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.
Thyroid disorders are common in pregnancy . This is potential treatable cause of bad obstetric history .Hypothyroidism and hyperthyroidism both should be screened for clinically as well as by laboratory tests .
Due to availability of Thyroid testing ,it is more easily diagnosed and Treated.
Hypothyroid mother if not adequately treated ,there is poor mental development of the baby.
Due to awareness more and more diagnosis is made .There should be universal screening for thyroidal illness in pregnancy .
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.
Thyroid disorders are common in pregnancy . This is potential treatable cause of bad obstetric history .Hypothyroidism and hyperthyroidism both should be screened for clinically as well as by laboratory tests .
Due to availability of Thyroid testing ,it is more easily diagnosed and Treated.
Hypothyroid mother if not adequately treated ,there is poor mental development of the baby.
Due to awareness more and more diagnosis is made .There should be universal screening for thyroidal illness in pregnancy .
Hypothyroidism in pregnancy by DR ALKA MUKHERJEE DR APURVA MUKHERJEE NAGPUR M.S.alka mukherjee
Pregnancy is a period that places great physiological stress on both the mother and the fetus. When pregnancy is compounded by endocrine disorders such as hypothyroidism, the potential for maternal and fetal adverse outcomes can be immense. While a lot of attention has been focused on the adverse fetal outcomes consequent to hypothyroidism, attention is also being gradually directed towards the adverse maternal outcomes of this disorder. Role of antibody positivity in influencing outcomes in a euthyroid woman, also needs further clarification. Prompt diagnosis and treatment of hypothyroidism in pregnancy is very essential. Subclinical hypothyroidism also needs to be detected and treated to prevent adverse outcomes, especially maternal. Since women with hypothyroidism during pregnancy, especially of the autoimmune variety might have a flare up of the disorder post-partum, or might continue to require thyroxine replacement post-partum, adequate follow-up is mandatory. While targeted case finding is generally practised, recent evidence seems to indicate that universal screening might be a better option. In conclusion, routine screening, early confirmation of diagnosis and prompt treatment. Allied with regular post-partum follow up, is required to ensure favourable maternal and fetal outcomes.
Thyroid physiology is perceptibly modified during normal pregnancy. These alterations take place throughout gestation, help to prepare the maternal thyroid gland to cope with the metabolic demands of pregnancy, are reversible post-partum and the interpretation of these changes can pose a challenge to the treating physician.
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.
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.
ABSTRACT- Thyroid disease commonly affects women of childbearing age and is the second most common
endocrinological disorder diagnosed in pregnancy after gestational diabetes. In normal gestation, the thyroid
gland adapts its structure and function to satisfy increasing functional demand. The marked physiological
changes that occur during normal pregnancy make it necessary to use specific reference ranges in interpretation
of thyroid function test. It is well documented that thyroid disorders are associated with maternal and fetal
complications during gestation, and its deleterious effects can also extend beyond pregnancy and delivery.
Available epidemiological data report widely varying prevalence rates of thyroid disorders during the antenatal
period. However, the need for universal thyroid screening remains controversial. Subclinical thyroid
dysfunction is very frequent but easily missed without specific screening programs. Furthermore, an appropriate
management is crucial to prevent adverse maternal and fetal outcomes. Despite the correlation between thyroid
function during pregnancy and maternal and fetal outcomes is a widely discussed issue, it remains important to
clarify several points regarding screening, diagnosis, and treatment of thyroid dysfunction in pregnant ladies. In
this article we try to discuss the physiological changes of the thyroid gland to meet the challenges of increased
metabolic demands during pregnancy and focusing on pathological function changes; we also try to summarize
the best way of screening, diagnosis and treatment of thyroid dysfunction during pregnancy to improve maternal
and fetal outcomes.
