Post-partum thyroiditis (PPT)
•
0 likes•1,027 views
Post-partum thyroiditis (PPT) By Dr. Usama Ragab Youssif Agenda Definition Epidemiology Pathophysioetiology? Presentations and phases Search for it? Treat it? Recap
Recommended
More Related Content
What's hot
What's hot (20)
Similar to Post-partum thyroiditis (PPT)
Similar to Post-partum thyroiditis (PPT) (20)
More from Usama Ragab
More from Usama Ragab (20)
Recently uploaded
Recently uploaded (20)
Post-partum thyroiditis (PPT)
- 1. Postpartum Thyroiditis Email: usamaragab@medicine.zu.edu.eg Slideshare: https://www.slideshare.net/dr4spring/ Mobile: 00201000035863
- 2. Quiz A 32-year-old woman with no past medical history presents to the clinic for 2 months postpartum follow up. Physical exam including thyroid is normal. Vital signs show blood pressure 110/72 mmHg, pulse 75/min, temperature 37, and respiratory rate 16/min. The patient breastfeeds her 2-month-old daughter. Labs as follows: TSH 0.05 mU/L (0.35-5.5), free T4 3.1 ng/dL (0.8-2.1), T3 202 ng/dL (60-171).
- 3. Which of the following is the next best step in the management of this patient? A- Carbimazole B- Repeat thyroid function tests in 6-8 weeks C- Propranolol D- Thyroid ultrasound
- 4. Agenda • Definition • Epidemiology • Pathophysioetiology? • Presentations and phases • Search for it? • Treat it? • Recap
- 5. Thyroid. 2017 Mar 1;27(3):315-89. J Clin Endocrinol Metab, August 2012, 97(8):2543–2565
- 6. Postpartum Thyroiditis • Inflammation of thyroid that occur after birth
- 7. Definition • PPT is the occurrence of thyrotoxicosis, hypothyroidism, or thyrotoxicosis followed by hypothyroidism in the first year postpartum in women who were without clinically evident thyroid disease before pregnancy. • This is an inflammatory autoimmune condition. • PPT occurs almost exclusively in women who are thyroid antibody positive. Ann Intern Med (2010) 153:194–199 J Clin Endocrinol Metab, August 2012, 97(8):2543–2565
- 8. Epidemiology • The prevalence of PPT is approximately 5% (1.1 to 16.7%). • Women with other autoimmune disorders have an increased risk of PPT e.g., T1D (18-25%), CAH (25%), SLE (14%), relapsed GD (up to 44%), and other autoimmune endocrinopathies (27%). • Individuals who recover fully from PPT have a 70% chance of developing PPT in each subsequent pregnancy. Thyroid. 2017 Mar 1;27(3):315-89. J Clin Endocrinol Metab (1994) 79:10–16
- 10. The occurrence of PPT reflects the rebound of the immune system in the postpartum period after the relative immune suppression of pregnancy
- 11. Mechanisms involved in thyroid autoimmune disease The Lancet Diabetes & Endocrinology. 2018 Jul 1;6(7):575-86.
- 12. Of course, as a rule of thumb Genetic Predisposition Environmental trigger Autoimmune disease
- 13. Who is at risk for developing PPT? • Autoimmune disorders (e.g., T1DM) • Positive anti-TPO antibodies (risk correlates with antibody levels, the higher the antibody the higher the risk) • History of previous thyroid dysfunction • History of previous PPT • Family history of thyroid dysfunction Clinical obstetrics and gynecology. 2019 Jun 1;62(2):359-64
- 14. TPO-Ab positivity is the most useful marker for the prediction of postpartum thyroid dysfunction N Engl J Med (1982) 306:849–852
- 15. Classic Course Transient Thyrotoxicosis Transient Hypothyroidism Euthyroid
- 16. Time course of postpartum thyroiditis Nature Reviews Endocrinology. 2022 Mar;18(3):158-71.
- 17. The thyrotoxic phase • Between 2- and 6-months post partum, but episodes have been reported as late as 1 year following delivery. • All episodes of thyrotoxicosis resolve spontaneously.
- 18. Hypothyroid phase The hypothyroid phase of PPT occurs from 3 to 12 months postpartum with 10%–20% of cases resulting in permanent hypothyroidism. Up to 50% of women with PPT remained hypothyroid at the end of the first postpartum year1 1- J Clin Endocrinol Metab (2011) 96:652–657.
