Seminar on Thyroid disease

during pregnancy
Moderator; Dr. Dereje T. (Ass. Professor of
OB/GYN.)
Presenter ; Dr.Teshome (Year-III resident)
January, 2024
 Out line

• Objective
• Introduction
• Physiologic changes on thyroid
• Screening for thyroid disorders
• Common thyroid disorders during regnancy
• Postpartum thyroid dysfunction
• References

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 Objectives

• Discuss on detection& monitoring of common

thyroid disease in pregnancy
• Recall clinical presentation of thyroid disease in
pregnancy.
• Describe the workup of thyroid disease in pregnancy.
• Summarize the treatment options for thyroid disease
in pregnancy.

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 Introduction

• Thyroid disorders are the 2nd most common

endocrine diseases in pregnancy after DM.
• Obstetric care providers are expected to diagnose,
treat, and monitor women with thyroid disorders.
• P/E of the neck, thyroid, and adjacent structures is a
standard and important element of any pregnant
patient.

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 Physiologic thyroid changes during px

• The thyroid gland is able adjust with demands of

pregnancy .
• thyroid gland increases in size by 10%–50%
depending on iodine supply.
• HCG stimulation of maternal thyroid: ά-sub unit
cross stimulate TSH receptors.
• It also Promotes TH production, modifies its life and
affinity for the TSH receptor.

01/16/2024 5
 Cont…

• Changes in Thyroid- Binding Proteins

– Estrogen ↑TBG(2-3X), half-life prolonged from 15
minutes to 3 days.
– With sufficient iodine∼50% increase in TT4 and
TT3 levels.
– Those with decreased thyroid reserve, TSH levels
may increase and FT4 and FT3 may fall.

01/16/2024 6
 Cont…

• Peripheral Metabolism of Thyroid Hormones by

Maternal and Fetal Tissues and Placenta
– TH supply, transport, de-iodinase activities,
degradation will all change
– renal iodide clearance nearly doubles
– Overall iodine and thyroxin requirement rises by
20-50%.

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 Screening for Thyroid Disease

• Thyroid disorders are common in women of

reproductive age, sometimes as a new diagnosis on
Px.
• Frequently asymptomatic or difficult to distinguish
from the features of normal px.
• It is logical to systematically screen pregnant woman
for thyroid disorders.

01/16/2024 8
 Cont…

• Universal screening or targeted screening can be

applied for those with risk factors.
• ATA& ACOG recommend targeted screening for high
risk patients.
• Targeted screening miss 18%–89% of pregnant
women with thyroid dysfunction.
• The primary screening test for thyroid dysfunction is
serum TSH testing.

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 Indications for thyroid testing
in pregnancy
• Self or family hx of • BMI≥40 , stillbirth
thyroid dysfunction • Use of amiodarone or
• prior thyroid surgery lithium
• Age >30, Symptomatic • recent use of iodinated
• presence of goiter contrast.
• TPO ab positive • Unexplained infertility
• Type 1 diabetes or other • Residing in an area
autoimmune disorders moderate-to-severe
• Hx of head/neck iodine sufficiency
radiation
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 Common thyroid disorders during regnancy

• Hyperthyroidism
• Thyroid storm during pregnancy
• Fetal and neonatal hyperthyroidism
• Pregnancy and hyperthyroidism
• Hypothyroidism
• Pregnancy& hypothyroidism
• Thyroid nodules on pregnancy

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 Hyperthyroidism

• Clinical disorder of hyper-metabolism &

hyperactivity of the thyroid with exposure to supra-
physiologic concentrations of thyroid hormone.
• Affect 0.1% to 0.4% of all gravidas.
• Etiologies: Immune, non-autoimmune, goitres,GTT,
Iatrogenic, central.

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 Clinical manifestations
Symptoms Signs
• Hyperactivity, • Tachycardia,
• Irritability, dysphoria • AF, Tremor,
• Heat intolerance and • Goiter,
sweating, • Warm moist skin,
Palpitations, • Muscle weakness,
• Fatigue and weaknes, • proximal myopathy
• Wt loss with • Ophthalmopathy and
increased appetite, dermopathy are distinctive
Diarrhea, of graves disease.

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 Subclinical Hyperthyroidism

• Occurs in 0.8–1.7% of pregnant women.

