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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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Pollé OG, Gheldof A, Lysy PA, Bernard P. Intra-amniotic levothyroxine infusions in a case of fetal goiter due to novel Thyroglobulin gene variants. Clin Case Rep 2021; 9:e04565. [PMID: 34484748 PMCID: PMC8405428 DOI: 10.1002/ccr3.4565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 11/22/2022] Open
Abstract
Indications and administration of intra-amniotic infusions of L-thyroxine in the context of non-immune fetal hypothyroidism with goiter lack of standardization. Systematic follow-up of clinical features related to thyroid hormonal homeostasis may be useful to evaluate their efficiency and develop standardized management guidelines.
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Affiliation(s)
- Olivier G. Pollé
- Paediatric Endocrinology UnitCliniques Universitaires Saint‐LucBrusselsBelgium
| | | | - Philippe A. Lysy
- Paediatric Endocrinology UnitCliniques Universitaires Saint‐LucBrusselsBelgium
| | - Pierre Bernard
- Department of ObstetricsCliniques Universitaires Saint‐LucBrusselsBelgium
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Varela MF, Pinzon-Guzman C, Riddle S, Parikh R, McKinney D, Rutter M, Lim FY, Peiro JL. EXIT-to-airway: Fundamentals, prenatal work-up, and technical aspects. Semin Pediatr Surg 2021; 30:151066. [PMID: 34172204 DOI: 10.1016/j.sempedsurg.2021.151066] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Ex-utero intrapartum treatment (EXIT) is a delivery strategy developed to manage a variety of prenatally diagnosed conditions in the transition to newborn life. This procedure allows control and provides time for intervention in otherwise life-threatening malformations, such as congenital upper airway obstructions. EXIT-to-airway has changed the outcome of fetuses with these anomalies. The main purpose of this intervention is to improve the safety of establishing a reliable airway at birth. Maximal but controlled uterine relaxation to maintain feto-maternal perfusion and thus gas exchange, while keeping the fetal and maternal well-being are the paradigms of any type of EXIT. The most important aspect of fetal airway management is to consolidate a highly trained, well-coordinated, multidisciplinary team that is prepared for every contingency. A comprehensive prenatal assessment, including ultrasound, fetal echocardiogram, fetal MRI, and genetic testing is imperative for patient selection. Extensive preoperative planning, ad-hoc team meetings, and surgical simulations for challenging cases are critical strategies to achieve the best outcomes. This article outlines the prenatal work-up, decision making, technical aspects, and principles for a successful EXIT-to-airway procedure.
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Affiliation(s)
- Maria Florencia Varela
- The Center for Fetal and Placental Research, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), 3333 Burnet Avenue, MLC 2023, Cincinnati, OH 45229, USA
| | - Carolina Pinzon-Guzman
- The Center for Fetal and Placental Research, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), 3333 Burnet Avenue, MLC 2023, Cincinnati, OH 45229, USA; Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA
| | - Stefanie Riddle
- Division of Neonatology, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA.; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rupi Parikh
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David McKinney
- Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael Rutter
- Division of Pediatric Otolaryngology, Head and Neck Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Foong-Yen Lim
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jose L Peiro
- The Center for Fetal and Placental Research, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), 3333 Burnet Avenue, MLC 2023, Cincinnati, OH 45229, USA; Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Cellini C, Labuz DF, Buchmiller TL. Novel Approach for Laparoscopically Placed Chronic Amniotic Fluid Catheters in Sheep. Fetal Diagn Ther 2021; 48:400-406. [PMID: 33951639 DOI: 10.1159/000515695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 03/08/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Several fetal therapies involve repeated amniotic fluid intervention. We hypothesize that a minimally invasive approach can be used to safely implant an intrauterine catheter infusion system in a fetal ovine model for chronic use during pregnancy. METHOD Five pregnant sheep underwent operation between gestational days 110 and 115 (term 145 days). A Codman® implantable infusion pump was adapted for intrauterine use. The chamber was placed in the maternal flank and the tunneled catheter laparoscopically inserted into the amniotic cavity, secured with a pursestring. Three had an additional uterine anchoring suture. Ewes were sacrificed after natural delivery, and the uterus underwent gross and microscopic analyses. RESULTS There were no maternal mortalities, abortions, or preterm labor. Pumps were accessed and remained functional throughout gestation. Four ewes delivered healthy term lambs; the other delivered twins with failure to progress and demise. On necropsy, catheters secured with an anchoring suture remained in place, while the other 2 dislodged during labor. There was no chorioamnionitis by culture or histology. CONCLUSION Laparoscopically placed intra-amniotic infusion catheters were implanted safely and remained functional until delivery in an ovine model. This novel approach has promise in providing safe, durable amniotic fluid access for the potential treatment of fetal disease.
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Affiliation(s)
- Christina Cellini
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Daniel F Labuz
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Terry L Buchmiller
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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Refetoff S, Pappa T, Williams MK, Matheus MG, Liao XH, Hansen K, Nicol L, Pierce M, Blasco PA, Wiebers Jensen M, Bernal J, Weiss RE, Dumitrescu AM, LaFranchi S. Prenatal Treatment of Thyroid Hormone Cell Membrane Transport Defect Caused by MCT8 Gene Mutation. Thyroid 2021; 31:713-720. [PMID: 32746752 PMCID: PMC8110025 DOI: 10.1089/thy.2020.0306] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: Mutations of the thyroid hormone (TH)-specific cell membrane transporter, monocarboxylate transporter 8 (MCT8), produce an X-chromosome-linked syndrome of TH deficiency in the brain and excess in peripheral tissues. The clinical consequences include brain hypothyroidism causing severe psychoneuromotor abnormalities (no speech, truncal hypotonia, and spastic quadriplegia) and hypermetabolism (poor weight gain, tachycardia, and increased metabolism, associated with high serum levels of the active TH, T3). Treatment in infancy and childhood with TH analogues that reduce serum triiodothyronine (T3) corrects hypermetabolism, but has no effect on the psychoneuromotor deficits. Studies of brain from a 30-week-old MCT8-deficient embryo indicated that brain abnormalities were already present during fetal life. Methods: A carrier woman with an affected male child (MCT8 A252fs268*), pregnant with a second affected male embryo, elected to carry the pregnancy to term. We treated the fetus with weekly 500 μg intra-amniotic instillation of levothyroxine (LT4) from 18 weeks of gestation until birth at 35 weeks. Thyroxine (T4), T3, and thyrotropin (TSH) were measured in the amniotic fluid and maternal serum. Treatment after birth was continued with LT4 and propylthiouracil. Follow-up included brain magnetic resonance imaging (MRI) and neurodevelopmental evaluation, both compared with the untreated brother. Results: During intrauterine life, T4 and T3 in the amniotic fluid were maintained above threefold to twofold the baseline and TSH was suppressed by 80%, while maternal serum levels remained unchanged. At birth, the infant serum T4 was 14.5 μg/dL and TSH <0.01 mU/L compared with the average in untreated MCT8-deficient infants of 5.1 μg/ and >8 mU/L, respectively. MRI at six months of age showed near-normal brain myelination compared with much reduced in the untreated brother. Neurodevelopmental assessment showed developmental quotients in receptive language and problem-solving, and gross motor and fine motor function ranged from 12 to 25 at 31 months in the treated boy and from 1 to 7 at 58 months in the untreated brother. Conclusions: This is the first demonstration that prenatal treatment improved the neuromotor and neurocognitive function in MCT8 deficiency. Earlier treatment with TH analogues that concentrate in the fetus when given to the mother may further rescue the phenotype.