- 19. What symptoms are associated with PPT? Thyrotoxic phase: • Most women are asymptomatic or only mildly symptomatic during the thyrotoxic phase: mild elevation + ratio of free T4 increase > T3 • If occurs it includes irritability, heat intolerance, fatigue, and palpitations. The hypothyroid phase of PPT is more frequently symptomatic: • Cold intolerance, dry skin, fatigue, impaired concentration, and paresthesia • Occur more frequently if anti TPO +ve Thyroid. 2017 Mar 1;27(3):315-89.
- 20. Differential Diagnosis • first 3 months • Occult • No treatment or Inderal • TPO Ab +ve PPT • After 6.5 months • Overt • Treatment according guidelines • TRAb +ve • Increase Tc99 or I123 uptake* GD Thyroid. 2017 Mar 1;27(3):315-89.
- 21. Not only this
- 22. Symptoms of PPT may be very similar to symptoms seen in women in the postpartum period without PPT
- 23. PPD and PPT
- 24. PPD • Inconsistent data • Data sometimes show significant association • Sometimes it is the antibody not TFT? • Sometimes no association • If treated no difference in outcome
- 25. Guidelines
- 26. Failure of lactation?? • Both hyperthyroidism and hypothyroidism can impact milk letdown and the ability to successfully breastfeed. • No clear data • TFT should be evaluated in a women demonstrating poor lactation • But please Don’t forget other causes • The data for the treatment of thyroid women and lactation is not clear and no clear recommendation exists. Thyroid. 2017;27:315–389
- 27. Laboratory Studies • Thyrotoxic phase: TSH is ↓ and T4 moderately ↑ • Hypothyroid phase: T4 and T3 ↓, TSH may lag and still be suppressed • TPOAb is positive in the majority of patients. • TRAb are not present in PPT, unless the patient had a previous history of GD. • Thyroglobulin (Tg) may be elevated during the thyrotoxic phase, but is not used as a diagnostic marker of PPT. Clinical obstetrics and gynecology. 2019 Jun 1;62(2):359-64
- 29. Treatment of thyrotoxic phase of PPT Data are scarce First DD between PPT and GD ATDs is not useful → it is destructive (-itis) If severe symptoms → inderal
- 30. ATA 2017
- 31. Pending Hypo
- 32. Treatment of hypothyroid phase of PPT Treat if Symptomatic Lactating Attempting Pregnancy If no treatment TFT q4-8 weeks Until euthyroid (12 mo) Counsel contraception
- 33. Guidelines
- 34. Is treatment being infinite? No enough data Maintain euthyroid if pregnant or think pregnant Taper by 12 months postpartum Taper gradual TFT every 6 – 8 months
- 35. ATA 2017
- 36. Long term follow-up It was found in 7 studies that: • 10%–50% of women in whom the hypothyroid phase of PPT initially resolves will develop permanent hypo Factors associated with an increased risk of developing permanent hypothyroidism are • Multiparity • thyroid hypoechogenicity on ultrasound • greater severity of the initial hypothyroidism • higher TPOAb titers • greater maternal age • History of pregnancy loss J Clin Endocrinol Metab 2011 96:652–657. Br J Gen Pract 1997 47:305–308. Br Med J (Clin Res Ed) 1988 296:241–244. J Clin Endocrinol Metab 1988 67:327–333. Acta Endocrinol (Copenh) 1990 123:395–401. Eur J Endocrinol 2005 153:367–371. J Clin Endocrinol Metab 2000 85:3191–3198. J Clin Transl Endocrinol. 2019;15: 12–18
- 37. Guidelines
- 38. What about prevention Two RCTs studied iodine or LT4 treatment during pregnancy to prevent PPT in TPO Ab +ve women. Neither intervention decreased the incidence of PPT. Selenium has been studied: may be beneficial, not validated yet, not recommended, risk of T2D J Clin Endocrinol Metab 1990 70:1014–1018. J Clin Endocrinol Metab 2007 92:1263–1268 Eur J Nutr 2016 55:55–61. Ann Intern Med 2007 147:217–223.