Key Words: Pregnancy, Thyroid gland, Hypothyroidism, Hyperthyroidism, Thyroid stimulating hormone
Hypothyroidism in pregnancy by DR ALKA MUKHERJEE DR APURVA MUKHERJEE NAGPUR M.S.alka mukherjee
Pregnancy is a period that places great physiological stress on both the mother and the fetus. When pregnancy is compounded by endocrine disorders such as hypothyroidism, the potential for maternal and fetal adverse outcomes can be immense. While a lot of attention has been focused on the adverse fetal outcomes consequent to hypothyroidism, attention is also being gradually directed towards the adverse maternal outcomes of this disorder. Role of antibody positivity in influencing outcomes in a euthyroid woman, also needs further clarification. Prompt diagnosis and treatment of hypothyroidism in pregnancy is very essential. Subclinical hypothyroidism also needs to be detected and treated to prevent adverse outcomes, especially maternal. Since women with hypothyroidism during pregnancy, especially of the autoimmune variety might have a flare up of the disorder post-partum, or might continue to require thyroxine replacement post-partum, adequate follow-up is mandatory. While targeted case finding is generally practised, recent evidence seems to indicate that universal screening might be a better option. In conclusion, routine screening, early confirmation of diagnosis and prompt treatment. Allied with regular post-partum follow up, is required to ensure favourable maternal and fetal outcomes.
Thyroid physiology is perceptibly modified during normal pregnancy. These alterations take place throughout gestation, help to prepare the maternal thyroid gland to cope with the metabolic demands of pregnancy, are reversible post-partum and the interpretation of these changes can pose a challenge to the treating physician.
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.
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.
ABSTRACT- Thyroid disease commonly affects women of childbearing age and is the second most common
endocrinological disorder diagnosed in pregnancy after gestational diabetes. In normal gestation, the thyroid
gland adapts its structure and function to satisfy increasing functional demand. The marked physiological
changes that occur during normal pregnancy make it necessary to use specific reference ranges in interpretation
of thyroid function test. It is well documented that thyroid disorders are associated with maternal and fetal
complications during gestation, and its deleterious effects can also extend beyond pregnancy and delivery.
Available epidemiological data report widely varying prevalence rates of thyroid disorders during the antenatal
period. However, the need for universal thyroid screening remains controversial. Subclinical thyroid
dysfunction is very frequent but easily missed without specific screening programs. Furthermore, an appropriate
management is crucial to prevent adverse maternal and fetal outcomes. Despite the correlation between thyroid
function during pregnancy and maternal and fetal outcomes is a widely discussed issue, it remains important to
clarify several points regarding screening, diagnosis, and treatment of thyroid dysfunction in pregnant ladies. In
this article we try to discuss the physiological changes of the thyroid gland to meet the challenges of increased
metabolic demands during pregnancy and focusing on pathological function changes; we also try to summarize
the best way of screening, diagnosis and treatment of thyroid dysfunction during pregnancy to improve maternal
and fetal outcomes.
Key Words: Pregnancy, Thyroid gland, Hypothyroidism, Hyperthyroidism, Thyroid stimulating hormone
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
Thyroid and Pregnancy, Review of PhysiologyUsama Ragab
Thyroid and Pregnancy
Facts and Messages
A series of changes in thyroid hormone economy take place in normal pregnancy.
As a result of these changes, thyroid hormone levels in pregnancy differ from those in the non-pregnant state.
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
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Thyroid Disorders in Obs & Gynae - Case based approach onHyperthyroidism & Thyroid Cancer--- Part 2
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
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This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
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STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
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3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
4. Definition of Hypothyroidism
Pregnancy
Overt Hypothyroid (OH) :
• TSH >2.5 mlU/ and FT4: Low
• TSH 210mlU/l irrespective of FT4 value .
• Normal upper limit -<4 miu/l (2017) .
Sub-Clinical Hypothyroid (SCH):
• TSH: 2.5 to 10 mlU/I, FT 4: Normal.
5. Prevalence of Thyroid
autoantibodies
• Thyroid autoantibodies : 5 % - 15 % in child
bearing age .
• Associated with increased rate of pregnancy loss.
