Thyroid disease in pregnancy

Archana Tandon MS 2AOGGIS CLASSES
THYROID DISEASE IN PREGNANCY

THYROID DISEASE AND
PREGNANCY
From unanswered questions to
questionable answers
Dr Archana Tandon MS

• Question 1: How do
thyroid function tests
change during
pregnancy?
4Archana Tandon MS

The thyroid gland increases 10% in size during
pregnancy in iodine-replete countries and by 20%–
40% in areas of iodine deficiency. Production of
thyroxine (T4) and triiodothyronine (T3) increases by
50%, along with a 50% increase in the daily iodine
requirement.
Following conception, circulating total T4 (TT4) and
T4 binding globulin (TBG) concentrations increase by
6–8 weeks and remain high until delivery.
Thyrotropic activity of hCG results in a decrease in
serum TSH in the first trimester (5,6). Therefore,
during pregnancy, women have lower serum TSH
concentrations than before pregnancy, and frequently
TSH is below the classical lower limit of 0.4
mIU/L .The set – Point of hypothalamo- pituitary axis
is reset by this altered physiology of pregnancy .
5Archana Tandon MS

Questions 2 - What are
the Common Causes Of
Hypothyroidism
6Archana Tandon MS

•Hashimoto’s Disease
• Viral Thyroiditis
• Radiation Therapy Of Neck
• Radioactive Iodine Treatment
• Medications – Psychiatric
conditions and cancers –
Amiodarone ,lithium ,
Interferon ,Interleukin 2
• Thyroid Surgery
• Dietary Deficiency – (lack of
intake of Iodised salt , shell fish ,
salt water fish , dairy products )
7Archana Tandon MS

DIAGNOSTIC DILEMMA –
Question No 3 --Should
every antenatal patient be
screened during first
trimester ?
8Archana Tandon MS

The ATA, after an exhaustive summary of
available evidence, concludes that it can
neither recommend for nor against universal
TSH screening at first trimester”, but clearly
states that “universal FT4 screening of
pregnant women is not recommended”. [1]
TES does not recommend universal
screening, but encourages TSH measurement
of ‘high-risk‘ individuals, and also promotes
prenatal low-dose L-thyroxine (T4) therapy,
with a target TSH of less than 2.5 mIU/l.
Regarding universal screening for all newly
pregnant women, TES committee could not
reach a firm conclusion. [2] 9
Archana Tandon MS

INDIA - Higher incidence of
thyroid antibody positivity in
India, makes it prudent for
Indian health care providers to
follow the ITS
recommendations of universal
screening for hypothyroidism
during pregnancy. 10Archana Tandon MS

The ITS guidelines clearly recommend that
"all pregnant women should be screened at
1 st antenatal visit by measuring TSH
levels", and highlight that "ideally
screening should be carried out during pre-
pregnancy evaluation or as soon as
pregnancy is confirmed“ .
The patient should be actively involved in
the decision making. A brief explanation of
why the test is important for the mother
and her unborn child goes a long way in
preventing discontent, especially in a pay
from pocket situation. 11
Archana Tandon MS

Question 4: What is the
normal range for TSH in
each trimester?
12Archana Tandon MS

If trimester-specific reference ranges for TSH are
not available in the laboratory, the following
reference ranges are recommended:
First trimester, 0.1–2.5 mIU/L;
Second trimester, 0.2–3.0 mIU/L;
Third trimester, 0.3–3.0 mIU/L.
When maternal TSH is elevated, measurement
of serum FT4 concentration is necessary to
classify the patient‘s status as either subclinical
(SCH) or overt hypothyroidism (OH).
This is dependent upon whether FT4 is within or
below the trimester-specific FT4 reference range.
13Archana Tandon MS

optimal method to
assess FT4 during
pregnancy?
14Archana Tandon MS

Free thyroid hormone concentrations measured by
LC/MS/MS (liquid chromatography/tandem mass
spectrometry )correlate generally to a greater degree
with log TSH values compared with concentrations
measured by immunoassay (31)
Application of LC/MS/MS for measurement of free
thyroid hormones is currently in routine clinical use
in a few centers. (9).
A working group of the International Federation of
Clinical Chemistry and Laboratory Medicine
recommends the use of isotope dilution-LC/MS/MS
for measuring T4in the dialysate from equilibrium
dialysis of serum in order to obtain a trueness-based
reference measurement procedure for serum FT4 (34).
This assay technology, unfortunately, is currently not
widely available due to high instrument and operating
costs. 15
Archana Tandon MS

