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Zhang Q, Zhang D, Liu H, Fu J, Tang L, Rao M. Associations between a normal-range free thyroxine concentration and ovarian reserve in infertile women undergoing treatment via assisted reproductive technology. Reprod Biol Endocrinol 2024; 22:72. [PMID: 38909259 PMCID: PMC11193230 DOI: 10.1186/s12958-024-01226-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 05/06/2024] [Indexed: 06/24/2024] Open
Abstract
BACKGROUND Some recent studies have shown that female subclinical hypothyroidism (SCH) is associated with diminished ovarian reserve (DOR). In this study, we aimed to investigate whether serum-free thyroxine (fT4) concentrations within the reference range are associated with ovarian reserve in women. METHODS This cross-sectional study included 4933 infertile women with normal-range fT4 concentrations who received assisted reproductive technology treatment in our clinic. The data of women in different fT4 concentration tertiles (namely 12-15.33, 15.34-18.67, and 18.68-22 pmol/L) were compared with ovarian reserve markers, namely the anti-Müllerian hormone (AMH) concentration, the antral follicle count (AFC), and the number of aspirated oocytes. The primary outcomes were the AMH concentration and the risk of DOR, diagnosed as an AMH concentration < 1.1 ng/mL. RESULTS The average ages of women in the low-normal, middle-normal, and high-normal fT4 tertiles were 33.20 (standard deviation [SD]: 5.11), 32.33 (SD: 5.13), and 31.61 (SD: 5.10) years, respectively (p < 0.0001). AMH concentrations (adjusted mean: 3.32 [95% confidence interval {CI}: 3.16 to 3.50] vs. 3.51 [3.40 to 3.62] vs. 3.64 [3.50 to 3.80] ng/mL, p = 0.022) were significantly different between the fT4 concentration tertiles. The risk of DOR was significantly increased in the low-normal (adjusted odds ratio: 1.61 [95% CI: 1.01 to 2.58]) and middle-normal (1.47 [95% CI: 1.00 to 2.16]) tertiles compared with the high-normal tertile. Subgroup analysis showed that AMH concentrations were significantly different among the fT4 concentration tertiles in women aged < 35 years (adjusted mean: 3.94 [95% CI: 3.70 to 4.20] vs. 4.25 [4.11 to 4.39] vs. 4.38 [4.18 to 4.58], p = 0.028), whereas this difference was not significant in women aged ≥ 35 years (p = 0.534). The general additive models using fT4 as a continuous variable indicated that a lower fT4 concentration within the normal range was significantly associated with a lower AMH concentration (p = 0.027), a lower AFC (p = 0.018), a lower number of aspirated oocytes (p = 0.001), and a higher risk of DOR (p = 0.007). CONCLUSION Low-normal fT4 concentrations are associated with lower ovarian reserve in infertile women.
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Affiliation(s)
- Qiaoling Zhang
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, No. 295 Xichang Road, Kunming, 650032, China
| | - Dandan Zhang
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, No. 295 Xichang Road, Kunming, 650032, China
| | - Haoyuan Liu
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, No. 295 Xichang Road, Kunming, 650032, China
| | - Jinyun Fu
- Department of Endocrinology, The First Affiliated Hospital of Kunming Medical University, No. 295 Xichang Road, Kunming, 650032, China.
| | - Li Tang
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, No. 295 Xichang Road, Kunming, 650032, China.
| | - Meng Rao
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, No. 295 Xichang Road, Kunming, 650032, China.
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2
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Chaker L, Cooper DS, Walsh JP, Peeters RP. Hyperthyroidism. Lancet 2024; 403:768-780. [PMID: 38278171 DOI: 10.1016/s0140-6736(23)02016-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/07/2023] [Accepted: 09/16/2023] [Indexed: 01/28/2024]
Abstract
Thyrotoxicosis causes a variety of symptoms and adverse health outcomes. Hyperthyroidism refers to increased thyroid hormone synthesis and secretion, most commonly from Graves' disease or toxic nodular goitre, whereas thyroiditis (typically autoimmune, viral, or drug induced) causes thyrotoxicosis without hyperthyroidism. The diagnosis is based on suppressed serum concentrations of thyroid-stimulating hormone (TSH), accompanied by free thyroxine and total or free tri-iodothyronine concentrations, which are raised (overt hyperthyroidism) or within range (subclinical hyperthyroidism). The underlying cause is determined by clinical assessment, detection of TSH-receptor antibodies and, if necessary, radionuclide thyroid scintigraphy. Treatment options for hyperthyroidism include antithyroid drugs, radioactive iodine, and thyroidectomy, whereas thyroiditis is managed symptomatically or with glucocorticoid therapy. In Graves' disease, first-line treatment is a 12-18-month course of antithyroid drugs, whereas for goitre, radioactive iodine or surgery are preferred for toxic nodules or goitres. Evidence also supports long-term treatment with antithyroid drugs as an option for patients with Graves' disease and toxic nodular goitre.
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Affiliation(s)
- Layal Chaker
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands; Department of Epidemiology, Erasmus University Medical Center, Rotterdam, Netherlands; Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - David S Cooper
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John P Walsh
- Department of Endocrinology & Diabetes, Sir Charles Gairdner Hospital, Nedlands, WA, Australia; Medical School, University of Western Australia, Crawley, WA, Australia
| | - Robin P Peeters
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands.
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3
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Fulton A, Mittal N, Deb A. Postpartum Psychosis as a Consequence of Thyroiditis Versus Relapse: A Diagnostic Dilemma. Cureus 2024; 16:e52357. [PMID: 38361668 PMCID: PMC10867710 DOI: 10.7759/cureus.52357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 02/17/2024] Open
Abstract
Thyrotoxicosis can exhibit overlapping symptoms of psychosis in the general population. Each of these pathologies has well-established workups and management. Rare presentations of thyroiditis and psychosis in the postpartum state have been seen in case studies mostly, but data on the prevalence of postpartum psychosis in association with postpartum thyroiditis are not available. Here, we present a unique case of a patient with a history of bipolar disorder who originally presented with postpartum thyroiditis that was worked up and managed appropriately. However, on follow-up, the patient was found to have progressed into prominent psychosis. Both thyroiditis and psychosis were managed individually with full remission upon discharge and is doing well today. The co-occurrence of postpartum psychosis and thyroiditis presents a unique challenge for timely diagnosis and management. We present a case of a young woman initially diagnosed with postpartum thyroiditis needing further management of postpartum psychosis due to persistent symptoms. Clinical presentation supported with a prior history of mood disorder increases the likelihood of these diagnoses together.
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Affiliation(s)
- Alec Fulton
- Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Neha Mittal
- Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Anasua Deb
- Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
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4
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Peng CCH, Pearce EN. An update on thyroid disorders in the postpartum period. J Endocrinol Invest 2022; 45:1497-1506. [PMID: 35181848 DOI: 10.1007/s40618-022-01762-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/07/2022] [Indexed: 12/21/2022]
Abstract
PURPOSE To review the pathophysiology, diagnosis and management of postpartum thyroid dysfunction, and related management of thyroid disorders during lactation. METHODS We reviewed the literature on postpartum thyroid dysfunction and management of thyroid disorders during lactation. RESULTS The postpartum period is characterized by a rebound from the immunotolerance induced by pregnancy. Routine thyroid function screening is not recommended for asymptomatic women in the postpartum period. Testing thyroid function should be considered at 6-12-week postpartum for high-risk populations, including women with a previous episode of postpartum thyroiditis, Graves' disease, or those with Hashimoto's thyroiditis on thyroid hormone replacement, known thyroid peroxidase antibody positivity, type 1 diabetes mellitus, other nonthyroidal autoimmune disease, or chronic hepatitis C. A serum TSH should also be checked in the setting of postpartum depression or difficulty lactating. If patients have thyrotoxicosis, new-onset or recurrent Graves' disease must be differentiated from postpartum thyroiditis, because the management differs. Periodic thyroid function testing is recommended following recovery from postpartum thyroiditis due to high lifetime risk of developing permanent hypothyroidism. Levothyroxine, and the lowest effective dose of antithyroid drugs, (propylthiouracil, methimazole, and carbimazole) can be safely used in lactating women. The use of radiopharmaceutical scanning is avoided during lactation and radioactive iodine treatment is contraindicated. CONCLUSIONS Diagnosing postpartum thyroid dysfunction is challenging, because symptoms may be subtle. A team approach involving primary care providers, endocrinologists, and obstetricians is essential for transitioning thyroid care from the gestational to the postpartum setting.
