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Dietlein M, Drzezga A, Schmidt M. [Commentary on the latest DGN procedure guidelines for radioiodine therapy for benign thyroid diseases]. Nuklearmedizin 2024; 63:4-7. [PMID: 37871627 DOI: 10.1055/a-2185-8082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
ZusammenfassungDie aktuelle DGN-Handlungsempfehlung behandelt das Thema der Entwicklung der TRAK-Spiegel nach der Radiojodtherapie der Immunhyperthyreose erstmals im Vergleich zu den vorangehenden Versionen. Diese neuen Hinweise sollten differenziert eingeordnet und anschließend dem Patienten z.B. in den Aufklärungsunterlagen geeignet zugänglich gemacht werden. Bei der Verwendung fertiger kommerzieller Aufklärungsbögen, herausgegeben von einigen medizinisch orientierten Verlagsgesellschaften, ist auf deren Aktualität zu achten, ggf. sind die noch nicht berücksichtigten Aspekte im Einzelfall handschriftlich nachzutragen. Die Verwendung eigener klinikinterner Aufklärungsblätter zur Radiojodtherapie gutartiger Schilddrüsenerkrankungen bietet den Vorteil, dass neue Aspekte durch den behandelnden Nuklearmediziner selbst eingefügt werden können.
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Affiliation(s)
- Markus Dietlein
- Klinik und Poliklinik für Nuklearmedizin, Universitätsklinikum Köln, Köln (Cologne), Germany
| | - Alexander Drzezga
- Klinik und Poliklinik für Nuklearmedizin, Universitätsklinikum Köln, Köln (Cologne), Germany
| | - Matthias Schmidt
- Klinik und Poliklinik für Nuklearmedizin, Universitätsklinikum Köln, Köln (Cologne), Germany
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Hong L, Tang MHY, Cheung KW, Luo L, Cheung CKY, Dai X, Li Y, Xiong C, Liang W, Xiang W, Wang L, Chan KYK, Lin S. Fetal Hyperthyroidism with Maternal Hypothyroidism: Two Cases of Intrauterine Therapy. Diagnostics (Basel) 2024; 14:102. [PMID: 38201411 PMCID: PMC10795960 DOI: 10.3390/diagnostics14010102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
Fetal hyperthyroidism can occur secondary to maternal autoimmune hyperthyroidism. The thyroid-stimulating hormone receptor antibody (TRAb) transferred from the mother to the fetus stimulates the fetal thyroid and causes fetal thyrotoxicosis. Fetuses with this condition are difficult to detect, especially after maternal Graves disease therapy. Here, we present two cases of fetal hyperthyroidism with maternal hypothyroidism and review the assessment and intrauterine therapy for fetal hyperthyroidism. Both women were referred at 22+ and 23+ weeks of gestation with abnormal ultrasound findings, including fetal heart enlargement, pericardial effusion, and fetal tachycardia. Both women had a history of Graves disease while in a state of hypothyroidism with a high titer of TRAb. A sonographic examination showed a diffusely enlarged fetal thyroid with abundant blood flow. Invasive prenatal testing revealed no significant chromosomal aberration. Low fetal serum TSH and high TRAb levels were detected in the cord blood. Fetal hyperthyroidism was considered, and maternal oral methimazole (MMI) was administered as intrauterine therapy, with the slowing of fetal tachycardia, a reduction in fetal heart enlargement, and thyroid hyperemia. During therapy, maternal thyroid function was monitored, and the dosage of maternal levothyroxine was adjusted accordingly. Both women delivered spontaneously at 36+ weeks of gestation, and neonatal hyperthyroidism was confirmed in both newborns. After methimazole and propranolol drug treatment with levothyroxine for 8 and 12 months, both babies became euthyroid with normal growth and development.
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Affiliation(s)
- Lu Hong
- Prenatal Diagnosis Centre, The University of Hong Kong—Shenzhen Hospital, Shenzhen 518053, China
| | - Mary Hoi Yin Tang
- Prenatal Diagnosis Centre, The University of Hong Kong—Shenzhen Hospital, Shenzhen 518053, China
| | - Ka Wang Cheung
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, The University of Hong Kong, Hong Kong 999077, China
| | - Libing Luo
- Prenatal Diagnosis Centre, The University of Hong Kong—Shenzhen Hospital, Shenzhen 518053, China
| | - Cindy Ka Yee Cheung
- Prenatal Diagnosis Centre, The University of Hong Kong—Shenzhen Hospital, Shenzhen 518053, China
| | - Xiaoying Dai
- Prenatal Diagnosis Centre, The University of Hong Kong—Shenzhen Hospital, Shenzhen 518053, China
| | - Yanyan Li
- Prenatal Diagnosis Centre, The University of Hong Kong—Shenzhen Hospital, Shenzhen 518053, China
| | - Chuqin Xiong
- Department of Ultrasound, The University of Hong Kong—Shenzhen Hospital, Shenzhen 518053, China
| | - Wei Liang
- Department of Endocrinology, The University of Hong Kong—Shenzhen Hospital, Shenzhen 518053, China
| | - Wei Xiang
- Department of Endocrinology, The University of Hong Kong—Shenzhen Hospital, Shenzhen 518053, China
| | - Liangbing Wang
- Neonatal Intensive Care Unit, The University of Hong Kong—Shenzhen Hospital, Shenzhen 518053, China
| | - Kelvin Yuen Kwong Chan
- Department of Applied Science, School of Science and Technology, Hong Kong Metropolitan University, Hong Kong 999077, China
| | - Shengmou Lin
- Prenatal Diagnosis Centre, The University of Hong Kong—Shenzhen Hospital, Shenzhen 518053, China
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van Hulsteijn LT, Prins JR, Scheffer-Rath MEA, van Trotsenburg ASP, Links TP, Dullaart RPF. Fetal Thyrotoxicosis due to Maternal TSH Receptor Stimulating Antibodies Causes Infant Central Hypothyroidism. Horm Res Paediatr 2023; 97:180-186. [PMID: 37231969 DOI: 10.1159/000530725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 04/11/2023] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION Women with a current diagnosis or past history of Graves' disease (GD) are at risk of developing fetal thyrotoxicosis (FT) during pregnancy when they are inadequately treated, or because of placental passage of TSH receptor antibodies (TRAb). It is known that FT induced by high maternal thyroid hormone concentrations may result in infant (central) hypothyroidism. CASE PRESENTATION In a euthyroid woman with a history of GD treated with radioactive iodide (I131), persistently high levels of maternal TRAb resulted in recurrent FT during two separate pregnancies, followed by neonatal hyperthyroidism and infant central hypothyroidism. DISCUSSION This case demonstrates the novel insight that FT due to high fetal thyroid hormone concentrations stimulated by high maternal TRAb levels might also result in (central) hypothyroidism, requiring long-term evaluation of the hypothalamus-pituitary-thyroid axis in these children.