Question 4: What are the
definitions of OH and
SCH in pregnancy?
16Archana Tandon MS

Elevations in serum TSH during pregnancy
should be defined using pregnancy-specific
reference ranges.
OH is defined as an elevated TSH (>2.5
mIU/L) in conjunction with a decreased
FT4 concentration. Women with TSH levels
of 10.0 mIU/L or above, irrespective of
their FT4 levels, are also considered to have
OH.
SCH is defined as a serum TSH between
2.5 and 10 mIU/L with a normal
FT4 concentration
17Archana Tandon MS

Question 5: How is isolated
hypothyroxinemia
defined in pregnancy?
18Archana Tandon MS

ATA - Isolated
hypothyroxinemia is defined
as a normal maternal TSH
concentration in conjunction
with FT4 concentrations in
the lower 5th or 10th
percentile of the reference
range.
19Archana Tandon MS

Question 6: What
adverse outcomes are
associated with OH in
pregnancy?
खतरे कि घटी बजेगी तो क्या होगा
20Archana Tandon MS

 Detrimental effects upon fetal neurocognitive
development (37).
 60 % fetal loss due to an increased risk of premature
birth, low birth weight, and miscarriage. Abalovich et
al. (38)
 22% risk of gestational hypertension in pregnant
women with OH , higher in comparison to euthyroid
women or those with SCH (Leung et al. (39) ).
 An increased risk of fetal death among pregnant women
with OH.(Allan and colleagues (36) )
 In conclusion, a firm association between OH and
adverse risk to the maternal–fetal unit has been
demonstrated.
21Archana Tandon MS

Question 7: What adverse
outcomes are associated
with SCH in pregnancy?
22Archana Tandon MS
NO

An association between
maternal SCH and adverse
fetal neurocognitive
development is biologically
plausible (49), though not
clearly demonstrated.
23Archana Tandon MS

Question No -8
TO TREAT OR NOT
TO TREAT SCH
How do we do the balancing act ?
24Archana Tandon MS

If the laboratory returns a high
TSH value, i.e., >2.5 mIU/l in
the first trimester, or >3.0 mIU/l
in the second and third
trimesters. The clinician is then
faced with a tougher question:
To treat or not to treat.
We discuss it at length
25Archana Tandon MS

All subclinically
hypothyroid patients with
antibody positivity (TSH >
2.5 mIU/l, above 5th % FT4,
TAb+).[1]
26Archana Tandon MS

ATA guidelines do not address a
situation where resource-
challenged clinical setups are
unable to offer accurate and/or
affordable thyroid antibody
testing to their patients, or
patients refuse to accept the same
or where the population is poor
and Iodine deficient .
27Archana Tandon MS

Archana Tandon MS
28
AND SO ---The unanswered query
remains: how to decide whether or not
to treat a patient with TSH 2.5-10 mIU/l,
with negative antibodies or those who
cannot get it done .
ATA TES AND ITS
TES recommends a starting dose of 50 μg/d or
more in all patients with a TSH > 2.5 mIU/l in
first trimester, or >3.0 mIU/l in second
trimester.[2]

ITS too is categorical in its recommendation.[3] , it
recommends thyroxine treatment for all antenatal
women with subclinical hypothyroidism, targeting the
upper limit of normal reference range for TSH.
The normal reference values for TSH are 0.1-2.5
mIU/l, 0.2-3.0 mIU/l and 0.3-3.0 mIU/l in the first,
second and third trimesters of pregnancy.[1,2,3]
TES suggests a simpler method of circumventing this
problem of assessing FT4 values which are method of
measurement specific such as multiplying the non-
pregnant total T4 range (5-12 μg%) by 1.5 to arrive at
a pregnancy-specific normal range for second and
third trimesters.
29
Archana Tandon MS

Archana Tandon MS 30
Can you throw some light
on Thyroid Antibody testing
And its importance in
pregnancy ?
Also tell us the cost incurred
..