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Affiliation(s)
- C C-H Peng
- Section of Endocrinology, Diabetes, Nutrition and Weight Management, Boston University School of Medicine, 720 Harrison Ave, Boston, MA, 02118, USA
| | - E N Pearce
- Section of Endocrinology, Diabetes, Nutrition and Weight Management, Boston University School of Medicine, 720 Harrison Ave, Boston, MA, 02118, USA.
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5
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Woman With Fatigue and Weight Loss. Ann Emerg Med 2022; 79:497-505. [DOI: 10.1016/j.annemergmed.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Indexed: 11/24/2022]
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6
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Lee SY, Pearce EN. Assessment and treatment of thyroid disorders in pregnancy and the postpartum period. Nat Rev Endocrinol 2022; 18:158-171. [PMID: 34983968 PMCID: PMC9020832 DOI: 10.1038/s41574-021-00604-z] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2021] [Indexed: 12/13/2022]
Abstract
Thyroid disorders are prevalent in pregnant women. Furthermore, thyroid hormone has a critical role in fetal development and thyroid dysfunction can adversely affect obstetric outcomes. Thus, the appropriate management of hyperthyroidism, most commonly caused by Graves disease, and hypothyroidism, which in iodine sufficient regions is most commonly caused by Hashimoto thyroiditis, in pregnancy is important for the health of both pregnant women and their offspring. Gestational transient thyrotoxicosis can also occur during pregnancy and should be differentiated from Graves disease. Effects of thyroid autoimmunity and subclinical hypothyroidism in pregnancy remain controversial. Iodine deficiency is the leading cause of hypothyroidism worldwide. Despite global efforts to eradicate iodine deficiency disorders, pregnant women remain at risk of iodine deficiency due to increased iodine requirements during gestation. The incidence of thyroid cancer is increasing worldwide, including in young adults. As such, the diagnosis of thyroid nodules or thyroid cancer during pregnancy is becoming more frequent. The evaluation and management of thyroid nodules and thyroid cancer in pregnancy pose a particular challenge. Postpartum thyroiditis can occur up to 1 year after delivery and must be differentiated from other forms of thyroid dysfunction, as treatment differs. This Review provides current evidence and recommendations for the evaluation and management of thyroid disorders in pregnancy and in the postpartum period.
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Affiliation(s)
- Sun Y Lee
- Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, Boston, MA, USA
| | - Elizabeth N Pearce
- Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, Boston, MA, USA.
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7
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Affiliation(s)
- Riley Epp
- Department of Medicine University of Ottawa, Ottawa, Ontario, Canada
- Division of Endocrinology and Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Janine Malcolm
- Department of Medicine University of Ottawa, Ottawa, Ontario, Canada
- Division of Endocrinology and Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Khiera Jolin-Dahel
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Erin Keely
- Department of Medicine University of Ottawa, Ottawa, Ontario, Canada
- Division of Endocrinology and Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada
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8
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Rao M, Yang Z, Su C, Zhao Z, Wan R, Liu J, Yao Y, Su Z, Wang K, Tang L, Zhao S. Paternal Subclinical Hypothyroidism Affects the Clinical Outcomes of In Vitro Fertilization/Intracytoplasmic Sperm Injection. Thyroid 2021; 31:12-22. [PMID: 32600220 DOI: 10.1089/thy.2020.0154] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Maternal subclinical hypothyroidism (SCH) is a risk factor for adverse pregnancy outcomes. However, it is still unclear whether SCH affects male fertility. The aim of this study was to determine the association between paternal SCH and clinical outcomes after in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI). Methods: This retrospective study included 2511 couples with paternal euthyroidism (n = 2282) or SCH (n = 229) who visited our clinic for infertility treatment between April 1, 2017, and September 30, 2019. The primary outcomes were the fertilization rate and clinical pregnancy rate; the secondary outcomes were the good-quality embryo rate, blastocyst formation rate, implantation rate, and early miscarriage rate. These outcomes were compared between the euthyroid and the SCH groups after adjusting for various potential confounders. Results: The mean paternal ages in the euthyroid and SCH groups were 34.5 and 36.0 years, respectively (p = 0.002). Semen parameters and sperm DNA fragmentation index were similar between the two groups (all p > 0.05). The adjusted fertilization (0.69 vs. 0.71, p = 0.30), good-quality embryo (0.49 vs. 0.52, p = 0.31), blastocyst formation (0.51 vs. 0.53, p = 0.57), and early miscarriage (0.11 vs. 0.10, p = 0.81) rates were also similar between the two groups. There was a significantly decreased adjusted clinical pregnancy rate [confidence interval, CI] and implantation rate [CI] in the paternal SCH group compared with the euthyroid group (0.32 [0.26-0.40] vs. 0.42 [0.40-0.45], p = 0.009 for the clinical pregnancy rate; 0.24 [0.19-0.29] vs. 0.29 [0.27-0.31], p = 0.037 for the implantation rate). Stratified analysis indicated that these differences were only significant in men aged ≥35 years (p = 0.009 and 0.022, respectively) and not in men <35 years (p = 0.39 and 0.45, respectively). Conclusions: Paternal SCH was associated with worse clinical outcomes after IVF/ICSI, whereas this detrimental impact was only present in males ≥35 years old. Prospective studies and basic research are warranted to confirm these results and to clarify the mechanisms underlying these associations, respectively.
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Affiliation(s)
- Meng Rao
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Zexing Yang
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Cunmei Su
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Zihan Zhao
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Ruixue Wan
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jiang Liu
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Youlin Yao
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Zhenfang Su
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Kunhua Wang
- The NHC Key Laboratory of Drug Addiction Medicine, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Li Tang
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Shuhua Zhao
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
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9
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Abstract
Subclinical autoimmune thyroiditis exacerbates after delivery through immune rebound mechanisms and results in 5 types of thyroid dysfunction. The prevalence of postpartum thyroid dysfunction is around 5% in mothers in the general population. Typically, an exacerbation induces destructive thyrotoxicosis followed by transient hypothyroidism, known as postpartum thyroiditis. Late development of permanent hypothyroidism is found frequently and patients should be followed up once every one to two years. Destructive thyrotoxicosis in postpartum thyroiditis should carefully be differentiated from post-partum Graves' disease. Postpartum thyroiditis typically occurs 1-4 months after parturition whereas Graves' disease develops at 4-12 months postpartum. Anti-TSH receptor antibodies (TRAb) are typically positive and thyroid blood flow is high in Graves' disease, whereas these features are absent in postpartum thyroiditis. Postpartum Graves' disease should be treated with antithyroid drugs.
