Maternal thyroid physiology is modulated during pregnancy by increases in hCG, urinary iodide excretion, and thyroxine-binding globulin. Thyroid disorders complicating pregnancy include hyperthyroidism, hypothyroidism, and postpartum thyroiditis. Hyperthyroidism is treated during pregnancy with antithyroid medications to maintain normal thyroid hormone levels. Hypothyroidism requires increasing levothyroxine doses during pregnancy. Postpartum thyroiditis involves transient hyperthyroid and hypothyroid phases due to thyroid autoimmunity after delivery.
Labour induction
Induction of labour
Guidelines on induction of labour
Guidelines on labour induction
induction of labour is not risk free
prostaglandins for induction of labour
Bishop score
Cervical ripening techniques
mechanical and pharmacological induction of labour
Post dates induction
options for cervical ripening
oral vs. vaginal misoprostol
advantages diadvantages and techniques for induction of labour
gynecology & obstetrics
Labour induction methods
review of guidelines for labour induction
Due to pregnancy thyroid economy is affected with changes in iodine metabolism, TBG and development of maternal goiter. The incidence of hypothyroidism in pregnancy is quite common with autoimmune hypothyroidism being the most important cause. Overt as well as subclinical hypothyroidism has a varied impact on maternal and neonatal outcome. After multiple studies also, routine screening in pregnancy for hypothyroidism can still not be recommended. Management mainly comprises of dosage adjustments as soon as pregnancy is diagnosed based on results of thyroid function tests. The aim should be to keep FT4 at the upper end of normal range.
Labour induction
Induction of labour
Guidelines on induction of labour
Guidelines on labour induction
induction of labour is not risk free
prostaglandins for induction of labour
Bishop score
Cervical ripening techniques
mechanical and pharmacological induction of labour
Post dates induction
options for cervical ripening
oral vs. vaginal misoprostol
advantages diadvantages and techniques for induction of labour
gynecology & obstetrics
Labour induction methods
review of guidelines for labour induction
Due to pregnancy thyroid economy is affected with changes in iodine metabolism, TBG and development of maternal goiter. The incidence of hypothyroidism in pregnancy is quite common with autoimmune hypothyroidism being the most important cause. Overt as well as subclinical hypothyroidism has a varied impact on maternal and neonatal outcome. After multiple studies also, routine screening in pregnancy for hypothyroidism can still not be recommended. Management mainly comprises of dosage adjustments as soon as pregnancy is diagnosed based on results of thyroid function tests. The aim should be to keep FT4 at the upper end of normal range.
A normal pregnancy results in a number of important reversible physiological and hormonal changes that alter thyroid structure and more importantly function.
Understanding these change are important to interpreting, identifying and managing of thyroid disease in pregnancy.
Thyroid disease in_pregnancy
Presented by: Dr. Ahmad mukhtar
M.B.B.Ch., M.Sc Obstetrics and GynecologyAssistante lecturer of Obstetrics and Gynecology
Faculty of Medicine, Zagazig University
Obstetrics and Gynecological Nursing
The PPT contains detailed information about Abnormal uterine action, its classifications, causes, sign and symptoms and management.
Retained placenta can be defined as lack of placental expulsion within 30 minutes of delivery of an infant. it is more common in preterm. Retained Placenta can lead to massive PPH and increase maternal morbidity and mortality.
A normal pregnancy results in a number of important reversible physiological and hormonal changes that alter thyroid structure and more importantly function.
Understanding these change are important to interpreting, identifying and managing of thyroid disease in pregnancy.
Thyroid disease in_pregnancy
Presented by: Dr. Ahmad mukhtar
M.B.B.Ch., M.Sc Obstetrics and GynecologyAssistante lecturer of Obstetrics and Gynecology
Faculty of Medicine, Zagazig University
Obstetrics and Gynecological Nursing
The PPT contains detailed information about Abnormal uterine action, its classifications, causes, sign and symptoms and management.
Retained placenta can be defined as lack of placental expulsion within 30 minutes of delivery of an infant. it is more common in preterm. Retained Placenta can lead to massive PPH and increase maternal morbidity and mortality.
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
High risk approach in maternal and child healthShrooti Shah
High risk pregnancy is defined as one which is complicated by factor or factors that adversely affects the pregnancy outcome –maternal or perinatal or both.The risk factors may be pre-existing prior to or at the time of first antenatal visit or may develop subsequently in the ongoing pregnancy labour or puerperium.
Over 50 percent of all maternal complications and 60 percent of all primary caesarean sections arise from the high risk group of cases.
