Thyroid Disease in Pregnancy
Abdelrahman Al-daqqa
Physiologic Changes in Thyroid
Function During Pregnancy
 Thyroid binding globulin (TBG) increases
due to reduced hepatic...
Physiologic Changes in Thyroid
Function During Pregnancy
Maternal
Status
TSH
**initial
screening
test**
Free T4 Free
Thyro...
The Fetal Thyroid
 Begins concentrating iodine at 10-
12 weeks
 Controlled by pituitary TSH by
approximately 20 weeks
Hyperthyroidism
 Occurs in 0.2% of
pregnancies; Graves’
disease accounts for
95% of cases
Look for:
-Nervousness
-Tremor
...
Fetal & Neonatal Effects of
Hyperthyroidism
 Associated with preterm delivery, low
birth weight, fetal loss
 Fetal thyro...
Causes & Diagnosis of
Hyperthyroidism
 Most common cause of hyperthyroidism is
Graves’ disease
 Document elevated FT4 or...
Treatment of Hyperthyroidism
 Goal is to maintain FT4/FTI in high normal
range using lowest possible dose
(minimize fetal...
Treatment of Hyperthyroidism
 Effect of treatment on fetal thyroid
function:
 Possible transient suppression of thyroid
...
Treatment of Hyperthyroidism
 Beta-blockers can be used for
symptomatic relief (usually Propanolol)
 Reserve thyroidecto...
Hypothyroidism
 Symptoms: fatigue, constipation, cold
intolerance, muscle cramps, hair loss, dry
skin, slow reflexes, wei...
Hypothyroidism: Fetal & Neonatal
Effects
 Higher incidence of LBW (due to
medically indicated preterm
delivery, pre-eclam...
Causes & Diagnosis of
Hypothyroidism
 Causes:
 Hashimoto’s (chronic thyroiditis; most common
in developed countries) & i...
Treatment of Hypothyroidism
 Treat with Levothyroxine in
sufficient dose to return TSH to
normal
 Adjust dosage every 4 ...
ACOG Recommendations
 Screening of all pregnant women
with a personal history, physical
examination, or symptoms of a
thy...
Rheumatoid Arthritis
Rheumatoid Arthritis in Pregnancy
Affects 1-2% of the general population
More common in women
RA in pregnancy is a common ...
Minimal effects on fetal morbidity and
mortality
Steroids may increase risk of IUGR and
PPROM
Active disease correlates wi...
Avoid NSAIDS and high dose aspirin
Low-dose aspirin safe
Use lowest doses of prednisone
Sulfasalazine, hydroxychloroquine ...
Aspirin
Azathioprine
Cyclosporin
Cyclophosphamide
Methotrexate
Chlorambucil
High dose prednisone
RA Medications and Breast...
Immune Thrombocytopenic
Purpura
ITP
Immune thrombocytopenic purpura
(ITP)
 is a clinical syndrome in which a decreased
number of circulating platelets
(throm...
Isolated thrombocytopenia
No drugs or other conditions that
may
affect platelet count
Exclude HIV, Hep C, SLE
ITP – Diagno...
Increased platelet destruction
Inhibition of platelet production at
megakaryocyte level
Mediated by IgG Abs against platel...
Petechiae, purpura, easy bruising
Epistaxis, menorrhagia, bleeding from gums
GIT bleeding, hematuria: rare
Intracranial he...
May affect fetus in up to 15% of cases
Neonatal count may drop sharply several days after
birth
Difficult to differentiate...
Incidence about 5%
Occurs late in pregnancy
Mild (>70 000)
No fetal neonatal
thrombocytopenia
Postpartum resolution
Gestat...
Myasthenia Gravis
Typically presents with fluctuating skeletal
muscular weakness
May be ocular or generalised
May have antibodies to the ACh...
Pregnancy has a variable effect on the
course of MG
Post-partum exacerbations in 30%
Infections can trigger exacerbations
...
Transplacental passage of IgG anti-AChR
Neuromuscular junction disorders
Transient neonatal MG in 10-20%
Decreased FM’s an...
First stage of labour not affected
Second stage: expulsive efforts may
weaken
Assisted vaginal delivery may be indicated
P...
Systemic Lupus Erythematosus
Severe pulmonary hypertension
Restrictive lung disease
Heart failure
History of severe HELLP or PET
Stroke within previous...
Disease exacerbation
Miscarriage, stillbirth
IUGR, preterm labour
Neonatal lupus
Drugs and breast-feeding
SLE complication...
Occurs in up to 2% of mothers with SLE
Targets skin and cardiac tissue,rarely other tissues
Congenital partial or complete...
