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Hypothyroidism During Pregnancy

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. R eview the pathophysiology of hypothyroidism during pregnancy

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Hypothyroidism During Pregnancy

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  1. 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

  2. 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

  3. 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)

  4. 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)

  5. Impact on the fetus • Fetus dependent on maternal T4 in 1st 10-12 weeks • Thyroid hormones critical for brain development • Contribute to maturation of retina, cochlea, lung, bones, & thermogenesis • Hypothyroidism can lead to cretinism - mental retardation & stunted physical growth

  6. Clinical Manifestations Widely separated sutures Large fontanelles Short arms/legs Umbilical hernia Macroglossia Mental retardation Hypotonia Jaundice Poor feeding (National Library of Medicine, 2014)

  7. Diagnostic Evaluation of Newborn

  8. 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).

  9. 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).

  10. Management of the Neonate • Thyroid hormone replacement started within 2 weeks of 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)

  11. Management of the Neonate Monitor T4 & TSH: • At 2 and 4 weeks after starting therapy • 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)

  12. Implications for Family Economic Social Increased time demands on parents Difficult to find childcare for disabled/sick child Decreased participation in social events (Reichman, Corman, & Noonan, 2008) Follow up care/appointments conflict with parent’s work Financial cost of healthcare May need public assistance

  13. Implications for FamilyEmotional 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)

  14. 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.

  15. 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.

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