AUCTORES
Globalize your Research
Research Article
*Corresponding Author: R F Gross man, Department of Endocrinology, Diabetics,Israel
Citation: R F Gross man , Sami Micheal. Management Thyroid Disease in Pregnancy: Preconception, and the postpartum complications. J. Endocrinology and Disorders. DOI:10.31579/2640-1045/012
Copyright: © 2017. R F Gross man. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 03 August 2017 | Accepted: 09 September 2017 | Published: 27 September 2017
Keywords: thyroid disorders, pregnancy, hypothyroidism
Pregnancy has a profound impact on the thyroid gland and thyroid function since the thyroid may encounter changes to hormones and size during pregnancy. The diagnosis and treatment of thyroid disease during pregnancy and the postpartum is complex but knowledge regarding the interaction between the thyroids and pregnancy/the postpartum period is advancing at a rapid pace.
For women known to have hypothyroidism, an increase in thyroxine dose by 20–40% when pregnancy is confirmed usually ensures they remain euthyroid. Treatment of subclinical hypothyroidism is recommended if the woman has antithyroid antibodies.
Treatment of hyperthyroidism, unless it is related to human chorionic gonadotrophin, involves propylthiouracil in the first trimester. Carbimazole may be used in the second trimester. Thyroid function tests are checked every month and every two weeks following a change in dose.
Women with a current or a past history of Graves’ disease who have thyrotropin receptor antibodies require early specialist referral as there is a 1–5% risk of fetal hyperthyroidism.
Women with thyroid disorders in pregnancy should be followed up by their GP in the postpartum period. Postpartum thyroiditis may present months after delivery.
Thyroid disorders are common in pregnancy and related to maternal and fetal complications.
Hyperthyroidism occurs in 0.1–0.4% of pregnant women. Whereas about 2–3% of pregnant women are hypothyroid, of whom 0.3–0.5% have overt hypothyroidism and 2–2.5% present subclinical hypothyroidism.
At least 5–10% of women are positive for thyroid antibodies and have an increased risk of developing a certain degree of thyroid insufficiency during pregnancy.
Thyroid function is influenzed by pregnancy and its dysfunction is associated with maternal and fetal morbidity. Moreover the role of subclinical hypothyroidism in the developement of fetal and maternal complications is not univocal. Indeed subclinical hyperthyroidism is not associated with adverse outcomes. Thyroid autoimmunity appears to be associated with an increased risk of miscarriage and preterm delivery.
In this article we aimed to review the possible adverse maternal and fetal outcomes of thyroid during pregnancy and the proper management of these conditions to avoid such complications.
Physiology of maternal and fetal thyroid in pregnancy
During pregnancy the thyroid gland undergoes hyperplasia and increased vascularity. Circulating iodine is reduced and thyroid-binding globulin increases.
The rising concentration of beta-human chorionic gonadotrophin (HCG) in the first trimester can directly stimulate the thyroid stimulating hormone (TSH) receptor as HCG has structural similarities to TSH. This in turn leads to increased free triidothyronine (fT3) and free thyroxine (fT4), suppressing TSH secretion. A serum TSH below 0.1 mIU/L may be present in 5% of women by the 11th week of pregnancy.
The TSH subsequently normalises as beta-HCG falls in the second and third trimesters.
In view of these physiological changes, consult gestation-specific TSH concentration ranges when interpreting thyroid function tests. These reference ranges differ from non-pregnant ranges (Table 1).
Note that individual laboratories may have slightly different pregnancy-specific ranges and it is important to confirm ranges with your local pathologist.
Women with hypothyroidism
After conception, an increase in thyroxine as soon as possible is recommended with the goal of normalising the TSH concentration. An easy approach is to increase the total weekly thyroxine dose by an extra two tablets per week or by 20–30% of the baseline dose when pregnancy is confirmed.
Serum TSH should be monitored every four weeks in the first trimester to ensure the woman is euthyroid, and then six to eight weekly therafter.Thyroid function tests should be rechecked four weeks after any dosage adjustments to ensure euthyroid levels are maintained. Aim to maintain TSH in the range 0.5–2.5 mIU/L.
Failure to achieve a euthyroid state despite appropriate therapy necessitates investigation into causes for a lack of thyroxine uptake. This can result from poor adherence to therapy or impaired absorption. Women should be advised to take their thyroxine on an empty stomach before breakfast. There should be a 4–5 hour gap before taking medicines such as vitamins, calcium and iron tablets as interactions in the gastrointestinal tract can reduce thyroxine absorption.
Following delivery, the thyroxine dose should be reduced to the patient’s preconception dose, assuming the woman was euthyroid on that dose. Check thyroid function tests 4–6 weeks after their dose has been reduced postpartum.
Hypothyroidism diagnosed during pregnancy
A new diagnosis of overt hypothyroidism should warrant immediate thyroxine replacement and further investigation for the presence of thyroid auto-antibodies:
antithyroid peroxidase antibodies (antiTPO)
antithyroglobulin antibodies (TgAb)
thyrotropin receptor antibodies (TRAb) (if there is a history of treated Graves’ disease).
