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Fetal/neonatal thyroid disorders (Citations (Léger J: Management of Fetal…
Fetal/neonatal thyroid disorders
Risk Factors/pre-exisiting problems in the mom
Ways to diagnose
Lab Values -
Thyroid antibodies:
TSI which accounts for 20% of fetal hyperthyroidism. Thyrotropin-stimulating receptor (TRab) is responsible for 95% of hyperthyroidism. These lead to goiters, cardiac failure, and fetal demise. When the mom has increased thyroid lab values can lead to increased fetal activity, enlargement of the fetal thyroid, and increased intensity of Doppler vascularization.
Image Modality
Ultrasound: a noninvasive modality that measures fetal thyroid dimensions. If dimensions are irregular, this can be the first sign of thyroid dysfunction. If there is a small increase in the gland size, this is the first sign of thyroid dysfunction. When measuring, you want to evaluate the longitudinal, anteroposterior, and transverse diameters. Radiologist will determine development based off of what percentile the measurements land in for normal or abnormal growth. An increased of color Doppler vascular circulation in the central portion of the fetal thyroid gland. Will include images on PPT
Etiology
Mom's T3 and T4 will increase, TSH can decrease, thyroid disorders are the most common endocrine gland disorders in pregnancy
Pre-existing thyroid dysfunciton
Hypo- can lead to infertility
Grave's Disease in mother- can cause goiter or hyperthyroidism in fetus due to excessive amounts of TSH, anti-thyroid meds should be stopped in first trimester, if possible, should have their thyroid receptor antibodies measured before 22 weeks of gestational age
Hyper- also increased TSH, can cause infertility, anemia, gestational HTN, can cause fetal goiter or hypothyroidism due to anti-thyroid drugs
Acquired thyroid dysfunction
Hypothyroidism-lack of iodine, can lead to fetal demise
Pregnancy induced hypertension- PIH women more susceptible to thyroid dysfunction, high or low levels of thyroid hormones in PIH women could cause fetal hypoxia
Fetus relies on thyroid hormones from mom until about 16 weeks when the thyroid becomes functional, goiters can develop from inadequate or excessive iodine or dyshormonogenesis
Types of disorders
Symptoms
Hypothyroidism
While most infants do not show obvious symptoms of hypothyroidism at birth, others may be born with symptoms or develop them within the first few months of life. These symptoms include:
A puffy-looking face
Large, thick tongue
Large soft spots of the skull
Hoarse cry
Distended stomach with outpouching of the belly button (umbilical hernia)
Feeding problems, including needing to be awakened for feedings and difficulty swallowing
Constipation
“Floppy” (poor muscle tone, also called hypotonia)
Jaundice
Thyrotoxicosis/Hyperthyroidism - slightly different diseases but are often used interchangeably, and ultimately result in the same signs/symptoms which are
Advanced bone age, craniosynostosis (premature fusion of 1 or more cranial sutures causing an abnormal head shape and restricting skull growth) and microcephaly
fetal goiter
low birth weight (fetal growth retardation)
The central nervous system signs are irritability restlessness, jitteriness and restlessness
Eye signs are periorbital edema, lid retraction and exophthalmos
Cardiovascular system signs are tachycardia, arrhythmias, cardiac failure, systemic and pulmonary hypertension
increased blood supply found using Doppler ultrasonography
Grave's Disease
disease of autoimmunity syndrome characterized by hyperthyroidism and includes thyrotoxicosis, goiter, exophthalmos, and pretibial myxedema when fully expressed, but can occur with one or more of these features.
nervousness
diminished sleep
tremulousness.
