THYROID IN PREGNANCY

WHAT IS THE THYROID

The thyroid is a small butterfly-shaped gland in the front of the neck below the larynx, or voice box.

HORMONES
The thyroid gland makes two thyroid hormones. Triiodothyronine (T3) Thyroxine (T4).

Thyroid hormones affect

Metabolism

Brain development and nervous system function

Cardiovascular system, cholesterol levels and blood cell formation

Body temperature, muscle strength, bone health and skin dryness

Menstrual cycles

 Thyroid hormone production is regulated by another hormone called thyroid-stimulating hormone (TSH). TSH is made by the pituitary gland, a pea-sized gland located in the brain.

How does pregnancy normally affect thyroid function? ****

Two pregnancy-related hormones-human chorionic gonadotropin (hCG) and estrogen-cause increased thyroid hormone levels in the blood. Made by the placenta, hCG is similar to TSH and mildly stimulates the thyroid to produce more thyroid hormone. Increased estrogen produces higher levels of thyroidbinding globulin, a protein that transports thyroid hormone in the blood. These normal hormonal changes can sometimes make thyroid function tests during pregnancy difficult to interpret.

 Thyroid hormone is critical to normal development of the baby's brain and nervous system. During the first trimester, the fetus depends on the mother's supply of thyroid hormone, which it gets through the placenta. At 10 to 12 weeks, the baby's thyroid begins to function on its own. The baby gets its supply of iodine, which the thyroid gland uses to make thyroid hormone, through the mother's diet.

DISORDERS OF THYROID IN PREGNANCY

Hyperthyroidism Hypothyroidism Post-partum Thyroiditis Subclinical Hypothyroidism

HYPERTHROIDISM
What causes hyperthyroidism in pregnancy? Graves' Disease Functioning adenoma ("hot nodule") and Toxic Multinodular Goiter (TMNG) Excessive intake of thyroid hormones Abnormal secretion of TSH Thyroiditis (inflammation of the thyroid gland) Excessive iodine intake Occurs in about one of every 500 pregnancies

GRAVES DISEASE **
Autoimmune disorder - The body's immune system makes antibodies that act against its own healthy cells and tissues. The immune system makes an antibody called thyroid stimulating immunoglobulin, sometimes called TSH receptor antibody, which mimics TSH and causes the thyroid to make too much thyroid hormone.

GRAVES DISEASE
Although Graves' disease may first appear during pregnancy, a woman with preexisting Graves' disease could actually see an improvement in her symptoms in her second and third trimesters. Remission of Graves' disease in later pregnancy may result from the general suppression of the immune system that occurs during pregnancy.

How does hyperthyroidism affect the mother

Uncontrolled hyperthyroidism during pregnancy can lead to Congestive heart failure Preeclampsia-a dangerous rise in blood pressure in late pregnancy Thyroid storm-a sudden, severe worsening of symptoms Miscarriage Premature birth

How does hyperthyroidism affect the baby

Premature birth Low birthweight Rapid heart rate that can lead to heart failure. Poor weight gain Irritability Enlarged thyroid that can press against the windpipe and interfere with breathing

DIAGNOSIS OF HYPERTHYROIDISM
Through a careful review of symptoms, as well as Blood tests to measure TSH, T4, and T3 levels. Some symptoms of hyperthyroidism are common features in normal pregnancies, including increased heart rate, heat intolerance, and fatigue.

DIAGNOSIS OF HYPERTHYROIDISM
More indicative symptoms: Rapid and irregular heartbeat A fine tremor Unexplained weight loss Failure to have normal pregnancy weight gain Severe nausea and vomiting associated with hyperemesis gravidarum.

LAB DIAGNOSIS

LAB DIAGNOSIS
Ultrasensitive TSH test. Detects even tiny amounts of TSH in the blood and is the most accurate measure of thyroid activity available.

Generally, below-normal levels of TSH indicate hyperthyroidism.

Low TSH levels may also occur in a normal pregnancy, especially in the first trimester. If TSH levels are low, another blood test is performed to measure T4 and T3.

LAB DIAGNOSIS
The T3 is increased in almost all cases of hyperthyroidism and goes up before the T4 is elevated. Hence, T3 is more sensitive indicator of hyperthyroidism

LAB DIAGNOSIS
Elevated levels of free T4-the portion of thyroid hormone not attached to thyroidbinding proteins-confirm the diagnosis. Rarely, free T4 levels are normal in a woman with hyperthyroidism but T3 levels are high. Because of normal pregnancy-related changes in thyroid function, test results must be interpreted with caution.

