Autoimmune Thyroid Disease and Pregnancy Follow-up

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

Further Inpatient Care

Treatment of maternal or fetal complications

Patients with clinically significant maternal or fetal complications from hyperthyroidism or hypothyroidism should be admitted to the hospital.

Management of thyroid storm

Patients with thyroid storm should be admitted to an intensive care unit. Thyroid storm is a life-threatening condition due to the acute exacerbation of symptoms of hyperthyroidism, such as the following:

  • Fever
  • Tremors
  • Agitation
  • Altered mental status (eg, coma)
  • Pronounced cardiovascular symptoms (eg, heart failure, tachyarrhythmias including atrial fibrillation)
  • Nausea, vomiting, and/or diarrhea

Thyroid storm can be triggered by stress, such as preeclampsia or induction of labor, especially in patients with poorly controlled hyperthyroidism.

The precipitating condition should be identified and treated. General management includes the intravenous administration of fluids, cardiovascular monitoring, and implementation of cooling measures. PTU is the ATD of choice because it blocks peripheral conversion of T4 to T3. Iodide is given 1-3 hours after the ATD to inhibit the release of thyroid hormones. Dexamethasone is also given to block peripheral conversion of T4 to T3 and to prevent adrenal insufficiency. Propanolol provides beta-blockade and controls the patient's heart rate.

Aggressive thyroid hormone replacement and supportive care are the cornerstones of managing myxedema.

Next

Further Outpatient Care

Hyperthyroidism

Pregnant women with hyperthyroidism should be monitored monthly. Important parameters include vital signs (specifically the pulse rate), weight, FT4 and TSH concentrations, and measures of fetal well-being. The woman's pulse should be maintained below 100 bpm. Maternal weight gain should be appropriate for the mother's prepregnancy weight. TSH levels can be maintained near the low limit of normal as long as the patient is clinically euthyroid. FT4 values should be maintained at the upper limit of normal to ensure that the fetus' requirements are adequately met.

Fetal monitoring during pregnancy is essential. Fetal thyrotoxicosis is suggested when the fetal heart rate is faster than 160 bpm. Ultrasonography may reveal intrauterine growth retardation, advanced bone age, and craniosynostosis. Thyroid-stimulating autoantibodies can cross the placenta and activate the fetal thyroid gland.

In all pregnant women with Graves disease, TSI levels should be measured in the third trimester. A high TSI value is most likely to be associated with fetal thyrotoxicosis. Neonates born to mothers with Graves disease should be evaluated for hyperthyroidism. Approximately 1% of these babies have hyperthyroidism. If left untreated, their mortality rate can be as high as 30%.

All patients' TSH and FT4 levels should be evaluated after delivery. Women can continue taking ATDs while breastfeeding.

Hypothyroidism

Patients with newly diagnosed hypothyroidism should receive TSH testing every 4 weeks, and their dosage of T4 should be adjusted as needed. The T4 replacement dosage increases by 30% by the 10th week of gestation and by 48% by the 20th week.

In all pregnant women with preexisting hypothyroidism, TSH levels should be measured at 6-8 weeks' gestation. Subsequent TSH measurements may be obtained at 16-20 and 28-32 weeks' gestation. After delivery, the dosage of T4 should be reduced to the prepregnancy amount.

Antenatal fetal surveillance may be beneficial. Delivery should be considered at term. In general, women should go past dates.

Long-term follow-up care of patients with hypothyroidism is mandatory.

Postpartum thyroiditis

Patients with PPT should receive long-term follow-up care because PTT frequently recurs with subsequent pregnancies.

Patients with significantly elevated levels antimicrosomal antibodies, a family history of hypothyroidism, or a prominent goiter are at the greatest risk for developing permanent hypothyroidism.

TSH levels should be measured at least once a year.

Previous
Next

Deterrence/Prevention

The benefits of universal screening for thyroid disease in pregnancy has not been justified. However, women with the following indicators of high risk should be screened:

  • Personal history of thyroid disease
  • Family history of thyroid disease
  • Goiter
  • Positive thyroid antibodies
  • Symptoms or clinical signs suggestive of thyroid disease (eg, anemia, elevated cholesterol level, hyponatremia)
  • Pregestational diabetes
  • Other autoimmune disorders
  • Infertility
  • Previous head and neck irradiation
  • History of miscarriage or preterm birth

Screening for PPT is recommended for postpartum women with type 1 diabetes and for those with positive anti-TPO results. Screening should occur at 3 and 6 months after delivery.

Previous
Next

Complications

Hyperthyroidism

Uncontrolled hyperthyroidism, especially in the second half of pregnancy, can lead to numerous complications.

Maternal complications

  • Miscarriage
  • Infection
  • Preeclampsia
  • Preterm delivery
  • Congestive heart failure
  • Thyroid storm
  • Placental abruption

Fetal and neonatal complications

  • Prematurity
  • Small size for gestational age
  • Intrauterine fetal death
  • Toxemia
  • Fetal or neonatal thyrotoxicosis, including accelerated bone maturation, goiter, and hydrops

Hypothyroidism

Maternal complications of untreated hypothyroidism

  • Microcytic anemia
  • Preeclampsia
  • Placental abruption
  • Postpartum hemorrhage
  • Cardiac dysfunction
  • Miscarriage

Fetal or neonatal complications

  • Prematurity
  • Stillbirth
  • Delayed bone maturation
  • Goiter
  • Hydrops
  • Poor neurologic development

Postpartum thyroiditis

Complications associated with PPT are maternal, and depression is common. Permanent hypothyroidism may occur in as many as 30% of patients. These women are also at high risk for recurrent PPT after subsequent pregnancies.

Previous
Next

Prognosis

  • The outcome of pregnancies affected by autoimmune thyroid disease depends on the degree of metabolic control.
  • Women with euthyroid disease can expect satisfactory outcomes of their pregnancy.
  • With close follow-up postpartum, medical therapy can be adjusted to ensure a euthyroid state. This helps ensure a good prognosis.
Previous
Next

Patient Education

  • The importance of compliance with medical therapy should be stressed.
  • The need for frequent laboratory assessment should be discussed.
  • The adverse effects of medical therapy, including the fetal risks, should be outlined.
  • For excellent patient education resources, visit eMedicine's Endocrine System Center. Also, see eMedicine's patient education article Thyroid Problems.
Previous
 
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.