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Affiliation(s)
- Samuel Refetoff
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
- Department of Pediatrics, The University of Chicago, Chicago, Illinois, USA
- Committees on Genetics, and The University of Chicago, Chicago, Illinois, USA
- Address correspondence to: Samuel Refetoff, MD, Department of Medicine, The University of Chicago, MC3090, 5841 South Maryland Avenue, Chicago, IL 60637, USA
| | - Theodora Pappa
- Department of Molecular Metabolism and Nutrition, The University of Chicago, Chicago, Illinois, USA
| | | | - M. Gisele Matheus
- Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Xiao-Hui Liao
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Karen Hansen
- Northwest Perinatal Center, Portland, Oregon, USA
| | - Lindsey Nicol
- Department of Pediatrics–Endocrinology and Oregon Health & Science University, Portland, Oregon, USA
| | - Melinda Pierce
- Department of Pediatrics–Endocrinology and Oregon Health & Science University, Portland, Oregon, USA
| | - Peter A. Blasco
- Neurodevelopmental Disabilities Doernbacher Children's Hospital, Oregon Health & Science University, Portland, Oregon, USA
| | - Mandie Wiebers Jensen
- Neurodevelopmental Disabilities Doernbacher Children's Hospital, Oregon Health & Science University, Portland, Oregon, USA
| | - Juan Bernal
- Instituto de Investigaciones Biomedicas, Consejo Superior de Investigaciones Cientificas, Universidad Autonoma de Madrid and Center for Biomedical Research on Rare Diseases, Madrid, Spain
| | - Roy E. Weiss
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Alexandra M. Dumitrescu
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
- Department of Molecular Metabolism and Nutrition, The University of Chicago, Chicago, Illinois, USA
| | - Stephen LaFranchi
- Department of Pediatrics–Endocrinology and Oregon Health & Science University, Portland, Oregon, USA
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Funaki S, Umehara N, Mezawa H, Kurakazu M, Matsushima S, Arata N, Okamoto A, Sago H. Ultrasonographic assessment of fetal thyroid in Japan: thyroid circumference and distal femoral and proximal tibial ossification. J Med Ultrason (2001) 2020; 47:603-608. [PMID: 32737626 DOI: 10.1007/s10396-020-01043-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/07/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE The present study established a nomogram of fetal thyroid circumference (FTC) and the appearance timing of fetal distal femoral and proximal tibial ossification to assess fetal thyroid function in Japan. METHODS Between April 2015 and July 2019, normal pregnant women at our hospital were recruited for the study. FTC was measured by the automatic ellipse outline and plotted against gestational age (GA). Fetal distal femoral and proximal tibial ossification measurements were obtained with standard electronic calipers from outer-to-outer margins (> 1 mm as the presence of ossification). RESULTS A total of 199 pregnant women were examined. FTC increased logarithmically to GA. A nomogram of FTC was expressed by a logarithmic formula: [Formula: see text]. The respective 5-95th percentiles of FTC at each GA were 20.2-36.2 mm at 22 weeks, 25.0-44.8 mm at 26 weeks, 29.2-52.3 mm at 30 weeks, and 32.9-59.0 mm at 34 weeks. The fetal distal femoral epiphysis was not visualized before 30 weeks, but was visualized in 100% of fetuses after 35 weeks of gestation. The fetal proximal tibial epiphysis was not visualized before 33 weeks, but was visualized in 73.7% of fetuses at 37 weeks of gestation. CONCLUSION We generated a GA-dependent FTC nomogram for Japanese fetuses. We also confirmed the appearance timing of fetal distal femoral and proximal tibial ossification to assess bone maturation. These assessments may be very useful for evaluating fetal thyroid function in Japan.
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Affiliation(s)
- Satoru Funaki
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Nagayoshi Umehara
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan.
| | - Hidetoshi Mezawa
- Division of General Allergy, Allergy Center, National Center for Child Health and Development, Tokyo, Japan
| | - Masamitsu Kurakazu
- Department of Obstetrics and Gynecology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Sachio Matsushima
- Department of Obstetrics and Gynecology, Kochi University, Kochi, Japan
| | - Naoko Arata
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Aikou Okamoto
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Haruhiko Sago
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
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Fujishima A, Sato A, Miura H, Shimoda Y, Kameyama S, Ariake C, Adachi H, Fukuoka Y, Terada Y. Fetal goiter identified in a pregnant woman with triiodothyronine-predominant graves' disease: a case report. BMC Pregnancy Childbirth 2020; 20:344. [PMID: 32493403 PMCID: PMC7268772 DOI: 10.1186/s12884-020-03035-2] [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: 02/26/2020] [Accepted: 05/25/2020] [Indexed: 11/28/2022] Open
Abstract
Background Approximately 10% of all Graves’ disease cases are triiodothyronine (T3)-predominant. T3-predominance is characterized by higher T3 levels than thyroxine (T4) levels. Thyroid stimulating hormone receptor autoantibody (TRAb) levels are higher in T3-predominant Graves’ disease cases than in non-T3-predominant Graves’ disease cases. Treatment with oral drugs is difficult. Here, we report a case of fetal goiter in a pregnant woman with T3-predominant Graves’ disease. Case presentation A 31-year-old woman had unstable thyroid function during the third trimester of pregnancy, making it impossible to reduce her dosage of antithyroid medication. She was admitted to our hospital at 34 weeks of gestation owing to hydramnios and signs of threatened premature labor, and fetal goiter (thyromegaly) was detected. The dose of her antithyroid medication was reduced, based on the assumption that it had migrated to the fetus. Subsequently, the fetal goiter decreased in size, and the hydramnios improved. The patient underwent elective cesarean delivery at 36 weeks and 5 days of gestation. The infant presented with temporary symptoms of hyperthyroidism that improved over time. Conclusions The recommended perinatal management of Graves’ disease is to adjust free T4 within a range from the upper limit of normal to a slightly elevated level in order to maintain the thyroid function of the fetus. However, in T3-predominant cases, free T4 levels may drop during the long-term course of the pregnancy owing to attempts to control the mother’s symptoms of thyrotoxicosis. Little is known about the perinatal management and appropriate therapeutic strategy for T3-predominant cases and fetal goiter. Therefore, further investigation is necessary.
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Affiliation(s)
- Akiko Fujishima
- Department of Obstetrics and Gynecology, Akita University Hospital, 1-1-1 Hondo, Akita, 010-8543, Japan.
| | - Akira Sato
- Department of Obstetrics and Gynecology, Akita University Hospital, 1-1-1 Hondo, Akita, 010-8543, Japan.,Perinatal Medical Center, Japanese Red Cross Akita Hospital, Akita, Japan
| | - Hiroshi Miura
- Department of Obstetrics and Gynecology, Akita University Hospital, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Yuki Shimoda
- Department of Obstetrics and Gynecology, Akita University Hospital, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Saeko Kameyama
- Department of Obstetrics and Gynecology, Akita University Hospital, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Chika Ariake
- Department of Obstetrics and Gynecology, Akita University Hospital, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Hiroyuki Adachi
- Department of Neonatal Medicine, Akita University Hospital, Akita, Japan
| | - Yuki Fukuoka
- Department of Diabetes and Endocrinology, Akita University Hospital, Akita, Japan
| | - Yukihiro Terada
- Department of Obstetrics and Gynecology, Akita University Hospital, 1-1-1 Hondo, Akita, 010-8543, Japan
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Nemescu D, Tanasa IA, Stoian DL, Navolan DB, Vinturache AE. Conservative in utero treatment of fetal dyshormonogenetic goiter with levothyroxine, a systematic literature review. Exp Ther Med 2020; 20:2434-2438. [PMID: 32765729 PMCID: PMC7401841 DOI: 10.3892/etm.2020.8794] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 05/14/2020] [Indexed: 12/16/2022] Open
Abstract
Fetal goitrous hypothyroidism is a rare condition associated with important obstetrical, neonatal complications, and neurodevelopmental impairments. Prenatal treatment remains controversial, and the risk to benefit ratio must be accurately assessed and considered for individualized management. The objective of this review was to evaluate the feasibility, safety, and effectiveness of the conservative in utero treatment of fetal goitrous hypothyroidism. In total, 25 reports that met our inclusion criteria were selected and the management of 38 cases was analyzed. Prenatal diagnosis consisted mainly of ultrasonographic findings. Fetal thyroid status was assessed by cordocentesis. Prenatal treatment varied widely in terms of levothyroxine (LT4) route of administration, dosage, number of injections, and frequency. Although different regimens and routes of administration were proposed, they seem to have similar results regarding fetal goiter reduction and thyroid status at birth. At birth, most babies had hypothyroidism, but the long-term follow-up indicated a normal psycho-neuromotor development. Our data confirm the feasibility of conservative treatment with LT4 for fetal goitrous hypothyroidism. Further studies are needed to determine the optimal management of this disorder.
