THYROID

DISEASES IN
PREGNANCY
Dr. Iwo-Amah
Department of Obstetrics and
Gynaecology, UPTH

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Introduction
 Pregnancy has a significant impact on normal
maternal thyroid physiology and function, many
of the physiologic change in pregnancy,
especially the hypermetabolic changes mimic
thyroid disease and abnormal thyroid function.
 Thyroid disease in pregnancy is difficult to
diagnose because there is hypertrophy of the
thyroid gland due to normal gravid physiologic
changes.
 Normal secretion from the thyroid gland contain
approx 80% thyroxine (T4) and 20% Tri-
iodothyronine (T3), T3 is the active thyroid
hormone, most of which is derived from
peripheral conversion of thyroxine (T4)
 Though total T4 and T3 increase, there is also an
increase in thyroid binding globulin (TBG),
albumin and pre –Thyroid
10/14/08 Diseases In Pregnancy
albumin, due to enhanced 2
Classification
 Thyroid diseases in pregnancy are
classified into 3 broad headings;
 Hypothyroidism
 Thyroiditis
 Hyperthyroidism

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HYPOTHYROIDISM:
 It affects 0.5 – 3% of pregnant women
common causes of primary
hypothyroidism include autoimmune
diseases such as Hashimoto thyroiditis.
 Iatrogenic causes like radiation treatment
or surgery.
 Congenital hypothyroidism, medications
such as lithium or amiodarone, iodine
deficiency, Radioactive iodine therapy
and infiltrative disease.
 Secondary hypothyroidism may be caused
by pituitary or Thyroid
10/14/08 hypothalamic
Diseases In Pregnancy disease such 4
THYROIDITIS
 Most commonly autoimmune in aetiology.
 Other causes are viral infection, bacterial
or fungal infection, radiation treatment. In
younger women, infection of the piriform
sinus is causative.
 Post partum thyroiditis is a silent
thyroiditis that usually present 3 – 6
months post partum. It is a sub-acute
condition.
 Riedel’s thyroiditis occurs in middle aged
gravitas. It is a chronic thyroiditis. Other
forms of chronic thyroiditis are
Hashmoto’s thyroiditis
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and parasitic
Thyroid Diseases In Pregnancy 5
HYPERTHYROIDISM:
 The incidence of hyperthyroidism in
pregnancy is 0.05 – 2%
 The etiology in order of frequency
are
 graves disease
 acute and sub-acute thyroiditis

 toxic nodular goiter

 toxic adenoma.

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 CLINICAL PRESENTATION
In Hypothyroidism:
 There could be a hx of previous
thyroid surgery, radiation treatment
or hashimoto thyroiditis.
 The signs and symptoms include skin
dryness, yellowing of skin (esp in the
periorbital area) hair loss, cold
intolerance constipation and sleep
disturbances, pallor, a goiter,
delayed relaxation of deep tendon
reflexes, eyelid oedema and weight
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IN THYROIDITIS:
 There is thyroid pain which is referred to
the ears and throat. Tender erythematous
asymmetrical goiter, fever and
lymphadenopathy. There could be a hx of
antecedent malaise and upper respiratory
symptoms.
 In chronic thyroiditis, there is uniform
goiter.
 Riedel’s thyroiditis present with a hard
thyroid gland, asymmetric and fixed. It
may cause compression symptoms
affecting the esophagus and trachea in
Thyroid Diseases In Pregnancy 8
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 IN HYPERTHYROIDISM,
 Clinical presentation include restlessness,
fatigue, and weakness, weight loss,
diarrhoea and heat intolerance.
 On examination, patient may exhibit
tachycardia, tremors, goiter, muscle
weakness, lid retraction or lag.
 The diagnostic triad for graves disease
includes hyperthyroidism with
dermopathy.
 However these 3 major manifestations
may not appear together.
 The disease appears to be precipitated by
emotional trauma or by metabolic stress.
 Toxic adenomas usually present as a
solitary nodule, which gradually increase 9
Thyroid Diseases In Pregnancy
in size, initially patient may not be
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INVESTIGATGIONS:
 In hypothyroidism,the thyroid function test
reveal low thyroxine (T4) and elevated
thyroid stimulating hormone (TSH) There
is presence of antibodies to thyroid
Peroxidase, Thyroid stimulating hormone
receptor or thyroglobulin.
 In thyroiditis, there may be normal thyroid
function test. Erythrocycte sedimentation
rate (ESR) is elevated. There may be
leukocytosis.
 The sera of patients with graves disease
reveal TSH receptor antibodies, or
antibodies to thyroid peroxidase. TSH is
usually decreased and free T4 values are
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DIAGNOSIS:
 Diagnosis of thyroid disease is made
from
 history
 clinical findings
 laboratory results.

