Thyroid Diseases In Pregnancy
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THYROID DISEASES IN PREGNANCY Dr. Iwo-Amah Department of Obstetrics and Gynaecology, UPTH 10/14/08
Thyroid Diseases In Pregnancy
1
Introduction Pregnancy has a significant impact on normal maternal thyroid physiology and function, many of the physiologic change in pregnancy, especially the hypermetabolic changes mimic thyroid disease and abnormal thyroid function. Thyroid disease in pregnancy is difficult to diagnose because there is hypertrophy of the thyroid gland due to normal gravid physiologic changes. Normal secretion from the thyroid gland contain approx 80% thyroxine (T4) and 20% Triiodothyronine (T3), T3 is the active thyroid hormone, most of which is derived from peripheral conversion of thyroxine (T4) Though total T4 and T3 increase, there is also an increase in thyroid binding globulin (TBG), Diseases In Pregnancy 10/14/08 albumin and pre –Thyroid albumin, due to enhanced
2
Classification
Thyroid diseases in pregnancy are classified into 3 broad headings; Hypothyroidism Thyroiditis Hyperthyroidism
10/14/08
Thyroid Diseases In Pregnancy
3
HYPOTHYROIDISM: It affects 0.5 – 3% of pregnant women common causes of primary hypothyroidism include autoimmune diseases such as Hashimoto thyroiditis. Iatrogenic causes like radiation treatment or surgery. Congenital hypothyroidism, medications such as lithium or amiodarone, iodine deficiency, Radioactive iodine therapy and infiltrative disease. Secondary hypothyroidism may be caused by pituitary or Thyroid hypothalamic disease such 4 Diseases In Pregnancy 10/14/08
THYROIDITIS Most commonly autoimmune in aetiology. Other causes are viral infection, bacterial or fungal infection, radiation treatment. In younger women, infection of the piriform sinus is causative. Post partum thyroiditis is a silent thyroiditis that usually present 3 – 6 months post partum. It is a sub-acute condition. Riedel’s thyroiditis occurs in middle aged gravitas. It is a chronic thyroiditis. Other forms of chronic thyroiditis are Thyroid Diseases In Pregnancy 5 10/14/08 Hashmoto’s thyroiditis and parasitic
HYPERTHYROIDISM:
The incidence of hyperthyroidism in pregnancy is 0.05 – 2% The etiology in order of frequency are graves disease acute and sub-acute thyroiditis toxic nodular goiter toxic adenoma.
10/14/08
Thyroid Diseases In Pregnancy
6
CLINICAL PRESENTATION In Hypothyroidism: There could be a hx of previous thyroid surgery, radiation treatment or hashimoto thyroiditis. The signs and symptoms include skin dryness, yellowing of skin (esp in the periorbital area) hair loss, cold intolerance constipation and sleep disturbances, pallor, a goiter, delayed relaxation of deep tendon reflexes, eyelid oedema and weight 10/14/08
Thyroid Diseases In Pregnancy
7
IN THYROIDITIS: There is thyroid pain which is referred to the ears and throat. Tender erythematous asymmetrical goiter, fever and lymphadenopathy. There could be a hx of antecedent malaise and upper respiratory symptoms. In chronic thyroiditis, there is uniform goiter. Riedel’s thyroiditis present with a hard thyroid gland, asymmetric and fixed. It may cause compression symptoms affecting the esophagus and trachea in Thyroid Diseases In Pregnancy 8 10/14/08
IN HYPERTHYROIDISM, Clinical presentation include restlessness, fatigue, and weakness, weight loss, diarrhoea and heat intolerance. On examination, patient may exhibit tachycardia, tremors, goiter, muscle weakness, lid retraction or lag. The diagnostic triad for graves disease includes hyperthyroidism with dermopathy. However these 3 major manifestations may not appear together. The disease appears to be precipitated by emotional trauma or by metabolic stress. Toxic adenomas usually present as a solitary nodule, which gradually increase 9 Thyroid Diseases In Pregnancy 10/14/08 in size, initially patient may not be
INVESTIGATGIONS: In hypothyroidism,the thyroid function test reveal low thyroxine (T4) and elevated thyroid stimulating hormone (TSH) There is presence of antibodies to thyroid Peroxidase, Thyroid stimulating hormone receptor or thyroglobulin. In thyroiditis, there may be normal thyroid function test. Erythrocycte sedimentation rate (ESR) is elevated. There may be leukocytosis. The sera of patients with graves disease reveal TSH receptor antibodies, or antibodies to thyroid peroxidase. TSH is Thyroid Diseases In Pregnancy 10 10/14/08 usually decreased and free T4 values are
DIAGNOSIS:
Diagnosis of thyroid disease is made from history clinical findings laboratory results.
