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How to Manage Hyperthyroid Disease in Pregnancy

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How to Manage Hyperthyroid Disease in Pregnancy SECOND OF 2 PARTS Annette E. Bombrys, DO How to manage hyperthyroid Dr. Bombrys is a Fellow in Maternal– Fetal Medicine, Department of Obstetrics and Gynecology, at the disease in pregnancy University of Cincinnati College of Medicine in Cincinnati, Ohio. Uncontrolled hyperthyroidism can be fairly Mounira A. Habli, MD Dr. Habli is a Fellow in Maternal– innocuous or life-threatening to mother and fetus Fetal Medicine, Department of Obstetrics and Gynecology, at the University of Cincinnati College of CASE Life on the line consistent with the estimated gestational Medicine in Cincinnati, Ohio. age and shows adequate amniotic fl uid and Baha M. Sibai, MD no gross fetal anomalies. Dr. Sibai is Professor, Department A 32-year-old woman in the 24th week of her What is the likely diagnosis? of Obstetrics and Gynecology, at the University of Cincinnati College fourth pregnancy arrives at the emergency of Medicine in Cincinnati, Ohio. department complaining of cough and con-® Dowdenhis is aHealth classic example Media of un- The authors report no fi nancial gestion, shortness of breath, and swelling in diagnosed hyperthyroidism in relationships relevant to this article. her face, hands, and feet. The swelling has T pregnancy manifesting as thy- become worse over theCopyright past 2 weeks,For and personalroid storm. use only she had several episodes of bloody vomit- As the case illustrates, uncontrolled ing the day before her visit. The patient says hyperthyroidism in pregnancy poses a she has not experienced any leakage of signifi cant challenge for the obstetrician. fl uid, vaginal bleeding, or contractions. She The condition can cause miscarriage, IN THIS ARTICLE reports good fetal movement. preterm delivery, intrauterine growth re- The patient’s medical history is unre- striction, preeclampsia, and—at its most ❙ Uncontrolled markable, but a review of systems reveals dangerous—thyroid storm.1 Thyroid hyperthyroidism: a 15-lb weight loss over the past 2 weeks, storm is a life-threatening emergency, Serious racing heart, worsening edema and short- and treatment must be initiated even consequences ness of breath, and diarrhea. before hyperthyroidism is confi rmed by Page 24 Physical fi ndings include exophthalmia thyroid function testing.2 The good news and an enlarged thyroid with a nodule on the is that these complications can be suc- ❙ Stepwise right side, as well as bilateral rales, tachy- cessfully avoided with adequate control cardia, tremor, and increased deep tendon of thyroid function. management of refl exes. There is no evidence of fetal car- Overt hyperthyroidism, seen in thyroid storm diac failure or goiter. 0.2% of pregnancies, requires active in- Page 27 A computed tomography (CT) scan of tervention to avert adverse pregnancy the mother shows bilateral pleural effusions outcome and neurologic damage to the Did you miss the authors’ indicative of high-output cardiac failure. fetus. Subclinical disease, seen in 1.7% earlier article? Thyroid ultrasonography (US) reveals a of pregnancies, can also create serious diffusely enlarged thyroid gland with a right- obstetrical problems.1 Part 1 of this review, which appeared in the January sided mass. The effects of hyperthyroidism in preg- issue of OBG MANAGEMENT, The thyroid-stimulating hormone (TSH) nancy vary in severity, ranging from the covered the impact of hypo- level is undetectable. Fetal heart rate is in fairly innocuous, transient, and self-limited thyroidism on gestation. You the 160s, with normal variability and oc- state called gestational transient thyrotoxi- can fi nd it in our archive at www.obgmanagement.com casional variable deceleration. Fetal US is cosis to the life-threatening emergency of www.obgmanagement.com February 2008 • OBG MANAGEMENT 21 For mass reproduction, content licensing and permissions contact Dowden Health Media. Hyperthyroid disease in pregnancy TABLE 1 Is your pregnant patient hyperthyroid? Five-test lab panel offers a guide TEST AND RESULT THYROID- THEN THE STIMULATING FREE TRI- FREE TOTAL TRI- TOTAL MOTHER’S HORMONE IODOTHYRONINE THYROXINE IODOTHYRONINE THYROXINE CONDITION IS … No change No change ü ü ü Pregnancy † ü ü ü ü Hyperthyroidism † No change No change No change No change Subclinical hyperthyroidism TABLE 2 Pregnant women who have a history Causes of hyperthyroidism of high-dose neck radiation, thyroid ther- in pregnancy apy, postpartum thyroiditis, or an infant born with thyroid disease should also be Graves’ disease tested at the fi rst prenatal visit.4 Adenoma Telltale signs and laboratory tests Toxic nodular goiter The signs and symptoms of hyperthyroid- Thyroiditis ism can include nervousness, heat intol- erance, tachycardia, palpitations, goiter, Excessive