Question 9 : Should OH be
treated in pregnancy?
31Archana Tandon MS

The available data confirm the
benefits of treating OH during
pregnancy. OH should be treated in
pregnancy. This includes women
with a TSH concentration above the
trimester- specific reference interval
with a decreased FT4, and all women
with a TSH concentration above
10.0 mIU/L irrespective of the level
of FT4.
32Archana Tandon MS

Question 10: Should
isolated hypothyroxinemia
be treated in pregnancy
33Archana Tandon MS

Isolated hypothyroxinemia
should not be treated in
pregnancy.
34Archana Tandon MS

Question 11:I would like
you to revise the
treatment plan of SCH
in pregnancy so that it
gets drilled in .
35Archana Tandon MS

ATA – Only if TPO Ab+ve or
In Ab –ve if
FT4 below 5th percentile
ITS – All SCH irrespective of
TPOAb +ve or –VE
TES – Treat all SCH with
50microgm Levo thyroxine
36Archana Tandon MS

Question 12: If provided ,
what is the optimal
treatment of OH or SCH?
37Archana Tandon MS

Only and Only Oral LT4.
Not to use other thyroid
preparations such as T3 or
desiccated thyroid.
38Archana Tandon MS

Question 13: When
provided, what is the goal
of OH or SCH treatment?
39Archana Tandon MS

The goal of LT4 treatment is to
normalize maternal serum
TSH values within the trimester-
specific pregnancy reference range
--
First trimester - 0.1–2.5 mIU/L
Second trimester - 0.2–3.0 mIU/L
Third trimester - 0.3–3.0 mIU/L
40Archana Tandon MS

Question 14: If pregnant
women with SCH are not
initially treated, what is the
key to monitor them through
gestation?
41
Archana Tandon MS

ATA --Women with SCH in pregnancy who are not
initially treated should be monitored for progression
to OH with a serum TSH and FT4 approximately
every 4 weeks until 16–20 weeks gestation and at
least once between 26 and 32 weeks gestation. This
approach has not been prospectively studied.
TES recommends screening in second trimester as
well. However they make no recommendation for
euthyroid antibody negative women. While this may
not be of major concern in iodine replete countries,
the chances of thyroid dysfunction developing
during pregnancy may be higher in iodine-deficient
nations.
42Archana Tandon MS

ITS recommends monitoring only the thyroid
antibody positive euthyroid women in each
trimester, thus cutting down the number of
individuals to be screened significantly. [3] But, it too,
does not address the issue of further monitoring in
euthyroid patient without antibody tests, or with
negative antibodies .
A case can be made for targeted screening at 26-32
weeks gestation.
Patients with symptoms and signs of
hypothyroidism, including goitre, a past bad
obstetric history, a history of thyroid disorder or
neck surgery, or irradiation, history of other
autoimmune illness, a family history of thyroid
illness, or residence in an iodine-deplete area may
be some of the clinical cues for ordering a repeat
TSH. 43
Archana Tandon MS

Question 15: How do treated
hypothyroid women
(receiving LT4) differ from
other patients during
pregnancy? What changes
can be anticipated in such
patients during gestation?
44Archana Tandon MS

Clinical studies have confirmed that the
increased requirement for T4 (or exogenous
LT4) occurs as early as 4–6 weeks of
pregnancy (54). Such requirements gradually
increase through 16–20 weeks of pregnancy,
and thereafter plateau until time of delivery.
These data provide the basis for
recommending adjustments to thyroid
hormone in affected women once pregnant and
for the timing of follow-up intervals for TSH
in treated patients .
45
Archana Tandon MS

Question 16: What proportion
of treated hypothyroid women
(receiving LT4) require fine
tuning of LT4dose during
pregnancy?
46Archana Tandon MS
Fine tuning the
DoseFine Tuning the dose

Between 50% and 85% (38,53,54) of
hypothyroid women being treated
with exogenous LT4 need to increase
dosing during pregnancy
There is a greater likelihood that dose
increase will be required in those
patients without functional thyroid
tissue (e.g., due to radio-ablation ,
surgery) in comparison with patients
with Hashimoto's thyroiditis (55,56).
47
Archana Tandon MS

Question 17: In treated
hypothyroid women (receiving
LT4) who are planning
pregnancy, how to focus to
adjust the LT4 dose?
48Archana Tandon MS
DOSE ADJUSTMENT