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Affiliation(s)
- Dragos Nemescu
- Department of Obstetrics and Gynecology, 'Grigore T. Popa' University of Medicine and Pharmacy,700115 Iasi, Romania
| | - Ingrid Andrada Tanasa
- Department of Obstetrics and Gynecology, 'Grigore T. Popa' University of Medicine and Pharmacy,700115 Iasi, Romania
| | - Dana Liana Stoian
- Department of Endocrinology, 'Victor Babes' University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Dan Bogdan Navolan
- Department of Obstetrics and Gynecology, 'Victor Babes' University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Angela Elena Vinturache
- Department of Obstetrics and Gynecology, Queen Elizabeth II Hospital, Grande Prairie, AB T8V 2E8, Canada
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Machado CM, Castro JM, Campos RA, Oliveira MJ. Graves' disease complicated by fetal goitrous hypothyroidism treated with intra-amniotic administration of levothyroxine. BMJ Case Rep 2019; 12:12/8/e230457. [PMID: 31420436 DOI: 10.1136/bcr-2019-230457] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Fetal goitrous hypothyroidism is a rare entity and is caused mainly by maternal treatment of Graves' disease (GD). We report a case of a 22-year-old woman referred at 12 weeks of gestation due to hyperthyroidism subsequent to recently diagnosed GD. She started treatment with propylthiouracil and, at 21 weeks of gestation, fetal goitre was detected. A cordocentesis confirmed the diagnosis of fetal goitrous hypothyroidism, and intra-amniotic administration of levothyroxine (LT4) was performed and repeated through the pregnancy due to maintenance of fetal goitre. The pregnancy proceeded without further complications and a healthy female infant was born at 37 weeks of gestation, with visible goitre and thyroid function within the normal range at birth. Although there is no consensus on the optimal dose, the number of injections and the interval between them, intra-amniotic LT4 administration is recommended once fetal goitrous hypothyroidism is suspected, in order to prevent long-term complications of fetal hypothyroidism.
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Affiliation(s)
| | - Jorge Manuel Castro
- Gynecology and Obstetrics, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Portugal
| | - Rosa Arménia Campos
- Pediatrics, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Portugal
| | - Maria João Oliveira
- Endocrinology, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Portugal
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Hardley MT, Chon AH, Mestman J, Nguyen CT, Geffner ME, Chmait RH. Iodine-Induced Fetal Hypothyroidism: Diagnosis and Treatment with Intra-Amniotic Levothyroxine. Horm Res Paediatr 2019; 90:419-423. [PMID: 29791909 DOI: 10.1159/000488776] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 03/26/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Iodine is necessary for fetal thyroid development. Excess maternal intake of iodine can cause fetal hypothyroidism due to the inability to escape from the Wolff-Chaikoff effect in utero. CASE REPORT We report a case of fetal hypothyroid goiter secondary to inadvertent excess maternal iodine ingestion from infertility supplements. The fetus was successfully treated with intra-amniotic levothyroxine injections. Serial fetal blood sampling confirmed fetal escape from the Wolff-Chaikoff effect in the mid third trimester. Early hearing test and neurodevelopmental milestones were normal. CONCLUSION Intra-amniotic treatment of fetal hypothyroidism may decrease the rate of impaired neurodevelopment and sensorineural hearing loss.
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Affiliation(s)
- Macy T Hardley
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Andrew H Chon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jorge Mestman
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine and Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Caroline T Nguyen
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Mitchell E Geffner
- The Saban Research Institute, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ramen H Chmait
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA,
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Current knowledge about the in utero and peripartum management of fetal goiter associated with maternal Graves' disease. Eur J Obstet Gynecol Reprod Biol X 2019; 3:100027. [PMID: 31404446 PMCID: PMC6687382 DOI: 10.1016/j.eurox.2019.100027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 04/09/2019] [Accepted: 04/18/2019] [Indexed: 11/20/2022] Open
Abstract
Maternal Graves’ disease is the most common cause of fetal goiter. Fetal goiter can cause complications attributable either to the physical effects of the goiter itself or to thyroid dysfunction, which can be life-threatening and cause neurological impairment. Determining whether a goiter is caused by fetal hyperthyroidism or hypothyroidism is the main clinical problem, and in utero evaluations and management are essential. Ultrasonography combined with color Doppler and magnetic resonance imaging are helpful for the initial diagnosis and monitoring, but these imaging techniques have a limited ability to discriminate between fetal hyperthyroidism and hypothyroidism. To determine the fetal thyroid status, fetal blood sampling using cordocentesis is reliable but hazardous, and the indications must be considered carefully. Amniocentesis is an easier and safer alternative, but the correlations between the amniotic fluid and fetal serum thyroid hormone levels remain unclear. If a fetal goiter is accompanied by hypothyroidism, administering thyroid hormone intra-amniotically may be effective and relatively safe. However, the wide variety of approaches to treatment exemplifies the lack of guidelines, and no systematic studies have been conducted to date. Therefore, intrauterine treatment should be reserved for selected patients at a high risk of complications. Moreover, when intrauterine treatment fails and a fetal goiter can cause airway obstruction, intrapartum management, such as ex utero intrapartum treatment, may be required; however, reports describing the use of this procedure for fetal goiter are limited. This review summarizes the current knowledge about fetal goiter associated with maternal Graves’ disease and evaluates the most significant new findings regarding its in utero and peripartum management.
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Tanase-Nakao K, Miyata I, Terauchi A, Saito M, Wada S, Hasegawa T, Narumi S. Fetal Goitrous Hypothyroidism and Polyhydramnios in a Patient with Compound Heterozygous DUOXA2 Mutations. Horm Res Paediatr 2019; 90:132-137. [PMID: 30110704 DOI: 10.1159/000491104] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/20/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Fetal goiter is only rarely observed in pregnant women without autoimmune thyroid disorders, and there is no epidemiological data on its pathophysiology. Dual oxidase maturation factor 2 (DUOXA2), together with dual oxidase 2, serves pivotal roles in thyroid hormone biosynthesis. To date, all reported patients with DUOXA2 mutations were diagnosed postnatally through newborn screening for congenital hypothyroidism. CASE REPORT The mother of a male fetus presented at 33 + 4 gestational weeks (GW) with a fetal goiter and polyhydramnios. Cordocentesis revealed fetal hypothyroidism (TSH 253.4 mU/L, FT4 0.29 ng/dL). Intra-amniotic levothyroxine injections were performed at GW 34 + 3 and 35 + 3. The patient was born after spontaneous vaginal delivery at 35 + 6 GW without obstetrical complications. He was treated with levothyroxine until the age of 6 years when reevaluation of his thyroid functions showed normal results (TSH 1.32 mU/L, FT4 1.81 ng/dL). Eleven causative genes of CH, including DUOXA2, were analyzed with use of a next-generation sequencing technique. RESULTS A next-generation sequencing-based mutation screen led us to find that he was compound heterozygous for 2 previously reported nonsense DUOXA2 mutations (p.[Tyr138*];[Tyr246*]). CONCLUSION The present case not only illustrates the phenotypic diversity of DUOXA2 mutation carriers but also implies that DUOXA2 is important in prenatal thyroid hormone production.
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Affiliation(s)
- Kanako Tanase-Nakao
- Department of Molecular Endocrinology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Ichiro Miyata
- Department of Pediatrics, Jikei University School of Medicine, Tokyo, Japan
| | - Ayako Terauchi
- Department of Pediatrics, Jikei University School of Medicine, Tokyo, Japan
| | - Maki Saito
- Department of Pediatrics, Jikei University School of Medicine, Tokyo, Japan
| | - Seiji Wada
- Department of Obstetrics and Gynecology, Jikei University School of Medicine, Tokyo, Japan
| | - Tomonobu Hasegawa
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Narumi
- Department of Molecular Endocrinology, National Research Institute for Child Health and Development, Tokyo, Japan.,Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
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13
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Munoz JL. Fetal thyroid disorders: Pathophysiology, diagnosis and therapeutic approaches. J Gynecol Obstet Hum Reprod 2019; 48:231-233. [PMID: 30634005 DOI: 10.1016/j.jogoh.2019.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 12/17/2018] [Accepted: 01/08/2019] [Indexed: 11/28/2022]
Abstract
Fetal thyroid disorders while uncommon in general, have significant morbidity and profound effects in the neonate. Pregnancy provides the opportunity not only for the diagnosis of these conditions but also for therapeutic interventions. In careful balance, these disorders range from hypothyroidism to hyperthyroidism, both may manifest with fetal thyroid goiters as well. The intrauterine therapeutic approach of these must also weight the balance in this range as well as the maternal well being which may also express thyroid dysfunction. In this review we explore the different fetal manifestations of thyroid disease, describe the pathophysiology and therapeutic approaches both in practice and in development.
