AMERICAN THYROID ASSOCIATION®

www.thyroid.org

Hyperthyroidism in Pregnancy
WHAT IS THE THYROID GLAND? WHAT IS THE INTERACTION BETWEEN THE
The thyroid gland is a butterfly-shaped endocrine gland THYROID FUNCTION OF THE MOTHER AND
that is normally located in the lower front of the neck. THE BABY?
The thyroid’s job is to make thyroid hormones, which are
secreted into the blood and then carried to every tissue For the first 18-20 weeks of pregnancy, the baby is
in the body. Thyroid hormone helps the body use energy, completely dependent on the mother for the production
stay warm and keep the brain, heart, muscles, and other of thyroid hormone. By mid-pregnancy, the baby’s thyroid
organs working as they should. begins to produce thyroid hormone on its own. The baby,
however, remains dependent on the mother for ingestion
WHAT ARE THE NORMAL CHANGES IN of adequate amounts of iodine, which is essential to make
the thyroid hormones. The World Health Organization
THYROID FUNCTION ASSOCIATED WITH recommends iodine intake of 250 micrograms/day
PREGNANCY? during pregnancy to maintain adequate thyroid hormone
HORMONE CHANGES. A normal pregnancy results in a production. Because iodine intakes in pregnancy are
number of important physiological and hormonal changes currently low in the United States, the ATA recommends
that alter thyroid function. These changes mean that that US women who are planning pregnancy, pregnant, or
laboratory tests of thyroid function must be interpreted breastfeeding should take a daily supplement containing
with caution during pregnancy. Thyroid function tests 150 mcg of iodine.
change during pregnancy due to the influence of two
main hormones: human chorionic gonadotropin (hCG), HYPERTHYROIDISM & PREGNANCY
the hormone that is measured in the pregnancy test and WHAT ARE THE MOST COMMON CAUSES OF
estrogen, the main female hormone. HCG can weakly HYPERTHYROIDISM DURING PREGNANCY?
turn on the thyroid and the high circulating hCG levels in Overall, the most common cause of hyperthyroidism in
the first trimester may result in a slightly low TSH. When women of childbearing age is Graves’ disease (see Graves’
this occurs, the TSH will be slightly decreased in the first Disease brochure), which occurs in 0.2% of pregnant
trimester and then return to normal throughout the duration patients. In addition to other usual causes of hyperthyroidism
of pregnancy. Estrogen increases the amount of thyroid (see Hyperthyroidism brochure), very high levels of hCG,
hormone binding proteins in the serum which increases seen in severe forms of morning sickness (hyperemesis
the total thyroid hormone levels in the blood since >99% gravidarum), may cause transient hyperthyroidism in early
of the thyroid hormones in the blood are bound to these pregnancy. The correct diagnosis is based on a careful
proteins. However, measurements of “Free” hormone (that review of history, physical exam and laboratory testing.
are not bound to protein, representing the active form
of the hormone) usually remain normal. The thyroid is WHAT ARE THE RISKS OF GRAVES’ DISEASE/
functioning normally if the TSH and Free T4 remain in the HYPERTHYROIDISM TO THE MOTHER?
trimester-specific normal ranges throughout pregnancy. Graves’ disease may present initially during the first
SIZE CHANGES. The thyroid gland can increase in size trimester or may be exacerbated during this time in a
during pregnancy (enlarged thyroid = goiter). However, woman known to have the disorder. In addition to the
pregnancy-associated goiters occur much more frequently classic symptoms associated with hyperthyroidism,
in iodine-deficient areas of the world. It is relatively inadequately treated maternal hyperthyroidism can
uncommon in the United States. If very sensitive imaging result in early labor and a serious complication known as
techniques (ultrasound) are used, it is possible to detect pre-eclampsia. Additionally, women with active Graves’
an increase in thyroid volume in some women. This is disease during pregnancy are at higher risk of developing
usually only a 10-15% increase in size and is not typically very severe hyperthyroidism known as thyroid storm.
apparent on physical examination by the physician. Graves’ disease often improves during the third trimester
However, sometimes a significant goiter may develop and of pregnancy and may worsen during the post partum
prompt the doctor to measure tests of thyroid function. period.

1
This page and its contents
are Copyright © 2019
the American Thyroid Association
®
 AMERICAN THYROID ASSOCIATION®
www.thyroid.org

