Hypothyroidism

In
Pregnancy
By – Nikhil Kumar Singh
Group - 1425
Table of contents

01 02 03
Introduction Background Interpretation Of
What is Thyroid Gland Physiological Changes Test
& & Value of TSH & FT4
Incidence of Hypothyroidism Normal Values & Fetal
Changes

04 05 06
Hypothyroidism Diagnosis Conclusions
Causes, Different Types, Lab Test Management
Symptoms & Signs &
& Screening
Effects
Introduction
Metabolic
• Thyroid Gland is a small Butterfly Absorption of Synthesis of
Hemostasis of
Iodine T3 & T4
shaped Endocrine Gland present at Body
the base of Neck, between C5 to T1.
• Consist of 2 lobes joined by
Isthumus
• Highly Vascular organ
• Consist of Follicular &
Parafollicular Cells Function
• Synthesis – Iodide Trapping,
Oxidation & Iodination, Coupling &
Release
• Transported bt TBG, TTR, Albumin
• Free Hormone level - T4(0.03%) & Calcium Growth
Parafollicular cells
Hemostasis Hemostasis of
T3(0.3%) produces Calcitonin
of Body Body
Incidence

Main Cause
• Endocrine disorder in Pregnancy
• 1-2% Pregnant women

Hypothyroidism
• Overt Hypothyroidism – 0.3% -0.5%
• Subclinical Hypothyroidism – 2%- 5%
• Isolated Hypothyroxinemia – 1%- 2%

Hyperthyroidism
• Overt Hyperthyroidism – 0.2% (Mainly Graves’ Disease)

Postpartum Thyroiditis – 5% - 10%

Normal Changes in Pregnancy
PHYSIOLOGICAL CHANGE IMPACT

Iodine Clearance (Renal & Transplacental) • Relative Iodine Deficiency State

• Risk of Foetal & Maternal
Hypothyroidism
Placental Deiodination of T4 • T4 Reverse T3

TBG • TT3 & TT4 levels

• FT4 same
1st Trimester HCG • FT4 & TSH
(Weak TSH Effect) • Foetal & Placental Development
3rd Trimester – Placenta enlarge, Preparation • FT4 & TSH
of Delivery • Mild Hypothyroidism
TSHR Ab reduced • Graves’ Disease Improvement

Postpartum increase in Thyroid Ab • Postpartum Thyroiditis

• Graves’ Disease Exacerbation
Normal Hormonal Value in Pregnancy
Test Non - Pregnant 1st Trimester 2nd Trimester 3rd Trimester

TSH (mIU/L) 0.3 – 4.3 0.1 – 2.5 0.2 – 0.3 0.3 – 3.0

TBG (mg/dL) 1.3 – 3.0 1.8 – 3.2 2.8 – 4.0 2.6 – 4.2

FT4 (ng/dL) o.8 – 1.7 0.8 – 1.2 0.6 – 1.0 0.5 – 0.8

TT4 (mcg/dL) 5.4 – 11.7 6.5 – 10.1 7.5 – 10.3 6.3 – 9.7

FT3 (pg/dL) 2.4 – 4.2 4.1 – 4.4 4.0 – 4.2 Not Reported

TT3 (ng/dL) 77 - 135 97 - 149 117 – 169 123 - 162

Pattern of Changes in Serum Conc. Of Thyroid Function studies
& HCG Acc. To Gestational Age

Shaded Area Represents Normal Range of TBG, T4, TSH orFT4

in Non – Pregnant Women
Interpretation of Tests
Maternal TSH FT4 FT4 TT4 T3 Resin T3
Condition Index Uptake

Normal
Pregnancy

Hypothyroi
dism

Hyperthyroi
dism

Change In Thyroid Function Test Results During Uncomplicated Pregnancy & In

Women With Thyroid Disease
 Primary NTI / Partially Secondary
Hyperthyroidism Eltroxin Hypothyroidism

Normal
Subclinical Euthyroid Subclinical
Hyperthyroidism Hypothyroidism
FT4

Secondary NTI Primary

Low

Hyperthyroidism Hypothyroidism
High

Low Normal
High
TSH
Pregnancy stages & Events in Foetus

1st Trimester 2nd Trimester 3rd Trimester

THR Gene
T3 in Expression
Fetal in Brain

Fe cret
Maternal T4

Se
t al i o
Brain Fetal Iodine Uptake
in Coelomic

T4 n
Fluid

Month
Weeks 6 7 8 10 11 12 13 18
1 2 14
3 4 5 6 7 8 9
• 30% Maternal T4 (Thyroxine) in foetal serum at birth.
Hypothyroidism
• Underactivity of the Thyroid like Decrease
secretion of Thyroid Hormone
• Deficiency of T3 & T4
• Nonspecific Insidious Clinical Findings like
Weight gain, Fatigue, Cold intolerance &
Muscle cramps
• 1 – 3 per 1000 pregnancies
• Types
1. Primary Hypothyroidism – Caused by
Damage to Thyroid Gland
2. Secondary Hypothyroidism – Caused by
Damage to Pituitary Gland, therefore low
production of TSH
3. Tertiary Hypothyroidism – Caused by failure
of Hypothalamus to release TRH
4. Subclinical Hypothyroidism
5. Overt Hypothyroidism
 Causes
Endemic Previous
Iodine Subacute
Thyroiditis Thyroidectomy
Deficiency
Isolated
Hypothyroxinemia