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Affiliation(s)
- Jessian L Munoz
- OB/GYN and Women's Health Institute A81, Cleveland Clinic, Cleveland, OH, 44105, USA.
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14
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Delay F, Dochez V, Biquard F, Cheve MT, Gillard P, Arthuis CJ, Winer N. Management of fetal goiters: 6-year retrospective observational study in three prenatal diagnosis and treatment centers of the Pays De Loire Perinatal Network. J Matern Fetal Neonatal Med 2019; 33:2561-2569. [PMID: 30513035 DOI: 10.1080/14767058.2018.1555803] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Introduction: The incidence of fetal goiters is reported to be around 1 per 40,000 births. The risk of complications is first of all obstetric, directly related to goiter size, but it may also affect longer term fetal and child development, depending on whether the goiter is due to hypo- or hyperthyroidism. Management is multidisciplinary, but not yet consensual and not always optimal by either endocrinologists or obstetricians.Objectives: The principal objective of this retrospective study was to analyze the data that enabled the physicians to assess whether the goiter was hypo- or hyperthyroid and then to analyze the obstetric practices used in the Pays de Loire network to describe in detail the tools used to diagnose and characterize the goiters and the management chosen in these cases. The secondary objectives are to assess, in our small cohort, the effectiveness of the in utero treatments provided, based on the examination of the children at birth and their outcome at 6 months of life, and to suggest a strategy for monitoring these women at risk that takes current guidelines into consideration.Materials and methods: This multicenter retrospective study covers a 6-year period and focused on the prenatal diagnosis centers (CPDPN) of the Pays de Loire perinatal network: in Nantes, Angers, and Le Mans. The network is responsible for around 42,000 births a year, and the study included 17 women, for a prevalence of 1 per 15,000 births.Results: Ten of the 17 fetuses had a hypothyroid goiter, 4 a hyperthyroid goiter, and 3 normal thyroid findings on fetal blood sample (FBS). For four women, these goiters were secondary to fetal dyshormonogenesis, for 9 more to Graves disease with TSH receptor antibodies (TRAb), and for four women to thyrotoxicosis at the start of pregnancy, managed by synthetic antithyroid drugs. Two newborns had severe complications associated with maternal transmission of Graves disease (TRAb positive at birth): one with exophthalmos and one with neonatal tachycardia. The other 14 had normal psychomotor development at 6 months, based on a clinical examination by a pediatric endocrinologist; only one child was lost to follow-up.Conclusion: Together, ultrasound and multidisciplinary expertise (of an endocrinologist and an obstetrician experienced with this disease) remain the best means for avoiding, or otherwise for accurately characterizing fetal goiter. An ultrasound diagnostic score, of the type proposed by Luton et al. in 2009, may make it possible to homogenize practices and thus to defer or delay the - currently too common - performance of invasive FBS procedures, which must remain rare in this management to limit comorbidities. A threshold TRAb value (>5 IU/l) makes it possible to define this group of women as at risk of fetal and neonatal hyperthyroidism and thus requiring close monitoring. The value of prenatal intra-amniotic thyroxine treatment for hypothyroid goiters (including dyshormonogenesis) remains to be demonstrated.
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Affiliation(s)
- Fabienne Delay
- Department of Gynecology and Obstetrics, CIC Hôpital Mère-Enfant, Nantes, France
| | - Vincent Dochez
- Department of Gynecology and Obstetrics, CIC Hôpital Mère-Enfant, Nantes, France.,INRA, UMR1280, Physiology of Nutritional Adaptations, University of Nantes, IMAD, Nantes, France
| | - Florence Biquard
- Department of Obstetrics and Gynecology, CHU Angers, Angers, France
| | - Marie-Thérèse Cheve
- Department of Obstetrics and Gynecology, Le Mans General Hospital, Le Mans, France
| | - Philippe Gillard
- Department of Obstetrics and Gynecology, CHU Angers, Angers, France.,Securite Naissance-Naitre ensemble, Perinatal Network Pays de Loire, Nantes, France
| | - C J Arthuis
- Department of Gynecology and Obstetrics, CIC Hôpital Mère-Enfant, Nantes, France.,Securite Naissance-Naitre ensemble, Perinatal Network Pays de Loire, Nantes, France
| | - Norbert Winer
- Department of Gynecology and Obstetrics, CIC Hôpital Mère-Enfant, Nantes, France.,INRA, UMR1280, Physiology of Nutritional Adaptations, University of Nantes, IMAD, Nantes, France.,Securite Naissance-Naitre ensemble, Perinatal Network Pays de Loire, Nantes, France
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15
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Prenatal Diagnosis and Management of a Fetal Goiter Hypothyroidism due to Dyshormonogenesis. Case Rep Endocrinol 2018; 2018:9564737. [PMID: 30662777 PMCID: PMC6313984 DOI: 10.1155/2018/9564737] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 11/13/2018] [Indexed: 11/17/2022] Open
Abstract
Fetal goiter is a rare disorder not expected to be found during a healthy woman's pregnancy. It can be a prenatal manifestation of congenital hypothyroidism due to thyroid dyshormonogenesis and it can lead to serious perinatal complications. A vascularized fetal neck mass was detected at 29 weeks' gestation of a healthy primigravida. Magnetic resonance was suggestive of goiter causing airway deviation without polyhydramnios. Maternal thyroid function was normal and thyroid antibodies were negative. Two intra-amniotic levothyroxine infusions were performed at 32 and 33 weeks. Serial imaging control showed no progression of the mass. Elective caesarean section was performed at 38 weeks. The male newborn was admitted to the intensive care unit due to cardiorespiratory insufficiency with pulmonary hypertension. Hormonal assays revealed primary congenital hypothyroidism and ultrasonography confirmed diffuse goiter. Levothyroxine was started. Currently, he is 6 years old with adequate growth and normal psychomotor development. Genetic study found a heterozygous mutation in the TPO gene.
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16
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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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17
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Vasudevan P, Powell C, Nicholas AK, Scudamore I, Greening J, Park SM, Schoenmakers N. Intrauterine death following intraamniotic triiodothyronine and thyroxine therapy for fetal goitrous hypothyroidism associated with polyhydramnios and caused by a thyroglobulin mutation. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM170040. [PMID: 28620499 PMCID: PMC5467655 DOI: 10.1530/edm-17-0040] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 05/10/2017] [Indexed: 11/15/2022] Open
Abstract
In the absence of maternal thyroid disease or iodine deficiency, fetal goitre is rare and usually attributable to dyshormonogenesis, for which genetic ascertainment is not always undertaken in the UK. Mechanical complications include tracheal and oesophageal compression with resultant polyhydramnios, malpresentation at delivery and neonatal respiratory distress. We report an Indian kindred in which the proband (first-born son) had congenital hypothyroidism (CH) without obvious neonatal goitre. His mother’s second pregnancy was complicated by fetal hypothyroid goitre and polyhydramnios, prompting amniotic fluid drainage and intraamniotic therapy (with liothyronine, T3 and levothyroxine, T4). Sadly, intrauterine death occurred at 31 weeks. Genetic studies in the proband demonstrated compound heterozygous novel (c.5178delT, p.A1727Hfs*26) and previously described (c.7123G > A, p.G2375R) thyroglobulin (TG) mutations which are the likely cause of fetal goitre in the deceased sibling. TG mutations rarely cause fetal goitre, and management remains controversial due to the potential complications of intrauterine therapy however an amelioration in goitre size may be achieved with intraamniotic T4, and intraamniotic T3/T4 combination has achieved a favourable outcome in one case. A conservative approach, with surveillance, elective delivery and commencement of levothyroxine neonatally may also be justified, although intubation may be required post delivery for respiratory obstruction. Our observations highlight the lethality which may be associated with fetal goitre. Additionally, although this complication may recur in successive pregnancies, our case highlights the possibility of discordance for fetal goitre in siblings harbouring the same dyshormonogenesis-associated genetic mutations. Genetic ascertainment may facilitate prenatal diagnosis and assist management in familial cases.
