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Throid malafunction in pregnancy (Hyperthyroidism (Graves disease…
Throid malafunction in pregnancy
TBG increase about 200% - estrogens stimulate production by liver cells and simultaneously inhibit disactivation
HCG has a TSH activity, stimulates the secretion of thyroid hormones, blocks production of TSH
TT4 and TT3 increase, fT3 and fT4 don’t change
The tissue metabolism of thyroid hormones is affected by fetal deiodinase (second half of pregnancy)
Increased thyroxine demand - 30-50%
Hypothyroidism
Occurs in 2-3% of pregnant women
The optimal TSH level during the periconceptional and early pregnancy <2.5
Subclinical hypothyroidism –TSH >2.5; fT4-N
Clinical hypothyroidism –TSH >2.5; fT4 ↓
The most common reason is Hashimoto's thyroiditis, anti-TPO antibodies are present in 90% of women with hypothyroidism
reasons
iodine deficiency, inflammation
autoimmune
congenital hypothyroidism
postoperative, hypophysitis
risk factors
family history of Hypothyroidism, history of thyroid disease, advanced age, diabetes, hormonal disorders, autoimmune diseases, obesity
complications
Hypertension, pre-eclampsia, Placental abruptio, PROM, Fetal intrauterine death, Mental retardation in the child, Neurological complications in the child
Should be treated?
clinical hypothyroidism – Yes
subclinical – there is no clear evidence of benefit (pregnancy and delivery outcome), iodine prophylaxis is important
Yes, when anti TPO are present
Recommendations of PTE 2011
TSH assessment in every woman planning pregnancy
TSH assessment in every pregnant woman in the first trimester of pregnancy
The recommended value is TSH <2.5
Hyperthyroidism
Hyperthyroidism is the excessive secretion of thyroid hormones, leads to thyrotoxicosis – TSH ↓, FT4 and FT3 ↑
Graves' disease is characterized by the production of TSI or TBI which stimulate or inhibit TSH receptors
Thyrotoxicosis - clinical and biochemical state resulting of production or exposure to thyroid hormones regardless of the reason
Gestational thyrotoxicosis: inhibition of TSH by HCG, hyperstimulation of thyroid
Thyroid storm - severe, sudden, life-threatening exacerbation, TSH <0.1uIU/ml, fT4-N , fT3-N or higher
causes in pregnancy
Graves' disease - 95%
gestational thyrotoxicosis
toxic nodular goiter
recurrent thyroiditis
gestational trophoblastic disease
risk for the mother
hypertension
pre-eclampsia and eclampsia
congestive heart failure
miscarriage
premature delivery
placental abruptio
risk for the fetus
fetal thyrotoxicosis
low birth weight
IUGR
increased rate of birth defects
prematurity
increased perinatal mortality
Graves disease
symptoms
HR ˃100/min
Exophthalmos, thyroid goiter
TRAb (+)
enlargement of the thyroid
proximal muscle weakness
lack of weight gain
rarely vomiting
I trimester - exacerbation of clinical symptoms
III trimester - decreased symptoms
After the birth, frequent exacerbation
treatment
Lowest effective doses of tyreostatics
PTU (propylthiouracil) – rare teratogenic effects, risk of liver damage (used in I trimester)
Tiamazol – observed cases of head skin aplasia and esophageal atresia in II trimester
fT4 – high level of the norm
Risk of hypothyroidism or goiter in the fetus – very low
No contraindications to breastfeeding
Gestational thyrotoxycosis
In 30% of women with hyperemesis
Negative history of thyroid diseases
Negative antibodies
Resolves at app. 20 weeks
If: ↑fT4,T4 >150%,TSH<0.1 uU/ml, clinical hyperthyreosis symptoms → tyreostatics
Hyperemesis gravidarum
etiology
Etiology unknown
Starts during 5-6th week of pregnancy
Mostly in primiparas
Important role of social or psychological factors (vomiting resolve spontaneously after admission to the hospital)
Elevated levels of HCG (human chorionic gonadotropin). Subunit B is similar to TSH and increases thyroxine secretion (clinical and biochemical hyperthyroidism – observed in 60% of pregnant women).
More often in twin pregnancies, molar pregnancies, chorioncarcinoma.
NAUSEA, VOMITING
Nausea and vomiting occur usually in the morning, on an empty stomach.
They are not harmful to pregnant women.
Weight loss is usually insignificant.
symptoms
Frequent vomiting (5-10 times a day)
Any time of the day
Increased thirst
Dehydration (dry tongue, flabby skin)
Rapid weight loss
Deterioration of the general condition
Increased body temperature
Jaundice (significant liver damage)
Symptoms of CNS damage (disturbances of consciousness)
Results of laboratory tests
Urine – proteinuria, acetone presence.
Serum - in severe cases bilirubin increased to about 2mg%
Treatment
hospitalization
stopping vomiting (popular remedies)
iv fluid replacement (sodium chloride, glucose, carbohydrate)
Vit. B, C, antiemetics (Torecan, Diphergan)
Differential diagnosis
gastritis and enterocolitis
pancreatitis
cholecystytis
hyper/hypo-parathyroidism