Infants Born from Mother

with Thyroid Problems:

Issues and Management
Vivekenanda Pateda
Pediatric Health Department
Universitas Sam Ratulangi – Prof. Dr. R. D. Kandou Hospital
Manado
 Fetal Thyroid Metabolism

Infant Born from a Hypothyroid Mother

Outline Infant Born from a Hyperthyroid Mother

Management

Conclusion
Fetal Thyroid Metabolism
• Thyroid function: vital for fetal cognitive
and brain development
• Originates from endoderm identifiable at
fourth week of gestation
• Fetal hypothalamus secretes thyrotropin
releasing hormone (TRH) in 8th wk of
gestation & Thyroid Stimulating Hormone
(TSH) starts to peak at 18 to 20th wk of
gestation
• Thyroid begins to increase in 2nd trimester
in response to TSH, though it is still
inadequate  dependent from maternal
thyroid
Eng L, et al.hormone
NeoReviews. 2017.
Transition of Fetal to Neonatal Thyroid

3-5 days
Peaks at 48
hours Decrease of TSH
levels
Production of T4

es
Surge of TSH
u t
in
3 0m Secretion of
to TRH

irth
B
Change of
temperature

Eng L, et al. NeoReviews. 2017.

Neonatal Conditions that Affect Thyroid

• Due to abrupt cessation of maternal thyroid transfer

Hypothyroxinaemia (esp. < 34 wk of gestation)
• Gradually resolves after several weeks beyond
of Prematurity
corrected term gestational age

• Inhibition of thyroid production secondary to severe

Nonthyroidal Critical illness (e.g. bacteraemia)
Illness • Management: treat underlying illness

Eng L, et al. NeoReviews. 2017. NEWBORN SCREENING

 • 2-3% pregnant women suffers
from hypothyroidism
• Most common causes
• Iodide insufficiency
Infant Born • Autoimmune thyroiditis
(Hashimoto Thyroiditis)
from
Hypothyroidic • Outcomes: abortion, pre-
Mother eclampsia, premature delivery,
low birthweight, cognitive
disfunction, etc.
Fetal Hypothyroid: Iodide Deficiency
• Iodine deficiency is associated with
maternal goiter and reduced
maternal thyroxenaemia
• Outcome:
• Mother with profound deficiency:
impaired neurointellectual
development, cretinism
• Mild to moderate deficiency: lower
intelligent quotient (IQ)
• Prevention: adequate daily iodine
intake
Alexander EK, et al. Thyroid. 2017.
Delshad H, et al. Hormones. 2019.
Fetal Hypothyroid: Maternal Autoimmune
Hypothyroidism
• Hashimoto’s Disease; circulating Thyroid Peroxidase antibody (TPOAb)
• In many cases, autoimmune hypothyroidic mother has been
diagnosed before pregnancy and treated with Levothyroxine (LT4)
• Recommended TSH levels before and during pregnancy to NOT
exceed 2,5 mIU/L
• Pregnant mother with overt hypothyroid: titration of LT4 dosage
• Infant can still be born with hypothyroid  neonatal screening
• Transient hypothyroid  treat with LT4 and resolves three to four months
• Congenital hypothyroid  treat with LT4 and monitor

Van Trotsenburg P, et al. Best Pract Res Clin Endocrinol. 2020.

Algorithm for
Neonatal
Hypothyroidis
m Screening

Wassner AJ. Clin Perinatol. 2018.

 Pregnant Mother with Graves’ Disease

• Diagnosis of Graves’ Disease is usually straightforward: thrilling goiter,

thyroid orbitopathy, hyperthyroidism and confirmed with anti-TSH-receptor
antibody (TSHRAb)
• Issues with mother with Graves’ disease
• Suboptimal treatment  lower or higher maternofetal TH transport
• Circulating TSAb  overstimulation of fetal thyroid gland
• Fetal hyperthyroidism may also be followed with central hypothyroidism (1
in 35.000 births)

Van Trotsenburg P, et al. Best Pract Res Clin Endocrinol. 2020.

 Algorithm for Assessment

Risk of Transient
Hypothyroid Fetal
Hypothyroidism

Neonates born to Mother Neonatal

Check Mother Thyroid Status Euthyroid
with Thyroid Dysfunction Screening

Hyperthyroid See Next Slide

Van Trotsenburg P, et al. Best Pract Res Clin Endocrinol. 2020.