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Affiliation(s)
- Leonie T van Hulsteijn
- Department of Endocrinology, University Medical Center Groningen, Groningen, The Netherlands
| | - Jelmer R Prins
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Groningen, The Netherlands
| | - Mirjam E A Scheffer-Rath
- Department of Pediatric Endocrinology, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - A S Paul van Trotsenburg
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam University Medical Center, Groningen, The Netherlands
| | - Thera P Links
- Department of Endocrinology, University Medical Center Groningen, Groningen, The Netherlands
| | - Robin P F Dullaart
- Department of Endocrinology, University Medical Center Groningen, Groningen, The Netherlands
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Bojunga J, Güngöze O, Hofbauer L, Müller E. [Thyroid disease during pregnancy]. Dtsch Med Wochenschr 2023; 148:17-26. [PMID: 36592630 DOI: 10.1055/a-1813-0892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Thyroid disease is the second most endocrinopathy during pregnancy 1. Thyroid dysfunction affects 2-3 % of pregnant women 2. Early diagnosis and initiation of therapy are important due to the potential complications in both mother and fetus. This article provides an overview of current recommendations regarding thyroid diagnostics and constellations during pregnancy that require therapy.
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Rotondi M, Bendotti G, Croce L, Molteni M, Carbone A, Magri F, Pearce EN, Chiovato L. A unique presentation of Graves' disease in a pregnant woman with severe hypothyroidism. Gynecol Endocrinol 2022; 38:697-701. [PMID: 35723545 DOI: 10.1080/09513590.2022.2087216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BackgroundGraves' disease occurrence during pregnancy is not a frequent event, showing an incidence of 0.2-0.4% in unselected pregnant women. Depending on their functional properties, TSH-receptor antibodies can induce hypothyroidism or hyperthyroidism. Recognizing the signs of altered thyroid function is essential to prevent possible complications on the fetus.Materials and methodsThe case of a pregnant woman without previous history of thyroid disease presenting with severe overt hypothyroidism during the first trimester is reported. Levothyroxine therapy was started and 6 weeks later overt hyperthyroidism was observed. TRAb were detected at high titers. Levothyroxine was withdrawn and low dose methimazole was started. Serial obstetric ultrasound scans were negative for indirect signs of fetal thyroid dysfunctions and no fetal goiter was visualized throughout pregnancy. Spontaneous delivery occurred without complications at 39 weeks of gestation. In the post-partum, severe overt hypothyroidism recurred, thus methimazole was discontinued and levothyroxine was restarted. TRAb persisted at high levels. The infant experienced a transient thyrotoxicosis, which fully resolved in three months with normalization of thyroid function and negativization of TRAb levels.ResultsThe present case report allows us to overview the challenges related to the management of hypo and hyperthyroidism in patients with high TRAb levels, requiring strict monitoring aimed at early detection of both maternal and fetal consequences.ConclusionsThis case underlines the importance of close follow-up and the need of collaboration in a multidisciplinary team when Graves's disease is diagnosed in a pregnant woman to prevent adverse neonatal outcomes.
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Affiliation(s)
- Mario Rotondi
- Istituti Clinici Scientifici Maugeri IRCCS, Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Pavia, Italy
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Giulia Bendotti
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Laura Croce
- Istituti Clinici Scientifici Maugeri IRCCS, Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Pavia, Italy
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Martina Molteni
- Unit of Internal Medicine, Medical-Oncologic Department, ASST Lodi, Lodi, Italy
| | - Andrea Carbone
- Unit of Internal Medicine, Medical-Oncologic Department, ASST Lodi, Lodi, Italy
| | - Flavia Magri
- Istituti Clinici Scientifici Maugeri IRCCS, Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Pavia, Italy
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Elizabeth N Pearce
- Section of Endocrinology Diabetes, and Nutrition, Boston University School of Medicine, Boston, MA, USA
| | - Luca Chiovato
- Istituti Clinici Scientifici Maugeri IRCCS, Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Pavia, Italy
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
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Ilias I, Milionis C, Koukkou E. Further understanding of thyroid function in pregnant women. Expert Rev Endocrinol Metab 2022; 17:365-374. [PMID: 35831988 DOI: 10.1080/17446651.2022.2099372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 07/05/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Normal thyroid status throughout pregnancy is important for both maternal and fetal health. Despite the bulk of contemporary research honing on thyroid function in gestation and the relevant disorders, there are still gaps in our current knowledge about the etiology and treatment of thyroid diseases in pregnant women. AREAS COVERED This article analyzes the adaptation of the thyroid gland to gestational physiological changes and attempts to explain the effect of several factors on thyroid function in pregnancy. It also stresses proper utilization and interpretation of thyroid tests during pregnancy and underlines the significance of proper screening and treatment of pregnant women aiming at favorable health outcomes. EXPERT OPINION Appropriate strategies for diagnosing and treating thyroid disease in pregnancy are important. Laboratory thyroid testing plays a leading role, but test results should be interpreted with caution. Given the possible serious maternal and fetal/neonatal complications of thyroid disease in pregnancy, we recommend universal screening with TSH measurements of all pregnant women. Additional assessment with determination of the levels of free thyroid hormones and thyroid antibodies may be necessary under certain conditions. The economic burden of such interventions should be considered.
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Affiliation(s)
- Ioannis Ilias
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, Athens, Greece
| | - Charalampos Milionis
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, Athens, Greece
| | - Eftychia Koukkou
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, Athens, Greece
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Del Campo Cano I, Alarza Cano R, Encinas Padilla B, Lacámara Ornaechea N, Royuela Vicente A, Marín Gabriel MÁ. A prospective study among neonates born to mothers with active or past Graves disease. Gynecol Endocrinol 2022; 38:495-498. [PMID: 35548945 DOI: 10.1080/09513590.2022.2073347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE The aim of this prospective study was to describe demographic and clinical characteristics of neonates born to mothers with active or past Graves disease and to assess compliance since implementation of a new protocol in our center. METHODS We prospectively followed up neonates born to mothers with active or past Graves disease in a tertiary hospital in Spain between August 2019 and September 2021 according to our protocol. We reviewed maternal and neonatal history of these neonates, and we followed up newborns at risk of neonatal hyperthyroidism. RESULTS Among 5808 births, 33 neonates were born to mothers with active or past Graves disease (0.57%). Six mothers (18.2%) had positive levels of thyroid-stimulating hormone receptor antibodies during pregnancy and five mothers (15.1%) between weeks 20 and 24 of pregnancy. Two of them had received definitive therapy for Graves disease before pregnancy. Two neonates (7.1%) were at high risk of neonatal hyperthyroidism and were followed-up until two months, without hyperthyroidism signs or abnormal thyroid hormone levels. Compliance of protocol during pregnancy was 84.9% and 75.8% at birth. CONCLUSIONS Prevalence of Graves disease among pregnant women was 0.57%, with no cases of neonatal hyperthyroidism. Compliance of protocol was adequate during pregnancy (84.9%) and acceptable at birth (75.8%).