- 39. ATA 2017
- 40. Thyroid 21:1081–1125, 2011 (68)
- 41. Recap PPT is a relatively common PPT predict PPT (30 – 70%) TPO Ab is predictor Autoimmune disorders (including previous thyroidopathies) PPT vs GD PPT phases Hypothyroidism may occur and will occur take care
- 42. Thank you
Editor's Notes
- PPT is the occurrence of thyrotoxicosis, hypothyroidism, or thyrotoxicosis followed by hypothyroidism in the first year postpartum in women who were without clinically evident thyroid disease before pregnancy. This is an inflammatory autoimmune condition. In the classic form, transient thyrotoxicosis is followed by transient hypothyroidism with a return to the euthyroid state by the end of the initial postpartum year. PPT occurs almost exclusively in women who are thyroid antibody positive. Postpartum thyroiditis is the occurrence of thyroid dysfunction, excluding GD, in the first postpartum year in women who were euthyroid prior to pregnancy
- Prevalence in unselected populations. The reported prevalence of PPT varies globally, and the mean prevalence in prospective studies in iodine-sufficient areas in which at least two thirds of the cohort was followed for at least 5 months postpartum is approximately 7% (127). Incidence is affected by genetic influences and iodine intake. ---------- The prevalence of PPT is approximately 5%, although it has varied markedly in different studies, with frequencies reported from 1.1% to 16.7% (555). Women with other autoimmune disorders have an increased risk of PPT. Specifically, the prevalence of PPT is 3–4 times higher in women with diabetes mellitus type 1 compared to unselected populations (556,557). The frequency of PPT is 25% in women with chronic viral hepatitis (558), 14% in women with systemic lupus erythematosus (559), 44% in women with a prior history of GD (560), and 27% in patients with antipituitary antibodies (561). Individuals who recover fully from PPT have a 70% chance of developing PPT in each subsequent pregnancy (562). Women on LT4 therapy secondary to Hashimoto’s thyroiditis may develop PPT if their thyroid gland is not completely atrophic (563). Cases of PPT have been reported following pregnancy loss, but the prevalence of PPT following pregnancy loss is unknown (564).
- Figure 1: Mechanisms involved in thyroid autoimmune disease Thyroid autoimmune disease, similar to other autoimmune diseases, occurs because of an absence of adequate T-cell tolerance. Although the cause of thyroid autoimmunity is unknown, genetic, and non-genetic factors, such as environmental factors, could be involved. In the initial stage of thyroid autoimmunity, these factors cause thyrocyte damage and exposure of thyroid antigens, such as thyroperoxidase, thyroglobulin, thyroid-stimulating hormone receptor, sodium iodine symporter, and pendrin. Antigen-presenting cells (APCs), particularly dendritic cells, recognise these peptides and infiltrate the thyroid gland. After processing the protein antigen, the thyroid APCs migrate to lymphoid tissue where they activate T cells. CD4+ T cells mediate B-cell activation and thyroid antibody induction. The T cells also release cytokines and have a direct cytotoxic effect on the thyroid gland. Cytotoxic T cells, B cells, macrophages, cytokines, and thyroid antibodies infiltrate the thyroid gland and induce apoptosis and destruction of the thyrocyte. ---------------- Postpartum thyroiditis is an autoimmune disorder associated with the presence of thyroid antibodies (TPOAb and TgAb), lymphocyte abnormalities, complement activation, increased levels of IgG1, increased NK cell activity, and specific HLA haplotypes (550–552). Women who are thyroid Ab positive in the first trimester have a high risk of developing PPT, ranging from 33% to 50% (553). Women with the highest Ab titers also have the highest risk of PPT (431). The occurrence of PPT reflects the rebound of the immune system in the postpartum period after the relative immune suppression of pregnancy.
- Other risk factors for PPT include family history AID and autoimmune thyroid disease (AITD), presence of a goiter, history of neck irradiation, preterm delivery, or miscarriage. The role of cigarette smoking as a risk factor remains unclear.
- PPT is caused by the immunological perturbations that occur during pregnancy and postpartum. Some of the immunological abnormalities are observed before the onset of thyroid dysfunction (128): TPO-Ab positivity is the most useful marker for the prediction of postpartum thyroid dysfunction (129). From 40–60% of women with positive TPO-Ab in early pregnancy develop postpartum thyroid dysfunction (112, 123). The majority of mothers with high titers of antibody develop postpartum thyroid dysfunction (129).