• Dx; low serum TSH concentration with normal free
T4 levels.
• Has not been associated with adverse pregnancy
outcomes.
• Treatment of pregnant women with subclinical
hyperthyroidism is not recommended.

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 Gestational Thyrotoxicosis

• Also called transient hyperthyroidism of HG.

• GTT occurs in 2%–5% of pregnancies.
• GTT in the 1st TM of px occurs due to high titers of
hCG stimulating TSH receptor.
• Common causes; multiple gestation, hydatidiform
mole, hyperplacentosis
• Nausea& vomiting predominant symptoms but no
goitre.

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 Cont…

• Patients usually have negative TSI or Tgab.

• TT3/TT4 usually <20.
• Unrelated with feto-maternal adverse events.
• Often resolve or improve after mid-gestation.
• Management: supportive, thioamides not indicated.
• β- blockers can be considered for symptomatic
tachycardia.

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 Graves Disease

• Accounts more than 90% of cases of overt

hyperthyroidism in pregnancy.
• 0.2% of gravidas have Graves disease with most
diagnosed since childhood.
• Cause; TSI mediated overproduction of TH; TT3/TT4
≥20.
• Natural course; worsen in the 1st tm, postpartum,
amelioration of symptoms in the second half of px.

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 Treatment and monitoring of
hyperthyroidism
• Ideally thyroid disorders have to optimized
preconception.
• Anti-thyroid Drugs; the mainstay of treatment in
pregnancy.
• Thioamides:↓ iodine organifcation &TH synthesis.
• Goal: FTI,TT4 or FT4 into the ULN as soon as
possible with the minimal ATD.
• Monitoring Q2-4 wks with free T4, not TSH

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 Cont…

• Dosage of ATDs vary based on disease severity.

• Initial thioamide dose is empirical.
• For PTU 100–600 mg in 3 divided doses, MMI 5–30
mg PO, divided into 2 doses i.e ratio (20:1).
• Both MMI and PTU similarly cross the placenta.
• Both can cause rash(3-5%), leukopenia (10%), non-
dose related agranulocytosis (0.3%).

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 Cont…

• MMI use in 1st TM↑ risks of cutis aplasia, choanal

atresia, TEF, abdominal wall and VSD, omphalo-
mesenteric duct anomalies.
• PTU causes severe liver toxicity (0.1%–0.2% of
pregnancies).
• Serial liver function test & or CBC for side effects:
not recommended .

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 Cont…

• Alternate Treatments: Iodine Therapies, Surgery, and

Plasmapheresis
– Iodides; decrease circulating T4 and T3 levels by
up to 50% within 10 days.
– acutely inhibiting the release of stored hormone.
– primarily used in thyroid storm or preparation for
surgery.
• RAI with 131I is contraindicated in pregnancy
because it has a long half-life.

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 Thyroid Storm

• Clinical diagnosis of severe hyper-metabolic state

resulting from severe signs of thyrotoxicosis.
• It’s a true endocrine emergency with high
mortality(20% to 30%).
• Occurs after precipitating condition on poorly
controlled or undiagnosed disease.
• Diagnosis: clinical, undetectable TSH, High FT3 &
FT4

01/16/2024 22
 Cont…

Precipitants:
– Medications,
– Preeclampsia,
– Radioiodine therapy
– Discontinuation of ATD,
– DKA, infection,
– Labor, preeclampsia
• Burch-Wartofsky Point Scale commonly use for
diagnosis and quantifying disease severity.

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01/16/2024 24
 Approach to thyroid storm

• Should be multi-desciplinary in ICU set-up

• Supportive care;
– ABCS of life
– IV fluid resuscitation
– Electrolyte replacement & nutritional support
– Cooling and temperature control
– Avoid aspirin (displace TH from TBG)
– Treat precipitating factors

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 Cont…

• Inhibit TH production;
– PTU 600mg loading followed by 200mg PO or
NGT q8-hrs or
– MMI 40mg PO or NGT q8-hrs
• Give ATD 1-hr before iodide administration
• Inhibit TH release; iodide, lithium carbonate for
iodine allergy
• plasma exchange or dialysis considerd if no clinical
improvement after 24-48hrs.