Thyroid Disorder:
Thyroid disease is the second most common endocrine disorder affecting women of reproductive age, and when untreated during pregnancy is associated with an increased risk of miscarriage, placental abruption, hypertensive disorders, and growth restriction.
Types of thyroid disorder incidence in pregnancy:
1. Hypothyroidism 0.05%
2. Hyperthyroidism 0.05-0.2%
3. Postpartum thyroiditis 5-10%
Signs:
Hair loss
Sweating
Irritability
Bulging eyes
Rapid heart beat
Nervousness
Tremor of fingers
Difficulty sleeping
Weight loss
Thyroid Disorders in Obs & Gynae - Case based approach onHyperthyroidism & T...Lifecare Centre
Thyroid Disorders in Obs & Gynae - Case based approach onHyperthyroidism & Thyroid Cancer--- Part 2
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
Over the past several years it has been proved that maternal thyroid disorder influence the outcome of mother and fetus, during and also after pregnancy. The most frequent thyroid disorder in pregnancy is maternal hypothyroidism. It is associated with fetal loss, placental abruptions, pre-eclampsia, preterm delivery and reduced intellectual function in the offspring.1 In pregnancy, overt hypothyroidism is seen in 0.2% cases2 and sub clinical hypothyroidism in 2.3% cases3. Fetal loss, fetal growth restriction, pre-eclampsia and preterm delivery are the usual complications of overt hyperthyroidism (low TSH and high T3, T4) seen in 2 of 1000 pregnancies whereas mild or sub clinical hyperthyroidism (suppressed TSH alone) is seen in
1.7% of pregnancies and not associated with adverse outcomes4. Autoimmune positive euthyroid pregnancy shows doubling of incidence of miscarriage and preterm delivery. Worldwide more than 20 million people develop neurological sequel due to intra uterine, iodine deprivation5. Other problems of thyroid disorders in pregnancy are post partum thyroiditis, thyroid nodules and cancer, hyper emesis gravidarum etc. Debates and disputes persist regarding several protocol and management plan in this specific spectrum of diseases.
Hypothyroidism is a condition marked by an underactive thyroid gland and may be present during pregnancy. It incidence
0.05% of pregnant women
31% positive for TPO Ab
Associated with Gest Hypertension.
Hyperthyroidism in pregnancy:
Hyperthyroidism is characterized by high level of serum thyroxine and triiodothyronine, low levels of thyroid-stimulating hormones.
Hyperthyroidism during pregnancy usually is caused by an
Autoimmune disorder called Grave’s disease. It incidence :-
- 0.2% of pregnant women
- 95% Grave’s disease
It is a presentation on Thyroid Disorder in Pregnancy 2023
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https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
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1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
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3. MATERNAL THYROID PHYSIOLOGY
During pregnancy, maternal thyroid function is
modulated by three factors
• An increase in HCG concentrations that stimulate
the thyroid glands,
• Significant increases in urinary iodide excretion,
resulting in a fall in plasma iodine concentrations,
• An increase in thyroxine-binding globulin (TBG)
during the first trimester, resulting in increased
binding of thyroxine
4. THYROID IN PREGNANCY
• Thyroid hormone concentrations in blood are
increased in pregnancy, partly due to the high
levels of oestrogen and due to the weak
thyroid stimulating effects of human chorionic
gonadotropin(hCG) that acts like TSH.
• Thyroxine (T4) levels rise from about 6–12
weeks, and peak by mid-gestation; reverse
changes are seen with TSH
5.
6. AUTOIMMUNE THYROID DISEASE
There are mainly two types of thyroid antibodies: Those that are
directed towards cytoplasmic antigen(thyroid peroxidise(TPOAb) and
thyroglobulin (TgAb) antibodies) and those directed to the TSH
receptor(TSHRAb).
The thyroid autoimmunity,with normal thyroid function ,has been
associated with increased miscarriage rate which may be due to:
Subtle maternal thyroid dysfunction
An underlying autoimmune imbalance reflected by the presence of
thyroid antibodies which result in rejection of the fetus.
Thyroid antibodies which crosses the placenta and directly affecting
the developing fetal thyroid gland ,increase early loss
Increased maternal age of women with thyroid autoimmunity
7. Definition: It is defined by excessive thyroid
hormone production due to an overactive gland.
Incidence: Hyperthyroidism occurs in about 2
per 1000 pregnancies
Types: Based on biochemical test
Subclinical:- suppressed TSH ,normal T4 and T3
Overt:- suppressed TSH and elevated T4 and /or
T3
12. On examination, patient may exhibit
Tachycardia
Tremor
Goitre
Muscle weakness
Lid retraction or lag
TSH decreased and T4 elevates
Patients with grave’s disease may have antibodies
to thyroid peroxidise or TSH receptor.