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Affiliation(s)
- Iván Del Campo Cano
- Department of Pediatrics, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Raquel Alarza Cano
- Department of Obstetric and Gynecology, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Begoña Encinas Padilla
- Department of Obstetric and Gynecology, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | | | - Ana Royuela Vicente
- Biostatistics Unit; Puerta de Hierro Biomedical Research Institute (IDIPHISA); CIBERESP, Madrid, Spain
| | - Miguel Ángel Marín Gabriel
- Department of Pediatrics, Section of Neonatology, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
- Pediatric Deparment Associate Professor, Autónoma University, Madrid, Spain
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Ravindra S, Shetty S. Neonatal thyrotoxicosis with maternal hypothyroidism. BMJ Case Rep 2022; 15:e247865. [PMID: 35264385 PMCID: PMC8915356 DOI: 10.1136/bcr-2021-247865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2022] [Indexed: 11/04/2022] Open
Abstract
Neonatal Graves' is uncommon, but a potentially fatal condition caused by transplacental transfer of thyroid stimulating immunoglobulin (TSI). It is seen in 1%-5% of infants born to a mother with Graves' disease. Here, we report a unique case of transient neonatal thyrotoxicosis with positive TSI in a premature neonate born to the mother with primary hypothyroidism. A short course of antithyroid drug treatment leads to significant clinical and biochemical improvement followed by complete recovery.
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Affiliation(s)
- Shruthi Ravindra
- Department of Endocrinology, Manipal Academy of Higher Education (MAHE), Kasturba Medical College Manipal, Udupi, Karnataka, India
| | - Sahana Shetty
- Department of Endocrinology, Manipal Academy of Higher Education (MAHE), Kasturba Medical College Manipal, Udupi, Karnataka, India
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Abstract
Fetal and neonatal dysfunctions include rare serious disorders involving abnormal thyroid function during the second half of gestation, which may persist throughout life, as for most congenital thyroid disorders, or be transient, resolving in the first few weeks of life, as in autoimmune hyperthyroidism or hypothyroidism and some cases of congenital hypothyroidism (CH) with the thyroid gland in situ. Primary CH is diagnosed by neonatal screening, which has been implemented for 40 years in developed countries and should be introduced worldwide, as early treatment prevents irreversible neurodevelopmental delay. Central CH is a rarer entity occurring mostly in association with multiple pituitary hormone deficiencies. Other rare disorders impair the action of thyroid hormones. Neonatal Graves' disease (GD) results from the passage of thyrotropin receptor antibodies (TRAbs) across the placenta, from mother to fetus. It may affect the fetuses and neonates of mothers with a history of current or past GD, but hyperthyroidism develops only in those with high levels of stimulatory TRAb activity. The presence of antibodies predominantly blocking thyroid-stimulating hormone receptors may result in transient hypothyroidism, possibly followed by neonatal hyperthyroidism, depending on the balance between the antibodies present. Antithyroid drugs taken by the mother cross the placenta, treating potential fetal hyperthyroidism, but they may also cause transient fetal and neonatal hypothyroidism. Early diagnosis and treatment are key to optimizing the child's prognosis. This review focuses on the diagnosis and management of these patients during the fetal and neonatal periods. It includes the description of a case of fetal and neonatal autoimmune hyperthyroidism.
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Affiliation(s)
- Juliane Léger
- Assistance Publique-Hôpitaux de Paris, Robert Debré University Hospital, Pediatric Endocrinology-Diabetology Department, Reference Center for Growth and Development Endocrine Diseases, Paris, France
- Université de Paris; NeuroDiderot, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - Clemence Delcour
- Université de Paris; NeuroDiderot, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
- Assistance Publique-Hôpitaux de Paris, Robert Debré University Hospital, Gynecology and Obstetric Department, Paris, France
| | - Jean-Claude Carel
- Assistance Publique-Hôpitaux de Paris, Robert Debré University Hospital, Pediatric Endocrinology-Diabetology Department, Reference Center for Growth and Development Endocrine Diseases, Paris, France
- Université de Paris; NeuroDiderot, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
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Caron P. MANAGEMENT OF THYROTOXICOSIS AND PREGNANCY: Review of the current literature and an update of the care pathway. ANNALES D'ENDOCRINOLOGIE 2022; 83:226-231. [PMID: 35143751 DOI: 10.1016/j.ando.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 01/12/2022] [Accepted: 01/20/2022] [Indexed: 10/19/2022]
Abstract
Pregnancy can be complicated by hyperthyroidism or thyrotoxicosis. Diagnosis is founded on an increase in free thyroid hormones and low TSH. The most frequent etiologies are Graves' disease, an autoimmune disease linked to stimulatory anti-TSH receptor antibodies, and non-autoimmune gestational hyperthyroidism linked to the TSH-like activity of the chorionic growth hormone (hCG). During pregnancy, thyrotoxicosis can entail maternal, obstetrical and fetal or neonatal complications. Graves' hyperthyroidism may be responsible for fetal and neonatal hyperthyroidism due to placental transfer of stimulatory anti-TSH receptor antibodies. During pregnancy, treatment of thyrotoxicosis must restore normal thyroid function in the mother without affecting fetal thyroid function. The recent reassessment of the prevalence of teratogenic effects in children of women treated with antithyroid drugs in the first weeks of gestation should orient the care pathway before and during pregnancy for women of child-bearing age with hyperthyroidism linked to Graves' disease.
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Affiliation(s)
- Philippe Caron
- Department of Endocrinology and Metabolic diseases, Cardiovascular and Metabolic Unit CHU-Larrey, Toulouse, France.
