screening? • ATA, AACE, ACE recommend screening high risk case only. • However different studies have shown upto 30% cases missed in high risk screening . ALL PREGNANT WOMEN SHOULD BE VERBALLY SCREENED AT THE INITIAL PRENATAL VISIT FOR ANY HISTORY OF THYROID DYSFUNCTION, AND PRIOR OR CURRENT USE OF EITHER
- 13. All patients seekingpregnancy, or newly pregnant, should undergo clinical evaluation. If any of the following risk factors are identified, testing for serum TSH is recommended. • A history of hypothyroidism/hyperthyroidism or current symptoms/signs of thyroid dysfunction • Known thyroid antibody positivity or presence of a goiter • History of head or neck radiation or prior thyroid surgery • Age >30 years
- 14. Continue • History ofpregnancy loss, preterm delivery, or infertility • Multiple prior pregnancies (2 or more) • Family history of autoimmune thyroid disease or thyroid dysfunction • Morbid obesity (BMI 40 kg/m2 or more) • Use of amiodarone or lithium, or recent administration of iodinated radiologic contrast • Residing in an area of known moderate to severe iodine insufficiency
- 15. Hyperthyroidism in pregnancy •0.2% of all pregnancies • Causes are- • Graves disease • Toxic MNG, toxic adenoma • Sub acute thyroiditis • Gestational trophoblastic tumor • Geststional transient thyrotoxicosis • Graves disease is most common ( 85%)
- 16. Effects of hyperthyroidismin pregnancy Maternal Foetal Miscarriage hyperthyroidism Abruptio placenta Prematurity Preterm delivary IUGR Congestive heart failure Still birth Thyroid strom & Pre eclampsia Thus there is an increase in maternal & perinatal mortality
- 17.
- 18. Graves disease inpregnancy Sign & symptoms: • Tachycardia, heat intolerance, anxiety, insomnia, wt loss, goiter, frequent stool, fine tremor etc. Graves specific sign: • Diffuse goiter, expothalmous, pretibial myxedema.
- 19. Continue • Disease activityflactuates during pregnancy . • Exacerbation during 1st trimester with gradual improvement during later half. • High risk of relapse during post partum.
- 20. Gestational transient thyrotoxicosis •Occurs in 1st trimester • Due to HCG mediated stimulation of thyroid gland • Thyroid gland usually not enlarged, no eye sign, no prior history of thyroid disease, mild disorder & associated emesis suggests transient thyrotoxicosis. • Resolution of symptoms parallel to decline in hcg level • Usually resolves spontaneously by 20 wks • If persists beyond 20 wks, repeat evaluation for
- 21. Trophoblastic hyperthyroidism • Associatedwith hydatidiform mole & choriocarcinoma • Nausea & vomiting predominant • Unusual high hCG with snow strom appearance on USG of L/A are found
- 22. Diagnosis of hyperthyroidism •TSH – decreased • FT4,FT3 – increased • TRAb – in GD ( when diagnostic uncertainity) • Thyroid scan – contraindicated • TT3, TT4 reference range should be adjusted at 1.5 times the non pregnant range
- 23. Treatment options ofhyperthyroidism •Anti thyroid drugs (ATD). •Beta blockers. •Thyroidectomy ( rarely, if needed done in 2nd trimester).
- 24. ATD • ATD therapyshould be uesd for hyperthyroism in pregnancy. • In 1st trimester –propylthiouracil (PTU) – 100- 600mg/day • 2nd & 3rd trimester – carbimazole(CM) - 10- 40mg/day • Lowest possible dose should be used. • Pt education about possible side effect of drugs specially teratogenecity • PTU – hepatoxicity
- 25. Continue • Carbimazole – •Teratogenicity - • Apalasia cutis • Choanal atresis • Esophageal atresia • For mother – • Rash • Agranulocytosis
- 26. Beta blockers • Betaadrenergic blocking agents, such as propranolol 10-40 mg every 6-8 hours may be used for controlling hyper-metabolic symptoms until patients have become euthyroid on ATD therapy. The dose should be reduced as clinically indicated. In the vast majority of cases the drug can be discontinued in 2 to 6 weeks. • Long-term treatment with beta-blockers has been associated with IUGR, fetal bradycardia and neonatal hypoglycemia
- 27. Monitoring • Clinical S/Sof improvement. • TSH, FT4/TT4 every 4 wkly. • ATD dose has to be reduced when TSH is in reference range to avoid fetal overtreatment.