 Algorithm for Assessment
Diagnosis
CONSIDERABLE RISK of
Unknown/TSHRAb
Neonatal HYPERthyroidism
Unavailable

Neonates born to TSHRAb Measurement?

TSHRAb > 3,7 times ref. FOLLOW UP AFTER BIRTH
Hyperthyroid Mother range
See Next Slide

TSHRAb < 3,7 times ref. LOW RISK of Neonatal

range HYPERthyroidism
No additional follow up
 newborn screening as
per local guidelines
Van Trotsenburg P, et al. Best Pract Res Clin Endocrinol. 2020.
Considerable Risk Neonates Follow-up
Examination

Thereafter: at day “three”

(48 to 72 hrs), “five”,
After birth: clinical Perform TSHRAb every
“seven or eight”, “10-14”
examination, cord blood three to four weeks (if
 clinical examination and
TSHRAb, FT4 and TSH available)
blood collection serum FT4
and TSH

Interpretation
Ref. range: low TSH is < 0,9 mIU/L between three to seven days of life
TSH FT4 Action
↓↓ ↑ (or clear sign of HYPERthyroid) Start anti-thyroid drugs
↓/N ↑↑ Consider anti-thyroid drugs
Any results ↓↓ Central hypothyroidism; start LT4
Van Trotsenburg P, et al. Best Pract Res Clin Endocrinol. 2020.
 Treatment for Infant Hyperthyroidism
Indication to start
• Supporting clinical diagnosis: irritability, insufficient weight gain, warm and moist skin, respiratory “distress”
• Evidence of hyperthyroidism (TSH < 0,9 mIU between day three to seven) and high FT4

Medication
• Propylthiouracil (PTU) 5-10 mg/kg divided to three doses
• Alternative for liver toxicity: Methimazole (MMZ) 0,2 – 0,5 mg/kg/day divided to two or three doses

Monitoring
• Aim for euthyroid without hypothyroid; add Levothyroxine (LT4) 8-10 mcg/kg/day once daily if hypothyroidism
• In hyperthyroidism with sympathetic activity  addition of Propranolol 2 mg/kg/day into two doses
• Hemodynamic instability 
• Prednisolone 2 mg/kg/day in one or two doses PO
Consider lugol solution 1 drop (0,05 ml) 3 times daily or potassium iodide 1 drop (0,05 ml) once daily, given 1 hour
after 1st dose of methimazole
• Measurement of TSH and FT4 every 10-14 days
• If available TSHRAb every three to four weeks; treatment can be stopped once TSHRAb undectectable

Van Trotsenburg P, et al. Best Pract Res Clin Endocrinol. 2020.

 Summary
Management of
Neonate born
to Hyperthyroid
Pregnant
Mother

Van Trotsenburg P,
et al. Best Pract
Res Clin
Endocrinol. 2020.
 Neonatal Thyrotoxicosis

Neonates with CONSIDERABLE RISK

may develop to thyrotoxicosis

Clinical signs: tachycardia,

hypertension, hyperthermia, irritability,
poor weight gain, weight loss, jaundice,
hematological abnormalities, etc

Possible long-term outcome: one small

study reported cognitive impairment
and craniosynostosis

Samuels SL, et al. Clin Perinatol. 2018.

Van der Kay DC, et al. Pediatrics. 2016.
Management of Neonatal Thyrotoxicosis
Breastfeeding and Thyroid Illness
• Breastfeeding is still advised for women with thyroid disorders
• Hypothyroidism may supress milk production and may be restored with
levothyroxine replacement
• Both MMI and PTU are detected in breast milk, but when women taking
< 20 mg MMI and PTU < 300 mg a day breastfeed, MMI in infant was
negligible
• Hypothyroidism in infants is NOT observed until mother with MMI 20
mg/day, and some reports the same for PTU.
• Long term monitoring for infant growth is a must; measurement of infant
thyroidal status may be necessary in higher anti-thyroidal drug doses
Amino N, et al. Best Pract Res Clin Endocrinol. 2020.
 Pregnancy affects thyroid levels,
inclining to hyperthyroidism

Neonates born to hypothyroid

mother may have hypothyroidism,
but is treatable

Conclusion Detection of TSHRAb is vital to start

anti-thyroidal therapy for the infant

Newborn screening is vital to

prevent neurodevelopmental
impairment
Thank You