Autoimmune Thyroid Disease and Pregnancy Clinical Presentation

  • Author: Dotun A Ogunyemi, MD; Chief Editor: Carl V Smith, MD   more...
 
Updated: Mar 8, 2012
 

History

Symptoms of hyperthyroid can be easily confused with symptoms of the hypermetabolic state of pregnancy. Mild hypothyroid symptoms can be difficult to distinguish from the common aches and pains of pregnancy. Obtaining a careful patient history is essential in the evaluation of women thought to have thyroid dysfunction.

Hyperthyroidism

  • Patients with hyperthyroidism usually report loss of concentration, nervousness, and emotional lability.
  • Tremor, heat intolerance, excessive sweating, palpitations, and hyperdefecation are also common findings.
  • Patients may report having difficulty with climbing stairs; this is a sign of proximal muscle weakness.
  • Some patients may report that their neck is getting bigger than it was before. This change is caused by the enlarged thyroid gland.

Hypothyroidism

  • Untreated patients with moderate-to-severe hypothyroidism have impaired fertility. As a result, women with this disease are rarely pregnant at the time of presentation.
  • Symptoms of mild hypothyroidism can mimic those of normal pregnancy, making diagnosis difficult.
  • Lethargy, weight increase, and constipation are commonly reported.
  • Patients frequently report having cold intolerance, stiffness, muscle cramping, carpal tunnel syndrome, dry hair and skin, and a deepened voice.

Postpartum thyroiditis

  • PPT has 3 phases:
    1. Hyperthyroid phase, when thyroid hormones are being released because of thyroid destruction
    2. Hypothyroid phase
    3. Resolution, or euthyroid, phase
  • The most common time for women present with PPT is 1-8 months after delivery, with a peak incidence at 6 months. This timing is important because the process may overlap with the next pregnancy in women who have short pregnancy intervals.
  • Depending on the stage of disease at the time of presentation, patients may have symptoms of hyperthyroid or hypothyroid, as outlined above.

Subclinical hypothyroidism

  • Subclinical hypothyroidism affects 2-3% of women in pregnancy.
  • The symptoms of subclinical hypothyroidism are vague and nonspecific.
  • The diagnosis is based on a normal level of free thyroxine (FT4) and an elevated TSH level.
Next

Physical

Hyperthyroidism

  • General appearance: In general, patients with hyperthyroidism are restless, anxious, and fidgety.
  • Skin and hair: The patient's skin is warm and moist, with a velvety texture, and their hair is fine and silky.
  • Eyes
    • The eyes usually have a characteristic stare, with a widened palpebral fissure.
    • Lid lag and failure to wrinkle the brow during the upward gaze are common findings.
    • With careful observation, infrequent blinking is noted.
    • With the infiltrating ophthalmopathy of Graves’ disease, potential findings include proptosis, ophthalmoplegia, chemosis, conjunctivitis, periorbital swelling, corneal ulceration, optic neuritis, and optic dystrophy.
  • Thyroid
    • A goiter is present in almost every pregnant patient with Graves’ disease.
    • The gland is diffusely enlarged, usually 2-4 times normal.
    • The gland can be soft or firm, and it is seldom tender to palpation.
    • A thrill or bruit may be present.
    • Thoroughly examine the thyroid gland for nodules. The presence of a nodule requires further workup during pregnancy to rule out malignancy.
  • Heart
    • Findings on cardiac examination include a wide pulse pressure due to increased systolic pressure and decreased diastolic pressure.
    • Sinus tachycardia is common. A resting tachycardia greater than 100 bpm that does not change with Valsalva is helpful in distinguishing hyperthyroid tachycardia from that of pregnancy.
    • Atrial arrhythmias can also be found on examination. These usually occur in the form of atrial fibrillation.
    • Other findings are systolic murmurs, an increased intensity of the apical first sound, cardiac enlargement, and cardiac failure.
  • Nails
    • Separation of the nail from the distal nail bed, known as onycholysis or Plummer nail, can often be found when the extremities are examined. The ring fingers are most commonly affected.
    • Fine tremor of the fingers and hyperreflexia can also be noted.