10/14/08
Thyroid Diseases In Pregnancy
11
TREATMENT: Hypothyroidism; In prenatal period – L-thyroxine 50 – 100ugld is given. This is a pure T4 preparation. The dosage is increased by 25ug per week until the patient is euthyroid. The goal of therapy is to bring TSH into the normal or low normal range Antepartum fetal assessment is necessary in the 3rd Trimester because of a small increase in stillbirth rate. Intrapartum: the euthyroid state is maintained. POST NATAL PERIOD: After delivery, the dosage of L-thyroxine will need to be decreased as necessary. Post partum exacerbations of sub – clinical thyroid disease have been reported to occur in approx 5 – 10% of women. Thyroid Diseases In Pregnancy 10/14/08 This hypothyroidism resolves spontaneously in 12
Thyroiditis:
Pain and inflammatory swelling is controlled by aspirin or other nonsteroidal anti inflammatory drugs. (not indomethacin) Antibiotics could be given in acute thyroiditis. L-thyroxine treatment may be necessary if there is a prolonged period of hypothyroidism. Riedel’s thyroiditis that causes
10/14/08
Thyroid Diseases In Pregnancy
13
HYPERTHYROIDISM: In prenatal period; The treatment of hyperthyroidism in pregnancy focuses on stopping release of Thyroxine (T4) and inhibiting conversion of T4 to T3. Propyl thiouracil (PTU) is initially given at 100g three times a day until patient is euthyroid. The dosage is subsequently decreased. Thyroid function should be assessed every 4 – 6weeks in pregnancy. Metamizole is also safe in pregnancy for patients who are non compliant, or refractory to medication, subtotal thyroidectomy can be done in the 2nd Trimester. INTRAPARTUM: No specific intrapartum concern exists, except when the patient Thyroid presents with and acute Diseases In Pregnancy 14 10/14/08
Thyroid storm is a maternal complication of untreated hyperthyroidism that can be precipitated by delivery, acute illness, infection, trauma or surgery it is associated with fever, that could exceed 40%c, A tachycardia, out of proportion to the fever may also be present. This tachycardia may even precipitate high output heart failure. Atrial fibrillation, with rapid ventricular response may also be present. There is increased pulse pressure mental status is commonly altered, ranging form restlessness and confusion to psychosis, seizures and coma. Mortality can be as high as 30% even with treatment. It is important to provide supportive care, identify and treat the cause, decrease the synthesis of T4. Large doses of propyl theiouracil 600mg loading dose is given followed by 200 – 300mg every hrs.15 Thyroid Diseases In Pregnancy 10/14/08 Potassium Iodide which should be administered
Propanohol 20-80mg given orally or 1 – 10mg intravenous every 4hrs to suppress adrenergic output and to block peripheral conversion of T4 to T3. In patients with congestive heart failure Beta Blockers also serve to increase stroke volume. Steroids could be used. Dexamethasone 2mg every 6hrs in this setting to block thyroid synthesis and as therapy for auto immune factors. Intravenous fluids, antibiotics and cooling blankets are also useful. Opthalmopathy may require short courses Thyroid severe Diseases In Pregnancy 16 10/14/08 of steroid. Rarely exophthalmos
PROGNOSIS AND COMPLICATION
Prognosis for both mother and fetus are excellent when hypothyroidism is corrected in pregnancy. Studies have shown that women with hypothyroidism have an increased likelihood of having children with lower 10 scores. Therefore it is important to identify and treat affected women congestive cardiac failure in the most serious complication of hypothyroidism megacolon adrenal crisis, organic Psychosis, hyponatraemia and Thyroid Diseases In Pregnancy 17 10/14/08 myxoedema coma and other
In general, prognosis for mother and fetus is good with treatment of thyroiditis. Maternal and fetal prognosis is also good in well controlled hyperthyroidism. A fetal goiter rarely may lead to extension of the head at delivery necessitating operative delivery. Skilled resuscitation of the newborn after delivery may be needed if the airway is obstructed by a goiter. Transplacental passage of IgG TSH
10/14/08
Thyroid Diseases In Pregnancy
18
Thyroid Diseases In Pregnancy
1