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 Cont…

• Block T4-T3 peripheral conversion;

Hydrocortisone 100mg IV q8-hr
• β-blockade;
– Propranolol 40mg q6-hrs if hemodynamically
stable
– IV esmolol recommended for heart failure
– Alternative: IV diltiazem for β-blocker intolerance
or contraindications
• Thyroid storm is not indication for expedite delivery

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Thyroid storm in the second stage of labor: a
case report, 2021

Saroyo YB, Harzif AK, Anisa BM, et al. BMJ Case Rep

• 20 yr G-II , P-1 @ GA of 29 wk
• Diagnosed as hyperthyroidism before 5 years
• Never took adequate treatment, no proper ANC
• Present with labor pain, agitated, dyspneic
• GCS=12/15, BP=220/120mm Hg,
• PR= 156, temperature= 38.4°C RR= 40, SaO2=95%

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 Cont…

• Had goitre, grade 3 apical murmur, bilateral basal

rales
• Extremities were warm, with pitting oedema.
• Fundal height was 30cm, with 4c/10’/45s.
• FHR=140, fully dilated cervix
• BWS=50
• Dx: thyroid storm + SSOL+ superimposed pewsf +
acute pulm. Edema with impending RF

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 Cont…

• Lab; U/A: protein +2 blood+1. low TSH (<0.02

µIU/mL) and high free T4 (3.75ng/Dl)
• ECG: sinus tachycardia. Deliverd 1.9 kg, F, APGAR
8/9.
• patient was treated with O2, PTU, propranolol and
Lugol solution
• pre-eclampsia treated with nifedipine and MgSO4
• Neonate evaluated (normal TFT).
• Symtoms improved & discharged on 5th day.

01/16/2024 30
 Pregnancy and hyperthyroidism

• Poorly controlled • Fetal complications

hyperthyroidism – IUGR, SB
increases risk of – fetal hydrops,
– miscarriage, tachycardia,
– PIH – fetal or neonatal
– GDM, PTB thyrotoxicosis,
– heart failure. – Goitre, LBW
– prematurity

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 Cont…

• Pregnancy has no uniform effect on the course of

hyperthyroidism, some variants worsen.
• Controlled hyperthyroidism: antenatal fetal
surveillance not recommended
• Poorly controlled or IUGR: surveillance weekly from
32-34 wks.
• Timing and mode of delivery; as per obstetric
indication

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 Fetal and neonatal hyperthyroidism

• Occur in <5% offspring of TRab positive gravidas.

• Most cases recognized in the late 2nd or 3rd trimester.
• Causes: stimulation by maternal TRab, over-treatment
of hypothyroidism.

Presentation: accelerated bone growth,

IUGR HSM,
fetal gotre craniosynostosis,
Hydrops, SB AF abnormalities.
fetal tachycardia
01/16/2024 33
 Cont…

• Diagnosis: maternal TFT, fetal blood sampling, U/S,

MRI, neonatal evaluation
• Sonography: Doppler, BPP, bone maturation, FHR,
thyroid size
• Rx: thioamides, potasium iodide, β-blockers
• Fetal goitre with UAO: delivery by C/S and
intrapartal treatment
• Neonatal team should be informed about details.

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 Case Report
diagnosis and management of fetal and
neonatal thyrotoxicosis
Bohîlt R.-E.; Mihai, B.-M.; Szini, E.; Sucaliuc, I.-A.; Badiu,
C.

• 37 yr old G-III P-I, A-I, known to have Grave’s

disease, euthyroid
• Had thyroidectomy and was on thyroid replacement
therapy.
• Previous pregnancy complicated: fetal
hyperthyroidism with goiter, tachycardia, hydrops,
fetal cerebral ventriculomegaly, terminated @ 31 wk.
01/16/2024 35
 Cont…

• T4 dose increased upon current pregnancy.

• Since 23 wks FHR began to increase up to 180.
• After 01 wk T4 dose titrated switched to MMI @ 26th
wk and again escalated
• Surveillance continued, CD done at 35 wk as fetal
status was deteriorating.

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 Cont…

• Neonate: 2.5kg, APGAR 6/8, had mild

exophthalmia, moderate congenital ventriculomegaly.
• Cord blood TFT confirmed the fetal thyrotoxicosis:
fT4 > 100 pmol/L, T3 = 8.4 nmol/L, raised TRAb
• Thiamazole& propranolol administered.
• Neonate improved and normal development
continued.

