Pregnancy and the thyroid gland: Important issues for mom and baby

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1 Pregnancy and the thyroid gland: Important issues for mom and baby

2 Normal Function : Hypothalamic Hypothalamic-Pituitary- Thyroid Axis is Centrally Determined ( - ) T4 T4 T3 ( - ) TRH PITUITARY TSH HYPOTHALAMUS Classic negative feedback loop Thyroid T3 Thyroxine (T4)

3 The Thyroid Gland Shaped like a butterfly Base of the neck About g in the adult Starts functioning at about 11 weeks in the fetus Most maternal T3 and T4 are inactivated by the placenta but the small amount that reaches the fetus is important for early fetal brain development

4 What does T3 and T4 affect? Everything! O2 consumption, heat production, free radical formation Cardiovascular Sympathetic Pulmonary Hemapoietic GI Skeletal Neuromuscular Lipids and Carbohydrates Metabolic turnover of many hormones

5 Thyroid Function in the Fetus Prior to development of independent fetal thyroid function, fetus is dependent on maternal thyroid hormones 11 th week of gestation measurable TSH and TRH are present in the fetus At this time the fetal thyroid begins to trap iodine Secretion of thyroid hormone begins weeks At birth there is a marked rise in T4 and T3

6 Thyroid Function in Pregnancy Rise in TBG (thyroid binding globulins) Effect of estrogen Rise in T4 and T3 New equilibrium of free and bound T3 and T4 hcg is weak TSH agonist Can cause thyroid enlargement And decreased TSH

7 Thyroid and Pregnancy Increased iodine clearance If low iodine intake can impair thyroid hormone synthesis Maternal thyroid antibodies can affect the fetal thyroid function

8 Maternal thyroid physiology First half of gestation to term Increase in thyroid binding globulin Lower free hormone concentrations of T3 and T4 Stimulation of hypothalamic-pituitary-thyroid axis (protective mechanisms)

9 Maternal thyroid physiology First trimester continued as hcg peaks and cross reacts with TSH receptor: partial inhibition of pituitary and lowering of TSH level between wks 8 and 14 20% of women will have TSH dip below lower level of normal: these women will have higher hcg concentrations In normal pregnancies these are of minor consequence

10 Maternal thyroid physiology continued Throughout pregnancy Alterations in the peripheral metabolism of thyroid hormone more prominent in second half Three enzymes deiodinate thyroid hormones Type 1 not modified Type 2 (placenta) maintains T3 production locally Type 3 (placenta) (protective mechanisms)

11 Normal Function : Hypothalamic Hypothalamic-Pituitary- Thyroid Axis is Centrally Determined ( - ) T4 T4 T3 ( - ) TRH PITUITARY TSH Thyroid HYPOTHALAMUS HCG Classic negative feedback loop Placenta T3 Thyroxine (T4)

12 Iodine deficiency Iodine deficiency: controversial. No recommendations for US women yet but as providers we should instruct our patients that iodine in the diet is recommended.

13 Thyroid Diseases in Pregnancy Autoimmune thyroid disease Hyperthyroidism 0.2% Hypothyroidism Clinical 0.3% Subclinical 2-3%

14 Thyroid Diseases in Pregnancy continued Non Autoimmune Gestational Hyperthyroidism 5-10% ( HCG) Iodine deficiency? Goiter? Post ablation (cancer, goiter)?

15 Laboratory evaluation of thyroid function during pregnancy TSH (ORDER THIS ONE!) If low, repeat with a T4 If higher than normal value repeat and consult Remember that total T4 and total T3 can be elevated because of increased thyroxine-binding globulin Anti-thyroid antibodies Drugs and thyroid function Nonthyroidal illness and thyroid function

16 Thyroid Dysfunction and reproductive disorders Hyperthyroidism Increased SAB s Possible low birth weight Possible neonatal goiter in Graves (TSI) Hypothyroidism Increased SAB s Possible effects of anti-tpo Radioiodine and gonadal function

17 Hyperthyroidism and Pregnancy Signs and symptoms Heat intolerance Sweating Fatigue Anxiety Emotional lability Tachycardia, pounding heart, palpitations Weight loss Nausea/excessive vomiting Diarrhea CHF, myopathy, lymphadenopathy

18 Hyperthyroidism continued TSH and T4 most important labs Other considerations: liver enzymes, CBC, alk phos, serum calcium, thyroid antibodies

19 Differential diagnosis Hyperthyroidism in pregnancy Graves (90-95%) Toxic adenoma Toxic multinodular goiter Hyperemesis gravidarum Gestational trophoblastic disease Exogenous T4 and T3 De Quervain (subacute) thyroiditis Painless lymphocytic thyroiditis Extremely rare Struma ovarii TSH-producing pituitary tumor Metastatic follicular cell carcinoma

20 Hyperthyroidism continued Treatment Thionamide therapy (methimazole or PTU) In United States PTU is most often used Infant should have ultrasound for signs of hypothyroidism Beta blockers Propranolol/Atenolol for tachycardia or tremulousness (need to watch fetus for bradycardia, etc) Iodides rarely used now Surgery rarely needed Thyroid storm severe hyperthyroidism with mental status changes, fever and/or CV collapse

21 Fetal and Neonatal hyperthyroidism Usually produced by transplacental passage of thyroid stimulating immunoglobulins in Graves disease (TSI) Antibodies can continue to be present after ablation, surgery and even in Hashimoto s thyroiditis Watch for TSI in mom of >300% as this can be predictive of fetal hyperthyroidism

22 Hypothyroidism Most common cause is chronic autoimmune thyroiditis Hashimoto s (with or without goiter) Ask if there is a family h/o thyroid problems If goiter and/or family h/o thyroid disease: order a TSH and anti-tpo.

23 Hypothyroidism If known hypothyroidism and patient is on replacement therapy: Ask pt to get TSH as soon as she knows she s pregnant AND Take one extra thyroid pill that day Consult She will likely need 30% more Thyroxine in first trimester

24 Hypothyroidism TSH goal is 0.2 to 2.0 during pregnancy normal is on most assays Labs every four weeks during pregnancy Dose of thyroxine can vary depending on the cause of hypothyroidism If hypothyroid because of thyroidectomy for thyroid cancer: refer pt to endocrinologist

25 Conclusions Many changes in maternal thyroid function Know if your patient has thyroid problems before conception IF POSSIBLE Pre-pregnancy counseling Women who have thyroid problems by history will need close monitoring If you have questions: ask

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