February 21, 2016 (DR.

IKHLAS LEC 1( THYROID IN PREGNANCY)[

Thyroid disease in pregnancy

• Thyroid disease is the commonest pre existing endocrine
disorder in pregnant female .it occur in 1% of the
population.

MATERNAL PHYSIOLOGY
• Increase TBG(thyroid binding globuline) due to increase
oestrogen hormon synthesis.TBG bind 75% of thyroid
hormone.
• Increase total T3 and T4(result from the preipheral
deiodination of T4and it is more potent than T4).
• FREE T3(0.o5) and T4(0.04) unchanged.
• TSH often suppressed.
• Iodine deficiency in pregnancy secondary to increase loss
through the kidney due to increase GFR and resullt in
thyroid enlargment.
Thyroid function test in pregnancy •
• Measure FREE T3 and T4
• TSH often suppressed and can be detected with new
ultwasensitive assays.
• HYPERTHYROIDISM
• Incidence 1/500
• It is usually due to GRAVES DISEASE,less than 5% result
from toxic nodule ,thyroiditis or carcinoma.
• GRAVES disease is associated with hyperplastic goiter
often with exophthalmos.it is due to thyrotropin receptor
stimulating antibodies.
• The disease typically remit in the last 2 trimesters and 1/3
of cases treatment may be discontinued ,it may be
exacerbated in the first trimester due to HCG levels.
:Clinical features •
• Typical signs of thyroidism are difficult to elicit in
pregnancy but poor WT gain inspite of good
appetite ,tachycardia more than 1oo BPM unresponsive to
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 February 21, 2016 (DR. IKHLAS LEC 1( THYROID IN PREGNANCY)[

valsulva manoeuver may indicate the disease .other

symptoms such as fatigue,heat intolerance are not useful.
• COMPLICATION:A/maternal:thyroid
storm,H.F,Hypertension.
• B/fetal:increase preterm labour,IUGR,stillbirth.
• Treaement:propylthyrouracil,carbimazole reduce the titer
of thyroid Abs.
• Both drugs are equally effective ,not teratogenic,can cause
agranulocytosis so as sore throat should be thoroughly
investigated.

• TFT performed every 4-6 WKs

• B-blockers are used to control symptoms.
• Both drugs are safe in breast feeding.

• HYOPTHYROIDISM
• Occur in 1%
• Usually due to hashimoto thyroiditis
• Babies are normaly grown and do not seem to have
increased risk of congenital anomalies.
• hypoth. Can be associated with subfertility,recurrent
miscarriage,low IQ.
• TREATMENT:
• thyroxin (safe in pregnancy and lactation).

Epilepsy •
• Incidence 1/1000(most common pre existing neurological
condition)
• Familial,cryptogenic,trauma related epilepsy account for
the fast majority of cases.minority of cases are caused by
brain tumor ,congenital abnormalities and vascular.

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 February 21, 2016 (DR. IKHLAS LEC 1( THYROID IN PREGNANCY)[

• Seizure frequency may increase ,decrease or stay the

same in pregnancy with labour being particularly high risk
time for convulsion.
D.Dx of seizure in preg.and post partum •
• Idiopathic
• Epilepsy secondary to specific causes e.g previous trauma
• Intracranial infection :meningitis,encephalitis.
• Vascular disease :CVA,pre-eclampsia.
• Metabolic:liver and renal disease
• drug toxicity:L.A e.g xylocain
• Pseudo epilepsy
.Managing epilepsy and preg •
• PRE PREGNANCY:
• The DX should be reviewed by neurologist especialy anti-
epileptic drugs.
• Cosideration should be given to stop AED(anti epileptic
drugs) in those who are seizure free for more than 2 years.
• Risk of relapse is 20-50%,serious health and social
consequences may result from recurrence (e.g driving pro
hibition).
• When possible single AED should be tried to decreased
teratogenicity and the lowest effective dose should be
tried.
• The risk to the mother and the fetus from non compliance
is more than the risk ofAED.
• FOLIC ACID (5 mg) taken each day 3 months before preg.

Antenatal management •
• Care should be carried out by an obsetrician specialist in
epilepsy together with neurologist.
• Screening for fetal anomalies should be offered especialy
(NTD,cleft lip and palate ,CHD,microcephaly).
• FOLIC acid 5 mg /day throughout preg.
• Drug level monitored each trimester.

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• Oral vitamin k(10 mg/day) FROM 36 WKS to prevent

haemorrhagic disease of new born .
• If steroid are to be given for lung maturity a dose of 48 mg
given instead of 24 mg in female taking enzume inducer
AED(phenytoin,carbamazepine).
Intra partum care •
• Induction of labour and C/S indicated for the usual
obstetrical indications.VD should be the aim
• Labour carries a higher risk of seizure due to sleep
disruption ,decrease intake and absorbtion of AED and
hyperventilation.so adminster AED as usual.
• If convulsion occur adminster anti convulsant.
Post partum care •
• Serum level of AED may rise in post partum peroid and
monitoring may be necessory to prevent t oxic side effect .
• Adequate sleep
• Encourage breast feeding
• 1 mg vitamin k is given to the neonate to prevent HDN.
• CONTRACEPTIVE advice :the enzyme inducer will reduce
the efficacy of OCP,minipills,depoprovera.so high dose COP
SHOULD be given with short pill-free interval (5-6) days
instead of 7 days.
• Depoprovera should be given every 10 wks instead of
every 12 WKs.
• Mirna is ideal contraceptive
• female should ask for extra help for her neonate.
THE END
BY
TAHER ALI TAHER