Hyperthyroidism in Pregnancy
WHAT ARE THE RISKS OF GRAVES’ DISEASE/ 3) ANTI-THYROID DRUG THERAPY (ATD). Methimazole
HYPERTHYROIDISM TO THE BABY? (Tapazole) or propylthiouracil (PTU) are the ATDs
The risks to the baby from Graves’ disease are due to one available in the United States for the treatment of
of three possible mechanisms: hyperthyroidism (see Hyperthyroidism brochure).
Both of these drugs cross the placenta and can
1) UNCONTROLLED MATERNAL HYPERTHYROIDISM: potentially impair the baby’s thyroid function and
Uncontrolled maternal hyperthyroidism has been cause fetal goiter. Use of either drug in the first
associated with fetal tachycardia (fast heart rate), trimester of pregnancy has been associated with birth
small for gestational age babies, prematurity, defects, although the defects associated with PTU
stillbirths and congenital malformations (birth are less frequent and less severe. Definitive therapy
defects). This is another reason why it is important to (thyroid surgery or radioactive iodine treatment) may
treat hyperthyroidism in the mother. be considered prior to pregnancy in order to avoid
2) EXTREMELY HIGH LEVELS OF THYROID the need to use PTU or methimazole in pregnancy.
STIMULATING IMMUNOGLOBLULINS (TSI): Graves’ When ATDs are required, PTU is preferred until week
disease is an autoimmune disorder caused by 16 of pregnancy. It is recommended that the lowest
the production of antibodies that stimulate the possible dose of ATD be used to control maternal
thyroid gland referred to as thyroid stimulating hyperthyroidism in order to minimize the development
immunoglobulins (TSI). These antibodies do cross of hypothyroidism in the baby. Overall, the benefits
the placenta and can interact with the baby’s thyroid. to the baby of treating a mother with hyperthyroidism
High levels of maternal TSI’s have been known to during pregnancy outweigh the risks if therapy is
cause fetal or neonatal hyperthyroidism, but this is carefully monitored.
uncommon (only 1-5% of women with Graves’ disease
during pregnancy). Fortunately, this typically only WHAT ARE THE TREATMENT OPTIONS FOR A
occurs when the mother’s TSI levels are very high PREGNANT WOMAN WITH GRAVES’ DISEASE/
(many times above normal). Measuring TSI in the
mother with Graves’ disease is recommended in early
HYPERTHYROIDISM?
pregnancy and, if initially elevated, again around Mild hyperthyroidism (slightly elevated thyroid hormone
weeks 18-22. levels, minimal symptoms) often is monitored closely
without therapy as long as both the mother and the baby
When a mother with Graves’ disease requires are doing well. When hyperthyroidism is severe enough to
antithyroid drug therapy during pregnancy, fetal require therapy, anti-thyroid medications are the treatment
hyperthyroidism is rare because antithyroid drugs of choice, with PTU being preferred in the first trimester.
also cross the placenta and can prevent the fetal The goal of therapy is to keep the mother’s free T4 in the
thyroid from becoming overactive. Of potentially more high-normal to mildly elevated range on the lowest dose of
concern to the baby is when the mother has been antithyroid medication. Addition of levothyroxine to ATDs
treated for Graves’ disease (for example radioactive (“block-and-replace”) is not recommended. Targeting this
iodine or surgery) and no longer requires antithyroid range of free hormone levels will minimize the risk to the
drugs. It is very important to tell your doctor if you baby of developing hypothyroidism or goiter. Maternal
have been treated for Graves’ Disease in the past so hypothyroidism should be avoided. Therapy should be
proper monitoring can be done to ensure the baby closely monitored during pregnancy. This is typically
remains healthy during the pregnancy. done by following thyroid function tests (TSH and thyroid
hormone levels) monthly.

FURTHER INFORMATION
Further details on this and other thyroid-related topics are available in the patient thyroid
information section on the American Thyroid Association® website at www.thyroid.org.
2
This page and its contents
are Copyright © 2019
the American Thyroid Association
®
For information on thyroid patient support organizations, please visit the
Patient Support Links section on the ATA website at www.thyroid.org
 AMERICAN THYROID ASSOCIATION®
www.thyroid.org

Hyperthyroidism in Pregnancy
In patients who cannot be adequately treated with WHAT IS THE NATURAL HISTORY OF
anti-thyroid medications (i.e. those who develop an
allergic reaction to the drugs), surgery is an acceptable GRAVES’ DISEASE AFTER DELIVERY?
alternative. Surgical removal of the thyroid gland is safest Graves’ disease typically worsens in the postpartum
in the second trimester. period or may occur then for the first time. When new
hyperthyroidism occurs in the first months after delivery,
Radioiodine is contraindicated to treat hyperthyroidism
the cause may be either Graves’ disease or postpartum
during pregnancy since it readily crosses the placenta
thyroiditis and testing with careful follow-up is needed to
and is taken up by the baby’s thyroid gland. This can
distinguish between the two. Higher doses of anti-thyroid
cause destruction of the gland and result in permanent
medications may be required during this time. As usual,
hypothyroidism.
close monitoring of thyroid function tests is necessary.
Beta-blockers can be used during pregnancy to help treat
significant palpitations and tremor due to hyperthyroidism. CAN THE MOTHER WITH GRAVES’ DISEASE,
They should be used sparingly due to reports of impaired WHO IS BEING TREATED WITH ANTI-THYROID
fetal growth associated with long-term use of these
medications. Typically, these drugs are only required DRUGS, BREASTFEED HER INFANT?
until the hyperthyroidism is controlled with anti-thyroid Yes. Although very small quantities of both PTU and
medications. methimazole are transferred into breast milk, total daily
doses of up to 20mg methimazole or 450mg PTU are
considered safe and monitoring of the breastfed infants’
thyroid status is not required.

FURTHER INFORMATION
Further details on this and other thyroid-related topics are available in the patient thyroid
information section on the American Thyroid Association® website at www.thyroid.org.
3
This page and its contents
are Copyright © 2019
the American Thyroid Association
®
For information on thyroid patient support organizations, please visit the
Patient Support Links section on the ATA website at www.thyroid.org