Hypothyroid Disorders in Obs & Gynae – Case based approach – Part -1 Moderator - Dr Meenakshi Sharma & Dr Puja Dewan Panelist Dr Dipti Nabh Dr Richa Singhal Dr Manju Sharma Dr Deepa Gupta Dr Renu Chawla Dr Anita Agarwal

1. Hypothyroid Disorders in
Obs & Gynae – Case based approach –
Part -1
Moderator - Dr Meenakshi Sharma
& Dr Puja Dewan
Panelist
Dr Dipti Nabh
Dr Richa Singhal
Dr Manju Sharma
Dr Deepa Gupta
Dr Renu Chawla
Dr Anita Agarwal

2. Early
Pregnancy
Serum
Thyrotropin
level decreases
Weak TSH effect of HCG
‘Spill over’
Increase in free
Thyroxine

3. Materno fetal Transfer
Crosses
Placenta
Antithyroid
drugs ● Fetal Hypothyroidism
Crosses
placenta
TRAB ● Fetal Hyperthyroidism
Do not cross
placenta
TSH, hCG,
Tg
● NIL
Deactivated
by Placental
Deiodinases
T4 25-50% transferred to fetus

4. Case 1
A 15 year old girl with ℅ of wt gain(>10kg in 6 mths),
delayed scanty period, mood swings and depression.
TSH-24.39 mIU/L (0.4–4.5),
FT4- 0.93 ng/dL (0.8–2.0),
T3-1.08 ng/mL (0.70–1.90),
AntiTPO antibodies >1300 IU/mL ( <35).

5. What are the causes of hypothyroidism
in young age?
Why is it so important to diagnose
hypothyroidism in young girls?

6. •Hashimoto’s thyroiditis (autoimmune
thyroiditis) – most common . It usually develops after the first few
years of life. Over time, the inflammation damages the thyroid gland,
leading to a gradual decline in thyroid hormone levels.
Less common causes-
•Thyroiditis, a temporary inflammation, may be caused by a viral infection.
•Surgical removal of the thyroid gland
•Radiation treatment
•Too much or too little iodine
•Damage to the pituitary gland.

7. Hypothyroidism in adolescence - retarded growth in
height and delayed development of secondary sexual
characteristics;
Early diagnosis and treatment of autoimmune
thyroiditis (AT) offers timely intervention in delayed
onset of puberty.

8. How will you treat this girl?
What can you expect of this girl’s disease
in the long run?

9. Start LT4 50ug daily.
The goal of treatment is to restore normal growth and
development, including pubertal development.
The replacement dose should be increased slowly
over several weeks to months to minimize the
unwanted side effects (deterioration in school
performance, short attention span, hyperactivity,
insomnia, and behavioral difficulties).

10. Hypothyroidism caused by Hashimoto’s thyroiditis, post
thyroidectomy or radiation treatment is permanent and
treatment is lifelong.
Hypothyroidism due to other causes (like medications or iodine)
may go away if the cause can be addressed.
The dose of LT4 often changes during childhood and adolescence
due to growth, change in metabolism, and if there is continued
decreased function of any remaining normal thyroid.

11. What is the normal reference
range for serum TSH
concentrations in each
trimester of pregnancy?

12. Thyroid reference values in
Pregnancy (ATA 2017)
Population based TSH reference values should be used
During pregnancy -.In the first trimester, the lower reference range of
TSH can be reduced by approximately 0.4 mU/L, while the upper
reference range is reduced by approximately 0.5mU/L. For the typical
patient in early pregnancy, this corresponds to a TSH upper reference
limit of 4.0mU/L. This reference limit should generally be applied
beginning with the late first trimester, weeks 7–12, with a gradual return
towards the nonpregnant range in the second and third trimesters.

13. Thyroid Problems
Euthyroid TSH <4mIU/ml
Subclinical Hypothyroid TSH 4-10mIU/ml T4 normal
Overt Hypothyroidism TSH > 10mIU/ml T4 low

14. What is the recommended
daily iodine intake in women
planning pregnancy, women
who are pregnant, and
women who are
breastfeeding?