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Affiliation(s)
- Nobuyuki Amino
- Amino Thyroid Research Laboratory, 5-60-38 Nanpeidai, Takatsuki-shi, Osaka, 569-1042, Japan.
| | - Naoko Arata
- Division of Maternal Medicine, Center for Maternal-Fetal-Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagayaku, Tokyo, 1578535, Japan.
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10
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Abstract
Thyrotoxicosis is a general term for excess circulating and tissue thyroid hormone levels, whereas hyperthyroidism specifically denotes disorders involving a hyperactive thyroid gland (Graves disease, toxic multinodular goiter, toxic adenoma). Diagnosis and determination of the cause rely on clinical evaluation, laboratory tests, and imaging studies. Hyperthyroidism is treated with antithyroid drugs, radioactive iodine ablation, or thyroidectomy. Other types of thyrotoxicosis are monitored and treated with β-blockers to control symptoms given that most of these conditions resolve spontaneously.
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11
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Velasco S, Illanes F. Unmasking Thyroid Disease in the Postpartum Period. J Womens Health (Larchmt) 2020; 29:473-474. [DOI: 10.1089/jwh.2020.8361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Soledad Velasco
- Endocrinology Unit, Clínica Alemana Santiago, Santiago, Chile
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12
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Abstract
Postpartum thyroiditis (PPT) is an autoimmune-mediated destructive thyroiditis that occurs in the first year postpartum with a prevalence of 5%. In order to appropriately counsel and treat the patient, physicians need to recognize the signs and symptoms of PPT and distinguish PPT from Graves hyperthyroidism. This review of PPT will discuss the etiology, clinical course, risk factors, prognosis, and treatment of PPT. Understanding PPT is important for all physicians taking care of women in the peripartum period as women who have had PPT are at an increased risk of subsequent episodes of PP and at risk of permanent hypothyroidism.
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13
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Katoh D, Yoshino H, Ikehara K, Kumashiro N, Uchino H, Tsuboi K, Hirose T. Successful Treatment of Amiodarone-induced Thyrotoxicosis Type 1 in Combination with Methimazole and Potassium Iodide in a Patient with Hashimoto's Thyroiditis. Intern Med 2020; 59:383-388. [PMID: 31554750 PMCID: PMC7028412 DOI: 10.2169/internalmedicine.2179-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A patient with underlying Hashimoto's thyroiditis developed amiodarone-induced thyrotoxicosis type 1 that was successfully treated using methimazole in combination with potassium iodide. A 35-year-old woman admitted for perinatal care of twin-to-twin transfusion syndrome was given amiodarone for 7 days for paroxysmal ventricular contraction following pulseless ventricular tachycardia 1 day after delivery. She developed thyrotoxicosis one month after the discontinuation of amiodarone therapy and was negative for thyroid-stimulating hormone receptor antibody. An increased peak velocity of the superior thyroid artery suggested amiodarone-induced thyrotoxicosis type 1. Her thyroid function recovered after combination therapy with methimazole and potassium iodide.
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Affiliation(s)
- Daisuke Katoh
- Division of Diabetes, Metabolism, and Endocrinology, Department of Medicine, Toho University Graduate School of Medicine, Japan
| | - Hiroshi Yoshino
- Division of Diabetes, Metabolism, and Endocrinology, Department of Medicine, Toho University Graduate School of Medicine, Japan
| | - Kayoko Ikehara
- Division of Diabetes, Metabolism, and Endocrinology, Department of Medicine, Toho University Graduate School of Medicine, Japan
| | - Naoki Kumashiro
- Division of Diabetes, Metabolism, and Endocrinology, Department of Medicine, Toho University Graduate School of Medicine, Japan
| | - Hiroshi Uchino
- Division of Diabetes, Metabolism, and Endocrinology, Department of Medicine, Toho University Graduate School of Medicine, Japan
| | - Kumiko Tsuboi
- Division of Diabetes, Metabolism, and Endocrinology, Department of Medicine, Toho University Graduate School of Medicine, Japan
| | - Takahisa Hirose
- Division of Diabetes, Metabolism, and Endocrinology, Department of Medicine, Toho University Graduate School of Medicine, Japan
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14
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Rao M, Wang H, Zhao S, Liu J, Wen Y, Wu Z, Yang Z, Su C, Su Z, Wang K, Tang L. Subclinical Hypothyroidism Is Associated with Lower Ovarian Reserve in Women Aged 35 Years or Older. Thyroid 2020; 30:95-105. [PMID: 31650898 DOI: 10.1089/thy.2019.0031] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Overt thyroid diseases have been identified as risk factors for female infertility. However, it remains largely unclear whether subclinical hypothyroidism (SCH), a very common thyroid disorder, is associated with female infertility. This study aimed to investigate the potential association between SCH and the ovarian reserve in women seeking infertility treatment. Methods: This retrospective study included 2568 women with normal thyroid function (n = 2279) or SCH (n = 289) who visited our clinic for infertility treatment. Ovarian reserve markers, including follicle-stimulating hormone (FSH) concentrations on days 2-4, the antral follicle count (AFC), and anti-Müllerian hormone (AMH) concentration, were compared between euthyroid women and those with SCH. Multiple linear and Poisson regression analyses were used to estimate the associations of SCH with ovarian reserve markers. These analyses were repeated separately in women aged <35 (n = 1349) and ≥35 years (n = 1219). Results: In the total study population, women with SCH had significantly lower AMH concentrations (median: 2.05 vs. 2.51 ng/mL, p = 0.015) and AFCs (median: 10.0 vs. 11.0, p = 0.013), compared with euthyroid women. In linear and Poisson regression analyses, SCH was significantly associated with a higher basal FSH concentration (mean difference = 1.13 mIU/mL [95% confidence interval (CI) 0.97 to 1.29 mIU/mL], p < 0.001), lower AMH concentration (mean difference = -0.27 ng/mL [CI -0.43 to -0.12 ng/mL], p = 0.001), and lower AFC (mean difference = -0.7 [CI -1.3 to -0.2], p = 0.005). In women aged ≥35 years, SCH was significantly associated with FSH (mean difference = 1.74 mIU/mL, p < 0.001) and AMH concentrations (mean difference = -0.40 mg/mL, p < 0.001) and AFC (mean difference = -0.8, p < 0.001). In women <35 years old, SCH was significantly associated with a higher FSH concentration (mean difference = 0.30 mIU/mL, p < 0.001), but not with AMH or AFC concentrations (p = 0.84 and 0.06, respectively). Thyroperoxidase antibody (TPOAb) positivity was not associated with measures of ovarian reserve. Conclusions: The data suggest that SCH is associated with decreased ovarian reserve during later reproductive age. TPOAb positivity was not associated with ovarian reserve. Future research is necessary to investigate the underlying molecular mechanisms regulating the diminished ovarian reserve in women with SCH and to evaluate whether levothyroxine supplementation may improve the ovarian function of women with SCH.
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Affiliation(s)
- Meng Rao
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Huawei Wang
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Shuhua Zhao
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jiang Liu
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Ya Wen
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Zhao Wu
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Zexing Yang
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Cunmei Su
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Zhenfang Su
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Kunhua Wang
- The MOH Key Laboratory of Drug Addiction Medicine, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Li Tang
- Department of Reproduction and Genetics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
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Abstract
Clinical hyperthyroidism affects 0.1% to 0.4% of pregnancies. Gestational thyrotoxicosis is due to homology of the structure of TSH and HCG, which weakly stimulates the TSH receptor. Graves' disease (GD) most commonly causes clinically significant hyperthyroidism. Given concerns for teratogenicity from antithyroid drugs, these may be discontinued in low-risk GD patients. High-risk patients are treated with propylthiouracil in the first trimester then may transition to methimazole. Surgery is reserved for special circumstances; radioactive iodine is contraindicated. In late pregnancy, GD may remit; postpartum relapse is common. Measurement of serum thyrotropin receptor antibodies identifies pregnancies at-risk for fetal and neonatal hyperthyroidism.