13. Clinical diagnosis of hyperthyroidism is
always be confirmed by measuring free T4
and T4 levels along with TSH
Suggestive complaints include nervousness,
heat intolerance, palpitations, thyromegaly or
goitre, failure to gain weight or loss weight,
exophthalmos.
Women with gestational thyrotoxicosis are
rarely symptomatic,have minimal thyroid
enlargement and are TSHRAb negative
14. Antithyroglobulin antimicrosomal antibodies
and thyroid stimulating immunoglobulin
should be measured
Radioactive iodine uptake and scans should
not be done during pregnancy as it cross the
placenta and damage the fetal thyroid gland
permanently
15. The goal of management of thyrotoxicosis is
primarily to normalize ,but not to suppress
thyroid hormone levels and to secondarily
treat bothersome adrenergic symptoms of
hyperthyroidism
Treatment of hyperthyroidism in pregnancy
focuses on stopping release of T4 and
inhibiting conversion of T4 to T3
16. Treatment options for nonpregnant women
include treatment for 12 – 24 months with
antithyroid drugs, radioactive iodine to
partially ablate the thyroid gland and near
total thyroidectomy.
Use of antithyroid drugs (carbimazole,
methimazole, propylthiouracil)
17. Thyroid function should be assessed every 4-
6 weeks.
Subtotal thyroidectomy is an option for
patients who are noncompliant or refractory
to medications.Surgery is best undertaken in
the second trimester.Radioiodine treatment is
contraindicated in pregnancy.
Thyrotoxicosis or thyroid storm is treated
with large dose of PTU,600mg loading dose
,followed by 200 – 300mg every 6 hrs should
be administered
19. ANTENATAL MANAGEMENT:
The goal of the treatment during pregnancy is to maintain free T4
in the upper normal range with lowest dose of thio amides.
Treatment with beta blockers for the symptomatic relief of severe
adrenergic symptoms until freeT4 levels are normalised
Women on thio –amide prior to pregnancy or newly diagnosed
toxic nodules or Grave’s disease should be continued or started
on thio amide during pregnancy.
The usual starting dose of PTU is 50 – 100 mg 3 times a day and
methiomezole 5 – 20 mg twice daily.
Thyroid studies should be repeated every 4 weeks and the
dosage should be based on T4 level and not on TSH level .
Dosage should be reduced when the T4 level reaches the normal.
20. FETAL MONITORING:
Foetuses of women taking antithyroid drug during the
third trimester or those with a persistent TSHRAb
have an increased risk for developing goiter.
Because of the placental transfer of thyroid
stimulating immunoglobulins fetal grave’s disease
may develop that results in nonimmune hydrops or
fetal demise.
Documentation of fetal heart rate at each visit and
USG every 2- 4 weeks in the third trimester
If any fetal abnormlity present routine fetal blood
sampling for thyroid indices are recommended
21. Labor and delivery:
Treatment of symptomatic women with
hyperthyroidism in labor include antithyroid
medication , beta – blockers if necessary and
supportive care.
If thyrotoxicosis is suspected in labor
appropriate management include –elective
caesarean delivery may be suitable to avoid
dystocia from an extremely large fetal goitre
and for the management of fetal airway.
The ex utero intrapartum treatment(EXIT)
was developed to to manage airway
obstruction with large neck masses.
22. There may be relapse of Grave’s disease
usually within the first 3 months after
delivery
Antithyroid therapy needs to be
reintroduced.
Perform TSH and free T4 approximately 6
weeks post partum.
Methimazole cause thyroid dysfunction in
breast feeding infants .In low dose (10 – 20
mg/day) does not pose a major risk to
nursing infants.
25. HYPOTHYROIDISM
• Definition: It is defined as inadequate thyroid
production despite pituitary gland
stimulation(primary) or insufficient stimulation
of the thyroid by the pituitary or hypothalamus.