15. RECOMMENDATION 5
All pregnant women should ingest approximately 250 mcg iodine daily.
To achieve a total of 250 mcg iodine ingestion daily, strategies may need
to be varied based on country of origin.
RECOMMENDATION 10
Sustained iodine intake from diet and dietary supplements exceeding 500
mcg daily should be avoided during pregnancy due to concerns about
the potential for fetal thyroid dysfunction.
Strong recommendation, moderate-quality evidence.
ATA 2017

16. Case 2
A 32 year old G2A1 at 6 weeks with thyroid profile as
TT3 1.16ng/ml 0.60-1.81
TT4 7.20 mcg/dl 5.01-12.45
TSH 3.5 mIU/ml 0.35-5.50
What is your diagnosis?
How will you manage further?

17. RECOMMENDATION 28
Pregnant women with TSH concentrations >2.5 mU/L should be
evaluated for TPOAb status.
RECOMMENDATION 11
Euthyroid pregnant women who are TPOAb or TgAb positive should
have measurement of serum TSH concentration performed at time of
pregnancy confirmation and every 4 weeks through midpregnancy.
Strong recommendation, high-quality evidence.

18. Is there an association between thyroid antibodies and sporadic
spontaneous pregnancy loss or RPL in euthyroid women?
Does treatment with LT4 or intravenous immunoglobulin therapy
decrease the risk for pregnancy loss in euthyroid women with thyroid
autoimmunity?

19. RECOMMENDATION 13
I/v immunoglobulin treatment of euthyroid women with a history of
recurrent pregnancy loss is not recommended. Weak recommendation,
low-quality evidence.
RECOMMENDATION 14
Insufficient evidence exists to conclusively determine whether LT4
therapy decreases pregnancy loss risk in TPOAb-positive euthyroid
women who are newly pregnant. However, administration of LT4 to
TPOAb-positive euthyroid pregnant women with a prior history of loss
may be considered given its potential benefits in comparison with its
minimal risk. In such cases, 25–50 lg of LT4 is a typical starting dose.
Weak recommendation, low-quality evidence.

20. Is there an association between thyroid autoantibody
positivity and premature delivery?
Does LT4 treatment of euthyroid women who are
thyroid autoantibody positive reduce risk for
premature delivery?

21. Anti TPO positivity not Anti TG positivity associated with preterm
delivery
RECOMMENDATION 15
Insufficient evidence exists to recommend for or against treating
euthyroid pregnant women who are thyroid autoantibody positive with
LT4 to prevent preterm delivery.
No recommendation, insufficient evidence.

22. A 34 year old G2 P1L1 at 6 weeks pregnancy
TT3 0.8ng/ml 0.60-1.81
TT4 3.4mcg/dl 5.01-12.45
TSH 2.3mIU/ml 0.35-5.50
What is the diagnosis?

23. A 34 year old G2 P1L1 at 6 weeks pregnancy
TT3 0.8ng//ml 0.60-1.81
TT4 3.4mcg/dl 5.01-12.45
TSH 2.3mIU/ml 0.35-5.50
What is the diagnosis?
Is isolated Hypothyroxinemia associated with adverse outcome in
pregnancy?

24. Isolated Hypothyroxinemia has been found to be associated with
altered cognitive development but RCT of LT4 treatment failed to
improve neurocognitive development in such women.
RECOMMENDATION 30
Isolated hypothyroxinemia should not be routinely treated in
pregnancy. Weak recommendation, low-quality evidence.

25. A 34 year G3P1A1 at 8 weeks pregnancy
TT3 1.2 bg/ml 0.60-1.81
TT4 8.20 mcg/dl 5.01-12.45
TSH 5.2mIU/ml 0.35-5.50
Anti TPO negative
What is the Diagnosis?
Does she require LT4 therapy?

27. TPO Ab + TPO Ab -
TSH 2.5-ULRR Consider LT4 No treatment
TSH ULRR-
10mIU/ml
Treat LT4 Consider LT4
TSH>10mIU/ml Treat LT4 Treat LT4
Treatment of Thyroid disorders in pregnancy

29. A 30 year old with infertility with thyroid profile as
TT3 1.6ng/ml 0.60-1.81
TT4 8.20 mcg/dl 5.01-12.45
TSH 6.8 mIU/ml 0.35-5.50
Anti TPO Ab negative
Is subclinical hypothyroidism related to infertility?
Should subclinical hypothyroidism be treated in infertility?
Is maternal subclinical hypothyroidism associated with ART
outcomes?