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Alves Junior JM, Bernardo WM, Ward LS, Villagelin D. Effect of Hyperthyroidism Control During Pregnancy on Maternal and Fetal Outcome: A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2022; 13:800257. [PMID: 35813653 PMCID: PMC9263848 DOI: 10.3389/fendo.2022.800257] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 04/27/2022] [Indexed: 11/13/2022] Open
Abstract
CONTEXT Although the overt hyperthyroidism treatment during pregnancy is mandatory, unfortunately, few studies have evaluated the impact of treatment on reducing maternal and fetal outcomes. OBJECTIVE This study aimed to demonstrate whether treatment to control hyperthyroidism manifested during pregnancy can potentially reduce maternal-fetal effects compared with euthyroid pregnancies through a systematic review with meta-analysis. DATA SOURCE MEDLINE (PubMed), Embase, Cochrane Library Central, LILACS/BIREME until May 2021. STUDY SELECTION Studies that compared, during the gestational period, treated women with hyperthyroidism versus euthyroid women. The following outcomes of this comparison were: pre-eclampsia, abruptio placentae, fetal growth retardation, gestational diabetes, postpartum hemorrhage, low birth weight, stillbirth, spontaneous abortions, premature birth. DATA EXTRACTION Two independent reviewers extracted data and performed quality assessments. Dichotomous data were analyzed by calculating risk differences (DR) with fixed and random effect models according to the level of heterogeneity. DATA SYNTHESIS Seven cohort studies were included. The results of the meta-analysis indicated that there was a lower incidence of preeclampsia (p=0.01), low birth weight (p=0.03), spontaneous abortion (p<0.00001) and preterm birth (p=0.001) favouring the euthyroid pregnant group when compared to those who treated hyperthyroidism during pregnancy. However, no statistically significant differences were observed in the outcomes: abruptio placentae, fetal growth retardation, gestational diabetes mellitus, postpartum hemorrhage, and stillbirth. CONCLUSIONS Our findings demonstrated that treating overt hyperthyroidism in pregnancy is mandatory and appears to reduce some potential maternal-fetal complications, despite there still being a residual risk of negative outcomes.
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Affiliation(s)
- Jose Mario Alves Junior
- Postgraduate Course Internal Medicine, Campinas State University, Campinas, Brazil
- *Correspondence: Jose Mario Alves Junior,
| | - Wanderley Marques Bernardo
- School of Medicine, University of São Paulo, São Paulo, Brazil
- Department of Evidence-Based Medicine, University of São Paulo, São Paulo, Brazil
| | - Laura Sterian Ward
- Laboratory of Cancer Molecular Genetics, School of Medicine Sciences, Campinas State University, Campinas, Brazil
| | - Danilo Villagelin
- Postgraduate Course Internal Medicine, Campinas State University, Campinas, Brazil
- Endocrinology and Metabolism, Hospital of the Pontifical Catholic University of Campinas (PUC-Campinas), Campinas, Brazil
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Jeong JE, Lee SH, Kim YH, Jang YY, Kim JK. A Case of Neonatal Thyrotoxicosis with Cardiac Insufficiency. NEONATAL MEDICINE 2021. [DOI: 10.5385/nm.2021.28.4.161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Neonatal thyrotoxicosis is rare and most of the cases are secondary to maternal Graves’ disease. It is usually transient, but can be associated with significant morbidity and mortality if not recognized promptly and treated adequately. Neonates born to mothers treated with antithyroid drugs or those who receive maternal thyroid blocking antibodies may exhibit normal thyroid function or even hypothyroidism at birth. Since there may not be any obvious symptoms of hyperthyroidism at birth, it may be overlooked. Therefore, such neonates should be evaluated properly and monitored regularly to prevent serious complications of hyperthyroidism. We report a case of a 21-day-old male infant who developed thyrotoxicosis with dyspnea, irritability, tachycardia, and cardiac insufficiency. He was born to a mother who was treated for Graves’ disease with antithyroid drugs during pregnancy. We have also discussed the importance of careful examination and monitoring to prevent the development of clinical hyperthyroidism.
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Hyperthyroidism in Pregnancy: The Delicate Balance between Too Much or Too Little Antithyroid Drug. J Clin Med 2021; 10:jcm10163742. [PMID: 34442037 PMCID: PMC8396831 DOI: 10.3390/jcm10163742] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 08/09/2021] [Accepted: 08/20/2021] [Indexed: 01/11/2023] Open
Abstract
Overt hyperthyroidism (HT) during pregnancy is associated with a risk of maternal–fetal complications. Antithyroid drugs (ATD) have a potential risk for teratogenic effects and fetal–neonatal hypothyroidism. This study evaluated ATD treatment and thyroid function control during pregnancy, and pregnancy outcome in women with HT. Patients and methods: A retrospective analysis of 36 single fetus pregnancies in 29 consecutive women (median age 30.3 ± 4.7 years) with HT diagnosed before or during pregnancy; a control group of 39 healthy euthyroid pregnant women was used. Results: Twenty-six women had Graves’ disease (GD, 33 pregnancies), 1 had a hyperfunctioning autonomous nodule, and 2 had gestational transient thyrotoxicosis (GTT). Methimazole (MMI) was administered in 22 pregnancies (78.5%), Propylthiouracil (PTU) in 2 (7.1%), switch from MMI to PTU in 4 (14.2%), no treatment in 8 pregnancies (3 with subclinical HT, 5 euthyroid with previous GD remission before conception). In the 8 pregnancies of GD patients diagnosed during gestation or shortly before (<6 weeks), i.e., with fetal exposure to uncontrolled HT, there was 1 spontaneous abortion at 5 weeks (3.4% of all ATD-treated pregnancies), and 1 premature delivery at 32 weeks with neonatal death in 24 h (3.4%); 1 child had neonatal hyperthyroidism (3.3% of live children in GD women) and a small atrial sept defect (4% of live children in ATD treated women). In women treated more than 6 months until conception (20 pregnancies): (a) median ATD doses were lower than those in women diagnosed shortly before or during pregnancy; (b) ATD was withdrawn in 40% of pregnancies in trimester (T)1, all on MMI < 10 mg/day (relapse in 14.2%), and in up to 55% in T3; (c) TSH level was below normal in 37%, 35% and 22% of pregnancies in T1, T2 and T3 respectively; FT4 was increased in 5.8% (T1) and subnormal in 11.75% in T2 and T3; (d) no fetal birth defects were recorded; one fetal death due to a true umbilical cord knot was registered. Mean birth weight was similar in both ATD-treated and control groups. Hyperthyroidism relapsed postpartum in 83% of GD patients (at median 3 ± 2.6 months). Conclusion: In hyperthyroid women with long-term ATD treatment before conception, drugs could be withdrawn in T1 in 40% of them, the thyroid function control was better, and pregnancy and fetal complications were rarer, compared to women diagnosed during pregnancy. Frequent serum TSH and FT4 monitoring is needed to maintain optimal thyroid function during pregnancy.