Introduction Pregnancy has a significant impact on normal maternal thyroid physiology and function, many of the physiologic change in pregnancy, especially the hypermetabolic changes mimic thyroid disease and abnormal thyroid function. Thyroid disease in pregnancy is difficult to diagnose because there is hypertrophy of the thyroid gland due to normal gravid physiologic changes. Normal secretion from the thyroid gland contain approx 80% thyroxine (T4) and 20% Triiodothyronine (T3), T3 is the active thyroid hormone, most of which is derived from peripheral conversion of thyroxine (T4) Though total T4 and T3 increase, there is also an increase in thyroid binding globulin (TBG), Diseases In Pregnancy 10/14/08 albumin and pre –Thyroid albumin, due to enhanced
2
Classification
Thyroid diseases in pregnancy are classified into 3 broad headings; Hypothyroidism Thyroiditis Hyperthyroidism
10/14/08
Thyroid Diseases In Pregnancy
3
HYPOTHYROIDISM: It affects 0.5 – 3% of pregnant women common causes of primary hypothyroidism include autoimmune diseases such as Hashimoto thyroiditis. Iatrogenic causes like radiation treatment or surgery. Congenital hypothyroidism, medications such as lithium or amiodarone, iodine deficiency, Radioactive iodine therapy and infiltrative disease. Secondary hypothyroidism may be caused by pituitary or Thyroid hypothalamic disease such 4 Diseases In Pregnancy 10/14/08
THYROIDITIS Most commonly autoimmune in aetiology. Other causes are viral infection, bacterial or fungal infection, radiation treatment. In younger women, infection of the piriform sinus is causative. Post partum thyroiditis is a silent thyroiditis that usually present 3 – 6 months post partum. It is a sub-acute condition. Riedel’s thyroiditis occurs in middle aged gravitas. It is a chronic thyroiditis. Other forms of chronic thyroiditis are Thyroid Diseases In Pregnancy 5 10/14/08 Hashmoto’s thyroiditis and parasitic
HYPERTHYROIDISM:
The incidence of hyperthyroidism in pregnancy is 0.05 – 2% The etiology in order of frequency are graves disease acute and sub-acute thyroiditis toxic nodular goiter toxic adenoma.
10/14/08
Thyroid Diseases In Pregnancy
6
CLINICAL PRESENTATION In Hypothyroidism: There could be a hx of previous thyroid surgery, radiation treatment or hashimoto thyroiditis. The signs and symptoms include skin dryness, yellowing of skin (esp in the periorbital area) hair loss, cold intolerance constipation and sleep disturbances, pallor, a goiter, delayed relaxation of deep tendon reflexes, eyelid oedema and weight 10/14/08
Thyroid Diseases In Pregnancy
7
IN THYROIDITIS: There is thyroid pain which is referred to the ears and throat. Tender erythematous asymmetrical goiter, fever and lymphadenopathy. There could be a hx of antecedent malaise and upper respiratory symptoms. In chronic thyroiditis, there is uniform goiter. Riedel’s thyroiditis present with a hard thyroid gland, asymmetric and fixed. It may cause compression symptoms affecting the esophagus and trachea in Thyroid Diseases In Pregnancy 8 10/14/08
IN HYPERTHYROIDISM, Clinical presentation include restlessness, fatigue, and weakness, weight loss, diarrhoea and heat intolerance. On examination, patient may exhibit tachycardia, tremors, goiter, muscle weakness, lid retraction or lag. The diagnostic triad for graves disease includes hyperthyroidism with dermopathy. However these 3 major manifestations may not appear together. The disease appears to be precipitated by emotional trauma or by metabolic stress. Toxic adenomas usually present as a solitary nodule, which gradually increase 9 Thyroid Diseases In Pregnancy 10/14/08 in size, initially patient may not be
INVESTIGATGIONS: In hypothyroidism,the thyroid function test reveal low thyroxine (T4) and elevated thyroid stimulating hormone (TSH) There is presence of antibodies to thyroid Peroxidase, Thyroid stimulating hormone receptor or thyroglobulin. In thyroiditis, there may be normal thyroid function test. Erythrocycte sedimentation rate (ESR) is elevated. There may be leukocytosis. The sera of patients with graves disease reveal TSH receptor antibodies, or antibodies to thyroid peroxidase. TSH is Thyroid Diseases In Pregnancy 10 10/14/08 usually decreased and free T4 values are
DIAGNOSIS:
Diagnosis of thyroid disease is made from history clinical findings laboratory results.