- In the classic form, transient thyrotoxicosis is followed by transient hypothyroidism with a return to the euthyroid state by the end of the initial postpartum year. --------------- The classic description of postpartum thyroiditis includes thyrotoxicosis followed by hypothyroidism. Not all women appear to go through both phases; approximately 1/3 of patients will manifest both, while 1/3 of patients will have only a thyrotoxic or only a hypothyroid phase. The thyrotoxic phase occurs 1-4 months after delivery of a child and lasts for 1-3 months. It is much more common for women to present during the hypothyroid phase. This typically occurs 4-8 months after delivery and may last up to 9 –12 months. Most women will regain normal thyroid function within 12-18 months after the onset of symptoms. However, approximately 20% of those that go into a hypothyroid phase will remain hypothyroid.
- Typical time course in changes in serum levels of thyroid stimulating hormone (TSH), T4 and radioactive iodine uptake in postpartum thyroiditis up to 12 months after delivery is depicted. Transient thyrotoxicosis is generally followed by transient hypothyroidism, before full recovery to euthyroidism. However, about 20% of women with postpartum thyroiditis might develop permanent hypothyroidism (as indicated by the dashed lines).
- FIGURE 1. Presentation and course of postpartum thyroiditis. Roughly 50% present with transient hypothyroidism, 25% with transient hyperthyroidism, and 25% with biphasic destructive thyroiditis. Up to 50% of patients with PPT will eventually develop persistent hypothyroidism.
- The clinical course of PPT varies, with approximately one quarter of patients presenting with the classical form, one quarter with isolated thyrotoxicosis, and one half presenting with isolated hypothyroidism The thyrotoxic phase of PPT typically occurs between 2 and 6 months post partum, but episodes have been reported as late as 1 year following delivery. All episodes of thyrotoxicosis resolve spontaneously.
- The frequency of asymptomatic hyperthyroidism among patients with PPT is approximately 30% (112). ----------- Postpartum thyroiditis is a painless condition and most women are asymptomatic or only mildly symptomatic during the thyrotoxic phase. This is because the degree of increase in thyroid hormones is typically mild, and T4 levels are usually more elevated than T3. Nevertheless, in prospective studies, reported symptoms include irritability, heat intolerance, fatigue, and palpitations (431,565–567). The hypothyroid phase of PPT is more frequently symptomatic. Symptoms during the hypothyroid phase of PPT may include cold intolerance, dry skin, fatigue, impaired concentration, and paresthesias (566,567). One study demonstrated that patients with TPO antibodies and PPT had more symptoms than those who were TPOAb negative (568).
- The major challenge is to differentiate thyrotoxicosis caused by PPT from thyrotoxicosis caused by GD. This is an important distinction because the two disease entities require different treatments and have markedly different clinical courses. The timing of onset provides some clues about etiology. In a Japanese hospital study of 42 patients who developed thyrotoxicosis within the first year after pregnancy, 86% of patients who had debut of disease within the first 3 months after delivery had thyroiditis, whereas all who developed thyrotoxicosis after 6.5 months had GD (554). TSH receptor antibodies are positive in GD in nearly all cases and are typically negative in PPT, although some mixed-type disease is seen. An elevated T4:T3 ratio suggests the presence of PPT. Physical stigmata of GD, such as goiter with a bruit or ophthalmopathy, are diagnostic when present. The radioiodine uptake is elevated or normal in GD and low in the thyrotoxic phase of PPT, but the use of radioactive diagnostic procedures in lactating patients is rarely indicated. Due to their short half-lives, 123I or technetium scans (Tc-99m) may be used in women who are breastfeeding if breast milk is pumped and discarded for several days after the scan pending the isotope used (see Section XI). As described in Section XI, the use of 131I is contraindicated in women who are breastfeeding. --------------- In circumstances where 123-I RAIA is indicated, breastmilk should be discarded for three to four days after the study.
- Studies evaluating the relationship of PPT to postpartum depression have been inconsistent (569–573). Two studies have reported a significant association between the presence of thyroid antibodies and depression (568,574), irrespective of thyroid function, whereas another study showed no association between the presence of microsomal antibodies and postpartum depression (575). A prospective trial of LT4 treatment versus placebo in postpartum TPOAb-positive women resulted in no difference in rates of postpartum depression between the two groups (576).
- Both hyperthyroidism and hypothyroidism can impact milk letdown and the ability to successfully breastfeed. However, there are no controlled human trials, only several case series and cohort analyses. The proportion of mothers affected and the degree of dysfunction necessary to affect lactation is not clear. However, thyroid function should be evaluated in a women demonstrating poor lactation, with the goal of effectively returning any hypothyroid mother to euthryoid state. The data for the treatment of hyperthyroid women and lactation is not clear and no clear recommendation exists.