• Chronic autoimmune thyroiditis is the leading
cause of hypothyroidism in pregnancy.
• lodine deficiency (UIE < 10 µg/dl) by WHO.
6.
7.
8. lodine Requirement in
pregnancy
WHO recommends- 250µg /d to
compensate
Increase in thyroxine requirement
Increase renal lodine loss
Increase fetal lodine requirement
9.
10.
11.
12. Trimester specific TSH level
If trimester specific TSH level is not
available in laboratory following ref.
range is recommended by (ATA 2011
endo soc 2012)
• First trimester 0.1-2.5 mlU/I
• Second trimester 0.2-3.0 mlU/I
• Third trimester 0.3-3.0 mlU/I
13. Screening during Pregnancy
• Targeted case finding vs. universal screening.
• Guideline by ATA,AACE, ACE - Screen only
high risk one.
Different studies revealed up to 30% cases
missed in high risk screening, and thus
universal screening is more prudent.
14. High risk
1.History of hyperthyroid or hypothyroid
disease, PPT, or thyroid lobectomy.
2. Family history of thyroid disease.
3. Women with a goiter.
4. Positive thyroid antibodies .
5. Symptoms or clinical signs suggestive of
hypo or hyperthyroidism.
15. 6. Type 1 diabetes.
7. Presence of other autoimmune disorders. 8.
Infertility who should have screening with TSH as
part of their infertility work-up.
9. Previous therapeutic head or neck irradiation.
10. History of miscarriage or preterm delivery.
16. Management of hypothyroidism in
Pregnancy
• Thyroxine dose require increment at 4-6
weeks of pregnancy and gradually increase up
to 20 weeks then plateau until time of
delivery.
• Those having thyroidectomy or radioablation
require more increase in dose than
autoimmune thyroid disease.
• Subclinical hypothyroidism needs be treated
17. Euthyroid women, (+) TPO
Ab's
• Euthyroid pregnant women with (+) TPO Ab's
develop impaired thyroid function as pregnancy
proceeds
• Treatment with Thyroxin reduces the risk of
miscarriage and prematurity in TPO Ab (+)
women
18. Euthyroid women, (+) TPO
Ab's
Miscarriege – 2-5 fold
• 70. Stagnaro-Green A, Roman SH, Cobin RH, el-
Harazy E, AlvarezMarfany M, Davies TF 1990
Detection of at-risk pregnancy by means of highly
sensitive assays for thyroid autoantibodies.
JAMA264:1422–1425
19. Euthyroid women, (+) TPO
Ab's
Peinatal death ATA 2017
Yes -191,
No death- 140 196
RDS
Yes -197
Intellectual Motor development 25-30 month -199
Neurocognition -5.5 yrs -200
Sensory neural loss @ 8 yrs -141
Low IQ @ 4 yr normal at 7 yrs --201
Autism spectrum-203
20. Increased Thyroxine requirement
during pregnancy
Known Hypothyroidism already on
LT4
• ↑ dose by 30% taking extra pill 2 days a
week as soon as pregnancy is confirmed.
• To make further dose changes based on
serum FT4 + TSH levels
21. • Thyroxine ingestion should be separated from
prenatal vitamins containing iron, iron and calcium
supplements, and soy products by at least 4 hours to
ensure adequate absorption.
• After delivery, reduce thyroxin to pre pregnancy
dosage, and check serum TSH in 6 weeks
22. Management contd..
Factors responsible for need of more
thyroxine during pregnancy
• ↑ in TBG (2- to 3-fold) due to E2
•↑ renal LT4 clearance
• Transfer of LT4 to the fetus
• Increased placental deiodinase activity
• Reduced Gl absorption due to iron
supplementation.
23.
24. • Pregnancy has a profound impact on thyroid
function.
• Trimester specific TSH range should be followed
to diagnose hypothyroidism and thyroxine dose
adjustment.
• SCH and antibody positivity are important issue in
treating hypothyroidism in pregnancy.
Take Home
Message