Dose adjustment as soon as possible after
pregnancy is confirmed .
For women who are euthyroid while
receiving once-daily dosing of
LT4 (regardless of amount), a
recommendation to increase by two
additional tablets weekly (nine tablets per
week instead of seven tablets per week;
29% increase)
Confirmatory biochemical testing should
also occur simultaneously. A separate
option is to increase the dosage of daily
LT4 by approximately 25%–30%.
49
Archana Tandon MS

Question 18: In treated hypothyroid
women (receiving LT4) what advice
should be given to them if they are
planning pregnancy and what
should a gynecologist aim at as far
as control value of TSH is
concerned ?
50Archana Tandon MS

It is recommended that in all treated
hypothyroid women (currently receiving
LT4) optimize thyroid status preconception.
Maternal serum TSH concentration of <2.5
mIU/L is a reasonable goal for all such
women. Ideally, lower TSH values
(<1.5 mIU/L) will likely further reduce the
risk of mild hypothyroidism in early
pregnancy .
51Archana Tandon MS

Question 19: In hypothyroid
women (receiving LT4) who
are newly pregnant, how often
should maternal thyroid
function be monitored during
gestation?
52Archana Tandon MS

In pregnant patients with treated
hypothyroidism, maternal serum
TSH should be monitored
approximately
 Every 4 weeks during the first
half of pregnancy because further
LT4 dose adjustments are often
required .
At least once between 26 and 32
weeks gestation.
53Archana Tandon MS

Question 20: How should
the LT4 dose be adjusted
postpartum?
54Archana Tandon MS

 Reduce to prepregnancy levels
 Assess serum TSH 6 weeks
thereafter
 A recent study demonstrated that
more than 50% of women with
Hashimoto's thyroiditis experienced
an increase in the pregestational
thyroid dose in the postpartum
period, presumably due an
exacerbation of autoimmune thyroid
dysfunction postpartum (59).
55Archana Tandon MS

outcome and long-term
prognosis when SCH and/or
OH are effectively treated
through gestation?
56Archana Tandon MS

Women with adequately treated
SCH or OH have no increased risk
of any obstetrical complication.
Consequently, there is no
indication for any additional testing
or surveillance in pregnancies of
women with either SCH or OH
who are being monitored and
being treated appropriately.
57Archana Tandon MS

Question 22: Except for
measurement of maternal thyroid
function, should additional
maternal or fetal testing occur in
treated, hypothyroid women
during pregnancy?
58Archana Tandon MS

In the care of women with
adequately treated Hashimoto's
thyroiditis, no other maternal or
fetal thyroid testing is
recommended beyond measurement
of maternal thyroid function (such
as serial fetal ultrasounds, antenatal
testing, and/or umbilical blood
sampling) unless for other
pregnancy circumstances
59Archana Tandon MS

Question 23: In euthyroid
women who are TAb+ prior
to conception, what is the
risk of hypothyroidism once
they become pregnant?
60Archana Tandon MS

In 1994, Glinoer et al. (60) performed a prospective study on 87
thyroid autoantibody positive (TAb+) euthyroid women evaluated
before and during early pregnancy. Twenty percent of women in the
study developed a TSH level of >4 mIU/L during gestation despite
normal TSH and no requirement for LT4prenatally
Patients who are TAb+ have an
increased propensity for
hypothyroidism to occur later in
gestation because some residual
thyroid function may still remain
and provide a buffer during the
first trimester.
61Archana Tandon MS

Question 24: How should
TAb+ euthyroid women be
monitored and treated
during pregnancy?
62Archana Tandon MS

Require monitoring for
hypothyroidism during pregnancy.
Serum TSH should be evaluated
every 4 weeks during the first half
of pregnancy and at least once
between 26 and 32 weeks
gestation.
63Archana Tandon MS

Question 25: Should TAb+
euthyroid women be monitored
or treated for complications
other than the risk of
hypothyroidism during
pregnancy?
64Archana Tandon MS