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Affiliation(s)
- Pradeep Vasudevan
- Leicester Clinical Genetics, Women's and Children's Services, Leicester Royal Infirmary, LeicesterUK
| | - Corrina Powell
- Leicester Clinical Genetics, Women's and Children's Services, Leicester Royal Infirmary, LeicesterUK
| | - Adeline K Nicholas
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, CambridgeUK
| | - Ian Scudamore
- Department of Obstetrics and Gynaecology, Women's and Prenatal Services, Leicester General Hospital, LeicesterUK
| | - James Greening
- Department of Paediatric Endocrinology, Leicester Royal Infirmary, LeicesterUK
| | - Soo-Mi Park
- Department of Clinical Genetics, Cambridge University Hospitals NHS Foundation Trust, CambridgeUK
| | - Nadia Schoenmakers
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, CambridgeUK
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18
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Fujii S, Nagaishi J, Mukuda N, Kaneda S, Inoue C, Fukunaga T, Ogawa T. Evaluation of Fetal Thyroid with 3D Gradient Echo T 1-weighted MR Imaging. Magn Reson Med Sci 2016; 16:203-208. [PMID: 28025468 PMCID: PMC5600026 DOI: 10.2463/mrms.mp.2015-0157] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Purpose: The characteristics of fetal thyroid on magnetic resonance (MR) imaging, including normal thyroid and disorders other than goiter have not been fully evaluated. Our aim was to assess fetal thyroid using three dimensional (3D) gradient echo (GRE) T1-weighted MR imaging and to examine the usefulness of this modality. Materials and Methods: The study included 27 3D GRE T1-weighted images from 26 fetuses. The largest possible region of interest (ROI) within the thyroid at the slice level depicting the thyroid was manually defined and three circular ROIs on neck muscle were manually defined on the image slices showing the highest signal intensity (SI) of the thyroid. Maximum and mean thyroid-to-muscle SI ratios (SIRs) were then calculated as SIR = maximum or mean thyroid SI/muscle SI. Results: The thyroid could not be identified in two cases. Fetal thyroid function was normal in 17 cases, and there were 7 cases of hypothyroidism (6 transient and 1 thyroid dysgenesis). There was no linear relationship between mean and maximum SIR and gestational age. The mean and maximum SIR in the cases of normal fetal thyroid were 1.85 ± 0.20 and 2.61 ± 0.39, and the mean and maximum SIR in fetal hypothyroidism were 1.58 ± 0.20 and 2.13 ± 0.37. Mean (P = 0.0088) and maximum (P = 0.0221) SIR values were significantly different between euthyroid and hypothyroid fetuses. Conclusion: Thyroid SIR measurement provided useful information regarding fetal thyroid function.
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Affiliation(s)
- Shinya Fujii
- Division of Radiology, Department of Pathophysiological and Therapeutic Science, Faculty of Medicine, Tottori University
| | | | - Naoko Mukuda
- Division of Radiology, Department of Pathophysiological and Therapeutic Science, Faculty of Medicine, Tottori University
| | - Sachi Kaneda
- Division of Radiology, Department of Pathophysiological and Therapeutic Science, Faculty of Medicine, Tottori University
| | - Chie Inoue
- Division of Radiology, Department of Pathophysiological and Therapeutic Science, Faculty of Medicine, Tottori University
| | - Takeru Fukunaga
- Division of Radiology, Department of Pathophysiological and Therapeutic Science, Faculty of Medicine, Tottori University
| | - Toshihide Ogawa
- Division of Radiology, Department of Pathophysiological and Therapeutic Science, Faculty of Medicine, Tottori University
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19
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Menut-Ruel A, Barthod M, Gauchez AS, Dupuis C, Charrie A, Dubois C, Leriche A, Polverelli JF, Althuser M, Jouk PS, Chabre O. Fetal hypothyroidism induced by maternal anti-TSH receptor blocking antibodies and complicated by polyhydramnios despite the absence of goiter. Treatment by intra-amniotic injections of levothyroxine. ANNALES D'ENDOCRINOLOGIE 2016; 78:61-64. [PMID: 27919402 DOI: 10.1016/j.ando.2016.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Revised: 07/31/2016] [Accepted: 09/13/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Adèle Menut-Ruel
- Pôle couple enfant, département de pédiatrie, CHU des Alpes, CS 10217, 38043 Grenoble cedex 9, France
| | - Marie Barthod
- Service d'endocrinologie, CHU des Alpes, CS 10217, 38043 Grenoble cedex 9, France
| | - Anne-Sophie Gauchez
- Pôle de biologie, institut de biologie et de pathologie, CHU des Alpes, CS 10217, 38043 Grenoble cedex 9, France; Laboratoire de radio analyses, service de médecine nucléaire, centre hospitalier métropole Savoie, 73000 Chambéry, France
| | - Clémentine Dupuis
- Pôle couple enfant, département de pédiatrie, CHU des Alpes, CS 10217, 38043 Grenoble cedex 9, France
| | - Anne Charrie
- Pôle de biologie, CHU de Lyon-Sud, CARMEN-Inserm U 1060, 69000 Lyon, France
| | - Claire Dubois
- Pôle couple enfant, département de gynécologie obstétrique, centre hospitalier métropole Savoie, 73000 Chambéry, France
| | - Agnès Leriche
- Endocrinologue libérale, 27, allée Albert-Sylvestre, 73000 Chambéry, France
| | | | - Marc Althuser
- Pôle couple enfant, département de génétique et procréation, centre pluridisciplinaire de diagnostic prénatal, CHU des Alpes, CS 10217, 38043 Grenoble cedex 9, France
| | - Pierre Simon Jouk
- Pôle couple enfant, département de génétique et procréation, centre pluridisciplinaire de diagnostic prénatal, CHU des Alpes, CS 10217, 38043 Grenoble cedex 9, France
| | - Olivier Chabre
- Service d'endocrinologie, CHU des Alpes, CS 10217, 38043 Grenoble cedex 9, France.
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20
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Ferianec V, Papcun P, Grochal F, Schenková K, Bártová M. Prenatal diagnosis and successful intrauterine treatment of severe congenital hypothyroidism associated with fetal goiter. J Obstet Gynaecol Res 2016; 43:232-237. [DOI: 10.1111/jog.13183] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 08/09/2016] [Accepted: 08/21/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Vladimír Ferianec
- 2nd Department of Obstetrics and Gynecology; University Hospital Bratislava; Bratislava
| | - Peter Papcun
- 2nd Department of Obstetrics and Gynecology; University Hospital Bratislava; Bratislava
| | | | | | - Michaela Bártová
- 2nd Department of Obstetrics and Gynecology; University Hospital Bratislava; Bratislava
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21
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Munoz JL, Kessler AA, Felig P, Curtis J, Evans MI. Sequential Amniotic Fluid Thyroid Hormone Changes Correlate with Goiter Shrinkage following in utero Thyroxine Therapy. Fetal Diagn Ther 2015; 39:222-7. [PMID: 26314950 DOI: 10.1159/000437367] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 06/30/2015] [Indexed: 11/19/2022]
Abstract
Several isolated reports of fetal goiter treatment have shown limited generalizability of approaches and provide no real guidance for optimal timing, dosages, and treatment strategies. Graves' disease accounts for >60% of these cases. Maternal treatments of hyperthyroidism include antithyroid medications such as methimazole and more commonly propylthiouracil (PTU). Here, our management of a patient with a fetal thyroid goiter from maternal exposure to PTU diagnosed at 23.6 weeks' gestation and the management of other cases allow us propose a general strategy for treatment. Intrauterine therapy with 200 and then 400 μg of levothyroxine (3 weeks apart) showed an 85% reduction in fetal thyroid goiter volume. We collected amniotic fluid samples at the time of treatments and assayed thyroid hormones and associated antibodies which closely reflected the changes in thyroid goiter mass volume. Our observations suggest a weekly or biweekly therapeutic intervention schedule. Utilizing both goiter size as well as a novel approach in using amniotic fluid hormone levels to monitor therapy efficacy might improve the quality of treatments. Only with a standardized approach and collection of amniotic fluid thyroid panels do we have the opportunity to develop the database required to determine the number and timing of treatments needed.