Fetal thyroid dysfunction

  • Suggestive findings
    • Fetal tachycardia (fetal heart rate >160 bpm)
    • Intrauterine growth restriction
    • Fetal goiter
    • Hydrops
  • Causes
    • The risk of fetal or neonatal thyrotoxicosis is related to the mother's level of thyroid receptor–stimulating antibodies because the antibodies freely cross the placenta.
    • Fetal or neonatal hypothyroidism may also be due to maternal use of antithyroid drugs (ATDs), as these cross the placenta.
  • Diagnosis and screening
    • Fetal diagnosis requires umbilical cord sampling to differentiate hyperthyroidism from hypothyroidism.
    • In women with a past or current history of autoimmune thyroid disease, thyroid antibody values should be checked at the end of the first pregnancy. For those with positive results for thyroid receptor–stimulating antibodies or those taking ATDs, fetal ultrasonography should be performed at least monthly after 20 weeks of gestation.
  • Treatment
    • Fetal thyroid dysfunction is treated with adjustment of maternal ATD therapy.
    • Fetal hypothyroidism may require intra-amniotic administration of T4.

Hypothyroidism

  • Motor function and cognition: Patients with hypothyroidism appear to have slowing of speech and movement. They can also be forgetful and exhibit difficulty with concentration.
  • Skin: The skin is usually dry, pale, and yellowish.
  • Hair: Hair is thin, brittle, and sparse.
  • Head, eyes, ears, nose, and throat
    • Auditory acuity may be decreased.
    • Eye examination may reveal periorbital puffiness.
    • A large tongue and an expressionless face can be observed in patients with severe disease.
  • Thyroid gland
    • A goiter associated with Hashimoto thyroiditis is firm, diffusely enlarged, and usually painless to palpation.
    • In patients with atrophic chronic thyroiditis, the thyroid gland may be normal or not palpable.
  • Heart
    • A low-normal heart rate is common.
    • The heart can be enlarged if it is dilated.
    • Pericardial effusion is present in severe cases.
  • GI tract
    • Bowel sounds may be decreased or absent.
    • Paralytic ileus has been reported in severe cases of hypothyroidism.
  • Extremities: Examination of the extremities may reveal nonpitting edema and hyporeflexia, with prolongation of the relaxation phase of the reflex response.
  • Fetus: Fetal examination usually reveals normal findings in mild cases.

Postpartum thyroiditis

  • Presenting findings: Patients with PPT can present with symptoms of hyperthyroidism or hypothyroidism, depending on the stage of disease.
  • Phases of disease: As many as one third of women with PPT present with hyperthyroidism at 1-4 months after birth. This period is followed by a hypothyroid phase lasting as long as 2 months. Recovery then ensues.
Previous
Next

Causes

The defect that predisposes an individual to develop autoimmune thyroid disease is still unknown. Proposed mechanisms include a tissue-specific defect in suppressor T-cell activity, a genetically programmed presentation of a thyroid-specific antigen, and an idiotype/anti-idiotype reaction. Regardless of the cause, the common outcome is the production of 1 or more types of autoantibodies.

Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Dotun A Ogunyemi, MD  Associate Professor of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA; Residency Program Director, Clerkship Director, Department of Obstetrics and Gynecology, Cedars Sinai Medical Center

Dotun A Ogunyemi, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, National Medical Association, and Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Carl V Smith, MD  The Distinguished Chris J and Marie A Olson Chair of Obstetrics and Gynecology, Professor, Department of Obstetrics and Gynecology, Senior Associate Dean for Clinical Affairs, University of Nebraska Medical Center

Carl V Smith, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Council of University Chairs of Obstetrics and Gynecology, Nebraska Medical Association, and Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Frederick B Gaupp, MD  Consulting Staff, Department of Family Practice, Hancock Medical Center

Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Chief Editor

Carl V Smith, MD  The Distinguished Chris J and Marie A Olson Chair of Obstetrics and Gynecology, Professor, Department of Obstetrics and Gynecology, Senior Associate Dean for Clinical Affairs, University of Nebraska Medical Center

Carl V Smith, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Council of University Chairs of Obstetrics and Gynecology, Nebraska Medical Association, and Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

References

  1. Abalovich M, Amino N, Barbour LA, Cobin RH, De Groot LJ, Glinoer D. Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. Aug 2007;92(8 Suppl):S1-47. [Medline].

  2. Thangaratinam S, Tan A, Knox E, et al. Association between thyroid autoantibodies and miscarriage and preterm birth: meta-analysis of evidence. BMJ. May 9 2011;342:d2616. [Medline]. [Full Text].

  3. McGiven AR, Adams DD, Purves HD. A comparison of the heat stability of long-acting thyroid stimulator and human thyroid-stimulating hormone. J Endocrinol. Apr 1965;32:29-33. [Medline].

  4. Adams DD, Kennedy TH, Purves HD, Siret NE. Failure of TSH antisera to neutralize long-acting thyroid stimulator. Endocrinology. Jun 1962;70:801-5. [Medline].

