HYPOTHYROID IN PREGNANCY

ANDI CAKRA
Hypothyroidism is characterized by
inadequate thyroid hormone
production, and usually requires for
diagnosis elevated thyroid
stimulating hormone (TSH) and low
free thyroxine (FT4)
A butterfly-shaped
organ at the base of
neck and is part of
the endocrine
system, which is
made up of several
glands and tissues
that produce
hormones
Thyroid hormon requirements HCG has some thyrotropic function, so it
increase by 20-40% in stimulates thyroid receptorsincrease free
pregnancy (as early as 4 FT4 levels and decrease TSH levers
weeks gestation) particularly in first trimester

Difficult to diagnose clinically because of overlap of

normal signs and symptomps of pregnancy

fatigue, constipation, muscle cramps, and weight

gain,decreasein exercise capacity,lethargy,
Intolerance to cold
Poros hipothalamus hipofise organ target
kelenjar tiroid
 Nonpregnant 1st 2nd 3th

TSH(uIU/ml) 0.34-4,25 0,60-3,40 0,37-3,60 0,38-4,04

Thyroxine-binding 1,3-3,0 1,8-3,2 2,8-4,0 2,6-4,2

globulin (mg/dl)

Ft4(ng/dl) 0,8-1,7 0,8-1,2 0,6-1,0 0,5-O,8

T4(ug/dL) 5,4-11,7 6,5-10,1 7,5-10,3 6,3-9,7

fT3(pg/ml) 2,4-4,2 4,1-4,4 4,0-4,2 NR

T3(ng/Dl) 77-135 97-149 117-169 123-162

 0,2 %- 0,3% overt
1 % in population
hypothyroid

General screening of
2,3 % hypothyroid subklinis obstetric  2,5% of
elevated serum TSH

5 % to 8% incidence in
patients with dm type 1.
Up to 25 % of dm type 1
develop postpartum
thyroid dysfunction.
 • fatigue, constipation,
cold intolerance, muscle
ANAMANESIS cramps, and weight
gain,decreasein exercise
capacity,lethargy,

• Edema, dry skin, hair

loss,, hoarseness,britttle
INSPECTION nail
 • include a goiter,a thyroidectomy scar,
and delay prolonged relaxation phase
of deep tendon reflexes.
Physical • A pathologically enlarged thyroid gland

signs may depens on the etiology of

hypothyroidisms

• Abnormal high serum TSH level, with or

without a suppresed free T4 value.
• elevated levels of creatinin
Laboratory phosphokinase, cholesterol, and
carotene and liver function

finding: abnormalities. Patients may have

macrocytic or normocytic, normocytic
anemia.
Two most common
Sufficient dietary Other causes
iodine supply

autoimmune
congenital (about
thyroiditis
1 in 3000 births in
(Hashimoto
US)
thyroiditis)

Drug induced(
Post thyroid
lithium,
ablation therapy,
amiodarone,
either surgical or I
iodine excess,
induced
antithyroid drugs)

Prior head and

neck radiation for
nonthyroid
malignant disease,

Congenital defects
in thyroid hormone
biosynthesis.
 Primary Secondary
hypothyroidism: hypothyroidism includes

Subclinical hypothyroidism(normal
serum T4 and elevated serum Disease of pituitary gland or
TSH)glandular destruction hypothalamus
autoantibodies (hashimoto thyroiditis)

Overt or clinical hypothyrodism (low

serum T4 and elevated Autoimmune hypophysitis  sheehan
TSH)Hereditery,type-1 syndrome
diabetes,thyroid peroxidase antibodies
1.Subclinical and overt hypothyroidism
diagnosed for the first time during pregnancy;
2. Hypothyroid women who discontinue
thyroid therapy before or at the time of
conception because of poor medical advice or
misconception that thyroid medications may
affect the fetus
3. Women on thyroid replacement therapy
requiring larger doses in pregnancy
4. Women previously diagnosed but not
concisistent in taking their medication
5. Hyperthyroid patients on excessive amounts
of antithyroid drug therapy
6. Some patients on lithium or
amiodaronetherapy  affect thyroid
function chronic thyroiditis
A history of hyperthyroid or hypothyroid
disease, post partum thyroiditis or thyroid
lobectomy
• Family history of thyroid disease
• Prior therapeutic head or neck irradiation