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Kim J, Choi MS, Park J, Park H, Jang HW, Choe JH, Kim JH, Kim JS, Cho YS, Choi JY, Kim TH, Chung JH, Kim SW. Changes in Thyrotropin Receptor Antibody Levels Following Total Thyroidectomy or Radioiodine Therapy in Patients with Refractory Graves' Disease. Thyroid 2021; 31:1264-1271. [PMID: 33947272 PMCID: PMC8377510 DOI: 10.1089/thy.2020.0756] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: The actions of thyrotropin-binding inhibitory immunoglobulins (TBIIs) against thyrotropin receptors in thyroid follicular cells have been studied as important etiological factors in Graves' disease (GD). The purpose of this study was to investigate changes in the TBII levels of patients undergoing total thyroidectomy (TTx) or radioactive iodine (RAI) therapy for GD refractory to antithyroid drugs (ATDs). Methods: We enrolled patients who underwent TTx or RAI for GD with previous ATD use between January 2011 and December 2017 at the Samsung Medical Center in Seoul, Korea. Thorough retrospective reviews of medical records were performed in 130 patients. Results: Patients with goiter, ophthalmopathy, high levels of TBIIs, and high doses of ATDs received TTx. Elderly patients with arrhythmia received RAI. We observed that TBII levels continued to decrease after TTx. On the contrary, TBIIs initially increased for 138 days (estimated median time) and then decreased slowly after RAI. A faster decline in TBII levels was observed in the TTx group than in the RAI group (p < 0.001). The estimated median time for TBIIs to decrease below 4.5 IU (3 × upper normal limit, which is known to be a risk factor for fetal hyperthyroidism) was 318 days in the TTx group and 659 days in the RAI group, respectively. In the RAI group, high levels of TBII (>4.5 IU/L) were present in 70 (82%) at 6 months, 57 (67%) at 1 year, and 3 (3%) at 2 years. In the TTx group, rapid decreases in TBII levels were observed in younger patients and those with lower baseline TBII levels. In the RAI group, smaller thyroid volume was correlated with more rapid decrease in TBII levels. Conclusions: The changes in TBII levels following TTx or RAI were different in patients with refractory GD. When deciding on TTx or RAI, this difference should be considered with patient age, severity of hyperthyroidism, goiter, ophthalmopathy, and future pregnancy plans (for young female patients).
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Affiliation(s)
- Jinyoung Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Min Sun Choi
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun Park
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyunju Park
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Won Jang
- Department of Medical Education, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun-Ho Choe
- Division of Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Han Kim
- Division of Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jee Soo Kim
- Division of Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Seok Cho
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon Young Choi
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Hyuk Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Hoon Chung
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sun Wook Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Address correspondence to: Sun Wook Kim, MD, PhD, Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, Korea
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16
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Lee SY, Pearce EN. Testing, Monitoring, and Treatment of Thyroid Dysfunction in Pregnancy. J Clin Endocrinol Metab 2021; 106:883-892. [PMID: 33349844 PMCID: PMC7947825 DOI: 10.1210/clinem/dgaa945] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Indexed: 11/19/2022]
Abstract
Both hyperthyroidism and hypothyroidism can have adverse effects in pregnancy. The most common causes of thyrotoxicosis in pregnancy are gestational transient thyrotoxicosis and Graves' disease. It is important to distinguish between these entities as treatment options differ. Women of reproductive age who are diagnosed with Graves' disease should be counseled regarding the impact of treatment options on a potential pregnancy. Although the absolute risk is small, antithyroid medications can have teratogenic effects. Propylthiouracil appears to have less severe teratogenicity compared to methimazole and is therefore favored during the first trimester if a medication is needed. Women should be advised to delay pregnancy for at least 6 months following radioactive iodine to minimize potential adverse effects from radiation and ensure normal thyroid hormone levels prior to conception. As thyroid hormone is critical for normal fetal development, hypothyroidism is associated with adverse obstetric and child neurodevelopmental outcomes. Women with overt hypothyroidism should be treated with levothyroxine (LT4) to a thyrotropin (thyroid-stimulating hormone; TSH) goal of <2.5 mIU/L. There is mounting evidence for associations of maternal hypothyroxinemia and subclinical hypothyroidism with pregnancy loss, preterm labor, and lower scores on child cognitive assessment. Although there is minimal risk of LT4 treatment to keep TSH within the pregnancy-specific reference range, treatment of mild maternal thyroid hypofunction remains controversial, given the lack of clinical trials showing improved outcomes with LT4 treatment.
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Affiliation(s)
- Sun Y Lee
- Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, Boston, MA, USA
- Correspondence: Sun Y. Lee, MD, MSc, Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, 720 Harrison Avenue, Suite 8100, Boston, MA 02118, USA.
| | - Elizabeth N Pearce
- Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, Boston, MA, USA
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Li C, Zhang N, Zhou J, Leung W, Gober HJ, Huang Z, Pan X, Chen L, Guan L, Wang L. Variations in the Antithyroid Antibody Titre During Pregnancy and After Delivery. Risk Manag Healthc Policy 2021; 14:847-859. [PMID: 33688281 PMCID: PMC7935493 DOI: 10.2147/rmhp.s279975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/01/2021] [Indexed: 01/01/2023] Open
Abstract
Background Immunosuppression occurs during pregnancy, and the antithyroid antibody titre drops, rebounding after delivery. We aimed to determine variations in antithyroid antibody titres during pregnancy and after delivery. Methods This retrospective study was conducted in a single centre. Antibody titres of 142 patients were measured to assess variations in the levels of thyroid-stimulating hormone receptor antibodies (TRAbs), thyroid peroxidase antibodies (TPOAbs), and thyroid globulin antibodies (TgAbs). We compared the titres of each antibody between adjacent time periods (eg, first trimester (T1) vs second trimester (T2), T2 vs third trimester (T3), T3 vs the postpartum period (PP)) by paired t-test or the Wilcoxon test. Then, we analysed data from patients with complete laboratory examination results in all four periods with the Friedman test, performing comparisons among groups. Results In the TgAb group, significant differences existed between T1 and T2 and between T2 and T3 in the LT4 subgroup and between T1 and T2 in the no-medication subgroup. In the TRAb group, significant differences existed between T1 and T2 in the LT4 subgroup. In the TPOAb group, significant differences existed among each group in the LT4 subgroup, and there were significant differences between T1 and T2 and between T2 and T3 in the no-medication subgroup. The Friedman test showed that the P-values were 0.013 and 0.004 in the LT4 and no-medication subgroups of the TgAb group, respectively; 0.122 in the LT4 subgroup of the TRAb group; and <0.001 and 0.272 in the LT4 and no-medication subgroups of the TPOAb group, respectively. In the LT4 subgroup of the TgAb group, the P-values for comparisons of time periods were 0.602 between T1 and T2, 0.602 between T2 and T3, 0.006 between T1 and T3, and 0.602 between T3 and PP. In the no-medication subgroup of the TgAb group, the P-values were 0.078 between T1 and T2, 1.000 between T2 and T3, 0.011 between T1 and T3, and 0.078 between T3 and PP. In the LT4 subgroup of the TPOAb group, the P-values were 0.09 between T1 and T2, 0.014 between T2 and T3, <0.001 between T1 and T3, and 0.772 between T3 and PP. Conclusion We can conclude that the TgAb and TPOAb titres dropped during pregnancy.