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Thyroid disease in pregnancy

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Thyroid disease in pregnancy

  1. 1. Thyroid Disease in Pregnancy Abdelrahman Al-daqqa
  2. 2. 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 size in 15% of women (without abnormal TFTs)
  3. 3. Physiologic Changes in Thyroid Function During Pregnancy Maternal Status TSH **initial screening test** Free T4 Free Thyroxine Index (FTI) Total T4 Total T3 Resin Triiodo- thyronine Uptake (RT3U) Pregnancy No change No change No change Increase Increase Decrease Hyperthyroidism Decrease Increase Increase Increase Increase or no change Increase Hypothyroidism Increase Decrease Decrease Decrease Decrease or no change Decrease
  4. 4. The Fetal Thyroid  Begins concentrating iodine at 10- 12 weeks  Controlled by pituitary TSH by approximately 20 weeks
  5. 5. Hyperthyroidism  Occurs in 0.2% of pregnancies; Graves’ disease accounts for 95% of cases Look for: -Nervousness -Tremor -Tachycardia -Frequent stools -Sweating -Heat intolerance -Weight loss -Goiter -Insomnia -Palpitations -Hypertension -Lid lag/lid retraction -Pretibial myxedema
  6. 6. Fetal & Neonatal Effects of Hyperthyroidism  Associated with preterm delivery, low birth weight, fetal loss  Fetal thyrotoxicosis (related to disease itself or treatment)  Risk of immune-mediated hypo/hyperthyroidism (due to antibodies crossing the placenta, esp. in Graves or chronic autoimmune thyroiditis)  Antibodies in Graves’ disease can be either stimulatory or inhibitory  Neonates of women with Graves’ who have been surgically/radioactively treated are at higher risk, b/c not taking suppression
  7. 7. Causes & Diagnosis of Hyperthyroidism  Most common cause of hyperthyroidism is Graves’ disease  Document elevated FT4 or elevated FTI with suppressed TSH, in absence of goiter/mass  Most patients have antibodies to TSH receptor, antimicrosomal, or antithyroid peroxidase antibodies, but measurement of these is not required (though some endocrinologists recommend measuring TSI, which are stimulatory antibodies to TSH receptor)  Other causes:  Excess TSH production, gestational trophoplastic disease, hyperfunctioning thyroid adenoma, toxic goiter, subacute thyroiditis, extrathyroid source of TH
  8. 8. Treatment of Hyperthyroidism  Goal is to maintain FT4/FTI in high normal range using lowest possible dose (minimize fetal exposure)  Measure FT4/FTI q2-4 weeks and titrate  Thioamides (PTU/methimazole) -> decrease thyroid hormone synthesis by blocking organification of iodide  PTU also reduces T4->T3 and may work more quickly  PTU traditionally preferred (older studies found that methimazole crossed placenta more readily and was associated with fetal aplasia cutis; newer studies refute this)
  9. 9. Treatment of Hyperthyroidism  Effect of treatment on fetal thyroid function:  Possible transient suppression of thyroid function  Fetal goiter associated with Graves’ (usually drug-induced fetal hypothyroidism)  Fetal thyrotoxicosis due to maternal antibodies is rare -> screen for growth and normal FHR  Neonate at risk for thyroid dysfunction; notify pediatrician  Breastfeeding safe when taking PTU/methimazole
  10. 10. Treatment of Hyperthyroidism  Beta-blockers can be used for symptomatic relief (usually Propanolol)  Reserve thyroidectomy for women in whom thioamide treatment unsuccessful  Iodine 131 contraindicated (risk of fetal thyroid ablation especially if exposed after 10 weeks); avoid pregnancy/breastfeeding for 4 months after radioactive ablation
  11. 11. Hypothyroidism  Symptoms: fatigue, constipation, cold intolerance, muscle cramps, hair loss, dry skin, slow reflexes, weight gain, intellectual slowness, voice changes, insomnia  Can progress to myxedema and coma  Subclinical hypothyroidism: elevated TSH, normal FTI in asymptomatic patient  Associated with other autoimmune disorders  Type 1 DM -> 5-8% risk of hypothyroidism; 25% postpartum thyroid dysfunction
  12. 12. Hypothyroidism: Fetal & Neonatal Effects  Higher incidence of LBW (due to medically indicated preterm delivery, pre-eclampsia, abruption)  Iodine deficient hypothyroidism -> congenital cretinism (growth failure, mental retardation, other neuropsychological deficits)
  13. 13. Causes & Diagnosis of Hypothyroidism  Causes:  Hashimoto’s (chronic thyroiditis; most common in developed countries) & iodine deficiency -> both associated with goiter  Subacute thyroiditis -> not associated with goiter  Thyroidectomy, radioactive iodine treatment  Iodine deficiency (most common worldwide; rare in US)
  14. 14. Treatment of Hypothyroidism  Treat with Levothyroxine in sufficient dose to return TSH to normal  Adjust dosage every 4 weeks  Check TSH every trimester
  15. 15. ACOG Recommendations  Screening of all pregnant women with a personal history, physical examination, or symptoms of a thyroid disorder.