Infertility ,miscarriage or preterm delivery

• Type1 diabetes
• Other autoimmune disorders

Symptoms or clinical sign suggestive of thyroid

under function or overt function
 Pituitary disease,
pituitary tumours
 Lymphocytic
hypophysitis
infertility
Preeclampsia
abruption placentae
Misscarriage,
anemia
Hipertensi gestational
Post Partu Haemorrhagic

Low birth weight

Stillbirth/fetal death
Congenital malformations,
Impaired mental and somatic development
PREVENTION POSTNATAL
ANTENATAL
 Consider diagnosis in those with
subfertility/menstrual disorder.
 Optimize medical therapy;
delay pregnancy until good control.
 Obtain baseline thyroid function tests
as soon as posible.
 Use pregnancy spesific reference
range when interpreting thyroid
function tests.
 Obtain thyroid function test every 3
mo. More frequently if dosage
adjusments are made.
 Routine increases in thyroxine doses
are not required. Make dosage
adjustments based on results of
thyroid function tests.
 Avoid taking iron suplements at the
same times as oral thyroxine therapy.
 Women planning their
pregnancies should have a
serum TSH below 2,5
Miu/l,ideally closer to 1
mIU/L
 Serum TSH should be
repeted every 2 to 6 weeks
during the first 20 weeks
gestation and at 24 to 28
weeks
 Well serum FT4 or FT4I
within normal trimester
spesific reference ranges
 Adjusted by 25-50 ug
increments until normal value
are reached
 Seleniumselenoproteins
act as antioxidants and
decrease thyroid
inflamation in
autoimmune thyroiditis by
reducing TPO antibody
titers.
Up to 30 % of women
with TPO antibodies
develop permanent
hypothyroidism following
postpartum thyroid
dysfunction
Iodine
supplementation
 220-250 ug of
iodine is
recommended
during pregnancy
and breast-feedinG
 Thionamide,
iodides,lithium.
 Carbamazepine,
phenytoin and
rifampicin
 Aluminium hydroxide,
cholestyramine, and
most importantly,
ferrous sulfate and
sucralfate
Levothyroxine 1 to 2 ug/kg/day or approximately 100 ug daily 
surveillance is with TSH levels measured 4 to 6 week intervals
•Severe hypothyroidism(delay in the normalization of the serum TSH, normal FT4 or
FT4I values first 2 weeks of therapy if sufficient L-thyroxine is administered.
Maintenance dose required between 75 and 250 mcg of L-thyroxine per day

Thyroxine dose is adjusted by 25 to 50 ug increments until TSH value

become normal

Armour Thyroid at 30 mg/day initial dose, then increased

incrementally by 15 mg every tow to three weeks until maintenance
dose of 60 to 120 mg/day
-Observe for signs of
postpartum thyroiditis.
-Screen for postpartum
depression.
-Immediately after
delivery, patient should
return to their pregnancy
dose
TSH levels should be
measured six to eight
weeks postpartum, with
follow up with
endocrinologist  develop
post partumthyroiditis (3-6
months after delivery)
Goal of levothyroxine
treatment in pregnancy is
maternal serum TSH 0,5 to
2,0 u U/ml, and FT4 in upper
third of normal range.
TSH and FT4 levels should be
checked preconceptionally, at
first prenatal visit in first
trimester, 4 weeks after
altering the dose,(therefore,
every 4 weeks until TSH is
normal, especially in the first
20 weeks), and at least every
trimester in pregnancy
Diagnosis Universal screening
for maternal hypothyroidism is
not usually recommended even
if some have proposed it.
Women at hight risk for
hypothyroidism should be
screened. Tests used for
screening and diagnosis include
TSH (most sensitive) and FT4
THANK YOU