Primary Hypothyroidism
Pituitary Lymphocytic
Tumor Hypophysitis
Hashimoto Previous Radio Medication
Thyroiditis Ablation Exposure
Secondary
Subclinical Hypothyroidism
Hypothyroidism

Sheehan’s
Radiation Surgery
Syndrome
Pathogenesis
1. Pregnancy increases the need for thyroid hormones which promotes relative
iodine deficiency; both factors aggravate the existing hypothyroidism and
lead to decompensation of subclinical hypothyroidism.
2. Decline in the content of thyroid hormones that regulate physiological
functions and metabolism results in suppression of all types of metabolism,
utilization of oxygen by tissues, reduced activity of various enzyme
systems, diminished gas exchange and basal metabolism. The slowing-down
of protein catabolism and synthesis and of its excretion leads to significant
increase in the protein degradation products in organs and tissues, skin and
musculature.
3. Pregnant women experience iodine deficiency that is within borderline
ranges, while there are no adequate adaptation mechanisms. Free T3 and T4
levels keep decreased until the middle of gestation and persist at low levels
till childbirth.
4. These changes are due to a compensatory increase in fetal thyroid activity
and the passage of thyroid hormones from mother to fetus. At later
gestational ages the existing hypothyroidism may go into remission
Effects of Hypothyroidism
 On Pregnancy
• Prolonged Infertility
• Recurrent Abortions
• Preeclampsia 5% - 10%
• Placental Abruption 1%
• Preterm Delivery 10% - 15%
• Anaemia
• Myxoedema Coma
• Malpresentation of Foetus
• LBW (Low Birth Weight)
• PPH (Postpartum Haemorrhage)
• Stillbirth

 On Foetus
• Neurodevelopmental Delay
• Deafness
• Stunted Growth
• Peripartum Hypoxia
• Neonatal Mortality
Signs & Symptoms
• Fatigue
• Constipation
• Cold Intolerance
• Weight Gain
• Carpal Tunnel Syndrome
• Hair Loss
• Voice Changes
• Slow Thinking
• Dry Skin
• Goitre
• Insomnia
• Periorbital Edema
• Myxoedema
• Prolonged relaxation of DTRs
• PR Slow
Iodine Deficiency Goitre (EDI)
● Leading Cause of Preventable
Mental Retardation
● Mean IQ Loss = 13.5 points
● Median Urinary Iodine Excretion
determine Iodine sufficiency
● Iodine Requirement
 Non Pregnant = 150 microgram
 Pregnant = 175 microgram
 Lactation = 200 microgram
• Congenital Cretinism
• If Cretinism is identified & treated
in the first 3 months of life; Near
Normal growth & Intelligence can
be expected
• For this reason, Newborn
screening for congenital
Hypothyroidism
Hashimoto Thyroiditis
• Main cause of
Hypothyroidism in
Pregnancy
• Lymphadenoid
Thyroiditis or
Chronic
Lymphocytic
Thyroiditis
• Autoimmune
Destruction of
Thyroid cells
• Transient
Hyperthyroidism
leads to
Hypothyroidism
Subacute Thyroiditis
Subacute Subacute
Granulomatous Lymphocytic
Thyroiditis Thyroiditis

• Painful • Painless
• Viral Infection • Postpartum
• Sudden Onset thyroiditis
• Fever, Myalgia, • Painlessly
Neck Pain Enlarged
• Painfully Thyroid
Enlarged
Thyroid

