PENGARUH HIPERTIROID TERHADAP KELAHIRAN PREMATUR

Oldriana P.H.

Physiologic Changes in Thyroid Function During Pregnancy

Thyroid binding globulin (TBG) increases due to reduced hepatic clearance and estrogenic stimulation of TBG synthesis The test results that change in pregnancy are influenced by changes in TBG concentration Plasma iodide levels decrease due to fetal iodide use and increased maternal clearance -> leads to notable increase in gland size in 15% of women

Physiologic Changes in Thyroid Function During Pregnancy

Maternal Status
Pregnancy
TSH **initial screening test** Free T4 Free Thyroxine Index (FTI) Total T4 Total T3 Resin Triiodothyronine Uptake (RT3U)

No change

No change

No change

Increase

Increase

Decrease

Hyperthyroidism

Decrease

Increase

Increase

Increase

Increase or no change Decrease or no change

Increase

Hypothyroidism

Increase

Decrease

Decrease

Decrease

Decrease

Hyperthyroidism

Occurs in 0.2% of pregnancies; Graves disease accounts for 95% of cases

Look for: -Nervousness -Tremor -Tachycardia -Frequent stools -Sweating -Heat intolerance -Weight loss -Goiter -Insomnia -Palpitations -Hypertension -Lid lag/lid retraction -Pretibial myxedema

Fetal & Neonatal Effects of Hyperthyroidism

Associated with preterm delivery, low birth weight, fetal loss Fetal thyrotoxicosis (related to disease itself or treatment) Risk of immune-mediated hypo/hyperthyroidism (due to antibodies crossing the placenta, esp. in Graves or chronic autoimmune thyroiditis)

Antibodies in Graves disease can be either stimulatory or inhibitory Neonates of women with Graves who have been surgically/radioactively treated are at higher risk, b/c not taking suppression

Causes & Diagnosis of Hyperthyroidism

Most common cause of hyperthyroidism is Graves disease

Document elevated FT4 or elevated FTI with suppressed TSH, in absence of goiter/mass Most patients have antibodies to TSH receptor, antimicrosomal, or antithyroid peroxidase antibodies, but measurement of these is not required (though some endocrinologists recommend measuring TSI, which are stimulatory antibodies to TSH receptor) Excess TSH production, gestational trophoplastic disease, hyperfunctioning thyroid adenoma, toxic goiter, subacute thyroiditis, extrathyroid source of TH

Other causes:

Causes & Diagnosis of Hyperthyroidism

Akibat autoimun menyebabkan terjadinya hipotiroidisme ringan Antibodi terhadap tiroid mencerminkan ketidakseimbangan autoimun pada tubuh wanita hamil Autoantibodi terhadap tiroid berefek secara langsung pada plasenta ataupun pada ovum yang telah dibuahi yang menyebabkan penolakan antigen

Treatment of Hyperthyroidism

Goal is to maintain FT4/FTI in high normal range using lowest possible dose (minimize fetal exposure) Measure FT4/FTI q2-4 weeks and titrate Thioamides (PTU/methimazole) -> decrease thyroid hormone synthesis by blocking organification of iodide

PTU also reduces T4->T3 and may work more quickly PTU traditionally preferred (older studies found that methimazole crossed placenta more readily and was associated with fetal aplasia cutis; newer studies refute this)

Treatment of Hyperthyroidism

Effect of treatment on fetal thyroid function:

Possible transient suppression of thyroid function Fetal goiter associated with Graves (usually drug-induced fetal hypothyroidism) Fetal thyrotoxicosis due to maternal antibodies is rare -> screen for growth and normal FHR Neonate at risk for thyroid dysfunction; notify pediatrician

Breastfeeding safe when taking PTU/methimazole

Treatment of Hyperthyroidism

Beta-blockers can be used for symptomatic relief (usually Propanolol) Reserve thyroidectomy for women in whom thioamide treatment unsuccessful Iodine 131 contraindicated (risk of fetal thyroid ablation especially if exposed after 10 weeks); avoid pregnancy/breastfeeding for 4 months after radioactive ablation

KESIMPULAN

Hipertiroidisme selama kehamilan salah satu penyebabnya merupakan proses autoimun Dampak hipertiroidisme selama kehamilan terhadap ibu berkaitan dengan kelainan seperti Preeclampsia, congestive heart failure, abruptio plasenta and persalinan caesar Dampak hipertiroidisme selama kehamilan terhadap janin berkaitan dengan meningkatnya risiko IUGR, kelahiran prematur, serta BBLR dan kecenderungan peningkatan terjadinya hipertensi akibat kehamilan.

Prolog Question #1

A 33 year-old G3 P2 at 10 weeks GA comes to the office for her 1st prenatal visit. She reports that she had hypothyroidism in the distant past, but was never treated and is asymptomatic. Physical examination is normal. On bimanual examination her uterus is 10 weeks size and FHR is 150 bpm. Her TSH level is 13.1 and, free T4 level is 0.7, and her anti-thyroid peroxidase antibody level is high. The next best step in the patients care is:

A) Begin levothyroxine B) Repeat serum TSH and Free T4 after 20 weeks of gestation C) Measure serum thyroid-stimulating immunoglobulins D) Perform ultrasonography of the maternal thyroid