tachycardia
increased appetite
weight loss
signs of goiter
exopthalamus
Physical findings include fine skin and hair, tremulousness, a hyperactive heart, Plummer's nails, muscle weakness, accelerated reflex relaxation, occasional splenomegaly, and often peripheral edema
autoimmune vitiligo or hives
Treatments
Hyperthryoidism
Prescribe maternal medication
Propylthiouracil (PTU)
Initial treatment
ATDs
Potassium iodide
Used in emergency situations
Beta blockers
Often used in addition to other medications to oppose side effects
Tachycardia
Importance
A large goiter could cause tracheal obstruction
Neonatal death
Fetal neck hyperextension
Difficult and dangerous birth
Hypothyroidism
Terminating maternal medicine
Methimazone (MMI)
Propythiouracil (PTU)
Intra-amniotic levothyroxine therapy
Injecting levothyroxine into amnion to reduce the size of the goiter and increase the amniotic fluid
Works because the fetus is swallowing the T4 in the amnion
Success rates of 70%
Cannot treat with same medications used for hyperthyroidism because there is little placental transfer of thyroxine
In the event medication doesn't work
Fetuses should be delivered by cesarean delivery with ex utero intrapartum treatment
Preserving uteroplacental gas exchange while the surgeons repair the airway
Fetus is partially connected to maternal blood/oxygen supply until airway can be formed
Should only be completed by experienced physicians and only for high risk patients
Presentation with Voice Over: Mikayla will present on etiology, Shelly will present on ways to diagnose, Myah will present on treatments, and Kaelyn will present on the symptoms with the different disorders.
Citations
(May 1, 2013). Special Feature: Thyroid Disease in Pregnancy. OB/GYN Clinical Alert. Retrieved from
https://advance-lexis-com.libproxy.misericordia.edu/api/document?collection=news&id=urn:contentItem:58DS-R1X1-JBDY-00GH-00000-00&context=1516831
.
Barbosa, R. M., Andrade, K. C., Silveira, C., Almedia, C. M., Souza, R. T., Oliveiera, P. F., & Cecatti, J. G. (2019). Ultrasound Measurements of Fetal Thyroid: Reference Ranges from a Cohort of Low-Risk Pregnant Women. Hindawi BioMed Research International.
https://doi.org/10.1155/2019/9524378
.
Queenan, J. T., Spong, C. Y., & Lockwood, C. J. (2015). Protocols for high-risk pregnancies : An evidence-based approach. John Wiley & Sons, Incorporated: New Jersey. Retrieved from
https://ebookcentral.proquest.com
. Pg. 172-179.
Panaitescu, A. M., & Nicolaides, K. (2018). Fetal goitre in maternal graves’ disease. Acta endocrinologica (1841-0987), 14(1), 85–89. doi: 10.4183/aeb.2018.85
States News Service. (August 10, 2012). The endocrine society revises clinical practice guidline for management of thyroid dysfunction. States News Service. Retrieved from
https://advance.lexis.com/api/document?collection=news&id=urn:contentItem:569J-T7W1-JCBF-S09M-00000-00&context=1516831
.
Xiao-dan Zhu, Shan-yu Yin, Bao-hua Wang, & Tian-an Jiang. (2018). The specificity of color Doppler ultrasound to detect fetal hypoxia in pregnancy-induced-hypertension with thyroid dysfunction. Biomedical Research (0970-938X), 29(1), 113–117.
Léger J: Management of Fetal and Neonatal Graves' Disease. Horm Res Paediatr 2017;87:1-6. doi: 10.1159/000453065
https://www.thyroid.org/thyroid-information/
Ain, K. B., & Rosenthal, M. S. (2005). The Complete Thyroid Book. New York: McGraw-Hill Professional.
Batra, C. M. (2013, October). Fetal and neonatal thyrotoxicosis. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3830367/#ref3
Kurtoğlu, S., & Özdemir, A. (2017, March 1). Fetal neonatal hyperthyroidism: diagnostic and therapeutic approachment. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5396815/
DeGroot, L. J. (2015, July 11). Graves' Disease and the Manifestations of Thyrotoxicosis. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK285567/
Iijima, Shigeo. "Current knowledge about the in utero and peripartum management of fetal goiter associated with maternal Graves’ disease." European Journal of Obstetrics & Gynecology and Reproductive Biology: X, vol. 3, 2 May 2019, p. 100027.
Kim, Min-Jung, et al. "Intra-amniotic thyroxine to treat fetal goiter." Obstetrics & Gynecology Science, vol. 59, no. 1, 15 Jan. 2016, p. 66.
Munoz, Jessian L. "Fetal thyroid disorders: pathophysiology, diagnosis and therapeutic approaches." Journal of Gynecology Obstetrics and Human Reproduction, vol. 48, no. 4, 8 Jan. 2019, pp. 231-233.