10/14/08
Thyroid Diseases In Pregnancy
11
TREATMENT: Hypothyroidism; In prenatal period – L-thyroxine 50 – 100ugld is given. This is a pure T4 preparation. The dosage is increased by 25ug per week until the patient is euthyroid. The goal of therapy is to bring TSH into the normal or low normal range Antepartum fetal assessment is necessary in the 3rd Trimester because of a small increase in stillbirth rate. Intrapartum: the euthyroid state is maintained. POST NATAL PERIOD: After delivery, the dosage of L-thyroxine will need to be decreased as necessary. Post partum exacerbations of sub – clinical thyroid disease have been reported to occur in approx 5 – 10% of women. Thyroid Diseases In Pregnancy 10/14/08 This hypothyroidism resolves spontaneously in 12
Thyroiditis:
Pain and inflammatory swelling is controlled by aspirin or other nonsteroidal anti inflammatory drugs. (not indomethacin) Antibiotics could be given in acute thyroiditis. L-thyroxine treatment may be necessary if there is a prolonged period of hypothyroidism. Riedel’s thyroiditis that causes
10/14/08
Thyroid Diseases In Pregnancy
13
HYPERTHYROIDISM: In prenatal period; The treatment of hyperthyroidism in pregnancy focuses on stopping release of Thyroxine (T4) and inhibiting conversion of T4 to T3. Propyl thiouracil (PTU) is initially given at 100g three times a day until patient is euthyroid. The dosage is subsequently decreased. Thyroid function should be assessed every 4 – 6weeks in pregnancy. Metamizole is also safe in pregnancy for patients who are non compliant, or refractory to medication, subtotal thyroidectomy can be done in the 2nd Trimester. INTRAPARTUM: No specific intrapartum concern exists, except when the patient Thyroid presents with and acute Diseases In Pregnancy 14 10/14/08
Thyroid storm is a maternal complication of untreated hyperthyroidism that can be precipitated by delivery, acute illness, infection, trauma or surgery it is associated with fever, that could exceed 40%c, A tachycardia, out of proportion to the fever may also be present. This tachycardia may even precipitate high output heart failure. Atrial fibrillation, with rapid ventricular response may also be present. There is increased pulse pressure mental status is commonly altered, ranging form restlessness and confusion to psychosis, seizures and coma. Mortality can be as high as 30% even with treatment. It is important to provide supportive care, identify and treat the cause, decrease the synthesis of T4. Large doses of propyl theiouracil 600mg loading dose is given followed by 200 – 300mg every hrs.15 Thyroid Diseases In Pregnancy 10/14/08 Potassium Iodide which should be administered
Propanohol 20-80mg given orally or 1 – 10mg intravenous every 4hrs to suppress adrenergic output and to block peripheral conversion of T4 to T3. In patients with congestive heart failure Beta Blockers also serve to increase stroke volume. Steroids could be used. Dexamethasone 2mg every 6hrs in this setting to block thyroid synthesis and as therapy for auto immune factors. Intravenous fluids, antibiotics and cooling blankets are also useful. Opthalmopathy may require short courses Thyroid severe Diseases In Pregnancy 16 10/14/08 of steroid. Rarely exophthalmos
PROGNOSIS AND COMPLICATION
Prognosis for both mother and fetus are excellent when hypothyroidism is corrected in pregnancy. Studies have shown that women with hypothyroidism have an increased likelihood of having children with lower 10 scores. Therefore it is important to identify and treat affected women congestive cardiac failure in the most serious complication of hypothyroidism megacolon adrenal crisis, organic Psychosis, hyponatraemia and Thyroid Diseases In Pregnancy 17 10/14/08 myxoedema coma and other
In general, prognosis for mother and fetus is good with treatment of thyroiditis. Maternal and fetal prognosis is also good in well controlled hyperthyroidism. A fetal goiter rarely may lead to extension of the head at delivery necessitating operative delivery. Skilled resuscitation of the newborn after delivery may be needed if the airway is obstructed by a goiter. Transplacental passage of IgG TSH
10/14/08
Thyroid Diseases In Pregnancy
18
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