- Thyrotoxic phase of PPT, TSH is suppressed and thyroxine levels are typically moderately elevated. During the hypothyroid phase of PPT, thyroxine (T4), and triiodothyronine (T3) are low. TSH may lag and still be suppressed because of the previous hyperthyroid phase before eventually increasing. As stated above, TPOAb is positive in the majority of patients and TgAb may also be positive. TSH-receptor antibody (TRAB) or thyroid-stimulating immunoglobulin (TSI) are not present in PPT, unless the patient had a previous history of GH. Thyroglobulin (Tg) may be elevated during the thyrotoxic phase, but is not used as a diagnostic marker of PPT.
- There have been no prospective studies evaluating when and how to treat PPT. Treatment of the thyrotoxic phase is guided by its transitory nature. ATDs (PTU and MMI) are ineffective in treating the thyrotoxic phase of PPT because it is a destructive thyroiditis in which thyroid hormone synthesis is not increased. Symptoms are typically mild. In rare cases when symptoms are clinically significant, propranolol at the lowest possible dose to alleviate symptoms may be used. The thyrotoxic phase of PPT must be differentiated from recurrent or de novo GD.
- In women with significant symptoms, those currently lactating or women who are actively attempting pregnancy, treatment should be started (431). LT4 treatment should be considered during the hypothyroid phase of PPT if the patient is mildly symptomatic, or recommended if the patient is considering another conception. If treatment is delayed, thyroid function should be rechecked every 4–8 weeks until euthyroidism is restored and women should be counseled to use contraception.
- The length of time that LT4 should be continued has not been systematically evaluated. Guiding principles are to maintain a euthyroid state in women who are attempting pregnancy or pregnant. Tapering LT4 doses in order to determine whether the hypothyroid phase of PPT was transitory or permanent can begin by 12 months post partum. Tapering should be gradual and TSH should be monitored every 6–8 weeks. ------------------ For hypothyroid symptoms, levothyroxine (LT4) 50 to 100 mcg/d will help with symptom relief. Because prediction of permanent hypothyroidism is not possible, treatment can be gradually weaned at approximately 12 months and thyroid function reevaluated for spontaneous resolution. In patients who are desiring future pregnancy, the physician should strongly advise continuing LT4 as the woman will be at high risk for developing hypothyroidism in a future pregnancy. In women who are successfully weaned, checking TSH annually is recommended as the rate of permanent hypothyroidism is high. Hypothyroid women who are breastfeeding should be treated with LT4. Women who are not treated for hypothyroidism should use contraception until thyroid levels normalize.
- The impact of PPT on long-term thyroid function has been evaluated in seven studies (549,562,577–581). These data demonstrate that 10%–50% of women in whom the hypothyroid phase of PPT initially resolves will ultimately go on to develop permanent hypothyroidism. Factors associated with an increased risk of developing permanent hypothyroidism are multiparity, thyroid hypoechogenicity on ultrasound, greater severity of the initial hypothyroidism, higher TPOAb titers, greater maternal age, and a history of pregnancy loss
- Two randomized placebo-controlled controlled trials have evaluated the efficacy of iodine or LT4 treatment during pregnancy to prevent the development of PPT in thyroid Ab–positive women. Neither intervention decreased the incidence of PPT (154,582). A single trial has suggested a benefit of selenium supplementation for the prevention of PPT in TPOAb-positive pregnant women, though this has not been independently validated. Furthermore, selenium use has been associated with an increased risk of type 2 diabetes (156). Currently there is not sufficient evidence to recommend selenium supplementation during pregnancy in thyroid Ab–positive women
- FIG. 1. Algorithm for the treatment and follow-up of women who are diagnosed with PPT. [Reprinted from A. Stagnaro-Green et al.: Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and postpartum. Thyroid 21:1081–1125, 2011 (68)
- PPT is a relatively common thyroid complication in the postpartum period. Women with a history of PPT are at high risk for PPT in future pregnancies with recurrence rates between 30% and 70% and TPOAb positive women who remain euthyroid during the first postpartum year are still at a 25% risk of developing PPT in a future pregnancy. Differentiating the diagnosis from GD is important as many patients with PPT may not require treatment. A physician must understand PPT’s clinical progression as almost half of women with PPT may eventually develop permanent hypothyroidism.