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بارداری و تیرویید

بارداری و تیرویید. ( J Clin Endocrinol Metab 97: 2543–2565, 2012). Anemia Hypertension Preeclampsia Abruptio placenta Postpartum hemorrhage. Miscarriage Low birth weight Stillbirth Psychoneurologic impairment. Effects of Hypothyroidism on Pregnancy Outcomes. Maternal. Fetal.

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بارداری و تیرویید

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  1. بارداری و تیرویید (J Clin Endocrinol Metab 97: 2543–2565, 2012)

  2. Anemia • Hypertension • Preeclampsia • Abruptioplacenta • Postpartum hemorrhage • Miscarriage • Low birth weight • Stillbirth • Psychoneurologicimpairment Effects of Hypothyroidism onPregnancy Outcomes Maternal Fetal JCEM, 2007

  3. Screening for Thyroid Disease in Pregnancy Although the benefits of universal screening for thyroid dysfunction may not be justified at this time, selected screening for the following should be done: • Positive FHxthyroid disease • Goiter • TPOAb+ • Symptoms • Type 1 DM • Miscarriage • Other autoimmunedisease • Infertility • Morbid obesity • >30 years • Iodine deficient area Thyroid 2011, JCEM 2012

  4. TSH level during pregnancy • 1st trimester<2.5 mIU/ml • 2nd and 3rd trimester<3 mIU/ml

  5. Graves ophthalmopathy

  6. پرکاری تیرویید و بارداری • فقط در سه ماهه اول پروپیل تیوراسیل بدهید. • ید رادیو اکتیو در بارداری غیر مجاز است. • در سه ماهه دوم در صورت نیاز می توانید تیروییدکتومی نمایید. • با علایم بالینی TSH, T4, T3RU بیمارتان را پیگیری نمایید

  7. اندیکاسیون های تیروییدکتومی • A severe adverse reaction to ATD therapy • Persistently high doses of ATD are required (over 30 mg/d of MMI or 450 mg/d of PTU); • Nonadherent to ATD therapy and uncontrolled hyperthyroidism بهترین زمان جراحی 3 ماهه دوم بارداری است.

  8. Thyrotoxicosis in pregnancy and in the post-partum period

  9. Subclinicalhyperthyroidism Treatment does not improve pregnancy outcome, and could potentially adversely affect fetal outcome

  10. Investigation of fetalor neonatal thyroid dysfunction Measure thyroid receptor antibodies (TRAb) by 22wk gestational age in mothers with: • 1) current Graves’ disease • 2) a history of Graves’disease and treatment with 131I or thyroidectomy before pregnancy • 3) a previous neonate with Graves’ disease • 4) previously elevated TRAb.

  11. If TRAb>2-3 Nl or women on ATD • Screen maternal free T4 & fetal thyroid dysfunction and do fetal anatomy ultrasound done in the 18th-22nd week and repeated every 4–6 wk or as clinically indicated Fetal thyroid dysfunction: Thyroid enlargement, growth restriction, hydrops, advanced bone age, tachycardia, or cardiac failure.

  12. Fetalhyperthyroidism therapy ATD with frequent clinical, laboratory, and ultrasound monitoring Umbilical blood sampling should be considered only if the diagnosis of fetal thyroid disease is not reasonably certain from the clinical and sonographic data and the information gained would change the treatment

  13. In USA neonatal thyroid function All newborns of mothers with Graves’ disease (except those with negative TRAb and not requiring ATD) should be evaluated for thyroid dysfunction.

  14. Gestational hyperthyroidism vsGraves’ disease • Negative TRAb • No goiter No need to treat with ATD Beta blockers such as metoprolol may be helpful

  15. Post partum thyroiditis

  16. Denmark 3.3% Netherlands 7.2% Sweden 6.5% Denmark 3.9% UK 16.7% Toronto 6.0% Netherlands 5.2% Spain 7.8% NYC 8.8% Iran 11.4% Italy 8.7% Japan 5.5% India 7% Thailand 1.1% Brazil13.3% Prevalence rate of postpartum thyroiditis is 7.5% Prevalence of PPT 3162596-20

  17. Autoimmune thyroid disease and miscarriage Only one randomized interventional trial has suggested a decrease in the first trimester miscarriage rate in euthyroid antibody-positive women • With history of abortion: Administer T4 • Elevated anti-TPO antibodies increases the risk for progression of hypothyroidism, so, screen for serum TSH abnormalities before pregnancy, as well as during the first and second trimesters of pregnancy

  18. Thyroid nodules FNA: nodules> 1 cm 0.5 cm <Nodules< 1 cm if high-risk history or suspicious findings on ultrasound During the last weeks of pregnancy, FNA can reasonably be delayed until after delivery

  19. Thyroid cancer If nodule on FNA is malignant or highly suspicious or exhibits rapid growth, or accompanies by pathological neck adenopathy, offer surgery in the 2nd trimester If it is papillary cancer or follicular neoplasm without evidence of advanced disease you can wait until the postpartum period for definitive surgery Administer suppresive dose of T4 Radioactive iodine (RAI) with 131I should not be given to women who are breastfeeding or for at least 4wk after nursing has ceased.

  20. Iodine nutrition during pregnancy • In the childbearing age: 150 µg/d • Before and during pregnancy and breastfeeding: 250 µg/d Iodine intake should not be >500 µg/d • Once-daily prenatal vitamins contain 150–200 g iodine

  21.  E  TBG  TSH  FT4 • iodine TPO Ab  HCG  FT4  TSH  T4  TSH  placental DI III Changes in maternalThyroid Function in Pregnancy  goiter  Tg  TSH Modified from JCEM 86:2349, 2001

  22. Thyroid & Pregnancy Physiologic changes •  TBG •  I requirement •  urinary I excretion •  T4 & T3 synthesis •  HCG •  immunity

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