  16. 16. Rheumatoid Arthritis
  17. 17. Rheumatoid Arthritis in Pregnancy Affects 1-2% of the general population More common in women RA in pregnancy is a common challenge Sex hormones have effects on disease activity 70-80% of cases improve during pregnancy Post-partum flare common
  18. 18. Minimal effects on fetal morbidity and mortality Steroids may increase risk of IUGR and PPROM Active disease correlates with lower birth weights Effect of Pregnancy on RA
  19. 19. Avoid NSAIDS and high dose aspirin Low-dose aspirin safe Use lowest doses of prednisone Sulfasalazine, hydroxychloroquine in refractory cases Treatment of RA in Pregnancy
  20. 20. Aspirin Azathioprine Cyclosporin Cyclophosphamide Methotrexate Chlorambucil High dose prednisone RA Medications and Breast-feeding – Avoid:
  21. 21. Immune Thrombocytopenic Purpura ITP
  22. 22. Immune thrombocytopenic purpura (ITP)  is a clinical syndrome in which a decreased number of circulating platelets (thrombocytopenia) manifests as a  bleeding tendency,  easy bruising (purpura), or extravasation of blood from capillaries into skin and mucous membranes (petechiae). Although most cases of acute ITP, particularly in children, are mild and self-limited, intracranial hemorrhage may occur when the platelet count drops below 10 × 109/L (< 10 × 103/µL);[1] this occurs in 0.5-1% of children, and half of these cases are fatal.[2]
  23. 23. Isolated thrombocytopenia No drugs or other conditions that may affect platelet count Exclude HIV, Hep C, SLE ITP – Diagnostic Criteria:
  24. 24. Increased platelet destruction Inhibition of platelet production at megakaryocyte level Mediated by IgG Abs against platelet membrane glycoproteins Usually a chronic condition ITP – Pathology:
  25. 25. Petechiae, purpura, easy bruising Epistaxis, menorrhagia, bleeding from gums GIT bleeding, hematuria: rare Intracranial hemorrhage – very rare ITP – Clinical Features:
  26. 26. May affect fetus in up to 15% of cases Neonatal count may drop sharply several days after birth Difficult to differentiate from gestational thrombocytopenia Epidurals safe if count > 50000 Prednisone +/- IVIG if count < 50000 Manage delivery according to standard obstetric practice Avoid NSAIDS post-partum ITP and Pregnancy
  27. 27. Incidence about 5% Occurs late in pregnancy Mild (>70 000) No fetal neonatal thrombocytopenia Postpartum resolution Gestational Thrombocytopenia
  28. 28. Myasthenia Gravis
  29. 29. Typically presents with fluctuating skeletal muscular weakness May be ocular or generalised May have antibodies to the AChR 10-15% have a thymoma Respiratory muscle involvement may lead to respiratory failure Myasthenia Gravis:
  30. 30. Pregnancy has a variable effect on the course of MG Post-partum exacerbations in 30% Infections can trigger exacerbations Steroids can cause transient worsening MgSO4 is contraindicated Myasthenia Gravis in Pregnancy:
  31. 31. Transplacental passage of IgG anti-AChR Neuromuscular junction disorders Transient neonatal MG in 10-20% Decreased FM’s and breathing Polyhydramnios Arthrogryposis multiplex congenita Myasthenia Gravis – Effect on the Fetus
  32. 32. First stage of labour not affected Second stage: expulsive efforts may weaken Assisted vaginal delivery may be indicated Pre-labour anaesthetic assessment indicated Myasthenia Gravis – Labour & Delivery
  33. 33. Systemic Lupus Erythematosus
  34. 34. Severe pulmonary hypertension Restrictive lung disease Heart failure History of severe HELLP or PET Stroke within previous 6/12 Lupus flare within previous 6/12 SLE features associated with high maternal and fetal risks – pregnancy relatively contraindicated
  35. 35. Disease exacerbation Miscarriage, stillbirth IUGR, preterm labour Neonatal lupus Drugs and breast-feeding SLE complications in pregnancy:
  36. 36. Occurs in up to 2% of mothers with SLE Targets skin and cardiac tissue,rarely other tissues Congenital partial or complete heart block Heart block detected in utero Complete heart block: PNM of 44% Rash: erythematous annular lesions Rash clears within 6/12 Maternal dexamethasone may prevent progression of heart block Neonatal pacemaker if HR<55 Neonatal Lupus:
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