Subclinical hypothyroidism
Subclinical hypothyroidism in pregnancy is associated with an increased risk of recurrent miscarriage, intrauterine growth restriction, preterm birth, low birth weight, perinatal mortality and pre-eclampsia.Thyroxine may reduce associated risks Recent studies support thyroxine replacement in women with subclinical hypothyroidism undergoing assisted reproduction technologies, to improve pregnancy outcome. The aim of treatment is to achieve a TSH less than 2.5 mIU/L.
The American Thyroid Association in 2017 updated its guidelines for the management of thyroid disease in pregnancy following new research. Thyroxine should be given if there are antithyroid antibodies and the initial TSH is 2.5–4 mIU/L. If the initial TSH is 4 mIU/L or more, start thyroxine irrespective of antibody status.
If a decision is made to treat subclinical hypothyroidism, the suggested starting dose of thyroxine is 50 micrograms per day. Thyroid function tests are checked within four weeks of starting therapy.
As the pregnancy advances, dose requirement comes down in most of the cases; one-third of pregnant women can actually stop anti-thyroid medication in the third trimester. A significant percentage of these women need to start after delivery for relapse. Our routine practice is to check the thyroid function two weeks after delivery as opposed to six to eight weeks in cases of hypothyroidism. Beta-blockers, if necessary, can be given for a short duration for controlling symptoms. When thyroidectomy is needed for the control of hyperthyroidism, it should be planned in the second trimester of pregnancy; fortunately, this is very rare, and none of the authors can remember a single case they referred to surgeons for uncontrolled hyperthyroidism in pregnancy.
Breast feeding while on anti-thyroid medication remains a sensitive issue; PTU is the preferred medicine as it is more protein-bound and is secreted least in breast milk. Up to 600 mg a day PTU is considered safe; it is recommended to keep an eye on growth of the baby clinically with biochemical test for thyroid function if suspected for growth problem.
Showing the thyroid function and treatment of a patient with Graves' disease in pregnancy treated by the authors
Gestational hyperthyroidism or gestational thyrotoxicosis is used when there are symptoms of hyperthyroidism due to the high levels of HCG, which causes thyroid hyperfunction. This condition needs to be differentiated from Graves' disease, as most of the symptoms are similar to those in pregnancy. Up to 15% of normal pregnancy TSH can be suppressed due to hCG effect; they do not require extra treatment; careful observation is good enough. There is another entity in pregnancy called transient gestational thyroticosis, where free thyroid hormone can be increased, and they require a short course of anti-thyroid medication. Gestational thyrotoxicosis is usually transient and recovers over a period of few weeks. This is essentially a retrospective diagnosis.
Management
The goal of treatment is to keep the patient euthyroid, using the lowest possible dose of antithyroid drugs necessary to maintain FT4 levels in the upper one-third of the normal non pregnant range or just above the normal range excessive doses of ATDs, indeed, may affect fetal thyroid function, with the development of hypothyroidism and/or goiter
The dose should be adjusted every 2–4 weeks and the presence of detectable TSH is an indication to decrease ATD dose
The treatment of choise is propylthiouracil (PTU), but methimazole (MMI) is also an alternative, both are considered compatible with breastfeeding. PTU is given in a dose of 100–450 mg/day. It may be necessary 2–4 weeks from the start of treatment to see a clinical change. MMI can be prescribed at 10–20 mg/day. Beta blockers may be, also, used to control the adrenergic symptoms of thyrotoxicosis. In addition, beta blockers block the peripheral conversion of T4 to T3. Propranolol in a dose of 10–40 mg every 4–6 h or atenolol 25–50 mg daily, are recommended. In acute cases, intravenous esmolol (up to 200 ∝g/kg/minute) may be used to maintain a heart rate of less than 90 beats/min. Thyroidectomy is reserved for patients requiring high doses of medication or in the rare case of allergies to ATD.
The use of iodine therapy in addition to anti-thyroid medications has fallen into disuse due to higher rates of neonatal goiter and hypothyroidism. Radioactive iodine therapy is contraindicated in pregnancy and lactation. It is recommended to continue medications throughout the postpartum period.
It is well documented that thyroid disorders are associated with maternal and fetal complications during gestation and sequelea after delivery.
Despite the correlation between thyroid function during pregnancy and maternal and fetal outcomes is a widely discussed topic, it remains to clarify several points.
While ADT therapy does not appear to be relevant in patients with subclinical hyperthyroidism, in cases of overt hyperthyroidism it plays a key role.
In pregnant women with newly diagnose of overt hypothyroidism it is strongly recommended to begin substitutive treatment with LT4 as soon as possible, that should be considered in case of subclinical hypothyroidism; hypothyroid women already being treated by LT4 require an increase of dosage by 30–50% at the start of pregnancy. In this review we tried to evaluate possible strategies to prevent and to apply appropriate management to avoid an unfavorable outcome for both mother and offspring.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
