PracticeGuidelines

ACOGPracticeBulletinonThyroidDiseaseinPregnancy
BarrettM.Schroeder
AmFamPhysician.2002May1565(10):21582162.
TheCommitteeonPracticeBulletinsObstetricsoftheAmericanCollegeofObstetriciansand
Gynecologists(ACOG)hasdevelopedapracticeguidelineonthyroiddiseaseinpregnancy.ACOG
PracticeBulletinNo.32appearsintheNovember2001issueofObstetricsandGynecology.
TheACOGguidelinediscusseschangesinthyroidfunctionduringpregnancy,hyperthyroidism,
hypothyroidism,andclinicalconsiderationsandprovidesrecommendations.Thefollowinginformationisa
summaryoftheACOGpracticebulletin.
ThyroidFunctionDuringPregnancy
Normalpregnancy,hyperthyroidism,andhypothyroidismaffectthyroidfunctiontestresults(see
accompanyingtable).Inpregnancy,thevaluesinfluencedbytheserumthyroidbindinghormonelevel(i.e.,
totalthyroxine,totaltriiodothyronine,andresintriiodothyronineuptake)changesignificantly.
Plasmaiodidelevelsdecreaseasaresultoffetaliodideuseandincreasedmaternalrenalclearance.In
about15percentofpregnantwomen,theseloweriodidelevelsareassociatedwithanoticeableincrease
inthyroidglandsize.
Hyperthyroidism
Thyrotoxicosisisaclinicalandbiochemicalstateresultingfromexcessproductionofandexposureto
thyroidhormonebecauseofanyetiology.Hyperthyroidism,whichoccursin0.2percentofpregnancies,is
thyrotoxicosisresultingfromhyperfunctionofthethyroidgland.Themanysignsandsymptomsof
hyperthyroidismincludetremors,nervousness,insomnia,excessivesweating,heatintolerance,
tachycardia,hypertension,andgoiter.
Graves'diseaseisresponsiblefor95percentofhyperthyroidismcasesinpregnancy.Distinctive
ophthalmicsignsincludeeyelidlagorretractiondermalsignsincludelocalizedandpretibialmyxedema.
Thediagnosisofthisdiseaseisgenerallybasedonanelevatedfreethyroxine(FT )levelorfreethyroxine
index(FTI),withsuppressionofthyroidstimulatinghormone(TSH)intheabsenceofthyroidmassor
nodulargoiter.
Thyroidstorm,arareconditionaffecting1percentofpregnantwomenwithhyperthyroidism,is
characterizedbysevere,acuteexacerbationofthesignsandsymptomsofhyperthyroidism.Thyroidstorm
isamedicalemergency.
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Unlesshyperthyroidismistreatedadequately,pregnantwomenareatincreasedriskforsevere
preeclampsia,pretermdelivery,heartfailure,and,possibly,miscarriage.Lowbirthweightinneonatesalso
canoccur.
Graves'diseaseanditstreatment(thioamides)increasefetalandneonatalrisks.Fetalthyrotoxicosis
needstobeconsideredinwomenwhohaveahistoryofGraves'diseaseifthisconditionisdiagnosed,
appropriateconsultationshouldbesought.Becauseofantibodiesthatcrosstheplacenta,thepossibilityof
neonatalimmunemediatedhypothyroidismorhyperthyroidismisanadditionalconcern.
ChangesinThyroidFunctionTestResultsinNormalPregnancyandinThyroid
Disease
MATERNAL
STATUS
TSH FT FTI TT TT RT U
Pregnancy No
change
No
change
No
change
Increase Increase Decrease
Hyperthyroidism Decrease Increase Increase Increase Increaseorno
change
Decrease
Hypothyroidism Increase Decrease Decrease Decrease Decreaseorno
change
Increase
TSH=thyroidstimulatinghormoneFT =freethyroxineFT =freethyroxineindexTT =total
thyroxineTT =totaltriiodothyronineRT U=resintriiodothyronineuptake.
ReprintedwithpermissionfromACOGPracticeBulletin.Clinicalmanagementguidelinesfor
obstetriciangynecologists.No.32,November2001.Thyroiddiseaseinpregnancy.ObstetGynecol
200198(5pt1):8798.
Hypothyroidism
Hypothyroidismisusuallycausedbyaprimarythyroidabnormality,althoughafewcasesarecausedby
hypothalamicdysfunction.Inpregnantorpostpartumwomen,themostcommoncausesarechronic
thyroiditisorchronicautoimmunethyroiditis(Hashimoto'sdisease),subacutethyroiditis,radioactiveiodine
therapy,thyroidectomy,andiodinedeficiency.Hashimoto'sdiseaseisthemostfrequentcausein
industrializednationsworldwide,iodinedeficiencyisthemostcommoncause.