30. RECOMMENDATION 16
Evaluation of serum TSH concentration is recommended for all women seeking care for
infertility.
Weak recommendation, moderate-quality evidence.
RECOMMENDATION 17
LT4 treatment is recommended for infertile women with overt hypothyroidism who desire
pregnancy.
Strong recommendation, moderate-quality evidence.
RECOMMENDATION 18
Insufficient evidence exist to determine if LT4 therapy improves fertility in subclinically
hypothyroid, thyroid autoantibody–negative women who are attempting natural conception
(not undergoing ART). However, administration of LT4 may be considered in this setting given
its ability to prevent progression to more significant hypothyroidism once pregnancy is
achieved. Furthermore, low dose LT4 therapy (25–50 μg/d) carries minimal risk.
Weak recommendation, low-quality evidence.

31. RECOMMENDATION 19
Insufficient evidence exists to determine if LT4 therapy improves
fertility in nonpregnant, thyroid autoantibody–positive euthyroid
women who are attempting natural conception (not undergoing ART).
Therefore, no recommendation can be made for LT4 therapy in this
setting.
No recommendation, insufficient evidence.

32. Is maternal subclinical hypothyroidism
associated with worse ART outcomes?
Does treatment of subclinically
hypothyroid women improve ART
outcomes?

33. RECOMMENDATION 20
Subclinically hypothyroid women undergoing IVF or intracytoplasmic sperm injection (ICSI)
should be treated with LT4. The goal of treatment is to achieve a TSH concentration <2.5
mU/L.
Strong recommendation, moderate-quality evidence.
RECOMMENDATION 21
Insufficient evidence exists to determine whether LT4 therapy improves the success of
pregnancy following ART in TPOAb-positive euthyroid women. However, administration of
LT4 to TPOAb- positive euthyroid women undergoing ART may be considered given its
potential benefits in comparison to its minimal risk. In such cases, 25–50 μg of LT4 is a typical
starting dose.
Weak recommendation, low-quality evidence.
RECOMMENDATION 22
Glucocorticoid therapy is not recommended for thyroid autoantibody–positive euthyroid
women undergoing ART.
Weak recommendation, moderate-quality evidence.

34. In a treated hypothyroid
women, how the dose should
be adjusted once she
conceives?

35. RECOMMENDATION 35
In hypothyroid women treated with LT4 who are planning pregnancy,
serum TSH should be evaluated preconception, and LT4 dose adjusted to
achieve a TSH value between the lower reference limit and 2.5 mU/L.
Strong recommendation, moderate-quality evidence.
RECOMMENDATION 36
Hypothyroid patients receiving LT4 treatment with a suspected or
confirmed pregnancy (e.g.,positive home pregnancy test) should
independently increase their dose of LT4 by -20%–30% and urgently
notify their caregiver for prompt testing and further evaluation. One
means of accomplishing this is to administer two additional tablets
weekly of the patient's current daily LT4 dosage.
Strong recommendation, high-quality evidence.

36. CASE 3
•Mrs Y, a 31 year old lady presented in OPD 2 mths after FTNVD with ℅
palpitation and depression.
•Known case of Type 1 DM, well controlled on insulin
•F/H- Father hypertensive, Mother hypothyroid
•Lab studies:
T3 -331.6 pg/mL ( 65 - 181 pg/mL)
FT4- 3.76 ng/dL( 0.89 - 1.76 ng/dL)
TSH-0.009 µIU/L (0.35 - 5.50 µIU/L)
Two months later, her TSH was 41.7 µIU/L and she was started
on LT4. Five month later, her TSH level returned to a normal range and
LT4 was stopped.

37. What is the diagnosis?
What is the etiology of post-partum
thyroiditis?

38. •PPT is an autoimmune disorder associated with the
presence of thyroid antibodies (TPO and Tg antibodies)
The occurrence of PPT in postpartum period reflects
the immune suppression that occurs during
pregnancy followed by the rebound of the immune
system in the postpartum period.