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TREATMENT:
Hypothyroidism;
 In prenatal period – L-thyroxine 50 – 100ugld is
given. This is a pure T4 preparation. The dosage
is increased by 25ug per week until the patient is
euthyroid. The goal of therapy is to bring TSH into
the normal or low normal range Antepartum fetal
assessment is necessary in the 3rd Trimester
because of a small increase in stillbirth rate.
 Intrapartum: the euthyroid state is maintained.

POST NATAL PERIOD:

 After delivery, the dosage of L-thyroxine will need
to be decreased as necessary.
 Post partum exacerbations of sub – clinical
thyroid disease have been reported to occur in
approx 5 – 10% of women.
 This hypothyroidism
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Thyroid Diseases spontaneously in 12
In Pregnancy
Thyroiditis:
 Pain and inflammatory swelling is
controlled by aspirin or other non-
steroidal anti inflammatory drugs.
(not indomethacin)
 Antibiotics could be given in acute
thyroiditis.
 L-thyroxine treatment may be
necessary if there is a prolonged
period of hypothyroidism.
 Riedel’s thyroiditis that causes
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HYPERTHYROIDISM:
In prenatal period;
 The treatment of hyperthyroidism in pregnancy
focuses on stopping release of Thyroxine (T4) and
inhibiting conversion of T4 to T3.
 Propyl thiouracil (PTU) is initially given at 100g
three times a day until patient is euthyroid. The
dosage is subsequently decreased.
 Thyroid function should be assessed every 4 –
6weeks in pregnancy.
 Metamizole is also safe in pregnancy for patients
who are non compliant, or refractory to
medication, subtotal thyroidectomy can be done
in the 2nd Trimester.
INTRAPARTUM:
 No specific intrapartum concern exists, except
when the patient Thyroid
10/14/08 presents with and acute
Diseases In Pregnancy 14
 Thyroid storm is a maternal complication of
untreated hyperthyroidism that can be
precipitated by delivery, acute illness, infection,
trauma or surgery it is associated with fever, that
could exceed 40%c,
 A tachycardia, out of proportion to the fever may
also be present. This tachycardia may even
precipitate high output heart failure.
 Atrial fibrillation, with rapid ventricular response
may also be present.
 There is increased pulse pressure mental status is
commonly altered, ranging form restlessness and
confusion to psychosis, seizures and coma.
 Mortality can be as high as 30% even with
treatment. It is important to provide supportive
care, identify and treat the cause, decrease the
synthesis of T4.
 Large doses of propyl theiouracil 600mg loading
dose is given followed
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by 200 – 300mg every hrs.15
Thyroid Diseases In Pregnancy
Potassium Iodide which should be administered
 Propanohol 20-80mg given orally or 1 –
10mg intravenous every 4hrs to
suppress adrenergic output and to block
peripheral conversion of T4 to T3.
 In patients with congestive heart failure
Beta Blockers also serve to increase
stroke volume.
 Steroids could be used. Dexamethasone
2mg every 6hrs in this setting to block
thyroid synthesis and as therapy for auto
immune factors.
 Intravenous fluids, antibiotics and cooling
blankets are also useful.
 Opthalmopathy may require short courses
of steroid. Rarely
10/14/08 Thyroid severe exophthalmos
Diseases In Pregnancy 16
PROGNOSIS AND
COMPLICATION
 Prognosis for both mother and fetus are
excellent when hypothyroidism is
corrected in pregnancy.
 Studies have shown that women with
hypothyroidism have an increased
likelihood of having children with lower 10
scores.
 Therefore it is important to identify and
treat affected women congestive cardiac
failure in the most serious complication of
hypothyroidism megacolon adrenal crisis,
organic Psychosis, hyponatraemia and
myxoedema coma
10/14/08 and
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In Pregnancy 17
 In general, prognosis for mother and
fetus is good with treatment of
thyroiditis.
 Maternal and fetal prognosis is also
good in well controlled
hyperthyroidism.
 A fetal goiter rarely may lead to
extension of the head at delivery
necessitating operative delivery.
 Skilled resuscitation of the newborn
after delivery may be needed if the
airway is obstructed by a goiter.
 Transplacental passage of IgG TSH
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