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Hypothyroidism During Pregnancy Rosa Carranza University of Texas Medical Branch at Galveston GNRS 5631: NNP1 Debra Armentrout, RN, MSN, NNP-BC, PhD Leigh Ann Cates, MSN, RN, NNP-BC, RRT-NPS March 20, 2014 Objectives Review the pathophysiology of hypothyroidism during pregnancy Recognize the clinical manifestations of hypothyroidism in the newborn Discuss diagnostic evaluation of the neonate Discuss therapeutic options for maternal/fetal treatment Review evidence based guidelines for neonatal management Understand the economic, emotional, & social implications for the family Pathophysiology: Review of normal thyroid function Thyroid uses iodine to form components of T3 & T4 Low T3 & T4 cause hypothalamus to release thyrotropin-releasing hormone (TRH) TRH stimulates pituitary to produce thyroid-stimulating hormone (TSH) TSH acts on thyroid to increase T3 & T4 Regulated by negative feedback (Blackburn, 2013) Pathophysiology: pregnancy induced changes in thyroid function Increased thyroid hormone & iodine needs in pregnancy Estrogen: Increases thyroid binding globulin (TBG) decreasing free thyroid hormones hCG: Increases T3 & T4 decreasing TSH (ratio of T3/T4 still less than TBG) Placenta: increases enzymes that catabolize thyroid hormones Increased renal blood flow & glomerular filtration iodine loss (Blackburn, 2013) Impact on the fetus Fetus dependent on maternal T4 in 1st 10-12 weeks Thyroid hormones for brain development Contribute to maturation of retina, cochlea, lung, bones, & thermogenesis Hypothyroidism can lead to cretinism - mental retardation & stunted physical growth Clinical Manifestations Widely separated sutures Large fontanelles Short arms/legs Umbilical hernia Macroglossia Mental retardation Hypotonia Jaundice Poor feeding (National Library of Medicine, 2014) Diagnostic Evaluation of Newborn Maternal/Family History Physical Exam Serum T4/TSH if NBS abnormal Newborn Screening (NBS) Program Thyroid Uptake Scan or Ultrasound Treatment Options: Maternal Hypothyroidism Diagnosed Before Pregnancy Levothyroxine adjustment for TSH < 2.5 mlU/L 30% Levothyroxine increase by 4-6 weeks of pregnancy Thyroid function test every 4-6 weeks Iodine 150 mcg/day before pregnancy Iodine 250 mcg/day during pregnancy (De Groot, Abalovich, Alexander, Amino, Barbour, Cobin, Eastman, Lazarus, Luton, Mandel, Mestman, Rovert, & Sullivan, 2012). Treatment Options: Maternal Hypothyroidism Diagnosed During Pregnancy Identify high risk women by medical history & exam Goal: Normalize thyroid function ASAP Start Levothyroxine & titrate dose for TSH < 2.5 mlU/L Thyroid function test every 4-6 weeks Iodine 250 mcg/day (De Groot, Abalovich, Alexander, Amino, Barbour, Cobin, Eastman, Lazarus, Luton, Mandel, Mestman, Rovert, & Sullivan, 2012). Management of the Neonate Thyroid hormone replacement started age can normalize cognitive development Serum T4 and TSH to confirm diagnosis Levothyroxine 10-15 mcg/kg Goal: normalize TSH, keep T4 in upper end of age appropriate range Thyroid scan/ultrasound to identify functional tissue Referral to pediatric endocrinologist Parent education (med administration, compliance) of Management of the Neonate Monitor T4 & TSH: At 2 and 4 weeks after starting therapy Normalize TSH Every 1-2 months in 1st 6 months of life Every 3-4 months between 6 months – 3 years Every 6-12 months until growth is completed More frequently with dosage changes, abnormal labs, compliance concerns (Palla & Srinivasan, 2013) T4 in upper end age appropriate range Implications for Family Economic Social Follow up care/appointments conflict with parent’s work Increased time demands on parents Financial cost of healthcare Difficult to find childcare for disabled/sick child May need public assistance Decreased participation in social events (Reichman, Corman, & Noonan, 2008) Implications for Family Emotional Caring for sick/disabled child can be stressful May feel guilt, blame, reduced self esteem poor mental health Parents may have decreased/altered interaction with their other children May decide not to have other children (Reichman, Corman, & Noonan, 2008) Summary Thyroid hormones are important for the body’s metabolic processes. Alterations in thyroid function occur during pregnancy. Hypothyroidism can result in mental retardation & stunted growth in the fetus. Therapy is replacement with Levothyroxine in both pregnancy & neonatal period. Families may experience financial, social, & emotional hardships if their infant is diagnosed. References American Academy of Pediatrics, American Thyroid Association, & Lawson Wilkins Pediatric Endocrine Society (2011). Clinical report: Update of newborn screening and therapy for congenital hypothyroidism. Pediatrics, 117(6),2290-2303. Retrieved from http://pediatrics.aappublications.org/content/129/4/e1103.full Blackburn, S. T. (Ed.). (2013). Maternal, fetal, & neonatal physiology; A clinical perspectivce (4th ed). Maryland Heights, MO: Elsevier Saunders. De Groot, L., M. Abalovich, E. K., Alexander, N., Amino, L., Barbour, R., Cobin, C., Eastman,, J., Lazarus, D., Luton, S., Mandel, J., Mestman, J., Rovert, & S., Sullivan, (2012). Management of thyroid dysfunction during pregnancy and postpartum: An Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 97, 2543-2565. Retrieved from https://www.endocrine.org/search?q=hypothyroidism%20pregnancy%20guidelines National Library of Medicine. (2014). Neonatal hypothyroidism. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/001193.htm Palla, M.M. & Srinivasan, G. (2013). Thyroid disorders. In T.L. Gomella, M. D. Cunningham, & F. G. Eyal (Eds.), Neonatology; Management, procedures, on-call problems, diseases, and drugs (7th ed., 908-913). New York, NY: McGraw Hill. Reichman, N. E., Corman, H., & Noonan, K. (2008). Impact of child disability on the family. Maternal and Child Health Journal, 12(6), 679-683. doi:10.1007/s10995-007-0307-z Rose, S. R. (2011). Thyroid disorders. In R.J. Martin, A. A. Fanaroff, & M. C. Walsh (Eds.), Neonatal-perinatal medicine: Diseases of the fetus and infant (9th ed., 84483-85930). Saint Louis, MO: Elseviere.