01/16/2024 37
 Hypothyroidism

• Hypothyroidism is an under-activity of the thyroid

gland, resulting in inadequate thyroxin production.
• Complicates 2–10 per 1,000 pregnancies.
• Severe hypothyroidism is not common due to relative
infertility.
• More than 90% of cases are subclinical.
• It can be caused by myriad of factors.

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 Etiologies

• Primary hypothyroidism
– Autoimmune hypothyroidism, Iodine deficiency
– Congenital, Iatrogenic, Drugs
– Sub-acute thyroiditis
• Secondary hypothyroidism
– Hypopituitarism, Isolated TSH deficiency or
inactivity
• Tertiary hypothyroidism
– Hypothalamic tumors, trauma, infiltrative
01/16/2024 39
 Iodine deficiency

• Is the most common cause of hypothyroidism

worldwide.
• Prevalent in many mountainous regions.
• WHO estimates 2 billion people are iodine-deficient.
• RDA; 220 mcg for pregnant women and 290 mcg
lactating women.
• Iodine fortified salt, prenatal preparations with iodine
can prevent it.
 Systematic review and meta-analysis of iodine
deficiency and its associated factors among pregnant
women in Ethiopia, 2021

kabthymer, R.H., Shaka, M.F., Ayele, G.M. et al.

• Seven studies fulfilling the inclusion criteria included

in the meta-analysis.
• It included 2190 pregnant women .
• Found pooled prevalence of ID during pregnancy
using UIC to be 68.76% .

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 Cont…

• The prevalence in Oromia region is 71.93% and in

Amhara region is 60.93%.
• using iodized salt &1st Tm Px were found to have a
significant association with iodine deficiency.
• Conclusion; The prevalence of ID during pregnancy
is considerably high in Ethiopia.

• Recommendation: universal salt iodization

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 Autoimmune hypothyroidism

• Commonest cause of hypothyroidism in iodine-

sufficient areas.
• Hashimoto’s thyroiditis often present with goitre and
later gets atrophied.
• Pathology: marked lymphocytic infiltration of the
thyroid with colloid loss.
• Antibodies to TPO & TG are clinically useful
markers of autoimmunity (95%).

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 Clinical manifestations of hypothyroidism

• Tiredness, cold Signs

intolerance • Goitre
• muscle cramps, • dry& cold skin,
constipation • delayed DTR
• deepening of the voice • bradycardia , ↑diastolic
• Wt. Gain, depression BP
• memory deficit, • periorbital edema,
myopathy slowing • Low output CHF,
speech etc. Pericardial effusion etc.

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 Subclinical Hypothyroidism

• Elevated serum TSH with normal free T4 level.

• Prevalence in pregnancy; 2–5%
• TPOAbs should be determined to settle the etiology
because they are present in 70-80% of hypothyroid
cases.
• No conclusive evidence that identification and
treatment during pregnancy improves feto-maternal
outcomes.

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 Isolated hypothyroxinemia

• Defined as a normal TSH& T3 with mildly low T4.

• Diagnosed in 2.1% of pregnant women.
• Usually incidentally diagnosed and patients are
asymptomatic.
• Not related with adverse pregnancy and perinatal
outcomes
• Routine treatment is not indicated unless it is of early
onset with high trab titer.

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 Approach to hypothyroidism

• Thyroxine is the mainstay of therapy

– Begin with dose 1-2 μg/kg/d or 100μg daily
– Surveillance is with TSH levels measured at 4-6
wk
• Goal TSH level: between the lower limit of the
reference range and 2.5 mIU/L
• Owing to higher oestrogen about one third of women
need dose escalation after px confirmation.
 Hypothyroidism and pregnancy

• Poorly controlled
hypothyroidism Fetal: prematurity, LBW
– ↑ infertility • impaired neuro-cognitive
– abortion, development,
– preeclampsia, • lower APGAR score,
– GDM, PTB, AP, • low adulthood IQ,
– heart failure, PPH • Congenital
hypothyroidism

01/16/2024 48
 Cont…

• Pregnancy has no dramatic effect on course of

hypothyroidism, but thyroxin demand can make them
symptomatic.
• Pre-existing hypothyroidism; TSH at 6-8 wk, then 16-
20 & 28-32 wk and 4-6 wks postpartum.
• Insufficient evidence to recommend antenatal fetal
surveillance.
• Timing and date of delivery: like general obstetric
patients.