• Symptomatic Treatment
Lymphocytic Hypophysitis
• Secondary Hypothyroidism
• Peripartum period
• Usually present with
Hyperprolactinemia
• Autoimmune
• Anterior Pituitary Destruction
• Panhypopituitarism due to Single
hormone deficiency
• Clinical Effects – Headache &
Visual Changes
• Diagnosis - On Imaging –
Enhanced Sella Turcica Mass
Subclinical Isolated
Hypothyroidism Hypothyroxinaemia
● Increase TSH & Normal FT4 & FT3
● 2% - 5% in pregnancy • Normal TSH & Decrease
● 31% positive for TPO Ab FT4
● Associated with Gest HTN, Preterm
Deliveries, Stillbirth, Abruption • 1% - 2% in pregnancy
● Foetal Psychomotor development • No adverse effect in
may be impaired
● Routine Screening not pregnancy
Recommended • No benefit of
● Low IQs of the children whose
mothers were not treated
Levothyroxine
● Undiagnosed Subclinical
Hypothyroidism were most likely
complicated by Placental abruption
● Preterm Birth
Neonatal Hypothyroidism
 Main cause Endocrinopathies
 Causes: Primary, secondary, tertiary.
 Cord blood at birth OR heel prick on 3 rd day
 Symptoms & Signs
 Sleeps a lot
 Poor Feeding
 Prolonged Jaundice
 Thick protruding Tongue & Swollen Protruding Belly Button
 Constipation or Reduced Stool
 Cool & Pale Skin
 Coarse Facial feature
 Poor Muscle tone & Slow Reflexes
 Goal - To normalize TSH(<5mU/I) & T4 (10-16µg/dl) as
quickly as possible.
 3rd trim foetal T4 required : 6µg/kg/d
 Main Medication
 Utero: Intraamniotic 250-500µg thyroxine 7-10d interval
 In term infants: 10-15 g/kg/d
Postpartum thyroiditis
● Etiology not confirmed
● But a problem in the self
immunity can be probably
caused by a constant increase of
the level of antimicrozomes
antibody in the first trimester of
the pregnancy.
● Post-partum thyroiditis affects
2-7% of the pregnant women.
● The Hypothyroid phase follows
a Hyperthyroid phase and it
manifests after 5-7 months in
post-partum.
● Treated by Levothyroxine
Diagnostics
Physical investigations
• Examination:
– patient’s facial expression;
– anterior neck surface;
– distribution of subcutaneous fat.
• Thyroid gland palpation.
• Measuring the pulse.
• Taking BP.
 On examination the patient shows pallor and edema of the skin and
subcutaneous tissue.
 The skin is dry, flaky, cold. One notes puffiness of the face and
extremities.
 The speech is slowed down, the voice is hoarse, the movements are
slow.
 The patients show bradycardia (52–60 per min), arterial hypotension,
reduced circulating blood volume, slow blood flow.
 Congenital hypothyroidism entails retardation of physical growth and
mental development to the extent of feeble-mindedness.
 Greater or lesser extent of mental disorder is noted in all patients.
Lab Test & Screening
TSH
FT4
Antithyroid Ab (Anti TPO & antithyroglobulin)
Ultrasound of the thyroid gland (determining the thyroid
volume; in women it normally does not exceed 18 ml), the
number, size and echo structure of nodules.
Dopplerometry. A dynamic assessment of thyroid function and
its volume is performed every 8 weeks (no less than once in
every trimester).
TSH should be done ideally before pregnancy
If not done, high risk women should be screened
 Strong family history
 Autoimmune disorder
 Personal history of thyroid disease
 Therapeutic neck irradiation
 Presence of goitre
 Medications
Management
● Treatment of Choice is Synthetic T4 or Levothyroxine
● Prepregnancy – 1.7 microgram/kg/day Levothyroxine started

4-6 weeks

TSH Normalized
● During Pregnancy
 Safe in pregnancy and lactation. Very little thyroxin crosses the placenta and the fetus is not at risk of
thyrotoxicosis.
 Patients who were on thyroxine therapy before pregnancy should increase the dose by 30% once pregnancy is
confirmed
 Monitoring: TSH should be monitored to maintain a TSH level between 1 and 2 mIU/L and FT4 in upper third of
normal.
 Once euthyroid state has been achieved, TSH should be monitored as per trimester until delivery.
 The following upper-normal reference ranges are recommended:
 1st Trimester : 0.1 - 2.5 mIU/L
 2nd Trimester : 0.2 - 3.0 mIU/L
 3rd Trimester : 0.3 - 3.5 mIU/L
• Cesarean section is performed for obstetric indications.
Mana
Patient with History of
Hypothyroidism
+HCG/Home Pregnancy Test

geme
Increase Levothyroxine
Dosage by 30%

nt
Laboratory Test :
TSH & FT4

TSH Between 1 & 2 mIU/L &

TSH & FT4 Abnormal
FT4 In Upper Third of Normal

Adjust Levothyroxine in
25 microgram Increments Monitor TSH & FT4 Every
Abnormal Trimester
Monitor TSH & FT4
Normal
Every 4 Weeks
 PREGNANCY

BLOOD VOLUME & TBG INCREASED

FREE T4 DECREASED

EUTHYROID HYPOTHYROID

COMPENSAT THYROXINE DOSE INCREASED 25-40%

E 4-6 WEEKS
REPEAT TSH (GOAL 0.5-2.5mIU/L)

ADJUST DOSE

REPEAT TSH EVERY 8WEEKS

Levothyroxine Sodium
 Most widely prescribed for treatment About 25-300
mcg
 If newly diagnosed in pregnancy started about 1-
2µg/kg/d or approx. 100-150µg/d
 If previously hypothyroid, dose increased by 25-
40%
 Taken empty stomach

 Separated from multivitamins, calcium, iron, soy

products by 4hrs
 Postpartum:

 Decrease dose by 30% (if newly diagnosed)

 Prepregnancy dose (known case)

 Reassess after 6 weeks

 Patient can Breastfeed

References

 https://www.aafp.org/afp/2014/0215/p273.pdf
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC
3472679/
 https://pubmed.ncbi.nlm.nih.gov/19935037/
 https://pubmed.ncbi.nlm.nih.gov/20463094/
 Obstetrics (Акушерство): учебник. Ed. by V.E.
Radzinski, A.M. Fuks, Сh.G. Gagaev