thyroid hormone intake weight loss, thyromegaly, exophthalmia, Choriocarcinoma increased appetite, nausea and vomit- ing, sweating, and tremor.1 The diffi culty Molar pregnancy here? Many of these symptoms are also FAST TRACK seen in pregnant women who have nor- ACOG does not thyroid storm. This review will update you mal thyroid function, so that symptoms on how to manage this disorder for opti- alone are not a reliable guide. endorse routine mal pregnancy outcome. Instead, the diagnosis of overt hy- screening for thyroid perthyroidism is made on the basis of dysfunction in laboratory tests indicating suppressed pregnant women To screen or not to screen TSH and elevated levels of free thy- Routine screening for thyroid dysfunction roxine (FT4) and free triiodothyronine has been recommended for women who (FT3). Subclinical hyperthyroidism is have infertility, menstrual disorders, or type defi ned as a suppressed TSH level with 2 1 diabetes mellitus, and for pregnant wom- normal FT4 and FT3 levels. en who have signs and symptoms of the dis- The effects of hyperthyroidism on order. Some authors recommend screening laboratory values are shown in TABLE 1. all pregnant women, but routine screening A form of hyperthyroidism called the T3– is not endorsed by the American College of toxicosis syndrome is diagnosed by sup- 2,3 Obstetricians and Gynecologists. pressed TSH, normal FT4, and elevated 4 Thyroid testing in pregnancy is rec- FT3 levels. ommended in women who: • have a family history of auto- immune thyroid disease What are the causes? • are on thyroid therapy The most common cause of hyperthy- • have a goiter or roidism in pregnancy—accounting for • have insulin-dependent diabetes mellitus. some 95% of cases—is Graves’ disease.2 22 OBG MANAGEMENT • February 2008 This autoimmune disorder is charac- TABLE 3 terized by autoantibodies that activate What causes severe the TSH receptor. These autoantibodies hyperthyroidism before cross the placenta and can cause fetal 20 weeks’ gestation? and neonatal thyroid dysfunction even when the mother herself is in a euthyroid Gestational transient thyrotoxicosis 4 condition. Choriocarcinoma Far less often, hyperthyroidism in pregnancy has a cause other than Gestational trophoblastic disease • Partial hydatidiform mole Graves’ disease; TABLE 2 summarizes the • Complete hydatidiform mole possibilities.1 Other causes of hyper- thyroidism in early pregnancy include choriocarcinoma and gestational tro- • had Graves’ disease with fetal or phoblastic disease (partial and complete neonatal hyperthyroidism in a pre- moles) (TABLE 3). vious pregnancy • have active Graves’ disease being Signs and symptoms treated with antithyroid drugs of Graves’ disease • are euthyroid or have undergone ab- Women who have Graves’ disease usu- lative therapy and have fetal tachycar- ally have thyroid nodules and may have dia or intrauterine growth restriction exophthalmia, pretibial myxedema, and • have chronic thyroiditis without goiter tachycardia. They also display other clas- • have fetal goiter on ultrasound. sic signs and symptoms of hyperthyroid- Newborns who have congenital hy- ism, such as muscle weakness, tremor, pothyroidism should also be screened for and warm and moist skin. thyroid antibodies.4 During pregnancy, Graves’ disease usually becomes worse during the fi rst trimester and postpartum period; symp- What are the consequences? toms resolve during the second and Hyperthyroidism can have multiple ef- FAST TRACK third trimesters.1 fects on the pregnant patient and her fe- The most tus, ranging in severity from the minimal Thyrotoxin receptor to the catastrophic. common cause of and antithyroid antibodies hyperthyroidism in Antithyroid antibodies are common in pa- Gestational transient thyrotoxicosis pregnancy is Graves’ tients with autoimmune thyroid disease, This condition is presumably related to disease, which as a response to thyroid antigens. The high levels of human chorionic gonado- accounts for about two most common antithyroid antibodies tropin, a substance known to stimulate are thyroglobulin and thyroid peroxidase TSH receptors. Unhappily for your pa- 95% of cases (anti-TPO). Anti-TPO antibodies are as- tient, the condition is usually heralded sociated with postpartum thyroiditis and by severe bouts of nausea and vomit- fetal and neonatal hyperthyroidism. TSH- ing starting at 4 to 8 weeks’ gestation. receptor antibodies include thyroid-stim- Laboratory tests show signifi cantly ulating immunoglobulin (TSI) and TSH- elevated levels of FT4 and FT3 and receptor antibody. TSI is associated with suppressed TSH. Despite this signifi cant Graves’ disease. TSH-receptor antibody derangement, patients generally have no is associated with fetal goiter, congenital evidence of a hypermetabolic state. hypothyroidism, and chronic thyroiditis This
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