  5. Adams DD. The presence of an abnormal thyroid-stimulating hormone in the serum of some thyrotoxic patients. J Clin Endocrinol Metab. Jul 1958;18(7):699-712. [Medline].

  6. Adams DD. The pathogenesis of thyrotoxicosis the discovery of LATS. N Z Med J. Jan 8 1975;81(531):15-7. [Medline].

  7. Wilson KL, Casey BM, McIntire DD, Halvorson LM, Cunningham FG. Subclinical thyroid disease and the incidence of hypertension in pregnancy. Obstet Gynecol. Feb 2012;119(2 Pt 1):315-20. [Medline].

  8. Friedrich N, Schwarz S, Thonack J, John U, Wallaschofski H, Völzke H. Association between parity and autoimmune thyroiditis in a general female population. Autoimmunity. Mar 2008;41(2):174-80. [Medline].

  9. Brent GA. Maternal thyroid function: interpretation of thyroid function tests in pregnancy. Clin Obstet Gynecol. Mar 1997;40(1):3-15. [Medline].

  10. FDA MedWatch Safety Alerts for Human Medical Products. Propylthiouracil (PTU). US Food and Drug Administration. Available at http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm164162.htm. Accessed June 3, 2009.

  11. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 37, August 2002. (Replaces Practice Bulletin Number 32, November 2001). Thyroid disease in pregnancy. Obstet Gynecol. Aug 2002;100(2):387-96. [Medline].

  12. Alexander EK, Marqusee E, Lawrence J, Jarolim P, Fischer GA, Larsen PR. Timing and magnitude of increases in levothyroxine requirements during pregnancy in women with hypothyroidism. N Engl J Med. Jul 15 2004;351(3):241-9. [Medline].

  13. American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics. Nov 1989;84(5):924-36. [Medline].

  14. Amino N, Mori H, Iwatani Y, Tanizawa O, Kawashima M, Tsuge I. High prevalence of transient post-partum thyrotoxicosis and hypothyroidism. N Engl J Med. Apr 8 1982;306(14):849-52. [Medline].

  15. Amino N, Tanizawa O, Mori H, Iwatani Y, Yamada T, Kurachi K. Aggravation of thyrotoxicosis in early pregnancy and after delivery in Graves' disease. J Clin Endocrinol Metab. Jul 1982;55(1):108-12. [Medline].

  16. Anonymous. Dangers of iodides in pregnancy. Lancet. Jun 13 1970;1(7659):1273-4. [Medline].

  17. Azizi F. Treatment of post-partum thyrotoxicosis. J Endocrinol Invest. Mar 2006;29(3):244-7. [Medline].

  18. Becks GP, Burrow GN. Thyroid disease and pregnancy. Med Clin North Am. Jan 1991;75(1):121-50. [Medline].

  19. Belfiore A, Garofalo MR, Giuffrida D, Runello F, Filetti S, Fiumara A. Increased aggressiveness of thyroid cancer in patients with Graves' disease. J Clin Endocrinol Metab. Apr 1990;70(4):830-5. [Medline].

  20. Browne-Martin K, Emerson CH. Postpartum thyroid dysfunction. Clin Obstet Gynecol. Mar 1997;40(1):90-101. [Medline].

  21. Bungard TJ, Hurlburt M. Management of hypothyroidism during pregnancy. CMAJ. Apr 10 2007;176(8):1077-8. [Medline].

  22. Burrow GN. The management of thyrotoxicosis in pregnancy. N Engl J Med. Aug 29 1985;313(9):562-5. [Medline].

  23. Canaris GJ, Manowitz NR, Mayor G, Ridgway EC. The Colorado thyroid disease prevalence study. Arch Intern Med. Feb 28 2000;160(4):526-34. [Medline].

  24. Casey BM, Dashe JS, Spong CY, McIntire DD, Leveno KJ, Cunningham GF. Perinatal significance of isolated maternal hypothyroxinemia identified in the first half of pregnancy. Obstet Gynecol. May 2007;109(5):1129-35. [Medline].

  25. Chattaway JM, Klepser TB. Propylthiouracil versus methimazole in treatment of Graves' disease during pregnancy. Ann Pharmacother. Jun 2007;41(6):1018-22. [Medline].

  26. Chopra IJ, Baber K. Treatment of primary hypothyroidism during pregnancy: is there an increase in thyroxine dose requirement in pregnancy?. Metabolism. Jan 2003;52(1):122-8. [Medline].

  27. Cooper DS. Clinical practice. Subclinical hypothyroidism. N Engl J Med. Jul 26 2001;345(4):260-5. [Medline].

  28. Davis LE, Lucas MJ, Hankins GD, Roark ML, Cunningham FG. Thyrotoxicosis complicating pregnancy. Am J Obstet Gynecol. Jan 1989;160(1):63-70. [Medline].