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Affiliation(s)
- Jessian L Munoz
- Fetal Medicine Foundation of America and Comprehensive Genetics, PLLC, New York, N.Y., USA
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22
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Léger J, Olivieri A, Donaldson M, Torresani T, Krude H, van Vliet G, Polak M, Butler G. European Society for Paediatric Endocrinology consensus guidelines on screening, diagnosis, and management of congenital hypothyroidism. Horm Res Paediatr 2015; 81:80-103. [PMID: 24662106 DOI: 10.1159/000358198] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Accepted: 09/18/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The aim was to formulate practice guidelines for the diagnosis and management of congenital hypothyroidism (CH). EVIDENCE A systematic literature search was conducted to identify key articles relating to the screening, diagnosis, and management of CH. The evidence-based guidelines were developed with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system, describing both the strength of recommendations and the quality of evidence. In the absence of sufficient evidence, conclusions were based on expert opinion. CONSENSUS PROCESS Thirty-two participants drawn from the European Society for Paediatric Endocrinology and five other major scientific societies in the field of pediatric endocrinology were allocated to working groups with assigned topics and specific questions. Each group searched the literature, evaluated the evidence, and developed a draft document. These papers were debated and finalized by each group before presentation to the full assembly for further discussion and agreement. RECOMMENDATIONS The recommendations include: worldwide neonatal screening, approaches to assess the cause (including genotyping) and the severity of the disorder, the immediate initiation of appropriate L-T4 supplementation and frequent monitoring to ensure dose adjustments to keep thyroid hormone levels in the target ranges, a trial of treatment in patients suspected of transient CH, regular assessments of developmental and neurosensory functions, consulting health professionals as appropriate, and education about CH. The harmonization of diagnosis, management, and routine health surveillance would not only optimize patient outcomes, but should also facilitate epidemiological studies of the disorder. Individuals with CH require monitoring throughout their lives, particularly during early childhood and pregnancy.
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Affiliation(s)
- Juliane Léger
- Université Paris Diderot, Sorbonne Paris Cité, Paris, France
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23
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Mastrolia SA, Mandola A, Mazor M, Hershkovitz R, Mesner O, Beer-Weisel R, Besser L, Shelef I, Loewenthal N, Golan A, Gruzman I, Erez O. Antenatal diagnosis and treatment of hypothyroid fetal goiter in an euthyroid mother: a case report and review of literature. J Matern Fetal Neonatal Med 2014; 28:2214-20. [PMID: 25363013 DOI: 10.3109/14767058.2014.983062] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Fetal goiter is an extremely rare complication of pregnancy. Its incidence is 1 in 40,000 deliveries. Antithyroid maternal therapy is responsible for 10-15% of fetal congenital hypothyroidism and can be considered as the most frequent underlying cause for this condition. The frequency of fetal goiter that is associated with fetal hypothyroidism and normal maternal thyroid function, as in our case, is even less frequent. Fetal goiter is associated with increased rate of perinatal complications and long-term morbidity, due to peripartum complications including labor dystocia due to its mass effect, as well as neonatal airway obstruction that may lead to hypoxic-ischemic brain injury and death. We present, in this study, a case report of late antenatal fetal goiter in an euthyroid woman and a literature review of the diagnosis and treatment of these cases.
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Affiliation(s)
- Salvatore Andrea Mastrolia
- a Department of Obstetrics and Gynecology , Azienda Ospedaliera-Universitaria Policlinico di Bari, School of Medicine, University of Bari "Aldo Moro" , Bari , Italy
| | | | | | | | | | | | | | | | | | | | - Igor Gruzman
- h Department of Anesthesiology and Critical Care, Faculty of Health Sciences , Soroka University Medical Center, School of Medicine, Ben Gurion University of the Negev , Beer Sheva , Israel
| | - Offer Erez
- c Department of Obstetrics and Gynecology
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24
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Khamisi S, Lindgren P, Karlsson FA. A rare case of dyshormonogenetic fetal goiter responding to intra-amniotic thyroxine injections. Eur Thyroid J 2014; 3:51-6. [PMID: 24847466 PMCID: PMC4005266 DOI: 10.1159/000357973] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 12/12/2013] [Indexed: 11/19/2022] Open
Abstract
Fetal goiter was detected by routine ultrasound in early pregnancy, gestational week (GW) 18, in a 28-year-old woman with no thyroid history, normal thyroid hormone levels and no TSH receptor or thyroid peroxidase antibodies. An umbilical cord blood sample was drawn in GW 23. The analysis indicated fetal hypothyroidism with TSH >100 mU/l (reference value 6.8 ± 2.9, mean ± SD), fT4 3.8 pmol/l (reference value 16.5 ± 5.3, mean ± SD). Intra-amniotic injections of thyroxine were given in conjunction with ultrasound every 7-10 days, in total nine times during GW 24-33. A dose of 10 µg thyroxine/kg of estimated fetal weight per day was administered on six occasions, and 5 µg/kg/day the last three times. Upon injections of thyroxine further growth of the goiter was reduced. Elevated amniotic TSH levels fell from 13 to 2.5 mU/l (reference range 0.04-0.51). Throughout pregnancy, fetal heart rate and skeletal maturation were within normal limits. In week 34, chorioamnionitis was suspected and the child was delivered by cesarean section. Cord blood revealed TSH 596 mU/l (reference value 8.0 ± 5.12, mean ± SD), fT4 4.4 pmol/l (reference value 19.3 ± 4.3, mean ± SD) and total T3 1.18 nmol/l (reference value 0.5 ± 0.3, mean ± SD); the newborn was put on thyroxine supplementation. Psychomotor development of the child, now 3 years old, has been uneventful. The reported experience of treating dyshormonogenetic fetal goiter is limited but growing, creating a need for guidelines on administration of intra-amniotic thyroxine and monitoring treatment.
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Affiliation(s)
- Selwan Khamisi
- Department of Endocrinology and Diabetes, Uppsala University, Uppsala, Sweden
| | - Peter Lindgren
- Women's and Children's Health, University Hospital, Uppsala University, Uppsala, Sweden
| | - F. Anders Karlsson
- Department of Endocrinology and Diabetes, Uppsala University, Uppsala, Sweden
- *F. Anders Karlsson, MD, PhD, Institute of Medical Sciences, Uppsala University Hospital, University of Uppsala, SE-751 85 Uppsala (Sweden), E-Mail
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Abstract
Advances in prenatal imaging techniques and in fetal hormonology now allow for identification of disorders of thyroid function in the fetus. These can potentially be treated in utero by giving drugs to the mother. This review shows the feasibility of in utero treatment of fetal thyroid disorders, either indirectly by treating the mother or by giving the necessary drugs directly to the fetus. For goitrous fetal hypothyroidism leading to hydramnios, repeated intra-amniotic injections of thyroxine have been reported to decrease the size of the fetal thyroid. Experience with such procedures is limited but positive. The risk that direct in utero treatment of the fetus may provoke premature labor or cause infection should be carefully evaluated. In women with Graves' disease, autoimmune fetal hyperthyroidism can generally be treated in a noninvasive way by optimizing treatment of the mother, such as by increasing the dose of antithyroid drugs. Follow-up of the efficacy and the possible long-term consequences of medical interventions to normalize thyroid function of the fetus are of great importance. Specialized care of the fetus should be provided by skilled teams with extensive experience in prenatal care.
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Affiliation(s)
- Michel Polak
- Pediatric Endocrinology, Gynecology and Diabetology, Necker Enfants-Malades Hospital, AP-HP, Paris, France; INSERM U845, IMAGINE affiliate, Université Paris Descartes, Sorbonne Paris Cité, Paris, France.
| | - Dominique Luton
- Obstetrics and Gynecology, AP-HP, GHU Nord, Hôpital Beaujon and Bichat, Paris and Clichy, Université Paris VII, Paris, France.