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Affiliation(s)
- Chuyu Li
- Laboratory for Reproductive Immunology, Hospital & Institute of Obstetrics and Gynecology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China.,The Academy of Integrative Medicine of Fudan University, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, People's Republic of China
| | - Na Zhang
- Laboratory for Reproductive Immunology, Hospital & Institute of Obstetrics and Gynecology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China.,The Academy of Integrative Medicine of Fudan University, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, People's Republic of China
| | - Jing Zhou
- Laboratory for Reproductive Immunology, Hospital & Institute of Obstetrics and Gynecology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China.,The Academy of Integrative Medicine of Fudan University, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, People's Republic of China
| | - Wingting Leung
- Laboratory for Reproductive Immunology, Hospital & Institute of Obstetrics and Gynecology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China.,The Academy of Integrative Medicine of Fudan University, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, People's Republic of China
| | - Hans-Jürgen Gober
- Department of Pharmacy, Neuromed Campus, Kepler University Hospital, Linz, 4020, Austria
| | - Zengshu Huang
- Laboratory for Reproductive Immunology, Hospital & Institute of Obstetrics and Gynecology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China.,The Academy of Integrative Medicine of Fudan University, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, People's Republic of China
| | - Xinyao Pan
- Laboratory for Reproductive Immunology, Hospital & Institute of Obstetrics and Gynecology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China.,The Academy of Integrative Medicine of Fudan University, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, People's Republic of China
| | - Lijia Chen
- Laboratory for Reproductive Immunology, Hospital & Institute of Obstetrics and Gynecology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China.,The Academy of Integrative Medicine of Fudan University, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, People's Republic of China
| | - Liang Guan
- Department of Nuclear Medicine, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China.,Department of Nuclear Medicine, Ruijin Hospital North, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - Ling Wang
- Laboratory for Reproductive Immunology, Hospital & Institute of Obstetrics and Gynecology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China.,The Academy of Integrative Medicine of Fudan University, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, People's Republic of China
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18
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Suzuki N, Yoshihara A, Yoshimura Noh J, Kinoshita K, Ohnishi J, Saito M, Sugino K, Ito K. TRAb elevations occurred even in the third trimester; a case of a mother of a child with neonatal thyroid dysfunction, who received radioactive iodine therapy for Graves' disease. Endocr J 2020; 67:1019-1022. [PMID: 32522908 DOI: 10.1507/endocrj.ej20-0039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Activity of Graves' disease (GD) is known to improve during gestation, as values of thyrotropin (TSH) receptor antibody (TRAb) also improve. However, the risk of neonatal hyperthyroidism increases when maternal TRAb values are high in the second to third trimester. A 29-year-old woman who had undergone radioactive iodine (RAI) therapy for GD 10 years earlier visited our hospital at 17 weeks of gestation, showing subclinical hypothyroidism and a positive TRAb value of 2.6 IU/L (reference range, <2.0 IU/L). Thyroid hormone replacement therapy was commenced and thyroid function normalized within 4 weeks, although TRAb was elevated at the time (3.8 IU/L). Prenatal check-up showed normal growth development and no irregularities. At 29 weeks of gestation, serum TRAb was extremely elevated, up to 16.8 IU/L. Since the risk of neonatal hyperthyroidism was of great concern, delivery was planned at an advanced-care medical center. At 38 weeks 5 days of gestation, she delivered a female neonate without any complications, although blood testing of the neonate showed subclinical hyperthyroidism with positive TRAb and TSH receptor stimulating antibody (TSAb). According to the American Thyroid Association guidelines, the TRAb value should be checked in the third trimester if mothers show a TRAb elevation between the initial visit after pregnancy and 18-22 weeks of gestation. However, if the mother has a history of RAI therapy for GD, regardless of thyroid function during gestation, the possibility of TRAb values elevating over time even years after the definitive therapy must be considered.
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Affiliation(s)
- Nami Suzuki
- Department of Internal Medicine, Ito Hospital, Tokyo 150-8308, Japan
| | - Ai Yoshihara
- Department of Internal Medicine, Ito Hospital, Tokyo 150-8308, Japan
| | | | - Kazuya Kinoshita
- Kinoshita Obstetrics and Gynecology Clinic, Tokyo 124-0004, Japan
| | - Junki Ohnishi
- Department of Obstetrics and Gynecology, The Jikei University Katsushika Medical Center, Tokyo 125-8506, Japan
| | - Maki Saito
- Department of Pediatrics, The Jikei University Katsushika Medical Center, Tokyo 125-8506, Japan
| | | | - Kochi Ito
- Department of Surgery, Ito Hospital, Tokyo 150-8308, Japan
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19
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Abstract
Thyrotoxicosis during pregnancy should be adequately managed and controlled to prevent maternal and fetal complications. The evaluation of thyroid function in pregnant women is challenged by the physiological adaptations associated with pregnancy, and the treatment with antithyroid drugs (ATD) raises concerns for the pregnant woman and the fetus. Thyrotoxicosis in pregnant women is mainly of autoimmune origin, and the measurement of thyroid stimulating hormone-receptor antibodies (TRAb) plays a key role. TRAb helps to distinguish the hyperthyroidism of Graves' disease from gestational hyperthyroidism in early pregnancy, and to evaluate the risk of fetal and neonatal hyperthyroidism in late pregnancy. Furthermore, the measurement of TRAb in early pregnancy is recommended to evaluate the need for ATD during the teratogenic period of pregnancy. Observational studies have raised concern about the risk of birth defects associated with the use of ATD in early pregnancy and challenged the clinical management and choice of treatment.