LAB DIAGNOSIS
If a woman has Graves' disease or has had surgery or radioactive iodine treatment for the disease, her doctor may also test her blood for the presence of thyroid-stimulating antibodies.

TREATMENT OF HYPERTHYROIDISM **
The options for treating hyperthyroidism include: Treating the symptoms Antithyroid drugs Radioactive iodine Surgery

TREATMENT OF HYPERTHYROIDISM **
Mild hyperthyroidism in which TSH is low but free T4 is normal does not require treatment. More severe hyperthyroidism is treated with propylthiouracil or sometimes methimazole (Tapazole), drugs that interfere with thyroid hormone production.

Antithyroid drugs cross the placenta in small amounts and can decrease fetal thyroid hormone production, so the lowest possible dose should be used to avoid hypothyroidism in the baby.
Rarely, surgery to remove all or part of the thyroid gland is considered for women who cannot tolerate propylthiouracil or methimazole. Radioactive iodine treatment is not an option for pregnant women because it can damage the fetal thyroid gland.

TREATING SYMPTOMS **
There are medications available to immediately treat the symptoms caused by excessive thyroid hormones, such as a rapid heart rate. One of the main classes of drugs used to treat these symptoms is a beta-blocker [eg., propranolol (Inderal), atenolol (Tenormin), metoprolol (Lopressor)]. These medications counteract the effect of thyroid hormone to increase metabolism, but they do not alter the levels of thyroid hormones in the blood.

ANTITHYROID DRUGS
Both propylthiouracil (PTU) and methimazole (MMI) have been used in pregnancy and are equally effective in the management of hyperthyroidism It would be reasonable to treat women whose free T4 levels are more than 2.5 ng/dL if the upper limit of normal is 2.0 ng/mL. However, for an asymptomatic woman whose pregnancy is progressing satisfactorily and whose serum free T4 is minimally above 2.5 ng/dL, careful clinical follow-up without antithyroid therapy may be appropriate.

ANTITHYROID DRUGS **
When the diagnosis of moderate to severe hyperthyroidism is made, therapy with 100 mg PTU every 8 h should be initiated. Lower doses should be used in milder cases, because baseline thyroid function is a major factor in the rate of drug response. If the patient has been taking MMI before she becomes pregnant, switching to PTU would be reasonable before a planned conception or if the pregnancy is diagnosed in the first trimester during the period of organogenesis.

ANTITHYROID DRUGS **
The data suggesting that PTU crosses the placenta more easily than previously thought would seem to remove PTUs advantage over MMI in pregnancy. On the other hand, the rare but probable real association between MMI usage and fetal anomalies makes MMI a less attractive first line alternative. All things being equal, PTU is probably still the first choice for the treatment of hyperthyroidism in pregnancy, although MMI remains a reasonable second-line agent in the case of an allergic reaction, intolerance, or poor response to PTU.

HYPOTHYROIDISM IN PREGNANCY
The most common cause of hypothyroidism is the autoimmune disorder known as Hashimotos thyroiditis . Hypothyroidism can occur during pregnancy due to the initial presentation of Hashimotos thyroiditis.

Inadequate treatment of a woman already known to have hypothyroidism from a variety of causes.
Over-treatment of a hyperthyroid woman with anti-thyroid medications. Approximately, 2.5% of women will have a slightly elevated TSH of greater than 6 and 0.4% will have a TSH greater than 10 duringpregnancy.

RISKS TO MOTHER
Most women with mild hypothyroidism may have no symptoms or attribute symtoms they may have as due tothe pregnancy. These complications are more likely to occur in women with severe hypothyroidism. Maternal anemia (low red blood cell count) Myopathy (musclepain, weakness) Congestive heart failure Pre-eclampsia Placental abnormalities Low birth weight infants Postpartum hemorrhage (bleeding).

RISKS TO BABY
Thyroid hormone is critical for brain development in the baby. Children born with congenital hypothyroidism (no thyroid function at birth) can have severe cognitive, neurological and developmental abnormalities if the condition is not recognized and treated promptly. These developmental abnormalities can largely be prevented if the disease is recognized and treated immediately after birth.