39. What are the symptoms and clinical course of the
disease?
Are there any predictors of PPT?

40. Initial Thyrotoxicosis phase followed by hypothyroidism.
1/3 of patients will manifest both phases, while 1/3 of patients will have only a thyrotoxic
or hypothyroid phase.
• The thyrotoxic phase occurs 1-4 months after delivery , lasts for 1-3 months and is
associated with symptoms including anxiety, insomnia, palpitations fatigue, weight loss,
and irritability. Since these symptoms are often attributed to being postpartum and the
stress of having a new baby, the thyrotoxic phase of post-partum thyroiditis is often
missed.
• More common for women to present in the hypothyroid phase, which typically occurs
4-8 months after delivery and may last up to 9 –12 months. Typical symptoms include
fatigue, weight gain, constipation, dry skin, depression and poor exercise tolerance.
• Most women will have return of their thyroid function to normal within 12-18 months
of the onset of symptoms. 20% will remain hypothyroid

41. Risk factors of PPT
Positive anti-thyroid antibodies (risk correlates with Ab levels)- PPT will
develop in 33%–50% of women who present with thyroid antibodies in the first
trimester
• Other autoimmune disorders prevalence of PPT is 25% with Type 1 DM,
25% with chronic viral hepatitis, 14% with SLE, and 44% with a prior history of
Graves' disease
•H/o previous thyroid dysfunction
•H/o previous postpartum thyroiditis (20% of women will have
recurrence in subsequent pregnancies)
•F/H/o thyroid dysfunction

42. •What is the treatment for the thyrotoxic phase of
PPT?
•Once the thyrotoxic phase of PPT resolves, how often
should TSH be measured to screen for the hypothyroid
phase?
•What is the treatment for the hypothyroid phase of
PPT?

43. RECOMMENDATION 86
During the thyrotoxic phase of PPT, symptomatic women may be
treated with β-blockers. A β-blocker that is safe for lactating women, such
as propranolol or metoprolol, at the lowest possible dose to alleviate
symptoms is the treatment of choice. Therapy is typically required for a few
weeks.
Strong recommendation, moderate-quality evidence.
RECOMMENDATION 87
ATDs are not recommended for the treatment of the thyrotoxic phase of
PPT. (as it is a destructive thyroiditis)
Strong recommendation, high-quality evidence.

44. RECOMMENDATION 89
LT4 should be considered for women with symptomatic hypothyroidism due to
PPT. If treatment is not initiated, their TSH level should be checked every 4–8
weeks until thyroid function normalizes. LT4 should also be started in hypothyroid
women who are attempting pregnancy or who are breastfeeding.
Weak recommendation, moderate-quality evidence.
RECOMMENDATION 90
If LT4 is initiated for PPT, discontinuation of therapy should be attempted after
12 months. Tapering of LT4 should be avoided when a woman is actively
attempting pregnancy or is pregnant.
Weak recommendation, low-quality evidence
It is always important to try to discontinue thyroid hormone after postpartum
thyroiditis, since 80% of patients will regain normal thyroid function

45. •Mrs. X, a 67 year old lady presented with chief ℅ mild
fatigue, dry skin, hoarseness of voice and difficulty in
losing weight.
•On exam, thyroid gland not palpable.
•Lab. Studies- TSH- 12.8 (0.4-4.5mIU/L)
TT3- 27(60-181ng/dl)
TT4- 3.45(5.01-12.45mcg/dl)

46. •Does hypothyroidism worsen with age?
•What is the normal TSH value for a 60 year old
female?
•Is there any alteration in treatment to be
considered at old age?

47. •Hypothyroidism is more common among the elderly,
especially women, due to increasing incidence of
autoimmune thyroiditis that occurs with ageing.
•Incidence steadily increases with advancing age

49. •Initial treatment of hypothyroidism in elderly patients should
typically start with LT4 administered in lower doses than those
prescribed for healthy younger patients (e.g. 0.25 to 0.5
mcg/kg/day).
“start low and go slow”
•Once cardiovascular tolerance of a starting dose has been
assessed, daily doses can be gradually increased by 12.5-25 mcg
every 4-6 weeks until adequate replacement is confirmed by TSH
measurement.

50. •Is there any change in dose of thyroxine
in postmenopausal hypothyroid females
on HRT?

51. Estrogen replacement therapy may lead to increased
thyroxine dose requirements as a consequence of
increased production of thyroid binding globulin (TBG)
in postmenopausal women with hypothyroidism.

52. What are the potential
deleterious effects of
inadequate levothyroxine?

53. Recommendation
The adverse effects of thyroid hormone deficiency
include detrimental effects on the serum lipid profile
and progression of cardiovascular disease.
Strong recommendation. Moderate quality evidence.