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Affiliation(s)
- Kristen Kobaly
- Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, 4th Floor West Pavilion, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Susan J Mandel
- Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, 4th Floor West Pavilion, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
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16
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Shengnan HMD, Lin Y, Lili PMD, Zhao WMD, Ming-an YMD. Microwave Ablation of An Autonomous Functioning Thyroid Nodule in A Pregnant Patient: A Case Report. ADVANCED ULTRASOUND IN DIAGNOSIS AND THERAPY 2019. [DOI: 10.37015/audt.2019.190824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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17
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Croce L, Di Dalmazi G, Orsolini F, Virili C, Brigante G, Gianetti E, Moleti M, Napolitano G, Tonacchera M, Rotondi M. Graves' Disease and the Post-partum Period: An Intriguing Relationship. Front Endocrinol (Lausanne) 2019; 10:853. [PMID: 31920967 PMCID: PMC6914725 DOI: 10.3389/fendo.2019.00853] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 11/21/2019] [Indexed: 11/29/2022] Open
Abstract
The post-partum period is an immunologically peculiar period in a woman's life. Indeed, most of the pregnancy-related immune changes gradually revert in the 12 months following delivery. Although the post-partum period has long been identified as a period of aggravation of autoimmune thyroid diseases, most of the currently available studies took into account the relationship between post-partum and autoimmune thyroiditis. More recently, the potential repercussions of the post-partum period on Graves' disease were also taken into account. The present mini review will briefly overview the most recent advances in our knowledge of the immunology of the post-partum period in relation with the potential repercussions on the clinical course of Graves' disease. Moreover, some peculiar aspects of post-partum Graves' disease in terms of clinical and biochemical presentation, diagnostic challenges, and specific therapeutic considerations also taking into account the recommendation of the latest clinical guidelines on the management of thyroid diseases in pregnancy will be overviewed.
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Affiliation(s)
- Laura Croce
- Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
- PHD course in Experimental Medicine, University of Pavia, Pavia, Italy
| | - Giulia Di Dalmazi
- Unit of Endocrinology, Department of Medicine and Sciences of Aging, “G. D'Annunzio” University of Chieti-Pescara, Chieti, Italy
| | - Francesca Orsolini
- Endocrinology Section, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Camilla Virili
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Giulia Brigante
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Elena Gianetti
- Endocrinology Section, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Mariacarla Moleti
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giorgio Napolitano
- Unit of Endocrinology, Department of Medicine and Sciences of Aging, “G. D'Annunzio” University of Chieti-Pescara, Chieti, Italy
| | - Massimo Tonacchera
- Endocrinology Section, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Mario Rotondi
- Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
- *Correspondence: Mario Rotondi
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Abstract
OBJECTIVE To review the diagnosis and management of thyrotoxicosis in women who are preconception, pregnant, and in the postpartum period. METHODS Literature review of English-language papers published between 1980 and 2018. RESULTS Overt thyrotoxicosis occurs in 0.2% of pregnancies and subclinical thyrotoxicosis in 2.5%. Hyperthyroidism in women of childbearing age most frequently is caused by Graves disease (GD). Gestational thyrotoxicosis, transient human chorionic gonadotropin (hCG)-mediated hyperthyroidism, may develop in the first trimester. In the first year following delivery, postpartum thyroiditis, which frequently includes a thyrotoxic phase, occurs in 5% of women. Hyperthyroidism from nodular autonomy is uncommon in women of childbearing age. It is essential to understand the underlying etiology for thyrotoxicosis in order to recommend appropriate treatment. Gestational thyrotoxicosis requires supportive care, without antithyroid drug therapy. GD may be treated with antithyroid drugs, radioactive iodine, or thyroidectomy. Pregnancy, plans for pregnancy, and lactation have important implications for the choice of GD treatment. When thyrotoxicosis presents following delivery, postpartum thyroiditis must be differentiated from GD. CONCLUSION The diagnosis and management of thyrotoxicosis in the peripregnancy period present specific challenges. In making management decisions, it is essential to weigh the risks and benefits of treatments not just for the mother but also for the fetus and for breastfed infants. A team approach to management is critical, with close collaboration among endocrinologists, maternal-fetal medicine specialists, and neonatologists. ABBREVIATIONS GD = Graves disease; hCG = human chorionic gonadotropin; MMI = methimazole; PPT = postpartum thyroiditis; PTU = propylthiouracil; T3 = triiodothyronine; T4 = thyroxine; TBG = thyroxine-binding globulin; TRAb = TSH receptor antibody; TSH = thyroid-stimulating hormone.
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Abstract
This section deals with the specificities of managing Graves' disease during pregnancy. Graves' disease incurs risks of fetal, neonatal and maternal complications that are rare but may be severe: fetal hyper- or hypothyroidism, usually first showing as fetal goiter, neonatal dysthyroidism, premature birth and pre-eclampsia. Treatment during pregnancy is based on antithyroid drugs alone, without association to levothyroxine. An history of Graves' disease, whether treated radically or not, with persistent maternal anti-TSH-receptor antibodies must be well identified. Fetal monitoring should be initiated in a multidisciplinary framework that should be continued throughout pregnancy. Neonatal monitoring is also crucial if the mother still shows anti-TSH-receptor antibodies at end of pregnancy or underwent antithyroid treatment. The risk of recurrence of hyperthyroidism in the weeks following delivery requires maternal monitoring. The long-term neuropsychological progression of children of mothers with Graves' disease is poorly known.
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Abdel Razek AAK, Abd Allah SS, El-Said AAEH. Role of Diffusion-Weighted Magnetic Resonance (MR) Imaging in Differentiation Between Graves' Disease and Painless Thyroiditis. Pol J Radiol 2017; 82:536-541. [PMID: 29662585 PMCID: PMC5894041 DOI: 10.12659/pjr.902416] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 01/14/2017] [Indexed: 12/14/2022] Open
Abstract
Background To assess the role of diffusion-weighted MR imaging in differentiation between Graves’ disease and painless thyroiditis. Material/Methods A prospective study was conducted among 37 consecutive patients with untreated thyrotoxicosis (25 female and 12 male; mean age of 44 years) and 15 ageand sex-matched controls. Diffusion-weighted MR imaging of the thyroid gland was performed in patients and controls. The apparent diffusion coefficient (ADC) value of the thyroid gland was calculated and correlated with Tc-99m uptake and thyroid function tests of the patients. Results There was a significant difference in the ADC value of the thyroid gland between patients and the control group (P=0.001). The mean ADC value of the thyroid gland in Graves’ disease was 2.03±0.28×10–3 mm2/sec, and in patients with painless thyroiditis 1.46±0.22×10–3 mm2/sec, respectively. There was a significant difference in the ADC values between Graves’ disease and painless thyroiditis (P=0.001). When the ADC value of 1.45×10–3 mm2/sec was used as a threshold value for differentiating Graves’ disease from painless thyroiditis, the best result was obtained with area under the curve of 0.934, accuracy of 83.8%, sensitivity of 95.8%, and specificity of 61.5%. The mean ADC value of the thyroid gland in patients positively correlated with serum TRAb and Tc-99m uptake (r=0.57, P=0.001 and r=0.74, P=0.001, respectively). Conclusions We concluded that ADC values of the thyroid gland can be used to differentiate Graves’ disease from painless thyroiditis in patients with untreated thyrotoxicosis.
