Hypothyroidism
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  • screening: heel prick blood at 2-5/7 of life : cord blood is accepted now: if TSH increased, take venous blood and test for TSH and free T4 at day 7-10 of life.

Transcript

  • 1. THYROID DISORDERS: HYPOTHYROIDISM
  • 2. REFERENCES
    • Practice Guidelines for Thyroid Disorders
    • The Malaysian Consensus 2000
    • Ministry of Health Malaysia
    • Oxford Handbook of Endocrinology & Diabetes
    • Helen E. Turner, and John A.H. Wass
    • 1 st edition, 2003
    • Update on the management of hyperthyroidism and hypothyroidism, Kenneth A. Woeber,, Arch Fam Med (2000) 9; 743-747
  • 3. INTRODUCTION
    • Hypometabolic state due to deficiency of thyroid hormones
    • Accumulation of GAGs (mucopolysaccharides) in the SC tissue
    • Incidence : mid-50s
    • : male:female ratio -> 1:10
  • 4. ETIOLOGY
    • PRIMARY : THYROID FAILURE ( 95%)
    • SECONDARY : PITUITARY TSH DEFICIT
    • TERTIARY : HYPOTHALAMIC DEFICIENCY OF TSH
    • PERIPHERAL RESISTANCE TO THE ACTIONS OF THYROID HORMONES
  • 5.
    • Autoimmune hypothyroidism:
      • Hashimoto’s thyroiditis
      • Atrophic thyroiditis
    • Iatrogenic:
      • Radio-iodine therapy
      • Thyroidectomy
      • External radiation to the neck (lymphoma/CA)
    • Drugs :
      • Antithyroid drugs , amiodarone, lithium, interferon
    • Congenital hypothyroidism:
      • Thyroid agenesis
      • Dyshormogenesis
      • TSH-R mutation
    PRIMARY CAUSES
    • Iodine deficiency
    • Infiltrative disorder
  • 6. 2°, 3° AND OTHER CAUSES
    • Hypopituitarism (2°):
      • Tumour
      • Surgery
      • Radiation
      • Postpartum: Sheehan’s syndrome
    • Hypothalamic causes (3°):
      • Tumour
      • Trauma
    • Peripheral resistance (rare)
  • 7.  
  • 8.  
  • 9.  
  • 10. LABORATORY INVX
    • Diagnosis : serum TSH
    • : serum T 4  total or free?
    • : thyroid autoantibodies
    • In outpatient setting -> serum TSH !!!
    • SUBCLINICAL HYPOTHYROIDISM:
    • patient is not overtly hyperthyroid
    • serum free T4 is normal, but TSH is ↑
  • 11. MANAGEMENT
    • Aim: to make patient euthyroid, clinically & biochemically.
    • Treatment with L-thyroxine is life-long -> ensure compliance!!
    • Monitoring:
      • Clinically & biochemically
      • Measure TSH and free T4 2-3 month after initiation of therapy -> determine maintenance dose
  • 12. Continue..
    • OVERT HYPOTHYROIDISM
      • Starting dose : 50-100 ug/d ->-> 100-200ug/d within 2 weeks
      • IHD / grossly hypothyroid / elderly:
        • Start at 25 ug/d
        • ↑ slowly within 2-4/52 according to pt response
        • Angina: withhold / ↓ dose. Proper mx of IHD
      • Hypopituitarism:
        • Cortisol: to avoid adrenal crisis
  • 13.
    • SUBCLINICAL HYPOTHYROIDISM:
      • L-thyroxine to ↓ risk of CAD
      • 50-100 ug/d ->-> adjust to maintain TSH at normal level
    • PREGNANCY:
      • ↑ dose, especially in 2 nd / 3 rd trimester
  • 14.
    • EMERGENCY:
    • MYXEDEMA COMA
  • 15.
    • Severe, uncompensated form of prolonged hypoTH
    • Precipitated by stress / infection / drug
    • Complication:
      • Hypoventilation
      • Cardiac failure
      • Fluid & electrolyte imbalance
      • coma
  • 16. PLAN OF MANAGEMENT
    • Treat precipitating cause
    • Gradual rewarming -> blanket
    • Accurate core T° -> rectal thermometer
      • Aim for slow ↑ in core T° : 0.5 °C/hr
    • Cardiac monitoring
    • Correction of electrolyte abnormalities
    • Adequate hydration & nutrition (dextrose)
    • L-thyroxine (300-400 ug oral/iv) &
    • tri-iodothyronine 10 ug 8 hrly
    • 8. Hydrocortisone : blood cortisol
  • 17.
    • CONGENITAL
    • HYPOTHYROIDISM
  • 18.
    • Incidence : 1 in 4000-5000 live births
    • Importance of TH hormones:
        • Normal development of nervous system !!
    • Features:
      • Prolonged jaundice
      • Poor feeding
      • Constipation
      • Unusually quite baby
  • 19. Continue..
    • Signs (if left untreated, appear at 3-6 months):
      • Coarse facies
      • Dry skin
      • Hoarse cry
      • Umbilical hernia
      • macroglossia
      • Delayed developmental milestones
  • 20. MANAGEMENT
    • Newborn screening
    • Diagnosis confirmed -> treat ASAP
    • Dose: start at 10-12 ug/kg/day
    • Aim : maintain TSH at normal level
    • : maintain free T4 at upper limit of normal range
    • Life-long treatment: if transient hypoTH is suspected, re-evaluate at 2 years old.
    • Monitoring: antropometry/milestones/bone age progression
  • 21.
    • THANK
    • YOU
  • 22.  
  • 23.