Autoimmune Thyroid Disease and Pregnancy Medication

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

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Next

Antithyroid drugs

Class Summary

ATDs are effective, reversible treatments for hyperthyroidism. The consensus among experts is that ATDs should be first-line treatments for pregnant women with hyperthyroidism. ATDs inhibit iodination of thyroid thyroglobulin and thyroglobulin synthesis by competing with iodine for peroxidase. PTU and MMI are available in the United States. PTU and MMI are equally effective.

Both PTU and MMI cross the placenta and can cause fetal hypothyroidism and goiter. In addition, both PTU and MMI are excreted in small amounts in breast milk. MMI is not bound to plasma protein as much as PTU; therefore, it is excreted into the breast milk in slightly higher concentrations than PTU is.

View full drug information

Propylthiouracil

 

Derivative of thiourea that inhibits organification of iodine by thyroid gland. Blocks oxidation of iodine in thyroid gland, inhibiting thyroid hormone synthesis. Inhibits T4-to-T3 conversion (advantage over other agents). DOC in patients with hyperthyroidism during pregnancy because of reports of fetal aplasia cutis (reversible scalp defect) in association with MMI or CMI. Taper gradually to minimum dosage required to maintain clinical euthyroid and to avoid fetal hypothyroidism.

View full drug information

Methimazole, MMI (Tapazole)

 

Inhibits thyroid hormone by blocking oxidation of iodine in thyroid gland, but not known to inhibit peripheral conversion of thyroid hormone. Taper gradually to minimum dosage required to maintain clinical euthyroid and to avoid fetal hypothyroidism. Cases of fetal aplasia cutis reported.

Previous
Next

Iodides

Class Summary

Iodides inhibit the release of stored thyroid hormones. They decrease serum T4 and T3 concentrations by 30-50% by the 10th day of treatment. Iodides are reserved for the treatment of severe thyrotoxicosis or for preoperative treatment in combination with ATDs and beta-blockers. These agents readily cross the placenta by the 12th week of gestation and are readily taken up by the fetal thyroid gland. Long-term use of iodides can lead to fetal hypothyroidism and goiter. In pregnant women, these drugs should generally be used for no longer than 2 weeks.

View full drug information

Iodide (SSKI, Pima)

 

DOC. Rapidly inhibits release of thyroid hormones by directly affecting thyroid gland. Inhibits synthesis of thyroid hormones. Also appears to attenuate cyclic adenosine monophosphate (cAMP)–mediated effects of TSH.

Previous
Next

Thyroid hormones

Class Summary

Several forms of thyroid hormones are commercially available. They include levothyroxine, liothyronine, and liotrix. Levothyroxine is the DOC for treating pregnant women with hypothyroidism. No conclusive evidence supports the use of levothyroxine to prevent perinatal hypothyroidism.

View full drug information

Levothyroxine (Synthroid)

 

Levo isomer of T4. Once absorbed, T4 deiodinated to T3 in extrathyroidal tissues. First choice in treatment of hypothyroidism during pregnancy because it mimics physiologic state. Measure TSH levels q4wk, and adjust dosage.

Previous
Next

Beta-adrenergic blocker

Class Summary

Beta-blockers are valuable adjunct to ATDs. These drugs are effective for alleviating symptoms of hypermetabolic state (eg, palpitation, sweating, nervousness, tremor). They are safe during pregnancy to achieve immediate control of symptomatic thyrotoxicosis. The goal of beta-blockage is to reduce the mother's heart rate to less than 100 bpm. Prolonged use of beta-blockers has been associated with intrauterine growth restriction, fetal bradycardia, hypoglycemia, and an abnormal response to stress; therefore, long-term use not recommended during pregnancy.

View full drug information

Propranolol (Inderal)

 

DOC in treating cardiac arrhythmias resulting from hyperthyroidism. Controls cardiac and psychomotor manifestations in minutes.

Previous
Proceed to Follow-up
 
 
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.