In addition to the risk of hypothyroidism, it has been described that being
TAb+ constitutes a risk factor for miscarriage, premature delivery (28,60),
perinatal death (44), postpartum dysfunction, and low motor and
intellectual development (IQ) in the offspring (51). Some studies have
found, in nonpregnant women, that selenium is capable of diminishing the
TPOAb titers (61–63). Other authors have described conflicting data (64).
It has also been described that the selenium level can be low in full-term
pregnant women compared with nonpregnant women. Recently, Negro et
al. (65) observed that TPOAb+ euthyroid pregnant women treated with
200 μg/d of selenium not only had a significant decrease in the frequency
of postpartum thyroid dysfunction (p < 0.01), but also had lower TPOAb
levels during pregnancy compared with women in the untreated group.
However, patients under treatment with selenium could be at higher risk
of developing type 2 diabetes mellitus (66).
At present, the risk to benefit
comparison does not support routine
selenium supplementation during
pregnancy.
65Archana Tandon MS

Archana Tandon MS
66
In 2015 there are now 7 level A recommendations.as
proposed by ACOG
1 . Do not do universal screening for thyroid disease in
pregnancy .
2 .TSH is the first-line screening test to assess thyroid
status in pregnancy.
3. TSH and FT4 should be measured to diagnose thyroid
disease in pregnancy.
4. Treat overt hypothyroid disease in pregnancy with
adequate thyroid hormone to minimize risk of adverse
outcomes.
5. TSH should be monitored in pregnant women who
have overt hypothyroidism and the dosage of thyroid
replacement adjusted accordingly.
6. Pregnant women with overt hyperthyroidism should be
treated with thioamide to minimize risk adverse
outcomes.
7. FT4 should be monitored in pregnant women with
hyperthyroidism and thioamide dose adjusted
accordingly.

Archana Tandon MS
67
• Universal screening for hypothyroidism during
pregnancy at 1st antenatal visit or as soon as preg confirmed .
• Trimester-specific reference ranges for TSH
First trimester, 0.1–2.5 mIU/L;
Second trimester, 0.2–3.0 mIU/L;
Third trimester, 0.3–3.0 mIU/L.
• Recommended treatment LT4
• Thyroxine treatment for all antenatal women with SCH
targeting the upper limit of normal reference range for TSH and
treat all OH
• For hypothyroid receiving treatment increase the dose by 2 tab
/week
• TSH level once in each trimester .
• Following delivery, maternal LT4 dosing should be reduced to
prepregnancy levels, and a serum TSH assessed 6 weeks
thereafter.

Archana Tandon MS
68
IN SHORT IODINE SUPPLEMENTATION AND
HYPERTHYROIDISM AND THYROID NODULES
Breast-feeding women should maintain a daily intake of 250
μg iodine to ensure breast-milk provides 100 µg iodine per
day to the infant.
Thyroid receptor antibodies should be measured before 22
weeks' gestational age in mothers with "1) current Graves'
disease; or 2) a history of Graves' disease and treatment
with 131I or thyroidectomy before pregnancy; or 3) a previous
neonate with Graves' disease; or 4) previously elevated
[thyroid-stimulating hormone (TSH) receptor antibodies
(TRAb)]," according to the authors.
Women with nodules from 5 mm to 1 cm in size should be
considered for fine-needle aspiration (FNA) if they have a
high-risk history or suspicious findings on ultrasound, and
women with complex nodules from 1.5 to 2 cm in size should
also receive an FNA. "During the last weeks of pregnancy,
FNA can reasonably be delayed until after delivery.
Ultrasound-guided FNA is likely to have an advantage for
maximizing adequate sampling," the authors conclude. [4]

ROLE OF ULTRASOUND
IN THYROID DISEASE IN
PREGNANCY
69Archana Tandon MS
Which Women require additional
fetal ultrasound monitoring for
growth, heart rate, and presence of
goiter in pregnancy?

Fetal surveillance with serial ultrasounds should
be performed in women who have uncontrolled
hyperthyroidism and/or women with high TRAb
levels (greater than three times the upper limit of
normal ) Refer them to experienced maternal–
fetal medicine specialist or refer her to radiologist
for ultrasound .
70Archana Tandon MS

When we refer women with
Grave’s disease with TRAb at
least 2- to 3-fold the normal
level and in women treated with
antithyroid drugs is sent to you
at 18-22 wks ,what will you
particularly see for ?