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Ide A, Amino N, Kudo T, Yoshioka W, Hisakado M, Nishihara E, Ito M, Fukata S, Nakamura H, Miyauchi A. Comparative frequency of four different types of pregnancy-associated thyrotoxicosis in a single thyroid centre. Thyroid Res 2017; 10:4. [PMID: 28804518 PMCID: PMC5549300 DOI: 10.1186/s13044-017-0039-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 07/26/2017] [Indexed: 11/10/2022] Open
Abstract
Background Pregnancy and delivery markedly influence thyroid function. However, the comparative prevalence of gestational thyrotoxicosis (GT), new onset of Graves’ disease during pregnancy (GD during pregnancy), postpartum destructive thyrotoxicosis (PPT), and postpartum Graves’ thyrotoxicosis (PPGD) has not yet been determined. Methods We prospectively registered and performed a review of 4127 consecutive non treated female patients with thyrotoxicosis, seen between August 2008 and December 2013 in our outpatient clinic of Kuma Hospital. 187 out of the 4127 women had new diagnosis of thyrotoxicosis during pregnancy or in the postpartum period. We investigated the prevalence of new diagnosis of GT, GD during pregnancy, PPT and PPGD and compared the characteristics of these types of thyrotoxicosis. The postpartum period is defined as twelve months after delivery. Results Out of 187 pregnant or postpartum women, we identified 30 (16.0%) with GT, 13 (7.0%) with GD during pregnancy, 42 (22.5%) with PPT, and 102 (54.5%) with PPGD. The onset time of thyrotoxicosis during pregnancy, i.e., both GT and GD during pregnancy, was delayed by a couple of weeks when hCG peaked at 10 gestational weeks. Seventy-six percent of patients with PPT developed thyrotoxicosis between delivery and 4 months postpartum; on the other hand, 83.3% of patients with PPGD developed thyrotoxicosis at 6 months postpartum or later. Conclusions We named gestational thyrotoxicosis, new onset of Graves’ disease during pregnancy, postpartum destructive thyrotoxicosis, and postpartum Graves’ thyrotoxicosis as pregnancy-associated thyrotoxicosis. A clinically significant number of women developed Graves’ disease in the postpartum period in a single thyroid centre.
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Affiliation(s)
- Akane Ide
- Kuma Hospital, Centre for Excellence in Thyroid Care, 8-2-35 Shimoyamate-dori, Chuo-ku, Kobe, 650-0011 Japan
| | - Nobuyuki Amino
- Kuma Hospital, Centre for Excellence in Thyroid Care, 8-2-35 Shimoyamate-dori, Chuo-ku, Kobe, 650-0011 Japan
| | - Takumi Kudo
- Kuma Hospital, Centre for Excellence in Thyroid Care, 8-2-35 Shimoyamate-dori, Chuo-ku, Kobe, 650-0011 Japan
| | - Waka Yoshioka
- Kuma Hospital, Centre for Excellence in Thyroid Care, 8-2-35 Shimoyamate-dori, Chuo-ku, Kobe, 650-0011 Japan
| | - Mako Hisakado
- Kuma Hospital, Centre for Excellence in Thyroid Care, 8-2-35 Shimoyamate-dori, Chuo-ku, Kobe, 650-0011 Japan
| | - Eijun Nishihara
- Kuma Hospital, Centre for Excellence in Thyroid Care, 8-2-35 Shimoyamate-dori, Chuo-ku, Kobe, 650-0011 Japan
| | - Mitsuru Ito
- Kuma Hospital, Centre for Excellence in Thyroid Care, 8-2-35 Shimoyamate-dori, Chuo-ku, Kobe, 650-0011 Japan
| | - Shuji Fukata
- Kuma Hospital, Centre for Excellence in Thyroid Care, 8-2-35 Shimoyamate-dori, Chuo-ku, Kobe, 650-0011 Japan
| | - Hirotoshi Nakamura
- Kuma Hospital, Centre for Excellence in Thyroid Care, 8-2-35 Shimoyamate-dori, Chuo-ku, Kobe, 650-0011 Japan
| | - Akira Miyauchi
- Kuma Hospital, Centre for Excellence in Thyroid Care, 8-2-35 Shimoyamate-dori, Chuo-ku, Kobe, 650-0011 Japan
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Baral S, Shrestha PK, Pant V. Serum Free T 3 to Free T 4 Ratio as a Useful Indicator for Differentiating Destruction Induced Thyrotoxicosis from Graves' Disease. J Clin Diagn Res 2017; 11:OC12-OC14. [PMID: 28892954 DOI: 10.7860/jcdr/2017/28293.10180] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 06/01/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Thyrotoxicosis is a common disease encountered in Endocrine Outpatient Department (OPD). Two common causes of thyrotoxicosis are Destruction Induced Thyrotoxicosis (DIT) and Graves' Disease (GD). Differentiating DIT and GD based on clinical findings, is often not possible due to nonspecific symptoms. Thyroid scan is considered most reliable method for differentiating DIT and GD. AIM To differentiate DIT and GD using the ratio of free triiodothyronine (fT3) and free thyroxine (fT4) thus avoiding thyroid technetium scan which is expensive and not accessible in developing countries like Nepal. MATERIALS AND METHODS Patients attending Endocrine OPD with diagnosis of thyrotoxicosis at their first visit in which Thyroid technetium scan could be done were taken as sample. The study was conducted from mid-June 2016 to February 2017 and total 55 samples were taken. Only selected cases were taken where diagnostic dilemma was present. Report of Thyroid Function Test (TFT) of patient at their first visit and findings of thyroid scan were recorded. Ratio of freeT3 and freeT4 was obtained in each case. ROC curve was plotted and the cut off value for differentiation of DIT and GD was obtained. All data were analysed using SPSS software version 20.0. RESULTS Mean ratio of fT3 to fT4 in GD and DIT was 0.395 and 0.287 respectively which was significant. On ROC analysis, cut off ratio for differentiating GD and DIT was 0.30 with sensitivity of 87% and specificity of 62.5%. CONCLUSION It is recommended that thyroid scan can be avoided if ratio of fT3 and fT4 is less than 0.3 and a diagnosis of DIT can be made.
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Affiliation(s)
- Suman Baral
- Faculty Doctor, Endocrinology Unit, Department of Medicine, Institute of Medicine, Kathmandu, Nepal
| | - Pradeep Krishna Shrestha
- Professor and Head, Endocrinology Unit, Department of Medicine, Institute of Medicine, Kathmandu, Nepal
| | - Vivek Pant
- Resident Doctor, Department of Biochemistry, Institute of Medicine, Kathmandu, Nepal
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Alexander EK, Pearce EN, Brent GA, Brown RS, Chen H, Dosiou C, Grobman WA, Laurberg P, Lazarus JH, Mandel SJ, Peeters RP, Sullivan S. 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum. Thyroid 2017; 27:315-389. [PMID: 28056690 DOI: 10.1089/thy.2016.0457] [Citation(s) in RCA: 1335] [Impact Index Per Article: 190.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Thyroid disease in pregnancy is a common clinical problem. Since the guidelines for the management of these disorders by the American Thyroid Association (ATA) were first published in 2011, significant clinical and scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid disease in women during pregnancy, preconception, and the postpartum period. METHODS The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles were eligible for inclusion. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations. The guideline task force had complete editorial independence from the ATA. Competing interests of guideline task force members were regularly updated, managed, and communicated to the ATA and task force members. RESULTS The revised guidelines for the management of thyroid disease in pregnancy include recommendations regarding the interpretation of thyroid function tests in pregnancy, iodine nutrition, thyroid autoantibodies and pregnancy complications, thyroid considerations in infertile women, hypothyroidism in pregnancy, thyrotoxicosis in pregnancy, thyroid nodules and cancer in pregnant women, fetal and neonatal considerations, thyroid disease and lactation, screening for thyroid dysfunction in pregnancy, and directions for future research. CONCLUSIONS We have developed evidence-based recommendations to inform clinical decision-making in the management of thyroid disease in pregnant and postpartum women. While all care must be individualized, such recommendations provide, in our opinion, optimal care paradigms for patients with these disorders.
