Nuances in the Treatment of Hypothyroidism in Pregnancy

Nuances in the Treatment of Hypothyroidism in Pregnancy

An underactive thyroid is known as hypothyroidism which is caused by a decreased production of thyroid hormones by the thyroid gland. The most common cause of hypothyroidism is Hashimoto Disease (also known as Chronic Lymphocytic thyroiditis, Hashimoto syndrome or Hashimoto thyroiditis). Hypothyroidism can occur during pregnancy or worsen in pregnant patient who already have hypothyroidism. These reasons include the fetusincreasing the mother’s metabolic demands and the mother undergoing changes in the pregnancy which affects the thyroid gland.

Hypothyroidism ismanaged by supplementing patients with oral thyroid hormones (levothyroxine, brand name Synthroid), even during pregnancy, but recent studies have suggested that an excess of these hormone can have adverse affects on both mother and child. Thus, it is important that the thyroid hormones levels should be kept at optimum levels. Unfortunately, even in normal pregnant women the thyroid hormone levels may be variable and thus cause difficulty in diagnosing women who need treatment for hypothyroidism.

Fluctuation of normal thyroid hormone levels during pregnancy

Hypothyroidism is diagnosed by an elevated thyroid stimulating hormone (TSH) and decreased thyroid hormoneslevels. Unfortunately, TSH levels are variable during pregnancy. TSH levels, even in normal women, are slightly reduced in thefirst trimester of pregnancy and begin to rise again by the end of the 1st trimester.In the second trimester, TSH levels fall again and then rise again slightly by the end of the third trimester.

These fluctuating levels of TSH therefore warrant trimester-specific references to be incorporated in order to prevent patients from being supplemented with thyroid hormones when it isn’t necessary.

Is it necessary to treat Subclinical Hypothyroidism in Pregnancy?

Hypothyroidism can be defined as being “Symptomatic” if the patient experiences sign and symptoms associated with the condition. If these issues are not present then the hypothyroidism is said to be “subclinical”.

Some doctors believe that pregnant women who have “subclinical hypothyroidism” should get treatment but research has not found any evidence to support the benefits of thyroid hormone replacement in subclinical hypothyroidism.

The Management Approach towardsSymptomatic Hypothyroidism in Pregnancy

In contrast to Subclinical hypothyroidism, symptomatichypothyroidism in pregnancy can cause severe issues to the health of the mother and the baby. Thus, symptomatic hypothyroidism needs to be treated immediately.

It is important to consider trimester-specific TSH levels when determining the dose of thyroid hormone levels in hypothyroid pregnant patients. In addition to trimester specific TSH levels, the cause of the hypothyroidism also affects the thyroid hormone dosage. For example, pregnant women, where the hypothyroidismis secondary to the treatment of Graves’ disease and goiter, need the largest thyroid hormone dosage.

Pregnancy and Iodine

All pregnant and breastfeeding women should get an adequate intake of iodine to compensate for the increased iodine loss in urine andmaternal iodine being delivered to the baby. The best way of supplementing with iodine is through the use of multivitamins which are specifically developed for use by pregnant women.

The Role of Thyroid Peroxidase Antibodies (TPOAb) in Pregnancy

The most common cause of hypothyroidism is Hashimoto Disease. Most patients with Hashimoto Disease have TPOAb in their bloodstream. Women who have TPOAbs should have close monitoring for hypothyroidismduring their pregnancy as they can develop Hashimoto Disease. The close monitoring is essential as TPOAbs can increase during pregnancy and, in themselves, can increase the chances of developing hypothyroidism.

Sameer Ather MD, PhD is a Cardiologist based out of Birmingham.He did his medical residency and PhD at Baylor College of Medicine, Houston, TX, and completed his cardiology fellowship at University of Alabama, Birmingham, AL visit his website

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