تیرویید و بارداری

(J Clin Endocrinol Metab 97: 2543–2565, 2012)

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Effects of Hypothyroidism onPregnancy Outcomes

JCEM, 2007

• Anemia• Hypertension• Preeclampsia• Abruptio

placenta• Postpartum

hemorrhage

• Miscarriage• Low birth weight• Stillbirth• Psychoneurologic

impairment

Maternal Fetal

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Screening for Thyroid Disease in Pregnancy

Although the benefits of universal screening for thyroid dysfunction may not be justified at this time, selected screening for the following should be done:

•Positive FHxthyroid disease

•Goiter

•TPOAb+

•Symptoms

•Type 1 DM

•Miscarriage

•Other autoimmunedisease

• Infertility

•Morbid obesity

•>30 years

• Iodine deficient area

Thyroid 2011, JCEM 2012

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TSH level during pregnancy

• 1st trimester<2.5 mIU/ml

• 2nd and 3rd trimester<3 mIU/ml

Graves ophthalmopathy

بارداری و تیرویید پرکاری

.فقط• بدهید تیوراسیل پروپیل اول ماهه سه در•. است مجاز غیر بارداری در اکتیو رادیو یدتوانید • می نیاز صورت در دوم ماهه سه در

. نمایید تیروییدکتومیبالینی • عالیم را TSH, T4, T3RUبا بیمارتان

نمایید پیگیری

تیروییدکتومی های اندیکاسیون

• A severe adverse reaction to ATD therapy• Persistently high doses of ATD are required

(over 30 mg/d of MMI or 450 mg/d of PTU); • Nonadherent to ATD therapy and uncontrolled

hyperthyroidism

جراحی زمان بارداری 3بهترین دوم ماههاست.

Thyrotoxicosis in pregnancy and in the post-partum period

Subclinicalhyperthyroidism

Treatment does not improve pregnancy outcome, and could potentially adversely affect fetal outcome

Investigation of fetalor neonatal thyroid dysfunction

Measure thyroid receptor antibodies (TRAb) by 22wk gestational age in mothers with:

• 1) current Graves’ disease• 2) a history of Graves’disease and treatment

with 131I or thyroidectomy before pregnancy• 3) a previous neonate with Graves’ disease• 4) previously elevated TRAb.

If TRAb>2-3 Nl or women on ATD

• Screen maternal free T4 & fetal thyroid dysfunction and do fetal anatomy ultrasound done in the 18th-22nd week and repeated every 4–6 wk or as clinically indicatedFetal thyroid dysfunction:Thyroid enlargement, growth restriction, hydrops, advanced bone age, tachycardia, or cardiac failure.

Fetalhyperthyroidism therapy

ATD with frequent clinical, laboratory, and ultrasound monitoring

Umbilical blood sampling should be consideredonly if the diagnosis of fetal thyroid disease is not reasonably certain from the clinical and sonographic data and theinformation gained would change the treatment

In USA neonatal thyroid function

All newborns of mothers with Graves’ disease(except those with negative TRAb and not requiring ATD)

should be evaluated for thyroid dysfunction.

Gestational hyperthyroidism vs Graves’ disease

• Negative TRAb• No goiter

No need to treat with ATDBeta blockers such as metoprolol may be helpful

Post partum thyroiditis

Brazil13.3%

Prevalence rate of postpartum thyroiditis is 7.5%

NYC 8.8%

Toronto 6.0%

Spain 7.8%

UK 16.7%

Italy 8.7%

India 7%

Thailand 1.1%

Japan 5.5%

Iran 11.4%

Netherlands 5.2%Denmark 3.9%

Sweden 6.5%Netherlands 7.2%Denmark 3.3%

Prevalence of PPT

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Autoimmune thyroid disease and miscarriage

Only one randomized interventional trial has suggested a decrease in the first trimester miscarriage rate in euthyroid antibody-positive women

• With history of abortion: Administer T4• Elevated anti-TPO antibodies

increases the risk for progression of hypothyroidism, so, screen for serum TSH abnormalities before pregnancy, as well as during the first and second trimesters of pregnancy

Thyroid nodules

FNA:nodules> 1 cm 0.5 cm <Nodules< 1 cm if high-risk history or suspicious findings on ultrasound

During the last weeks of pregnancy, FNA can reasonably be delayed until after delivery

Thyroid cancer

If nodule on FNA is malignant or highly suspicious or exhibits rapid growth, or accompanies by pathological neck adenopathy, offer surgeryin the 2nd trimesterIf it is papillary cancer or follicularneoplasm without evidence of advanced disease you can wait until the postpartum period for definitive surgeryAdminister suppresive dose of T4

Radioactive iodine (RAI) with 131I should not begiven to women who are breastfeeding or for at least 4wkafter nursing has ceased.

Iodine nutrition during pregnancy

• In the childbearing age: 150 µg/d

• Before and during pregnancy and breastfeeding: 250 µg/d Iodine intake should not be >500 µg/d

• Once-daily prenatal vitamins contain 150–200 g iodine

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Changes in maternalThyroid Function in Pregnancy

Modified from JCEM 86:2349, 2001

goiter Tg TSH

TSH TBG

E

FT4¯ iodine TPO Ab

TSH

placental DI III

T4 TSH

FT4

HCG

Thyroid & Pregnancy

Physiologic changes

– TBG

– I requirement

– urinary I excretion

– T4 & T3 synthesis

– HCG

– immunity