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Affiliation(s)
- Erik K Alexander
- 1 Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Elizabeth N Pearce
- 2 Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine , Boston, Massachusetts
| | - Gregory A Brent
- 3 Department of Medicine, VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA , Los Angeles, California
| | - Rosalind S Brown
- 4 Division of Endocrinology, Boston Children's Hospital , Harvard Medical School, Boston, Massachusetts
| | - Herbert Chen
- 5 Department of Surgery, University of Alabama at Birmingham , Birmingham, Alabama
| | - Chrysoula Dosiou
- 6 Division of Endocrinology, Stanford University School of Medicine , Stanford, California
| | - William A Grobman
- 7 Department of Obstetrics and Gynecology, Northwestern University , Chicago, Illinois
| | - Peter Laurberg
- 8 Departments of Endocrinology & Clinical Medicine, Aalborg University Hospital , Aalborg, Denmark
| | - John H Lazarus
- 9 Institute of Molecular Medicine, Cardiff University , Cardiff, United Kingdom
| | - Susan J Mandel
- 10 Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Robin P Peeters
- 11 Department of Internal Medicine and Rotterdam Thyroid Center, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Scott Sullivan
- 12 Department of Obstetrics and Gynecology, Medical University of South Carolina , Charleston, South Carolina
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Di Bari F, Granese R, Le Donne M, Vita R, Benvenga S. Autoimmune Abnormalities of Postpartum Thyroid Diseases. Front Endocrinol (Lausanne) 2017; 8:166. [PMID: 28751877 PMCID: PMC5507951 DOI: 10.3389/fendo.2017.00166] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 06/27/2017] [Indexed: 01/08/2023] Open
Abstract
The year following parturition is a critical time for the de novo appearance or exacerbation of autoimmune diseases, including autoimmune thyroid disease. The vast majority of postpartum thyroid disease consists of postpartum thyroiditis (PPT) and the minority by Graves' disease and non-autoimmune thyroiditis. PPT has a worldwide prevalence ranging from 1 to 22% and averaging 5% based on a review published in 2012. Several factors confer risk for the development of PPT. Typically, the clinical course of PPT is characterized by three phases: thyrotoxic, hypothyroid, and euthyroid phase. Approximately half of PPT women will have permanent hypothyroidism. The best humoral marker for predictivity, already during the first trimester of gestation, is considered positivity for thyroperoxidase autoantibodies (TPOAb), though only one-third to half of such TPOAb-positive pregnant women will develop PPT. Nutraceuticals (such as selenium) or omega-3-fatty acid supplements seem to have a role in prevention of PPT. In a recent study on pregnant women with stable dietary habits, we found that the fish consumers had lower rates of positivity (and lower serum levels) of both TPOAb and thyroglobulin Ab compared to meat eaters. Finally, we remind the reader of other diseases that can be observed in the postpartum period, either autoimmune or non-autoimmune, thyroid or non-thyroid.
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Affiliation(s)
- Flavia Di Bari
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- *Correspondence: Flavia Di Bari,
| | - Roberta Granese
- Department of Obstetrics and Gynecology, University Hospital “G. Martino”, Messina, Italy
| | - Maria Le Donne
- Department of Obstetrics and Gynecology, University Hospital “G. Martino”, Messina, Italy
| | - Roberto Vita
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Master Program on Childhood, Adolescent and Women’s Endocrine Health, University of Messina, Messina, Italy
- Interdepartmental Program of Molecular & Clinical Endocrinology, and Women’s Endocrine Health, University Hospital “G. Martino”, Messina, Italy
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Bucci I, Giuliani C, Napolitano G. Thyroid-Stimulating Hormone Receptor Antibodies in Pregnancy: Clinical Relevance. Front Endocrinol (Lausanne) 2017; 8:137. [PMID: 28713331 PMCID: PMC5491546 DOI: 10.3389/fendo.2017.00137] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 06/02/2017] [Indexed: 12/31/2022] Open
Abstract
Graves' disease is the most common cause of thyrotoxicosis in women of childbearing age. Approximately 1% of pregnant women been treated before, or are being treated during pregnancy for Graves' hyperthyroidism. In pregnancy, as in not pregnant state, thyroid-stimulating hormone (TSH) receptor (TSHR) antibodies (TRAbs) are the pathogenetic hallmark of Graves' disease. TRAbs are heterogeneous for molecular and functional properties and are subdivided into activating (TSAbs), blocking (TBAbs), or neutral (N-TRAbs) depending on their effect on TSHR. The typical clinical features of Graves' disease (goiter, hyperthyroidism, ophthalmopathy, dermopathy) occur when TSAbs predominate. Graves' disease shows some peculiarities in pregnancy. The TRAbs disturb the maternal as well as the fetal thyroid function given their ability to cross the placental barrier. The pregnancy-related immunosuppression reduces the levels of TRAbs in most cases although they persist in women with active disease as well as in women who received definitive therapy (radioiodine or surgery) before pregnancy. Changes of functional properties from stimulating to blocking the TSHR could occur during gestation. Drug therapy is the treatment of choice for hyperthyroidism during gestation. Antithyroid drugs also cross the placenta and therefore decrease both the maternal and the fetal thyroid hormone production. The management of Graves' disease in pregnancy should be aimed at maintaining euthyroidism in the mother as well as in the fetus. Maternal and fetal thyroid dysfunction (hyperthyroidism as well as hypothyroidism) are in fact associated with several morbidities. Monitoring of the maternal thyroid function, TRAbs measurement, and fetal surveillance are the mainstay for the management of Graves' disease in pregnancy. This review summarizes the biochemical, immunological, and therapeutic aspects of Graves' disease in pregnancy focusing on the role of the TRAbs in maternal and fetal function.
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Affiliation(s)
- Ines Bucci
- Unit of Endocrinology, Department of Medicine and Sciences of Aging, Ce.S.I.-Me.T., University of Chieti-Pescara, Chieti, Italy
- *Correspondence: Ines Bucci,
| | - Cesidio Giuliani
- Unit of Endocrinology, Department of Medicine and Sciences of Aging, Ce.S.I.-Me.T., University of Chieti-Pescara, Chieti, Italy
| | - Giorgio Napolitano
- Unit of Endocrinology, Department of Medicine and Sciences of Aging, Ce.S.I.-Me.T., University of Chieti-Pescara, Chieti, Italy
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Laurberg P, Andersen SL. ENDOCRINOLOGY IN PREGNANCY: Pregnancy and the incidence, diagnosing and therapy of Graves' disease. Eur J Endocrinol 2016; 175:R219-30. [PMID: 27280373 DOI: 10.1530/eje-16-0410] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 06/01/2016] [Indexed: 12/27/2022]
Abstract
Thyroid hormones are essential developmental factors, and Graves' disease (GD) may severely complicate a pregnancy. This review describes how pregnancy changes the risk of developing GD, how early pregnancy by several mechanisms leads to considerable changes in the results of the thyroid function tests used to diagnose hyperthyroidism, and how these changes may complicate the diagnosing of GD. Standard therapy of GD in pregnancy is anti-thyroid drugs. However, new studies have shown considerable risk of birth defects if these drugs are used in specific weeks of early pregnancy, and this should be taken into consideration when planning therapy and control of women who may in the future become pregnant. Early pregnancy is a period of major focus in GD, where pregnancy should be diagnosed as soon as possible, and where important and instant change in therapy may be warranted. Such change may be an immediate stop of anti-thyroid drug therapy in patients with a low risk of rapid relapse of hyperthyroidism, or it may be an immediate shift from methimazole/carbimazole (with risk of severe birth defects) to propylthiouracil (with less risk), or maybe to other types of therapy where no risk of birth defects have been observed. In the second half of pregnancy, an important concern is that not only the mother with GD but also her foetus should have normal thyroid function.