Signsandsymptomsofhypothyroidismincludefatigue,musclecramps,constipation,coldintolerance,hair
loss,andothers.Withprogressionofthedisorder,voicechanges,weightgain,intellectualslowness,and
insomniacanoccur.Untreatedhypothyroidismprogressestomyxedemaandmyxedemacoma.
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3 3
Presentationofadvancedhypothyroidisminpregnancyisunusual.Subclinicalhypothyroidismisidentified
byanelevatedTSHlevelinapregnantwomanwithoutsymptoms.
Untreatedmaternalhypothyroidismincreasestheriskofpreeclampsia.Whethersubclinicalhypothyroidism
increasesthisriskisuncertain.Inadequatetreatmentofhypothyroidismisassociatedwithlowbirthweight
inneonates.Maternalhypothyroidismfromirondeficiencyincreasestheriskofcongenitalcretinism
(growthfailure,mentalretardation,otherneuropsychologicdefects).Iodinetherapyinthefirstandsecond
trimesterssignificantlyreducesneurologicabnormalitiesassociatedwiththisdisorder.
Cretinismalsooccurswithuntreatedcongenitalhypothyroidism.Newbornscreeningforcongenital
hypothyroidismisofferedthroughouttheUnitedStates.Treatmentinthefirstseveralweeksoflifecan
resultinnearlynormalintelligenceandgrowth.
ClinicalConsiderationsandACOGRecommendations
Whatlaboratorytestsforthyroiddiseaseareusedinpregnantwomen?TSHtesting(nowperformedusing
monoclonalantibodies)istherecommendedinitialtestforscreeningandevaluatingpatientswith
symptomaticdisease.TSHandFT orFTItestingshouldbeperformedinpregnantwomenwithsuspected
hyperthyroidismorhypothyroidism.Thethyrotropinreleasinghormonelevelisanothertestofthyroid
function.Theclinicalusefulnessofvariousantibodytestsdependsontheindividualsituation.
Whatmedicationsareusedtotreathyperthyroidismandhypothyroidisminpregnancy?Hyperthyroidismin
pregnantwomenistreatedwithathioamide(propylthiouracilormethimazole).Recentstudieshavefound
nosignificantdifferencesbetweenpropylthiouracilandmethimazoleinmeanFT orTSHlevelsinnewborn
cordbloodsamples,aswellasnocasesofaplasiacutisandsimilarratesoffetalanomaliesforboth
agents.Womentreatedwithpropylthiouracilormethimazolecanbreastfeedsafely.
ThegoalistomaintainFT orFTIinthehighnormalrangeusingthelowestpossiblethioamidedosage.
MeasuringtheFT orFTIeverytwotofourweekscanbehelpful.Untilthioamidetherapyreducesthyroid
hormonelevels,abetablocker(e.g.,propranolol)canbeusedtoreducesymptoms.
Agranulocytosis,asideeffectofthioamides,usuallypresentswithsorethroatandfever.Ifthese
symptomsdevelop,acompletebloodcellcountshouldbeobtained,andthethioamideshouldbe
discontinued.Othersideeffectsincludehepatitis,vasculitis,andthrombocytopenia.
AlthoughsuppressionoffetalandneonatalthyroidfunctioncanoccurwiththioamidetherapyforGraves'
disease,itisusuallytransient,andtreatmentisrarelyrequired.FetusesofwomenwithGraves'disease
shouldbemonitoredfornormalheartrateandappropriategrowthunlessproblemsaredetected,
ultrasoundscreeningforfetalgoiterisnotnecessary.Thenewborn'sphysicianneedstobeawarethatthe
motherhasGraves'diseasebecauseoftheassociatedriskofneonatalthyroiddysfunction.
Thyroidectomyshouldbereservedforwomenwhodonotrespondtothioamidetherapy.Treatmentwith
iodine131(I131)iscontraindicatedinpregnantwomen.Fetalthyroidisunlikelytohavebeenablatedif
inadvertentexposuretothisagentoccurredbefore10weeksofgestation.Ifexposureoccurredafterthis
time,thewomanneedstoconsidertheriskofinducedcongenitalhypothyroidismandwhetherpregnancy
shouldbecontinued.WomenshouldnotbreastfeedforfourmonthsaftertreatmentwithI131.