RISKS TO BABY
The effect of maternal hypothyroidism on the babys brain development is not as clear. Untreated severe hypothyroidism in the mother can lead to impaired brain development in the baby. This is mainly seen when the maternal hypothoidism is due to iodine deficiency, which also affects the baby

TREATMENT DURING PREGNANCY

The treatment of hypothyroidism is the adequate replacement of thyroid hormone in the form of synthetic levothyroxine . It is important to note that levothyroxine requirements frequently increase during pregnancy, often times by 25 to 50 percent.

TREATMENT DURING PREGNANCY

Thyroid function tests should be checked approximately every 6-8 weeks during pregnancy to ensure that the woman has normal thyroid function throughout pregnancy.

If a change in levothyroxine dose is required, thyroid tests should be measured 4 weeks later. As soon as delivery of the child occurs, the woman may go back to her usual pre-pregnancy dose of levothyroxine.

TREATMENT DURING PREGNANCY

Interactions There are also foods and other substances that can interfere with absorption of thyroxine replacement. People ought to avoid taking calcium and iron supplements within 4 hours, as well as soy products within 3 hours of the medication, as these can reduce absorption of the drug. Grapefruit juice may delay the absorption of levothyroxine, but it is not believed to have a significant effect on bioavailability. Other substances that reduce absorption are aluminium and magnesium containing antacids, simethicone or sucralfate,cholestyramin e,colestipol .

TREATMENT DURING PREGNANCY

The empirical increase in levothyroxine dosage in women with hypothyroidism when pregnancy is first confirmed could prevent maternal hypothyroidism in the first trimester of pregnancy in the majority of cases Monthly thyroid function testing until 20 weeks of pregnancy could detect over 90% of abnormal TSH values Subsequent need for further dose increments and dose reductions in levothyroxine occurred in almost half of the cases

POSTPARTUM THYROIDITIS
Postpartum thyroiditis is an inflammation of the thyroid gland that appears 1 to 8 months after giving birth and affects about 8 percent of women who delivered within the previous year.

EFFECTS ***
Thyroiditis can cause stored thyroid hormone to leak out of the inflamed gland and raise hormone levels in the blood. Postpartum thyroiditis is believed to be an autoimmune condition and causes mild hyperthyroidism that usually lasts 1 to 2 months. Many women then develop hypothyroidism lasting 6 to 12 months before the thyroid regains normal function.

EFFECTS
In some women, the thyroid is too damaged to regain normal function and their hypothyroidism is permanent, requiring lifelong treatment with synthetic thyroid hormone. Postpartum thyroiditis sometimes goes undiagnosed because the symptoms are mistaken for postpartum bluesthe exhaustion and moodiness that sometimes follow delivery. If symptoms of fatigue and lethargy do not go away within a few months or a woman develops postpartum depression, she should talk with her doctor. She may have developed a permanent thyroid condition and will need to take medication.

SUBCLINICAL HYPOTHYROIDISM
A TSH level above normal, with normal free T4 levels is associated with negative health outcomes for both the mother and baby. Treatment of the mother has been shown to help ensure a healthier pregnancy. Treatment has not, however, been proven to affect the babys long-term neurological development. The experts believe that the potential benefits of treatment do outweigh any potential risks, however, and recommend treatment in women with subclinical hypothyroidism.

POINTS TO REMEMBER
Pregnancy causes normal changes in thyroid function but can also lead to thyroid disease.
If uncontrolled during pregnancy, hyperthyroidism-too much thyroid hormone in the blood-can be dangerous to the mother and cause health problems such as congestive heart failure and poor weight gain in the baby. Mild hyperthyroidism in pregnancy does not require treatment.

POINTS TO REMEMBER
More severe hyperthyroidism is usually treated with drugs that interfere with thyroid hormone production.
If uncontrolled during pregnancy, hypothyroidism-too little thyroid hormone in the blood-also threatens the mother's health and can lead to developmental disabilities in the baby. Hypothyroidism in pregnancy is safely and easily treated with synthetic thyroid hormone.

Postpartum thyroiditis-inflammation of the thyroid gland-causes a brief period of hyperthyroidism, often followed by hypothyroidism that usually resolves within a year. Sometimes the hypothyroidism is permanent.