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Affiliation(s)
- Peter Laurberg
- Department of Endocrinology Department of Clinical MedicineAalborg University, Aalborg, Denmark
| | - Stine Linding Andersen
- Department of Endocrinology Department of Clinical BiochemistryAalborg University Hospital, Aalborg, Denmark,
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Ide A, Amino N, Nishihara E, Kudo T, Ito M, Kimura Y, Tatsumi N, Yamazaki M, Miyauchi A. Partial prediction of postpartum Graves' thyrotoxicosis by sensitive bioassay for thyroid-stimulating antibody measured in early pregnancy. Endocr J 2016; 63:929-932. [PMID: 27432817 DOI: 10.1507/endocrj.ej16-0296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Graves' disease often occurs after delivery. However, it has been difficult to predict who will develop Graves' hyperthyroidism. We attempted to predict postpartum onset of Graves' disease by measuring anti-TSH receptor antibodies (TRAb) and thyroid-stimulating antibodies (TSAb) in early pregnancy. TRAb was measured by a third generation assay and TSAb was measured by a newly developed sensitive bioassay. In 690 early pregnant women, 2 showed borderline TRAb positive reactions. However, none of them developed Graves' disease after delivery. Thirty-eight of 690 pregnant women were positive for anti-thyroid peroxidase antibodies (TPOAb) and 4 were positive for TSAb. Two of these 4 women developed postpartum Graves' hyperthyroidism. These findings indicate that the third generation TRAb assay was not useful, but that the sensitive TSAb bioassay was moderately useful for predicting the postpartum onset of Graves' hyperthyroidism.
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Affiliation(s)
- Akane Ide
- Department of Internal Medicine, Kuma Hospital, Kobe, Japan
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Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, Rivkees SA, Samuels M, Sosa JA, Stan MN, Walter MA. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid 2016; 26:1343-1421. [PMID: 27521067 DOI: 10.1089/thy.2016.0229] [Citation(s) in RCA: 1339] [Impact Index Per Article: 167.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Thyrotoxicosis has multiple etiologies, manifestations, and potential therapies. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions and patient preference. This document describes evidence-based clinical guidelines for the management of thyrotoxicosis that would be useful to generalist and subspecialty physicians and others providing care for patients with this condition. METHODS The American Thyroid Association (ATA) previously cosponsored guidelines for the management of thyrotoxicosis that were published in 2011. Considerable new literature has been published since then, and the ATA felt updated evidence-based guidelines were needed. The association assembled a task force of expert clinicians who authored this report. They examined relevant literature using a systematic PubMed search supplemented with additional published materials. An evidence-based medicine approach that incorporated the knowledge and experience of the panel was used to update the 2011 text and recommendations. The strength of the recommendations and the quality of evidence supporting them were rated according to the approach recommended by the Grading of Recommendations, Assessment, Development, and Evaluation Group. RESULTS Clinical topics addressed include the initial evaluation and management of thyrotoxicosis; management of Graves' hyperthyroidism using radioactive iodine, antithyroid drugs, or surgery; management of toxic multinodular goiter or toxic adenoma using radioactive iodine or surgery; Graves' disease in children, adolescents, or pregnant patients; subclinical hyperthyroidism; hyperthyroidism in patients with Graves' orbitopathy; and management of other miscellaneous causes of thyrotoxicosis. New paradigms since publication of the 2011 guidelines are presented for the evaluation of the etiology of thyrotoxicosis, the management of Graves' hyperthyroidism with antithyroid drugs, the management of pregnant hyperthyroid patients, and the preparation of patients for thyroid surgery. The sections on less common causes of thyrotoxicosis have been expanded. CONCLUSIONS One hundred twenty-four evidence-based recommendations were developed to aid in the care of patients with thyrotoxicosis and to share what the task force believes is current, rational, and optimal medical practice.
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Affiliation(s)
- Douglas S Ross
- 1 Massachusetts General Hospital , Boston, Massachusetts
| | - Henry B Burch
- 2 Endocrinology - Metabolic Service, Walter Reed National Military Medical Center , Bethesda, Maryland
| | - David S Cooper
- 3 Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | | | - Peter Laurberg
- 5 Departments of Clinical Medicine and Endocrinology, Aalborg University and Aalborg University Hospital , Aalborg, Denmark
| | - Ana Luiza Maia
- 6 Thyroid Section, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul , Porto Alegre, Brazil
| | - Scott A Rivkees
- 7 Pediatrics - Chairman's Office, University of Florida College of Medicine , Gainesville, Florida
| | - Mary Samuels
- 8 Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University , Portland, Oregon
| | - Julie Ann Sosa
- 9 Section of Endocrine Surgery, Duke University School of Medicine , Durham, North Carolina
| | - Marius N Stan
- 10 Division of Endocrinology, Mayo Clinic , Rochester, Minnesota
| | - Martin A Walter
- 11 Institute of Nuclear Medicine, University Hospital Bern , Switzerland
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Abstract
Hyperthyroidism is characterised by increased thyroid hormone synthesis and secretion from the thyroid gland, whereas thyrotoxicosis refers to the clinical syndrome of excess circulating thyroid hormones, irrespective of the source. The most common cause of hyperthyroidism is Graves' disease, followed by toxic nodular goitre. Other important causes of thyrotoxicosis include thyroiditis, iodine-induced and drug-induced thyroid dysfunction, and factitious ingestion of excess thyroid hormones. Treatment options for Graves' disease include antithyroid drugs, radioactive iodine therapy, and surgery, whereas antithyroid drugs are not generally used long term in toxic nodular goitre, because of the high relapse rate of thyrotoxicosis after discontinuation. β blockers are used in symptomatic thyrotoxicosis, and might be the only treatment needed for thyrotoxicosis not caused by excessive production and release of the thyroid hormones. Thyroid storm and hyperthyroidism in pregnancy and during the post-partum period are special circumstances that need careful assessment and treatment.