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HypothyroidisminpregnantwomenistreatedwithlevothyroxineinasufficientdosagetoreturntheTSH
leveltonormal.ThedosageshouldbeadjustedeveryfourweeksuntiltheTSHlevelisstable.Checking
theTSHleveleverytrimesterisadvised.
Whatthyroidfunctionchangesoccurwithhyperemesisgravidarum?Nauseaandvomitingofpregnancyis
associatedwithbiochemicalhyperthyroidism(undetectableTSHlevel,elevatedFTI,orboth).The
conditionisrarelyassociatedwithclinicalhyperthyroidism,andnotreatmentisusuallyrequired.Routine
thyroidtestingisnotrecommendedunlessothersignsofhyperthyroidismarepresent.
Howisthyroidstormdiagnosedandtreatedinpregnancy?Thisextremehypermetabolicstateis
associatedwithahighriskofmaternalheartfailure.Diagnosisisbasedonacombinationofsignsand
symptoms:fever,tachycardiaoutofproportiontothefever,alteredmentalstatus(nervousness,
restlessness,confusion,seizures),vomiting,diarrhea,andcardiacarrhythmia.Anincitingevent(e.g.,
surgery,infection,labor,delivery)maybeidentified.Untreatedthyroidstormcanresultinshock,stupor,
andcoma.Serumfreetriiodothyronine(FT ),FT ,andTSHlevelshelpconfirmthediagnosis,but
treatmentshouldnotbedelayedfortestresults.
Astandardseriesofdrugsisusedtotreatthyroidstorm:propylthiouracilormethimazolesaturated
solutionofpotassiumiodideorsodiumiodide(alternatives:Lugol'ssolution,lithium)dexamethasone(and
withahistoryofseverebronchospasm:reserpine,guanethidine,diltiazem)andphenobarbital.General
supportivemeasures,suchasoxygen,antipyretics,andappropriatemonitoring,arealsoimportant.The
perceivedunderlyingcauseofthyroidstormshouldbetreated.
Dependingongestationalage,fetalstatusshouldbeevaluatedwithultrasoundexamination,nonstress
testing,orabiophysicalprofile.Unlessdeemednecessary,deliveryduringthyroidstormshouldbe
avoided.
Howshouldthyroidcancerbemanagedduringpregnancy?Allthyroidnodulesshouldbeevaluatedupto
40percentarefoundtobemalignant.Thyroidcanceristreatedwiththyroidectomyandradiation(i.e.,I
131).Thyroidectomycanbeperformed,preferablyduringthesecondtrimester,butradiationtherapy
shouldnotbeadministereduntilafterthepregnancy.Managementoptionsforthyroidcancerare
terminationofthepregnancyfollowedbyfulltreatment,treatmentduringpregnancy,andpretermorterm
deliveryfollowedbyfulltreatment.Gestationalageandtumorcharacteristicsaffectthemanagement
choice.WomenshouldnotbreastfeedforfourmonthsafterI131treatment.
Howispostpartumthyroiditisdiagnosedandtreated?Postpartumthyroiditisisdiagnosedbynewonsetof
anabnormalTSHlevel,abnormalFT level,orboth.Antibodytestingmaybeusefulinconfirmingthe
diagnosis.Whetherpostpartumthyroiditisrequirestreatmentislessclear.
TSHandFT levelsshouldbeevaluatedinwomenwhodevelopagoiterduringpregnancyorafter
delivery.Evaluationmayalsobeappropriateforwomenwhodeveloppostpartumsymptomsof
hyperthyroidismorhypothyroidism.Evaluationdependsonthephysician'sjudgment,assomeofthese
symptomsarecommoninthepostpartumperiod.Whethertreatmentisneededdependsontheseverityof
theabnormalityandsymptoms.Theriskofpermanenthypothyroidismisgreatestinwomenwiththe
highestlevelsofTSHandantithyroidperoxidaseantibodies.
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Whichpregnantwomenshouldbescreenedforthyroiddysfunction?Screeningisappropriateinpregnant
womenwithsymptomsofthyroiddiseaseorahistoryofthyroiddisease.Thyroidnodulesorgoitershould
beevaluated.
Availabledatasupportapossibleassociationbetweenmaternalhypothyroidismanddecrementsinsome
neuropsychologictestsintheirchildren.However,furthertestingisneededtodocumentvalidityand
provideevidenceoftreatmentefficacy.AccordingtoACOG,itisprematuretorecommenduniversal
hypothyroidismscreeninginpregnantwomen.
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