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Affiliation(s)
- Stine Linding Andersen
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Louise Knøsgaard
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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20
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van Trotsenburg ASP. Management of neonates born to mothers with thyroid dysfunction, and points for attention during pregnancy. Best Pract Res Clin Endocrinol Metab 2020; 34:101437. [PMID: 32651060 DOI: 10.1016/j.beem.2020.101437] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Thyroid hormone (TH) is indispensable for normal embryonic and fetal development. Throughout gestation TH is provided by the mother via the placenta, later in pregnancy the fetal thyroid gland makes an increasing contribution. Maternal thyroid dysfunction, resulting in lower or higher than normal (maternal) TH levels and transfer to the embryo/fetus, can disturb normal early development. (Maternal) thyroid dysfunction is mostly caused by autoimmune hypo- or hyperthyroidism, i.e. Hashimoto and Graves disease. Autoimmune hyperthyroidism is caused by stimulating TSH receptor antibodies (TSHR Ab), patients with autoimmune hypothyroidism may have blocking TSHR Ab. Maternal TSHR Ab cross the placenta from mid gestation and may cause fetal and transient neonatal hyper- or hypothyroidism. Anti-thyroid drugs taken for autoimmune hyperthyroidism cross the placenta throughout gestation, and may cause fetal and transient neonatal hypothyroidism. This review focusses on the consequences of maternal hypo- and hyperthyroidism for fetus and neonate, and provides a practical approach to clinical management of neonates born to mothers with thyroid dysfunction.
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Affiliation(s)
- A S Paul van Trotsenburg
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Endocrinology, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
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21
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Dillon CF, Weisman MH, Miller FW. Population-based estimates of humoral autoimmunity from the U.S. National Health and Nutrition Examination Surveys, 1960-2014. PLoS One 2020; 15:e0226516. [PMID: 31929535 PMCID: PMC6957172 DOI: 10.1371/journal.pone.0226516] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 11/26/2019] [Indexed: 02/06/2023] Open
Abstract
Objective Based on US National Health and Nutrition Examination Survey (NHANES) data, we attempted to provide an unbiased, population-based estimate of autoantibody prevalence overall and by age and sex. Methods US autoantibody prevalence estimates for detectable rheumatoid factor, anti-thyroglobulin, anti-thyroperoxidase, anti-transglutaminase, anti-endomysial, anti-GAD65, antinuclear autoantibodies, and autoantibodies to extractable nuclear antigens were estimated from the 1960–1962 National Health Examination Survey, NHANES III (1988–1994), and the NHANES 1999–2014 cross-sectional surveys. Survey design variables and sample weights were used to account for differential probabilities of selection within the complex survey design. Data analysis used SASTM and SUDAAN™ software. US Census Bureau data were used to estimate the absolute numbers of persons with autoantibodies. Results NHANES III data show that the overall US prevalence of having a detectable serum autoantibody is substantial in adults, in both women and men. Thyroid autoantibodies were present in 18% of US adults (31 million persons) including 10% of younger adults and 25% of older persons. Overall autoantibody prevalences increased significantly with age: 32% of US adults 60+ years of age (12.8 million persons) had at least one of the four autoantibodies rheumatoid factor, anti-thyroglobulin, anti-thyroperoxidase, or anti-tissue transglutaminase. Older women had higher levels of autoantibodies, but this was a relative difference. Autoantibody prevalence in both sexes was substantial (women 39%; men 22%). Fourteen percent of adults 60+ years of age have multiple autoantibodies. Conclusions Autoantibodies are present in a significant fraction of the general population, especially in older adults and women relative to men. Although all known clinically significant autoantibodies were not analyzed, these data provide an important population perspective on the scope and magnitude of humoral autoimmunity in the US. This is vital for prevention efforts to reduce autoimmune disease and helps clarify the potential impact of autoimmunity on the general population.
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Affiliation(s)
- Charles F. Dillon
- National Institute of Environmental Health Sciences, NIH, Bethesda, Maryland, United States of America
| | - Michael H. Weisman
- Cedars-Sinai Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Frederick W. Miller
- National Institute of Environmental Health Sciences, NIH, Bethesda, Maryland, United States of America
- * E-mail:
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22
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Cui Y, Rijhsinghani A. Role of Maternal Thyroid-Stimulating Immunoglobulin in Graves' Disease for Predicting Perinatal Thyroid Dysfunction. AJP Rep 2019; 9:e341-e345. [PMID: 31723454 PMCID: PMC6847696 DOI: 10.1055/s-0039-1694035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 05/06/2019] [Indexed: 01/18/2023] Open
Abstract
Objective To assess maternal thyroid-stimulating immunoglobulin (TSI) as a predictor of neonatal thyroid hyperthyroidism in pregnancies complicated by Graves' disease. Methods This is a 10-year retrospective study of patients with a history of Graves' disease and elevated TSI activity level defined as 1.3 times the normal. All subjects underwent cordocentesis for ultrasound findings of suspected fetal thyrotoxicosis (fetal tachycardia, oligohydramnios, hydrops, and thyromegaly). Neonatal diagnosis was made based on neonatal thyroid function testing or symptoms. Results Fourteen patients were included in the study, seven with active Graves' disease requiring antithyroid drug ("ATD group") and seven with iatrogenic hypothyroidism on levothyroxine ("levothyroxine group"). Four cases (57%) of neonatal thyrotoxicosis were diagnosed in the levothyroxine group compared with two cases (28%) in the ATD group. The lowest maternal TSI level at which a neonate did not develop hyperthyroidism was 2.6 for the levothyroxine group and 2.5 for the ATD group. The odds ratio of a neonate from the levothyroxine group developing hyperthyroidism compared with one from the ATD group is 3.3 (95% confidence interval: 0.4-30.7). Conclusion For patients with Graves' disease, those with iatrogenic hypothyroidism and TSI > 2.5 times the basal level are at the highest risk for neonatal thyrotoxicosis.