(central hypothyroidism)
• Incidence: 1-3 per 1000 pregnancy
• Types:
• Subclinical:- elevated TSH and normal free T4
• Overt:- elevated TSH and low free T4
26. HYPOTHYROIDISM
Causes:
• Autoimmune distruction of thyroid
gland(hashimoto’s thyroiditis) –most common
• Iodine deficiency – leading cause
• Radio ablation of the thyroid for Grave’s disease
or thyroid nodule
• Thyroidectomy – partial or near complete for
treatment of benign or malignant
neoplasm,Grave’disease)
• Medications – Lithium,amioderone
27. HYPOTHYROIDISM
Signs and symptoms:
• vague ,nonspecific signs and symptoms that are
insidious in onset
• fatigue
• constipation
• cold intolerance
• weight gain
• carpel tunnel syndrome
• hair loss
• voice changes
• reduced memory
• muscle cramps
• dry skin
28. Diagnosis during pregnancy is very
difficult
serum TSH is more sensitive than free T4 for
detecting hypothyroidism.If TSH is
abnormal , then elevation of free T4 is
recommended.
The range for serum TSH concentration in
nonpregnant individual is 0.45 – 4.5 mU/L
29. Strong family history
Known autoimmune disease
Presence of goitre
Previous therapeutic neck irradiation
Those taking medication known to cause
thyroid disturbance
TSH testing for hypothyroidism should
ideally be done prior to pregnancy
30. Management:
Discussion of
the importance of euthyroidism at the time of
conception
Risk of hypothyroidism to mother and off
spring
Anticipation of medication changes during
pregnancy
31. Management:
Preconceptional councelling:
The goal of treatment is bringing a euthyroid state
at the time of conception
TSH should be considered as an indication of
adequate replacement and women should delay
pregnancy until TSH is normal
Do not take levothyroxine and multivitamins at the
same time since iron and calcium may interfere
with absorption of thyroxine
All women should have adequate iodine intake
(200microgram/day)
32. Antenatal management:
By 16 week of gestation women need an
increase in thyroid hormone by 47 %.
This begins as early as 5th week of gestation
and those with previous history of
thyroidectomy
Patients can be told to take a double dose of
their levothyroxine on two days out of seven
A low normal TSH is the goal during
pregnancy (<2.5mU/ml)
33. Antenatal management:
Newly diagnosed women during pregnancy
should be initiated on 1.0 – 2.0 microgram/kg
/day or 100 microgram of levothyroxine daily
Thyroid stimulating hormone should be
measured in 6 weeks and levothyroxine dose
adjusted in 25 or 50 microgram
When normalized TSh should be checked
every 6 -8 weeks through out pregnancy
34. Labor and delivery:
Known hypothyroid women should be
euthyroid before delivery
Obstetric complications include increased risk
of still birth , pre term delivery , pre –
eclampsia,and placental abruption,increased
risk of breech and low birth weight
35. Post partum care:
After delivery levothyroxine therapy should be
returned to the prepregnant dose and the TSH
should be checked in 6 – 8 weeks
Breastfeeding is not contraindicated in women
treated for hypothyroidism. Levothyroxine is
excreated into breast milk but levels are too
low to alter thyroid function in infants
Annual monitoring of serum TSH is
recommended as changing weight and age
may modify thyroid function.
36. POST PARTUM THYROIDITIS
Post partum thyroiditis is caused by a rebound in
thyroid autoimmunity after delivery leading to
lymphatic infiltration of the thyroid gland and
transient changes in the thyroid function.
37. POST PARTUM THYROIDITIS-
Clinical phases:
Phase 1:- The autoimmune destruction of the gland
first results in release of stored thyroid hormone into
the circulation. This hyperthyroid phase generally
occurs between 1 and 4 months after delivery and is
self limiting to 1 – 2 months. The onset is abrupt ,with
symptoms of fatigue and palpitation . A small painless
goitre may develop. If these symptoms become severe ,
it require treatment with Beta – blockers until
resolution of hyperthyroid phase. Antithyroid
medications are not beneficial.
38. POST PARTUM THYROIDITIS-
Clinical phases:
Phase 2:
The loss of functioning thyrocytes from the immune destruction
results in hypothyroid phase between 3 and 8 months
postpartum. The hypothyroid phase usually last longer than
hyperthyroid phase ( 4 – 6 months). This disorder is often
unrecognised because women usually present with nonspecific
symptoms including fatigue , weight gain , loss of concentration
and depression. The hypothyroid phase should be treated in
women who are symptomatic and in those planning a pregnancy
near in future. It is usually recommended to treat women for
approximately for 6 months and withdraw thyroid hormone ,
unless pregnancy is being attempted. A TSH should be
rechecked in 5 – 6 weeks after withdrawal of thyroid hormone.
39. Nursing care:
Education of the pregnant women is necessary
to plan treatment.
Discuss with the women and her family members
about the outcome.
Assist the client to cope with the discomfort and
frustrations due to symptoms.
Nutritional councelling with a registered dietician
will help in selecting a well balanced diet.