Gestational age, fetal viability, amniotic fluid
volume, fetal anatomy, and detection of
malformations. Fetal well-being may be
compromised in the presence of elevated TRAb,
uncontrolled hyperthyroidism, and pre-eclampsia
(80 ,83 ,111 ,112 ).
Signs of potential fetal hyperthyroidism that may
be detected by ultrasonography include fetal
tachycardia (bpm >170, persistent for over 10
minutes), intrauterine growth restriction,
presence of fetal goiter (the earliest sonographic
sign of fetal thyroid dysfunction), accelerated
bone maturation, signs of congestive heart
failure, and fetal hydrops (106,111–114).

Fetal thyroid dysfunction should be
screened for during the fetal anatomy
ultrasound done in the 18th–22nd
week and repeated every 4 to 6 weeks
or as clinically indicated. Evidence of
fetal thyroid dysfunction could include
thyroid enlargement, growth
restriction, hydrops, presence of goiter,
advanced bone age, tachycardia, or
cardiac failure .

BIBLIOGRAPHY
1 – (1-124 ) - Guidelines of the American Thyroid Association for the
Diagnosis and Management of Thyroid Disease During Pregnancy and
Postpartum
The American Thyroid Association Taskforce on Thyroid Disease During
Pregnancy and Postpartum, Alex Stagnaro-Green, (Chair),1 Marcos
Abalovich,2 Erik Alexander,3 Fereidoun Azizi,4 Jorge Mestman,5 Roberto
Negro,6 Angelita Nixon,7 Elizabeth N. Pearce,8 Offie P. Soldin,9 Scott
Sullivan,10 and Wilmar Wiersinga11
2 -Hypothyroidism in pregnancy: From unanswered questions to
questionable answers
Sanjay Kalra, Manash P. Baruah,1 and Ambika G. Unnikrishnan2
3 - Management of Thyroid Dysfunction during Pregnancy and
Postpartum: An Endocrine Society Clinical Practice Guideline Marcos
Abalovich, Nobuyuki Amino, Linda A. Barbour, Rhoda H. Cobin, Leslie J. De
Groot, Daniel Glinoer, Susan J. Mandel, and Alex Stagnaro-Green
4 -New Guidelines Released for Thyroid Dysfunction in Pregnancy
News Author: Emma Hitt, PhD
CME Author: Penny Murata, MD
Faculty and Disclosures
CME/CE Released: 08/30/2012; Reviewed and Renewed: 09/27/2012; Valid for
credit through 08/30/2013
5 - ACOG Guidelines at a Glance Thyroid Disease in Pregnancy
July 01, 2015
By Sarah J. Kilpatrick, MD, PhD

ANY QUERRIES ?
HYPOTHYROIDISM
IN PREGNANCY UNLOCKED

A 33 year-old G3 P2 at 10 weeks GA comes you for her
1st pre natal visit. She reports that she had
hypothyroidism in the distant past, but was never
treated and is asymptomatic. Physical examination is
normal. On bimanual examination her uterus is 10
weeks size and FHR is 150 bpm. Her TSH level is 13.1
and, free T4 level is 0.7, and her anti-thyroid
peroxidase antibody level is high. The next best step in
the patient’s care is:
A) Begin levothyroxine
B) Repeat serum TSH and Free T4 after 20 weeks
of gestation
C) Measure serum thyroid-stimulating
immunoglobulins
D) Perform ultrasonography of the maternal thyroid

Archana Tandon MS
77
A) Begin levothyroxine
WHY ?
• Although the patient is asymptomatic she has
laboratory evidence of overt hypothyroidism
with an elevated TSH and low free T4 level
• She also has elevated anti-thyroid peroxidase
antibody level which indicates that the likely
cause of her hypothyroidism is chronic
autoimmune thyroditis (Hashimoto’s disease)
• The anti-thyroid peroxidase antibodies also
indicate an increased risk of her developing
other autoimmune disease, such as adrena
insufficiency or type 1 DM.
• Hypothyroidism in pregnancy has been
associated with pre-eclampsia, GHTN,
abruptio placentae, preterm delivery, and
neuropsychologic deficits in the child.

case 2 - A 33-year-old woman had
received a diagnosis of primary
hypothyroidism when she was 23 years
of age and had been taking an
essentially stable dose of levothyroxine
(0.112 mg/d) for at least 2 years.
She comes to you for advice before
conceiving .
2 -What advice will you give her ?

• Folic Acid supplementation .
2 months before natural planned
conception
• Serum TSH – 5.95mIU/ml
2 -What should u advice now ?