  29. Dayan CM, Daniels GH. Chronic autoimmune thyroiditis. N Engl J Med. Jul 11 1996;335(2):99-107. [Medline].

  30. Franklyn JA, Davis JR, Gammage MD, Littler WA, Ramsden DB, Sheppard MC. Amiodarone and thyroid hormone action. Clin Endocrinol (Oxf). Mar 1985;22(3):257-64. [Medline].

  31. Furmaniak J, Smith BR. Immunity to the thyroid-stimulating hormone receptor. Springer Semin Immunopathol. 1993;14(3):309-21. [Medline].

  32. Gerstein HC. How common is postpartum thyroiditis? A methodologic overview of the literature. Arch Intern Med. Jul 1990;150(7):1397-400. [Medline].

  33. Haddow JE, Palomaki GE, Allan WC, Williams JR, Knight GJ, Gagnon J. Maternal thyroid deficiency during pregnancy and subsequent neuropsychological development of the child. N Engl J Med. Aug 19 1999;341(8):549-55. [Medline].

  34. Hayslip CC, Fein HG, O'Donnell VM, Friedman DS, Klein TA, Smallridge RC. The value of serum antimicrosomal antibody testing in screening for symptomatic postpartum thyroid dysfunction. Am J Obstet Gynecol. Jul 1988;159(1):203-9. [Medline].

  35. Houck JA, Davis RE, Sharma HM. Thyroid-stimulating immunoglobulin as a cause of recurrent intrauterine fetal death. Obstet Gynecol. Jun 1988;71(6 Pt 2):1018-9. [Medline].

  36. Jansson R, Bernander S, Karlsson A, Levin K, Nilsson G. Autoimmune thyroid dysfunction in the postpartum period. J Clin Endocrinol Metab. Apr 1984;58(4):681-7. [Medline].

  37. Jansson R, Dahlberg PA, Winsa B, Meirik O, Säfwenberg J, Karlsson A. The postpartum period constitutes an important risk for the development of clinical Graves' disease in young women. Acta Endocrinol (Copenh). Nov 1987;116(3):321-5. [Medline].

  38. Kvetny J, Poulsen H. Transient hyperthyroxinemia in newborns from women with autoimmune thyroid disease and raised levels of thyroid peroxidase antibodies. J Matern Fetal Neonatal Med. Dec 2006;19(12):817-22. [Medline].

  39. Lazarus JH, Ammari F, Oretti R, Parkes AB, Richards CJ, Harris B. Clinical aspects of recurrent postpartum thyroiditis. Br J Gen Pract. May 1997;47(418):305-8. [Medline].

  40. Lazarus JH, Kokandi A. Thyroid disease in relation to pregnancy: a decade of change. Clin Endocrinol (Oxf). Sep 2000;53(3):265-78. [Medline].

  41. Leung AS, Millar LK, Koonings PP, Montoro M, Mestman JH. Perinatal outcome in hypothyroid pregnancies. Obstet Gynecol. Mar 1993;81(3):349-53. [Medline].

  42. Lucas A, Pizarro E, Granada ML, Salinas I, Roca J, Sanmartí A. Postpartum thyroiditis: long-term follow-up. Thyroid. Oct 2005;15(10):1177-81. [Medline].

  43. Mandel SJ, Larsen PR, Seely EW, Brent GA. Increased need for thyroxine during pregnancy in women with primary hypothyroidism. N Engl J Med. Jul 12 1990;323(2):91-6. [Medline].

  44. Martino E, Aghini-Lombardi F, Lippi F, Baschieri L, Safran M, Braverman LE. Twenty-four hour radioactive iodine uptake in 35 patients with amiodarone associated thyrotoxicosis. J Nucl Med. Dec 1985;26(12):1402-7. [Medline].

  45. Milham S Jr. Scalp defects in infants of mothers treated for hyperthyroidism with methimazole or carbimazole during pregnancy [letter]. Teratology. Oct 1985;32(2):321. [Medline].

  46. Momotani N, Noh J, Oyanagi H, Ishikawa N, Ito K. Antithyroid drug therapy for Graves' disease during pregnancy. Optimal regimen for fetal thyroid status. N Engl J Med. Jul 3 1986;315(1):24-8. [Medline].

  47. Nachum Z, Rakover Y, Weiner E, Shalev E. Graves' disease in pregnancy: prospective evaluation of a selective invasive treatment protocol. Am J Obstet Gynecol. Jul 2003;189(1):159-65. [Medline].