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Affiliation(s)
- Simone De Leo
- Endocrine Unit, Fondazione IRCCS Cà Granda, Milan, Italy (S De Leo MD); Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy (S De Leo); and Section of Endocrinology, Diabetes and Nutrition, Boston University School of Medicine, Boston, MA, USA (S De Leo, S Y Lee MD, Prof L E Braverman MD)
| | - Sun Y Lee
- Endocrine Unit, Fondazione IRCCS Cà Granda, Milan, Italy (S De Leo MD); Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy (S De Leo); and Section of Endocrinology, Diabetes and Nutrition, Boston University School of Medicine, Boston, MA, USA (S De Leo, S Y Lee MD, Prof L E Braverman MD)
| | - Lewis E Braverman
- Endocrine Unit, Fondazione IRCCS Cà Granda, Milan, Italy (S De Leo MD); Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy (S De Leo); and Section of Endocrinology, Diabetes and Nutrition, Boston University School of Medicine, Boston, MA, USA (S De Leo, S Y Lee MD, Prof L E Braverman MD)
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31
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Gaberšček S, Osolnik J, Zaletel K, Pirnat E, Hojker S. An Advantageous Role of Spectral Doppler Sonography in the Evaluation of Thyroid Dysfunction During the Postpartum Period. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:1429-1436. [PMID: 27208199 DOI: 10.7863/ultra.15.07033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 10/16/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To evaluate the diagnostic value of spectral Doppler sonography in women with thyroid dysfunction during the first postpartum year. METHODS This prospective observational clinical study included 83 consecutive untreated women: 32 with hyperthyroid postpartum thyroiditis, 32 with hypothyroid postpartum thyroiditis, and 19 with Graves disease, which first appeared within 12 months after delivery. Thyrotropin, free thyroid hormones, thyroid peroxidase antibodies, thyroglobulin antibodies, and thyrotropin receptor antibodies were measured. With a 7.5-MHz linear transducer, we measured the thyroid volume and peak systolic velocity (PSV) at the level of intrathyroid arteries. RESULTS Hyperthyroid postpartum thyroiditis appeared significantly earlier (mean ± SD, 4.4 ± 1.9 months after delivery) than hypothyroid postpartum thyroiditis (6.5 ± 2.1 months) and Graves disease (7.2 ± 2.7 months; P< .001). The thyroid volume in hyperthyroid postpartum thyroiditis (9.7 ± 6.3 mL) was significantly lower than in hypothyroid postpartum thyroiditis (14.7 ± 10.2 mL; P = .030) and Graves disease (19.4 ± 10.2 mL; P< .001). The PSV in hyperthyroid postpartum thyroiditis (9.4 ± 3.4 cm/s) was significantly lower than in hypothyroid postpartum thyroiditis (14.4 ± 3.9 cm/s; P < .001) and Graves disease (19.8 ± 7.0 cm/s; P < .001). With a cutoff level of 15 cm/s, the sensitivity and specificity of the PSV as a predictor of the correct diagnosis in hyperthyroid postpartum women were 94.7% and 96.8%, respectively. A multinomial logistic regression revealed PSV and the time after delivery at which the disorders presented as independent predictors of the differentiation between hyperthyroid postpartum thyroiditis and Graves disease (P = .003; P = .022). CONCLUSIONS Spectral Doppler sonography was shown to be a useful and accurate method for thyroid dysfunction evaluation during the postpartum period.
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Affiliation(s)
- Simona Gaberšček
- Department of Nuclear Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia. Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Jasna Osolnik
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Katja Zaletel
- Department of Nuclear Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Edvard Pirnat
- Department of Nuclear Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Sergej Hojker
- Department of Nuclear Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia. Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Araki N, Iida M, Amino N, Morita S, Ide A, Nishihara E, Ito M, Saito J, Nishikawa T, Katsuragi K, Miyauchi A. Rapid bioassay for detection of thyroid-stimulating antibodies using cyclic adenosine monophosphate-gated calcium channel and aequorin. Eur Thyroid J 2015; 4:14-9. [PMID: 25960957 PMCID: PMC4404900 DOI: 10.1159/000371740] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 12/22/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Thyroid-stimulating antibodies (TSAb) are known to be responsible for hyperthyroidism in Graves' disease (GD). The conventional methods to measure TSAb depend on cell-based assays that require cumbersome procedures and a sterilized tissue culture technique. The aim of the present study was to develop a ready-to-use cell-based assay for measuring TSAb activity without requiring sterilized conditions. METHODS We developed a new assay kit using a frozen Chinese hamster ovary cell line expressing the thyroid-stimulating hormone receptor, cyclic adenosine monophosphate (cAMP)-gated calcium channel and aequorin, tentatively named the aequorin TSAb assay. Activated stimulatory G-protein-coupled adenylate cyclase increases intracellular cAMP, which then binds to the cyclic nucleotide-gated calcium channel. Activation of this channel allows Ca(2+) to enter the cell, and the influx of Ca(2+) can be measured with aequorin, which is quantified by a luminometer. Results can be obtained in only 4 h without sterilized conditions. TSAb activities were expressed by international units using the NIBSC 08/204 standard. RESULTS Positive results of aequorin TSAb were obtained in 197 of 199 (98.9%) of untreated patients with GD. Only 1 of 42 (2.3%) patients with painless thyroiditis had a weakly positive aequorin TSAb. All 45 patients with subacute thyroiditis and 185 normal subjects showed negative aequorin TSAb. As for chronic thyroiditis, all 52 euthyroid patients showed negative aequorin TSAb, but 8 of 50 (16.0%) hypothyroid patients had a positive reaction. However, these positive reactions were not induced by serum thyroid-stimulating hormone (TSH) and were thought to be induced by the stimulating activity of anti-TSH receptor immunoglobulins. Conventional porcine TSAb and Elecsys thyroid-stimulating hormone receptor antibodies were positive in 69.3 and 95.5% of GD, respectively. CONCLUSION The aequorin TSAb assay was positive in 98.9% of GD and was more sensitive than the conventional assay. This assay can be conducted in only 4 h without sterilized conditions and is practically useful in general clinical laboratories.
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Affiliation(s)
- Naohiro Araki
- Diagnostic Division, Otsuka Pharmaceutical Co. Ltd., Tokushima, Japan
| | - Mitsuru Iida
- Diagnostic Division, Otsuka Pharmaceutical Co. Ltd., Tokushima, Japan
| | - Nobuyuki Amino
- Department of Internal Medicine, Kuma Hospital, Kobe, Japan
- *Nobuyuki Amino, MD, Department of Internal Medicine, Kuma Hospital, 8-2-35 Shimoyamate-dori, Chuo-ku, Kobe 650-0011 (Japan), E-Mail
| | - Shinji Morita
- Department of Internal Medicine, Kuma Hospital, Kobe, Japan
| | - Akane Ide
- Department of Internal Medicine, Kuma Hospital, Kobe, Japan
| | | | - Mitsuru Ito
- Department of Internal Medicine, Kuma Hospital, Kobe, Japan
| | - Jun Saito
- Department of Medicine, Yokohama Rosai Hospital, Yokohama, Japan
| | - Tetsuo Nishikawa
- Department of Medicine, Yokohama Rosai Hospital, Yokohama, Japan
| | | | - Akira Miyauchi
- Department of Internal Medicine, Kuma Hospital, Kobe, Japan
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33
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Labadzhyan A, Brent GA, Hershman JM, Leung AM. Thyrotoxicosis of Pregnancy. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2014; 1:140-144. [PMID: 25243108 PMCID: PMC4166486 DOI: 10.1016/j.jcte.2014.07.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Thyrotoxicosis presenting during pregnancy is a common clinical problem and can be challenging to differentiate between physiologic patterns of thyroid dysfunction during gestation and intrinsic hyperthyroidism. This review provides a summary of the differential diagnosis, clinical presentation, diagnostic options, potential adverse effects of maternal thyrotoxicosis to the fetus, and treatment recommendations for thyrotoxicosis arising in pregnancy.
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Affiliation(s)
- Artak Labadzhyan
- Division of Endocrinology, Cedars-Sinai Medical Center and VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Gregory A Brent
- Division of Endocrinology, David Geffen School of Medicine, University of California Los Angeles
| | - Jerome M Hershman
- Division of Endocrinology, David Geffen School of Medicine, University of California Los Angeles
| | - Angela M Leung
- Division of Endocrinology, David Geffen School of Medicine, University of California Los Angeles
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