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 Thyroid nodules during pregnancy

• Distinct hyperplastic lesions that can result from

several pathologic mechanisms.
• Palpable nodules found in up to 5% of reproductive
aged women.
• 3-5X more common on women than men.
• diagnostic incidence increased with advancing age,
higher parity, and across gestation and postpartum.

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 Cont…

• Non-neoplastic causes; pure cysts, hyperplastic

nodules, pseudo-nodules
• Neoplastic
• 90-95% benign.
• Patients thyroid needs to be well characterized along
with sentinel lymph nodes
• Pregnancy is unlikely to alter natural course of such
disorders.

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 Evaluation of thyroid nodules

• Sonography; for detecting thyroid nodules,

monitoring growth, assessing cervical lymph nodes
• Reliably detects nodules >5 mm.
• ACR Tl-RADS is the standard reporting way.
• Suspicious features for malignancy on U/S
– Micro-calcifications
– hypoechoic pattern
– irregular margin
– longer than wide

01/16/2024 52
 Cont…

• FNAC: findings not influenced by pregnancy.

• Can be done at any GA
• Does not pose any additional risks.
• ATA and ACR TI-RADS guidelines do not
recommend FNA for <1 cm unless symptomatic
• FNAC result interpretation and management strategy
should be as per the Bethesda criteria.

01/16/2024 53
 Cont…

• TSH is critical to identify autonomously functioning

“hot” nodules.
• most thyroid cancers will have a normal or elevated
TSH
• Radioiodine scanning during pregnancy and breast
feeding is usually not recommended.
• Management: pharmacologic, supportive or surgical

01/16/2024 54
 Postpartum Thyroid Dysfunction

• Transient thyroid dysfunction in the 1 st year after

delivery in previously euthyroid women.
• Possible spontaneous or medically induced abortions.
• PTT complicates ⁓5–10% of women during the first
year after childbirth.
• New-onset abnormal levels of TSH and free T4
confirm the diagnosis.

01/16/2024 55
 Cont…

• Classically two recognized clinical phases develop in

succession.
• The 1st phase destruction-induced thyrotoxicosis lasts
only a few months; supportive treatment suffice.
• The usual 2nd phase is overt hypothyroidism that
occurs between 4& 8 months postpartum.
• Non-specific symptoms common in the postpartum
period & testing is often overlooked

01/16/2024 56
 Cont…

• hypothyroid phase frequently requires treatment,

especially if
– the patient is mildly symptomatic (TSH is ≥10
mIU/L),
– overt hypothyroidism (low FT4) is diagnosed,
– patient is lactating
– considering future conception

01/16/2024 57
 Cont…

• ⅓ of women PPT will develop permanent, overt

hypothyroidism.
• Predictors for onset of PPT
– high titers of TPO Ab in the 1st Tm of Px,
– family or personal history of thyroid disease,
– presence of goiter, and smoking.
• Patients at risk should be evaluated in the 1 st yr
postpartum at 3, 6, and 12 months after delivery.

01/16/2024 58
 References

• Gabbe’s OBSTETRICS normal and problem

pregnancies; 8th ed. (pages 924-943).
• Creasy & Resnik’s MATERNAL-FETAL MEDICINE;
9th ed. (Pages 1187- 1213).
• Williams OBSTETRICS; 26th edition. (Pages 2809-
2836).

• Harrison’s Principles Internal medicine, 21st ed.

Pages (2926-2955)

01/16/2024 59
 Cont…

• ACOG practice bulletin; number 223.

• Management of Thyroid Disorders in Pregnancy,
RCOG Green-top Guideline, May-June 2023.
• Pregnancy and postpartum thyroid management
guidelines, ATA, 2017.
• Uptodate 2023.

01/16/2024 60
 Cont…

• Systematic review and meta-analysis of iodine

deficiency and its associated factors among
pregnant women in Ethiopia. Kabthymer et al. (2021)
21:106
• Saroyo YB, Harzif AK, Anisa BM, et al. BMJ Case
Rep 2021;14:e243159. doi: 10.1136/bcr-2021-
243159.
• Bohîlt,ea, R.E.; Mihai, B.M.;Szini, E. ;S, ucaliuc,
I.A.; Badiu, C. Diagnosis and Management of Fetal
and Neonatal Thyrotoxicosis.
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 Thank you

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