  48. Neto LV, De Almeida CA, Da Costa SM, Vaisman M. Prospective evaluation of pregnant women with hypothyroidism: implications for treatment. Gynecol Endocrinol. Mar 2007;23(3):138-41. [Medline].

  49. Ordookhani A, Mirmiran P, Walfish PG, Azizi F. Transient neonatal hypothyroidism is associated with elevated serum anti-thyroglobulin antibody levels in newborns and their mothers. J Pediatr. Mar 2007;150(3):315-7, 317.e2. [Medline].

  50. Poppe K, Velkeniers B, Glinoer D. Thyroid disease and female reproduction. Clin Endocrinol (Oxf). Mar 2007;66(3):309-21. [Medline].

  51. Pruyn SC, Phelan JP, Buchanan GC. Long-term propranolol therapy in pregnancy: maternal and fetal outcome. Am J Obstet Gynecol. Oct 15 1979;135(4):485-9. [Medline].

  52. Roti E, Emerson CH. Clinical review 29: Postpartum thyroiditis. J Clin Endocrinol Metab. Jan 1992;74(1):3-5. [Medline].

  53. Salvi M, How J. Pregnancy and autoimmune thyroid disease. Endocrinol Metab Clin North Am. Jun 1987;16(2):431-44. [Medline].

  54. Simsek M, Mendilcioglu I, Mihci E, Karagüzel G, Taskin O. Prenatal diagnosis and early treatment of fetal goitrous hypothyroidism and treatment results with two-year follow-up. J Matern Fetal Neonatal Med. Mar 2007;20(3):263-5. [Medline].

  55. Singer PA, Cooper DS, Levy EG, Ladenson PW, Braverman LE, Daniels G. Treatment guidelines for patients with hyperthyroidism and hypothyroidism. Standards of Care Committee, American Thyroid Association. JAMA. Mar 8 1995;273(10):808-12. [Medline].

  56. Tachi J, Amino N, Tamaki H, Aozasa M, Iwatani Y, Miyai K. Long term follow-up and HLA association in patients with postpartum hypothyroidism. J Clin Endocrinol Metab. Mar 1988;66(3):480-4. [Medline].

  57. Tagami T, Hagiwara H, Kimura T, Usui T, Shimatsu A, Naruse M. The incidence of gestational hyperthyroidism and postpartum thyroiditis in treated patients with graves' disease. Thyroid. Aug 2007;17(8):767-72. [Medline].

  58. Tamaki H, Amino N, Aozasa M, Mori M, Tanizawa O, Miyai K. Serial changes in thyroid-stimulating antibody and thyrotropin binding inhibitor immunoglobulin at the time of postpartum occurrence of thyrotoxicosis in Graves' disease. J Clin Endocrinol Metab. Aug 1987;65(2):324-30. [Medline].

  59. Degroot LJ, Larsen PR, Henneman G, eds. The Thyroid and Its Diseases. 6th ed. New York, NY: Churchill Livingstone; 1996.

  60. Van Dijke CP, Heydendael RJ, De Kleine MJ. Methimazole, carbimazole, and congenital skin defects. Ann Intern Med. Jan 1987;106(1):60-1. [Medline].

  61. Vargas MT, Briones-Urbina R, Gladman D, Papsin FR, Walfish PG. Antithyroid microsomal autoantibodies and HLA-DR5 are associated with postpartum thyroid dysfunction: evidence supporting an autoimmune pathogenesis. J Clin Endocrinol Metab. Aug 1988;67(2):327-33. [Medline].

  62. Walfish PG, Chan JY. Post-partum hyperthyroidism. Clin Endocrinol Metab. May 1985;14(2):417-47. [Medline].

  63. Weetman AP. Graves' disease. N Engl J Med. Oct 26 2000;343(17):1236-48. [Medline].

  64. Widerhorn J, Bhandari AK, Bughi S, Rahimtoola SH, Elkayam U. Fetal and neonatal adverse effects profile of amiodarone treatment during pregnancy. Am Heart J. Oct 1991;122(4 Pt 1):1162-6. [Medline].

  65. Wing DA, Millar LK, Koonings PP, Montoro MN, Mestman JH. A comparison of propylthiouracil versus methimazole in the treatment of hyperthyroidism in pregnancy. Am J Obstet Gynecol. Jan 1994;170(1 Pt 1):90-5. [Medline].

 
Previous
Next
 
Table. Mean Increases in Dosages of Thyroid Hormone According to Serum TSH levels
Serum TSH level,



mIU/mL or mIU/L



Increase,



mcg/d



5-1025-50
10-2050-75
< 2075-100
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.