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Affiliation(s)
- Yiwen Cui
- Department of Obstetrics and Gynecology, Albany Medical Center, Albany, New York
| | - Asha Rijhsinghani
- Department of Obstetrics and Gynecology, Albany Medical Center, Albany, New York.,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Fetal Diagnosis Unit, University of Iowa, Iowa City, Iowa
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23
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Abstract
PURPOSE OF REVIEW Graves' hyperthyroidism is associated with significant obstetric, maternal, fetal, and neonatal complications. Early diagnosis and an understanding of the management of Graves' hyperthyroidism in pregnancy can help to prevent these complications. Antithyroid drugs (ATD) should be avoided in early pregnancy, given their association with congenital malformations. RECENT FINDINGS TSH-receptor antibodies (TRAb) are integral in the management of Graves' hyperthyroidism in pregnancy and in the preconception period. TRAb are indicative of the current activity of Graves' hyperthyroidism and the likelihood of relapse. Furthermore, TRAb predicts the risk of fetal and neonatal hyperthyroidism.The incidence of congenital malformations is roughly the same for propylthiouracil (PTU) and methimazole (MMZ). Exposure to both ATDs in early pregnancy has been associated with increased incidence of congenital malformations compared with exposure to either ATD alone. SUMMARY The goal of the physician is maintaining euthyroidism throughout pregnancy and delivery of a healthy, euthyroid baby. An understanding of the natural progression of Graves' hyperthyroidism in pregnancy and the proper utilization of TRAb enables the physician to minimize the risks associated with Graves' hyperthyroidism and side effects of ATDs unique to pregnancy. The physician should prioritize preconception counseling in women with Graves' hyperthyroidism in order to avoid hyperthyroidism and having to use ATDs in pregnancy.
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Affiliation(s)
- Caroline T Nguyen
- Division of Endocrinology, Diabetes, & Metabolism, Department of Medicine and Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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24
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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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25
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Moleti M, Di Mauro M, Sturniolo G, Russo M, Vermiglio F. Hyperthyroidism in the pregnant woman: Maternal and fetal aspects. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2019; 16:100190. [PMID: 31049292 PMCID: PMC6484219 DOI: 10.1016/j.jcte.2019.100190] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 04/10/2019] [Accepted: 04/11/2019] [Indexed: 12/19/2022]
Abstract
Hyperthyroidism during pregnancy is uncommon. Nonetheless, prompt identification and adequate management of hyperthyroidism in a pregnant woman is essential, because uncontrolled thyrotoxicosis significantly increases the risk of maternal and fetal complications. Also, fetal prognosis may be affected by the transplacental passage of maternal thyroid stimulating antibodies or thyrostatic agents, both of which may disrupt fetal thyroid function. Birth defects have been reported in association with the use of antithyroid drugs during early pregnancy. Although rarely, offspring of mothers with Graves’ disease may develop fetal/neonatal hyperthyroidism, the management of which requires a close collaboration between endocrinologists, obstetricians, and neonatologists. Because of the above considerations, the management of pregnant and lactating women with hyperthyroidism requires special care, bearing in mind that both maternal thyroid excess per se and related treatments may adversely affect the newborn’s health. In this review we discuss the diagnosis and management of hyperthyroidism in pregnancy, along with the impact of thyrotoxicosis and medications on fetal outcome.
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Affiliation(s)
- Mariacarla Moleti
- Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria, 1, 98125 Messina, Italy
| | - Maria Di Mauro
- Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria, 1, 98125 Messina, Italy
| | - Giacomo Sturniolo
- Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria, 1, 98125 Messina, Italy
| | - Marco Russo
- Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria, 1, 98125 Messina, Italy
| | - Francesco Vermiglio
- Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria, 1, 98125 Messina, Italy
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26
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Promintzer-Schifferl M, Krebs M. [Thyroid disease in pregnancy : Review of current literature and guidelines]. Wien Med Wochenschr 2019; 170:35-40. [PMID: 30649652 DOI: 10.1007/s10354-018-0680-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 12/19/2018] [Indexed: 11/26/2022]
Abstract
Impaired thyroid function is observed in 15% of all pregnancies and thus represents a relevant clinical issue. The key recommendations of currents as well as a selection of recently published literature are presented in this review.
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Affiliation(s)
- Miriam Promintzer-Schifferl
- Klinische Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Michael Krebs
- Klinische Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
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Yoshihara A, Iwaku K, Noh JY, Watanabe N, Kunii Y, Ohye H, Suzuki M, Matsumoto M, Suzuki N, Tadokoro R, Sekiyama C, Hiruma M, Sugino K, Ito K. Incidence of Neonatal Hyperthyroidism Among Newborns of Graves' Disease Patients Treated with Radioiodine Therapy. Thyroid 2019; 29:128-134. [PMID: 30426886 DOI: 10.1089/thy.2018.0165] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The serum thyrotropin receptor antibody (TRAb) titers of Graves' disease (GD) patients are known to increase after radioiodine (RAI) therapy, and they can remain high for years. The incidence of neonatal hyperthyroidism (NH) among newborns of mothers with GD who conceived after RAI therapy has not been previously reported. The aims of this study were to investigate the incidence of NH among newborns of mothers who conceived within two years after RAI therapy, and to identify predictors of NH. METHODS GD patients (n = 145) who conceived within two years after RAI therapy were retrospectively reviewed, and information regarding their newborns was collected. RESULTS Of the 145 pregnant women, 54 (37%) were treated with antithyroid drugs or potassium iodide for maternal hyperthyroidism during the first trimester. There were eight newborns with NH, resulting in an incidence of 5.5%. Seven of the eight mothers whose newborns had NH were treated with antithyroid drugs or potassium iodide during their pregnancy. The incidence of NH among the newborns of mothers who conceived within 6-12 months after RAI therapy was 8.8%, within 12-18 months was 5.5%, and within 18-24 months was 3.6%. Multivariate analysis revealed that the TRAb values in the third trimester were the only risk factor for NH. The cutoff TRAb value in the third trimester for predicting NH was 9.7 IU/L (reference value <2.0 IU/L). CONCLUSIONS The incidence of NH among newborns of mothers who conceived within two years after RAI therapy was 5.5%. The fetuses of pregnant GD patients whose TRAb value is high in the third trimester should be carefully followed by an obstetrician during pregnancy, and the newborns should be carefully followed by a pediatrician after birth.
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Affiliation(s)
- Ai Yoshihara
- Department of Internal Medicine, Ito Hospital, Tokyo, Japan
| | - Kenji Iwaku
- Department of Internal Medicine, Ito Hospital, Tokyo, Japan
| | | | | | - Yo Kunii
- Department of Internal Medicine, Ito Hospital, Tokyo, Japan
| | - Hidemi Ohye
- Department of Internal Medicine, Ito Hospital, Tokyo, Japan
| | - Miho Suzuki
- Department of Internal Medicine, Ito Hospital, Tokyo, Japan
| | | | - Nami Suzuki
- Department of Internal Medicine, Ito Hospital, Tokyo, Japan
| | - Rie Tadokoro
- Department of Internal Medicine, Ito Hospital, Tokyo, Japan
| | | | - Marino Hiruma
- Department of Internal Medicine, Ito Hospital, Tokyo, Japan
| | | | - Koichi Ito
- Department of Internal Medicine, Ito Hospital, Tokyo, Japan
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28
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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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