- 28. Hypothyroidism • Untreated hypothyroidismis associated with sub fertility, so hypothyroidism is uncommon in pregnency. • However the causes may be – • Iodine deficiency • Hashimoto thyroiditis • Prior radio iodine therapy • Prior thyroid surgery
- 29. S/S of hypothyroidism •Inappropriate wt gain • Cold intolerance • Dry skin • Asthenia • Hoarseness of voice • HTN • Constipation
- 30. Effects of hypothyroidismin pregnancy Maternal Fetal HTN/ PE Preterm delivery Abruptio Placenta Increase perinatal morbidity Miscarriage Neuropsychologic & cognitive impairment PPH Increase C/S Delivary
- 31. Investigation • Raised TSH •FT4 – normal/ suppresed • Anti TPO antibody in autoimmune thyroiditis
- 32.
- 33. Subclinical hypothyroism • Suspectwhen TSH > 2.5mU/L & FT4 normal • Increase risk of abruptio placenta, preterm baby • Indication of treatment • TPO (+)ve with TSH > pregnancy specific referance range • TPO (+)ve with TSH >2.5mU/L & below the upper limit of pregnancy specific referance range • TPO (-)ve with TSH > 10mU/L • TPO (-)ve with TSH > pregnancy specific referance range & below 10.0mU/L
- 34. Treatment of hypothyroidism •By oral Levothyroxin • Levothyroxin should be administered as 2mcg/kg/day • Usual starting dose 100mcg/day & then titrate. • If already on Levothyroxin before pregnancy, on confirmation of pregnancy increase dose by 30% ( 20-50mcg) • Never give FeSO4 simultaneously with thyroxin.
- 35. Monitoring • By TSHevery 4 wk until mid gestation, & at least once near 30 wks of gestation ( ATA 2017) • Target TSH < 2.5mU/L • Target FT4 – upper end of normal
- 36. Euthyroid & TPOAb(+) ve • 2 times risk of miscarriage • No risk of neonatal hypothyroidism • Risk of developing overt hypothyroidism as pregnancy progress, so check TFT between 28- 32 wks of gestation • Increase risk of post partum thyroiditis ( check TFT at 3 month post partum)
- 37. Post-partum thyroid dysfunction •Post-partum thyroiditis is the occurance of thyroid dysfunction , excluding graves disease, in the 1st postpartum year in woman who were euthyroid prior to pregnancy. ( Ata 2017) • Aetiology: • Chronic autoimmune thyroiditis. • Presentation: triphasic pattern • Transient thyrotoxicosis ( 2-6 months) • Transient hypothyroidism(3-12 months)
- 38. Continue • DD ofPPT: • Graves disease that relapse in post patum period • Lymphocytic hypophysitis( rare) • INVESTIGATION: • TPO (+)ve in 80% case • Thyroid scan to diferentiate from GD ( low uptake in thyrotoxic phase of PPT, high uptake in GD)
- 39. Management • Beta blockersif thyrotoxic & symptomatic until TFT normalize. ATD not necessary. • Levothyroxine if TSH > 10mU/L • TSH 2.5-10mU/L with symptoms • Prognosis: • 25% recurrence in future pregnancies • 30% permanent hypothyroidism within 10 yrs
- 41. Thyroid cancer inpregnancy • 2nd most common malignancy during pregnancy next to breast cancer • Thyroid nodules and thyroid cancer discovered during pregnancy present unique challenges to both the clinician and the mother. • A careful balance is required between making a definitive diagnosis and instituting treatment while avoiding interventions that may adversely impact the mother, the health of the fetus, or the maintenance of the pregnancy.
- 42. Diagnostic approach forthyroid cancer • History and physical examination • The patient with a thyroid nodule should be asked about a family history of benign or malignant thyroid disease, familial medullary thyroid carcinoma, multiple endocrine neoplasia type 2 (MEN 2), familial papillary thyroid carcinoma, and a familial history of a tumor syndrome predisposing to thyroid cancer syndrome. • USG • Most accurate tool for detecting nodule , determining sonographic features & pattern ,
- 43. Continue • Thyroid functiontests • All women with a thyroid nodule should have a TSH performed. Thyroid function tests are usually normal in women with thyroid cancer • Calcitonin and thyroglobulin As within the general population, the routine measurement of calcitonin remains controversial. Calcitonin measurement may be performed in pregnant women with a family history of medullary thyroid carcinoma or multiple endocrine neoplasia 2 or a known RET gene mutation
- 44. Continue Fine needle aspiration •Fine needle aspiration is a safe diagnostic tool in pregnancy and may be performed in any trimester Radionueclide screening • Containdicated
- 46. Acknowledgment • American thyroidassociation guidelines for the diagnosis and management of thyroid disease during pregnancy and the postpartum 2017, 2011 • Thyroid disease in pregnancy, practice bulletin ,number 223, june 2020,ACOG • Davidson principles & practice of medicine 23rd edition • Oxford handbook of endocrinology3rd edition