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NEONATE BORN TO MOTHER WITH GRAVE’S DISEASE Baby boy born at 24 weeks gestation, weight 559G Mother 25year,G6 P4 Ab1 LC

NEONATE BORN TO MOTHER WITH GRAVE’S DISEASE Baby boy born at 24 weeks gestation, weight 559G Mother 25year,G6 P4 Ab1 LC4. Known case of Grave’s disease, with uncontrolled thyrotoxicosis since 1999…non compliant on treatment (PTU/Inderal). No PNC.

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NEONATE BORN TO MOTHER WITH GRAVE’S DISEASE Baby boy born at 24 weeks gestation, weight 559G Mother 25year,G6 P4 Ab1 LC

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  1. NEONATE BORN TO MOTHER WITH GRAVE’S DISEASE • Baby boy born at 24 weeks gestation, weight 559G • Mother 25year,G6 P4 Ab1 LC4. • Known case of Grave’s disease, with uncontrolled thyrotoxicosis since 1999…non compliant on treatment (PTU/Inderal). No PNC. • With pre-eclampsia, abruption- severe decelerations-Emergency C-section.

  2. NICU COURSE • Maternal TSI on Sept 2003: 212% (Normal 0 - 129%) • Resuscitated at birth Apgars 3,6 & 8.Ventilated ….given curosurf and transferred to ICN on portable ventilator • On exam, baby 24 weeks gestation AGA • Systemic exam WNL. No evidence of goiter/exophthalmos. Initially had heart rates in 160-170 but later normalized.

  3. MANAGEMENT IN NICU • Hypoperfusion/hypotension/metabolic acidosis needing NS bolus x 2 and inotrope support. • D2-3 echo showed PDA…treated with Indomethacin • Head sono…no IVH. Drug screen normal

  4. THYROID CHEMISTRIES

  5. PRESENT CONDITION • Presently baby on IMV, being treated for evolving lung disease…diuretics and steroid nebulization • On TPN and NG feeds.

  6. OBSTETRIC HISTORY • 7/96 40wks 9lbs NSVD Dallas • 9/97 40wks 7lbs NSVD Mexico • 11/01 31wks 2lbs NSVD Thomason • 9/03 36wks 3lbs NSVD Thomason • 12/00 15wks miscarriage • 7/04 24wks 1.2lbs CS Thomason

  7. BABY WITH NEONATALTHYROTOXICOSIS • Baby No.3 was born at Thomason in 2001 • Preterm 31 wks SGA , BW:1130 G • No prenatal-care. Presented 1 hour prior to delivery. • Had fetal bradycardia/abruptio. • Ventilated

  8. CLINICAL FEATURES/COURSE • IUGR. Microcephaly, Bone age noted to be advanced. • Had persistent tachycardia • Baby had fluctuating levels of T4 and T3. • Treated with Lugol’s iodine, Inderal and PTU

  9. THYROID CHEMISTRY

  10. COURSE AFTER DISCHARGE • Discharged at 2 m with T4 :0.6 and T3 :69. Stopped meds prior to discharge. • Had initially weight loss which later improved. • At 2 m age had seizures. F/Up thyroid tests were normal. • Head scan/MRI July 2004 showed non communicating hydrocephalus

  11. THYROTOXICOSIS IN NEONATE • Typically a transient hyperthyroidism • 1 in 70 Grave’s affected pregnancies. • Mortality :up to 25% Etiology • Placental transfer : Thyroid-stimulating immunoglobulins. Maternal antibodies wane over 2-3 months

  12. MATERNAL TBII • TSH binding inhibiting immunoglobulin Levels > 70% predictive neonatal thyrotoxicosis • Role of stimulatory and inhibitory immunoglobulins • Duration of disease depends on concentration, degradation rate and presence or absence of inhibitory Ab

  13. BABIES AT RISK • Raised level of TBII in pregnancy • TBII not assessed • Thyotoxicosis in 3rd trimester • Thionamide required in 3rd trimester • Family H/O TSH receptor mutation • Evidence of fetal thyrotoxicosis

  14. POINTS TO CONSIDER • Mother with Grave’s disease may not have thyrotoxicosis and may be euthyroid or hypothyroid. • Exposure to anti-thyroid drugs in-utero may delay symptoms • Newborn Screening with T4-radioimmune assay, can detect raised levels of T4 • Positive assay for Thyroid stimulating immunoglobulins….confirmatory • Consider narcotic withdrawal

  15. CLINICAL FEATURES OF NEONATAL THYROTOXICOSIS • Hyperirritability • Tachycardia • Goiter • Exophthalmos • LBW and weight loss • CHF • Craniosynostosis/ advanced bone age/microcephaly…psychomotor retardation • Jaundice/thrombocytopenia

  16. APPROACH TO BABY OF MOTHER WITH GRAVES DISEASE

  17. TREATMENT • Should biochemical abnormality in absence of symptoms be treated? • Thionamides block hormone synthesis • PTU 5-10mg/kg/d in 3 divided doses • Carbimazole 0.5-1.5mg/kg/d • Lugol’s iodine (8mg/drop) 1-3 drops/D • Iopanoic acid/sodium ipodate, Propanolol, Prednisolone–in refractory cases

  18. TREATMENT (CONTINUED) • Exchange transfusions…to reduce TSI levels • Baby on treatment for thyrotoxicosis is reviewed weekly until stable, then every 2 weeks and drug dose reduced. • Usually treated for 4-8 weeks. • Thyrotoxicosis secondary to mutations of TSH receptor require ablative treatment with surgery.

  19. SUMMARY • Possibility of fetal thyrotoxicosis must be kept in all mothers with a history of Grave’s disease regardless of thyroid status/treatment. • Thyroid stimulating immunoglobulins (TSI) persist even after thyroid surgery/radioablation in mother. • Neonatal thyrotoxicosis secondary to TSIs is a transient disorder, limited by clearance of maternal antibodies

  20. SUMMARY (CONTINUED) • In neonates signs of thyrotoxicosis may be delayed due to effect of maternal anti-thyroid drugs or effect of blocking antibodies. Cases reported as late as 45 days. • TSH binding inhibitor Ig levels from mother and from neonate correlate well with neonatal thyrotoxicosis.

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