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Léger J, Olivieri A, Donaldson M, Torresani T, Krude H, van Vliet G, Polak M, Butler G. European Society for Paediatric Endocrinology consensus guidelines on screening, diagnosis, and management of congenital hypothyroidism. J Clin Endocrinol Metab 2014; 99:363-84. [PMID: 24446653 PMCID: PMC4207909 DOI: 10.1210/jc.2013-1891] [Citation(s) in RCA: 250] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim was to formulate practice guidelines for the diagnosis and management of congenital hypothyroidism (CH). EVIDENCE A systematic literature search was conducted to identify key articles relating to the screening, diagnosis, and management of CH. The evidence-based guidelines were developed with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system, describing both the strength of recommendations and the quality of evidence. In the absence of sufficient evidence, conclusions were based on expert opinion. CONSENSUS PROCESS Thirty-two participants drawn from the European Society for Paediatric Endocrinology and five other major scientific societies in the field of pediatric endocrinology were allocated to working groups with assigned topics and specific questions. Each group searched the literature, evaluated the evidence, and developed a draft document. These papers were debated and finalized by each group before presentation to the full assembly for further discussion and agreement. RECOMMENDATIONS The recommendations include: worldwide neonatal screening, approaches to assess the cause (including genotyping) and the severity of the disorder, the immediate initiation of appropriate L-T4 supplementation and frequent monitoring to ensure dose adjustments to keep thyroid hormone levels in the target ranges, a trial of treatment in patients suspected of transient CH, regular assessments of developmental and neurosensory functions, consulting health professionals as appropriate, and education about CH. The harmonization of diagnosis, management, and routine health surveillance would not only optimize patient outcomes, but should also facilitate epidemiological studies of the disorder. Individuals with CH require monitoring throughout their lives, particularly during early childhood and pregnancy.
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Affiliation(s)
- Juliane Léger
- Université Paris Diderot (J.L.), Sorbonne Paris Cité, F-75019 Paris, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Robert Debré, Service d'Endocrinologie Diabétologie Pédiatrique et Centre de Référence des Maladies Endocriniennes Rares de la Croissance, F-75019, Paris, France; Institut National de la Santé et de la Recherche Médicale (INSERM), Unité Mixte de Recherche 676, F-75019 Paris, France; Department of Cell Biology and Neurosciences (A.O.), Istituto Superiore di Sanità, 00161 Rome, Italy; Child Health Section of Glasgow University School of Medicine (M.D.), Royal Hospital for Sick Children, Yorkhill, Glasgow G3 8SJ, Scotland, United Kingdom; Swiss Neonatal Screening Laboratory (T.T.), University Children's Hospital, CH-8032 Zurich, Switzerland; Department of Pediatric Endocrinology and Diabetes (H.K.), Charite Children's Hospital, Berlin 10117, Germany; Endocrinology Service and Research Center (G.v.V.), Centre Hospitalier Universitaire Sainte-Justine and Department of Pediatrics, University of Montreal, Montreal, Canada H3T 1C5; AP-HP, Hôpital Necker Enfants-Malades, Endocrinologie, Gynécologie et Diabétologie Pédiatriques (M.P.), Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Université Paris Descartes, Sorbonne Paris Cité, INSERM, Unité 845, F-75015 Paris, France; and Department of Paediatric and Adolescent Medicine and Endocrinology (G.B.), University College London Hospital, and University College London Institute of Child Health, London NW1 2PQ, United Kingdom
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Namouz-Haddad S, Koren G. Fetal Pharmacotherapy 4: Fetal Thyroid Disorders. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2014; 36:60-63. [DOI: 10.1016/s1701-2163(15)30684-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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28
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Hipertiroidismo y embarazo. ACTA ACUST UNITED AC 2013; 60:535-43. [DOI: 10.1016/j.endonu.2012.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2012] [Revised: 11/09/2012] [Accepted: 11/12/2012] [Indexed: 11/20/2022]
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Blumenfeld YJ, Davis A, Milan K, Chueh J, Hudgins L, Barth RA, Hintz SR. Conservatively managed fetal goiter: an alternative to in utero therapy. Fetal Diagn Ther 2013; 34:184-7. [PMID: 23920148 DOI: 10.1159/000353387] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 05/29/2013] [Indexed: 11/19/2022]
Abstract
Fetal goiter may arise from a variety of etiologies including iodine deficiency, overtreatment of maternal Graves' disease, inappropriate maternal thyroid replacement and, rarely, congenital hypothyroidism. Fetal goiter is often associated with a retroflexed neck and polyhydramnios, raising concerns regarding airway obstruction in such cases. Prior reports have advocated for cordocentesis and intra-amniotic thyroid hormone therapy in order to confirm the diagnosis of fetal thyroid dysfunction, reduce the size of the fetal goiter, reduce polyhydramnios, aid with the assistance of maternal thyroid hormone therapy and reduce fetal malpresentation. We report two cases of conservatively managed fetal goiter, one resulting in a vaginal delivery, and no evidence of postnatal respiratory distress despite the presence of polyhydramnios and a retroflexed neck on prenatal ultrasound.
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Affiliation(s)
- Yair J Blumenfeld
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, Calif., USA
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Stewart CJM, Constantatos S, Joolay Y, Muller L. In utero treatment of fetal goitrous hypothyroidism in a euthyroid mother: a case report. JOURNAL OF CLINICAL ULTRASOUND : JCU 2012; 40:603-606. [PMID: 22505274 DOI: 10.1002/jcu.21921] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Accepted: 02/24/2012] [Indexed: 05/31/2023]
Abstract
Fetal goitrous hypothyroidism is a rare condition in euthyroid pregnant women. Complications such as tracheal and esophageal compression with resultant polyhydramnios, as well as the possibility of neurodevelopmental effects of hypothyroidism, have prompted prenatal treatment with intra-amniotic L-thyroxine. We report a case of this condition and its in utero management.
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Affiliation(s)
- Chantal J M Stewart
- Department of Obstetrics and Gynaecology, Groote Schuur Hospital, Cape Town, South Africa
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Kornacki J, Mroziński B, Skrzypczak J. A Rare Case of Recurrent Fetal Goiter. Fetal Diagn Ther 2012; 31:69-72. [DOI: 10.1159/000331454] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Accepted: 08/04/2011] [Indexed: 11/19/2022]
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Abstract
Thyroid diseases are common in women of childbearing age and it is well known that untreated thyroid disturbances result in an increased rate of adverse events, particularly miscarriage, preterm birth and gestational hypertension. Furthermore, thyroid autoimmunity per se seems to be associated with complications such as miscarriage and preterm delivery. While strong evidence clearly demonstrates that overt dysfunctions (hyper- or hypothyroidism) have deleterious effects on pregnancy, subclinical disease, namely subclinical hypothyroidism, has still to be conclusively defined as a risk factor for adverse outcomes. Additionally, other conditions, such as isolated hypothyroxinemia and thyroid autoimmunity in euthyroidism, are still clouded with uncertainty regarding the need for substitutive treatment.
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Affiliation(s)
- Roberto Negro
- Division of Endocrinology, "V. Fazzi" Hospital, Lecce, Italy.
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Vanmiddlesworth L, Vanmiddlesworth NR, Egerman RS, Bush AJ, Ramsey RD, Delmar LP, Ho EC, Wu SY. Thyroid function and 3,3'-diiodothyronine sulfate cross-reactive substance (compound W) in maternal hyperthyroidism with antithyroid treatment. Endocr Pract 2011; 17:170-6. [PMID: 20713348 DOI: 10.4158/ep09305.or] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To test whether the serial measurement of maternal levels of compound W, a 3,3'-diiodothyronine sulfate cross-reactive substance, can serve as a potential indicator of fetal thyroid function in pregnant women receiving antithyroid medication. METHODS Compound W was measured repeatedly in serum of pregnant women with hyperthyroidism treated with antithyroid medication. Free thyroxine levels of mothers and serum thyroid-stimulating hormone levels of 1-day-old neonates were analyzed by local clinical or state laboratories. RESULTS Use of minimal antithyroid medication impaired the progressive increase of compound W seen in euthyroid mothers during pregnancy. At term, depressed compound W levels in maternal serum were found in 7 of 22 pregnancies; in 1 case, maternal compound W was suppressed and newborn thyroid-stimulating hormone was elevated. Seven mothers with treated hyperthyroidism failed to show an increase in serum levels of compound W after midterm. CONCLUSION Normal progression of maternal serum compound W may be an index of normal fetal thyroid development in mothers with hyperthyroidism treated with necessary antithyroid medication.
