Graves' Disease Pharmacotherapy in Women of Reproductive Age

Preoperative preparation for Graves' disease

Thyroidectomy is always regarded as the crucial treatment for Graves' disease, especially in cases of poor efficacy or excessive side effects of antithyroid- drugs and 131I radioiodine therapy. To decrease the incidence of hemorrhage, thyroid storms and other severe complications during the perioperative period, surgeons explore different therapies to prepare for thyroidectomy. We performed a review of preoperative preparation with a focus on the Graves' disease population. Most of the previous schemes are effective, which contributes to the smooth operation of patients, but there is no unified standard for preoperative preparation. This review aims to summarize the preoperative preparation of Graves' disease and the latest developments. Prospective studies with longer follow up-up periods are required to select appropriate preoperative regimens based on personal thyroid statements and to identify target populations of benefit.

Thyrotropin receptor antibody: A novel risk indicator for pregnancy loss

BACKGROUND

Thyroid autoantibody has been associated with adverse pregnancy outcomes. However, thyroid-receptor antibody (TRAb) has not been considered as a potential risk assessment indicator for adverse pregnancy outcomes. Therefore, we assessed the role of TRAb in evaluation of the risk of adverse pregnancy outcomes.

METHODS

Pregnant women residing in Chongqing were enrolled in the study from 2012 to 2014. The TRAb, thyroid-stimulating hormone (TSH), free thyroxine (FT₄), and free triiodothyronine (FT₃) of all patients were analyzed via electrochemiluminescence assays. All data were recorded and analyzed statistically using SPSS.

RESULTS

A total of 468 pregnant women were included in the analysis. TRAb levels were higher in women with adverse pregnancy outcomes than those in women without adverse pregnancy outcomes. The incidence rate of pregnancy loss was significantly higher in the TRAb-positive group than that in the negative group, but this difference was not found in preterm delivery and early preterm delivery. In the logistic regression model, TRAb was an independent risk factor for pregnancy loss, but not for preterm delivery and early preterm delivery. The optimal cutoff point for TRAb was 3.53 IU/L, and the sensitivity and specificity of TRAb to assess the risk of pregnancy loss are 83.5% and 85.3%, respectively. Receiver-operating characteristic (ROC) curves revealed that TRAb was superior to the combination of TSH, FT₄ and FT₃ as an indicator for assessment.

CONCLUSIONS

TRAb as a more sensitive indicator providing valuable detection to assess the potential risk of pregnancy loss, and it can be used as an effective tool to improve the clinical management of thyroid disease in pregnant women.

Effects of methimazole and propylthiouracil exposure during pregnancy on the risk of neonatal congenital malformations: A meta-analysis

Objective

The aim of this study was to determine the effect of exposure to different antithyroid drugs during pregnancy on the incidence of neonatal congenital malformations.

Methods

A meta-analysis was performed to compare the incidence of neonatal congenital malformations after exposure to different antithyroid drugs during pregnancy. Twelve studies that met the inclusion criteria were included in this meta-analysis. PubMed, Embase, and CENTRAL databases were searched from inception until January 2017. Study designs included case–control studies, prospective cohort studies, and retrospective cohort studies.

Results

Twelve studies involving 8028 participants with exposure to different antithyroid drugs during pregnancy were included in this study; however, only 10 studies involving 5059 participants involved exposure to different antithyroid drugs exactly during pregnancy. Our results indicated that exposure to methimazole (MMI)/carbimazole (CMZ) only during pregnancy significantly increased the risk of neonatal congenital malformations compared to no antithyroid drug exposure (OR 1.88; 95%CI 1.33 to 2.65; P = 0.0004). No differences were observed between propylthiouracil (PTU) exposure and no antithyroid drug exposure only during pregnancy (OR 0.81; 95%CI 0.58 to 1.15; P = 0.24). Exposure to MMI/CMZ only during pregnancy significantly increased the risk of neonatal congenital malformations compared to that associated with exposure to PTU (OR 1.90; 95%CI 1.30 to 2.78; P = 0.001).

Conclusion

For pregnant women with hyperthyroidism, exposure to MMI/CMZ significantly increased the incidence of neonatal congenital malformations compared to exposure to PTU and no antithyroid drug exposure; however, no differences were observed between PTU exposure and no antithyroid drug exposure.

Antithyroid drugs during breastfeeding

Antithyroid drugs (ATDs) are widely used for the treatment of Graves' disease (GD) in the general population. Over the past decade, there has been an increasing awareness that several disturbances of thyroid function may occur in mothers after delivery which may be more prevalent than previously appreciated. Exacerbation of immune reactions occurs 3-12 month following delivery. Management of hyperthyroidism during lactation requires special considerations and should be implemented to prevent any adverse outcomes in mother and neonate. Continuation of breastfeeding is safe and should be encouraged in hyperthyroid mothers taking ATDs, whether these are ATDs being continued after gestation or indeed ATD treatment initiated in the postpartum period. Given PTU hepatotoxicity concerns, experts currently recommend using low-to-moderate MMI doses as a first-line therapy in lactating mothers. PTU should be reserved only as a second-line agent for cases of severe hyperthyroidism (thyroid storm) and allergic reactions to previous MMI treatment. ATD should be administered in divided doses immediately following each feeding. Evaluation of thyroid function tests is advisable at least 3-4 weeks after the initiation of breastfeeding.