Levothyroxine dose is increased to
0.116 mg/d
(25 % of previous dose ).
Then She comes to you on missing
her periods and doing a urine home
pregnancy test which is positive or
she comes to you and you do it and
it’s positive
How do you proceed now ?

Folic acid ,levothyroxine continued .
TSH is checked at 8 wks of LMP
Found to be elevated (40.75 mU/L), with
a normal free thyroxine level (12.6
pmol/L)
2 –What next ?

The dose of
levothyroxine
is increased..
• Adv Scan at 12wks

At 12 wk scan you find
diamniotic dichorionic
twins .
3- Now how do you proceed ?

Repeat TSH .
AND YOU HAVE TO DO IT EVERY 4 WKS
Throughout her pregnancy, the dose of levothyroxine is
adjusted multiple times in response to her thyroid
stimulating hormone levels.
Labour is induced during week 37 .
3 - Post delivery ? Thyroxine ?

Archana Tandon MS
85
Case 3
A 20-year-old woman, gravida 2, para 1, presents to
you as an emergency with a history of nausea,
weight loss of about 10 kg in 6 weeks, and
intermittent vaginal bleeding. On examination, she
has tachycardia (108 BPM), a blood pressure of
146/86 mm Hg, and a regular respiration rate of 18
breaths per minute. There is no exophthalmos, and
her extraocular movements are normal. The thyroid
gland is palpable and of normal size. Cardiovascular
examination reveals sinus tachycardia without
murmurs, rub, or gallops. Breath sounds are equal
bilaterally, without rhonchi or wheezes. There is no
peripheral edema. The size of the uterus is
compatible with a 12-week gestation.
4 -What investigaions to be performed ?
How to manage ?

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86
Antenatal Profile –
Serum HCG
Ultrasound
Blood tests reveal
Her thyroid-function tests are found to be markedly
elevated . Her thyrotropin (TSH) was <0.07 mIU/ml
(normal range, 0.3 to 4.2), free thyroxine (FT4) 5.59
ng/dl (normal range, 0.8 to 2.0), triiodothyronine
(T3) 465 ng/dl (normal range, 40 to 180),
Laboratory data on admission reveal microcytic
hypochromic anemia and elevated transaminase and
alkaline phosphatase. The remainder of her
electrolytes, complete blood count, and platelets are
normal. Her electrocardiogram showed sinus
tachycardia.
4- Ultrasound still awaited .
Ur diagnosis and management ?

Ultrasonography of her enlarged uterus revealed
that the uterine cavity was significantly distended
and filled with an echogenic soft-tissue mass that
had small cystic components, most compatible
with complete molar pregnancy.
Human chorionic gonadotropin (hCG) close to 2
million mIU/ml.
4 - So now what will you do -------

•The patient should be put on anti-thyroid drugs
as she has hyperthyroidism and if there is no time
and comes with profuse bleeding or arhythmias ,
β-blockers should be administered and evacuation
done in emergency .[1]
• You can expect respiratory failure secondary to
noncardiogenic pulmonary edema.
• Pulmonary hypertension, which is correlated with
inadequately controlled hyperthyroidism can result
in heart failure and pulmonary oedema.[ 2] Few
authors have reported incidences of acute
respiratory distress syndrome (ARDS) and
pulmonary oedema in cases of vesicular mole with
hyperthyroidism.[1,3 ]

1- Erol DD, Cevryoglu AS, Uslan I. Preoperative preparation and
general anesthesia administration with sevoflurane in a patient who
develops thyrotoxicosis and cardiac dysfunction due to a
hydatidiform mole.The Internet Journal of
Anesthesiology. 2004 Available
from:http://www.ispub.com/journal/the_internet_journal_of_anesthe
siology/archive/volume_8_number_1_12.html[last accessed on
2010 Aug 20]
2 -8. Yang MJ, Cheng MH. Pregnancy complicated with pulmonary
edema due to hyperthyroidism. J Chin Med Assoc. 2005;68:336–
8. [PubMed]
3 - 9. Malye RH, Trivedi TH, Padhiyar NN, Moulick ND, Yeolekar
ME. ARDS in a case of vesicular mole with secondary
hyperthyroidism. J Assoc Physicians India. 2004;52:992–
3. [PubMed]

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