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Affiliation(s)
- Lester Vanmiddlesworth
- Department of Physiology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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34
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Hui L, Bianchi DW. Prenatal pharmacotherapy for fetal anomalies: a 2011 update. Prenat Diagn 2011; 31:735-43. [PMID: 21638296 DOI: 10.1002/pd.2777] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 04/12/2011] [Accepted: 04/17/2011] [Indexed: 11/11/2022]
Abstract
Fetal therapy can be defined as any prenatal treatment administered to the mother with the primary indication to improve perinatal or long-term outcomes for the fetus or newborn. This review provides an update of the pharmacological therapies that are solely directed at the fetus with anomalies and outlines a future transcriptomic approach. Fetal anomalies targeted with prenatal pharmacotherapy are a heterogeneous group of structural, endocrine, and metabolic conditions, including congenital cystic adenomatoid malformation (CCAM), congenital adrenal hyperplasia, congenital heart block, fetal tachyarrhythmias, inborn errors of metabolism, fetal thyroid disorders, and polyhydramnios. To date, the majority of pharmacotherapies for fetal anomalies have been evaluated only in retrospective, uncontrolled studies. The way forward will be with an evidence-based approach to prenatal pharmacological interventions.
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Affiliation(s)
- Lisa Hui
- Mother Infant Research Institute, Tufts Medical Center, Boston, MA, USA.
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Citterio CE, Coutant R, Rouleau S, Miralles García JM, Gonzalez-Sarmiento R, Rivolta CM, Targovnik HM. A new compound heterozygous for c.886C>T/c.2206C>T [p.R277X/p.Q717X] mutations in the thyroglobulin gene as a cause of foetal goitrous hypothyroidism. Clin Endocrinol (Oxf) 2011; 74:533-5. [PMID: 21128992 DOI: 10.1111/j.1365-2265.2010.03932.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bliddal S, Rasmussen AK, Sundberg K, Brocks V, Feldt-Rasmussen U. Antithyroid drug-induced fetal goitrous hypothyroidism. Nat Rev Endocrinol 2011; 7:396-406. [PMID: 21403664 DOI: 10.1038/nrendo.2011.34] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Maternal overtreatment with antithyroid drugs can induce fetal goitrous hypothyroidism. This condition can have a critical effect on pregnancy outcome, as well as on fetal growth and neurological development. The purpose of this Review is to clarify if and how fetal goitrous hypothyroidism can be prevented, and how to react when prevention has failed. Understanding the importance of pregnancy-related changes in maternal thyroid status when treating a pregnant woman is crucial to preventing fetal goitrous hypothyroidism. Maternal levels of free T(4) are the most consistent indication of maternal and fetal thyroid status. In patients with fetal goitrous hypothyroidism, intra-amniotic levothyroxine injections improve fetal outcome. The best way to avoid maternal overtreatment with antithyroid drugs is to monitor closely the maternal thyroid status, especially estimates of free T(4) levels.
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Affiliation(s)
- Sofie Bliddal
- Department of Medical Endocrinology, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
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Negro R, Beck-Peccoz P, Chiovato L, Garofalo P, Guglielmi R, Papini E, Tonacchera M, Vermiglio F, Vitti P, Zini M, Pinchera A. Hyperthyroidism and pregnancy. An Italian Thyroid Association (AIT) and Italian Association of Clinical Endocrinologists (AME) joint statement for clinical practice. J Endocrinol Invest 2011; 34:225-31. [PMID: 21427528 DOI: 10.1007/bf03347071] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- R Negro
- Division of Endocrinology, V Fazzi Hospital, Piazza F Muratore, 73100 Lecce, Italy.
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Marín RC, Bello-Muñoz JC, Martínez GV, Martínez SA, Moratonas EC, Roura LC. Use of 3-dimensional sonography for prenatal evaluation and follow-up of fetal goitrous hypothyroidism. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2010; 29:1339-1343. [PMID: 20733190 DOI: 10.7863/jum.2010.29.9.1339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE Fetal goitrous hypothyroidism is a rare and potentially lethal condition. Consequently, its early diagnosis and treatment improve prognosis. Thyroid hormone measurement in either fetal serum or amniotic fluid implies important risks. Here we present a fetal goiter and the follow-up procedure, both done by the traditional method and by using 3-dimensional power Doppler (3DPD) imaging and virtual organ computer-aided analysis (VOCAL). METHODS A single well-documented case of fetal goiter was followed weekly from 22 weeks until delivery. Amniocentesis for thyrotropin (TSH) and free thyroxine (T(4)) measurement as well as levothyroxine injections were performed at every control. In addition to amniocentesis, every control involved a sonographic evaluation, which included standard measurements of the gland and the capture of volume image sets in gray scale and 3DPD. Volume calculation of the gland was done using VOCAL software. Vascularization of the gland was evaluated by the vascularization index (VI) included in the software. RESULTS With treatment, TSH levels decreased progressively until normalization. Free T(4) levels increased toward the end of gestation. Sonographic measurements of the gland volume to estimated fetal weight ratio decreased across treatment as levels of TSH did. The VI clearly depicted the vascular regression of the goiter, decreasing throughout treatment in a consistent way until 24 hours before delivery. CONCLUSIONS Gray scale and 3DPD evaluations of the thyroid gland have been validated under similar circumstances and might be reliable complements to the invasive methods used in the management of this fetal condition.
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Affiliation(s)
- Rodrigo Cuevas Marín
- Fetal Medicine Unit, Vall d'Hebron University Hospital, Universidad Autónoma de Barcelona, Barcelona, Catalunya, Spain
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Corral E, Reascos M, Preiss Y, Rompel SM, Sepulveda W. Treatment of fetal goitrous hypothyroidism: value of direct intramuscular L-thyroxine therapy. Prenat Diagn 2010; 30:899-901. [DOI: 10.1002/pd.2560] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Stoppa-Vaucher S, Francoeur D, Grignon A, Alos N, Pohlenz J, Hermanns P, Van Vliet G, Deladoëy J. Non-immune goiter and hypothyroidism in a 19-week fetus: a plea for conservative treatment. J Pediatr 2010; 156:1026-1029. [PMID: 20304420 DOI: 10.1016/j.jpeds.2010.01.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2009] [Revised: 11/25/2009] [Accepted: 01/12/2010] [Indexed: 11/16/2022]
Abstract
Hypothyroidism was documented by cordocentesis at 19 weeks in a fetus with non-immune goiter. Intra-amniotic thyroxine was injected at 25 weeks when amniotic fluid volume increased. Psychomotor outcome was normal. We argue that intra-amniotic thyroxine should not be used to treat the hypothyroidism but only to correct the development of polyhydramnios.
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Affiliation(s)
- Sophie Stoppa-Vaucher
- Endocrinology Service and Research Center and Department of Pediatrics, CHU Sainte-Justine and Université de Montréal, Montréal, Canada
| | - Diane Francoeur
- Department of Obstetrics and Gynecology, CHU Sainte-Justine and Université de Montréal, Montréal, Canada
| | - Andrée Grignon
- Department of Radiology, CHU Sainte-Justine and Université de Montréal, Montréal, Canada
| | - Nathalie Alos
- Endocrinology Service and Research Center and Department of Pediatrics, CHU Sainte-Justine and Université de Montréal, Montréal, Canada
| | - Joachim Pohlenz
- Pediatric Endocrinology, the Department of Pediatrics, Children's Hospital of Johannes Gutenberg University, Mainz, Germany
| | - Pia Hermanns
- Pediatric Endocrinology, the Department of Pediatrics, Children's Hospital of Johannes Gutenberg University, Mainz, Germany
| | - Guy Van Vliet
- Endocrinology Service and Research Center and Department of Pediatrics, CHU Sainte-Justine and Université de Montréal, Montréal, Canada
| | - Johnny Deladoëy
- Endocrinology Service and Research Center and Department of Pediatrics, CHU Sainte-Justine and Université de Montréal, Montréal, Canada.
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