Hyperthyroidism in pregnancy
Introduction
Introduction to pregnancy combined with hyperthyroidism Hyperthyroidism (hyperthyroidism) is a common endocrine disease caused by excessive secretion of thyroid hormone. Women with hyperthyroidism often present with menstrual disorders, reduced or amenorrhea, and low fertility. However, among the untreated women with hyperthyroidism after treatment, there are many pregnant women, and the incidence rate is about 1:1000-2500 pregnancies. Most of the hyperthyroidism during pregnancy is Graves' disease, which is mainly caused by autoimmune and mental stimulation, characterized by diffuse goiter and exophthalmos. basic knowledge The proportion of illness: the incidence rate of pregnant women is about 0.04%-0.09% Susceptible population: pregnant women Mode of infection: non-infectious Complications: abortion, premature delivery, anemia, pregnancy-induced hypertension, placental abruption, type 1 diabetes, fetal distress
Cause
Pregnancy with hyperthyroidism
The etiology of hyperthyroidism during pregnancy is basically the same as that of non-pregnancy hyperthyroidism. Among them, Graves disease is the most common, followed by toxic nodular goiter, thyroid autonomic adenoma, etc. In addition, hyperemesis of pregnancy, hydatidiform mole, malignant Hyperthyroidism can occur in both hydatidiform and chorionic epithelial cancer.
Graves disease (32%):
Graves disease (referred to as GD), also known as toxic diffuse goiter or Basedow disease, is an organ-specific autoimmune disease with increased secretion of thyroid hormone (TH). The clinical manifestations are not limited to the thyroid gland, but a multi-system Syndrome.
Nodular goiter (24%):
Alias: adenoma-like goiter. Most have a history of simple goiter, and in the late stage, multiple nodules are formed. The incidence rate is higher. The cause of nodular goiter is similar to that of simple goiter.
Hydatidiform mole (20%):
Hydatidiform mole refers to the proliferation of placental villus trophoblast cells after pregnancy, with high interstitial edema, forming blisters of different sizes. The blisters are connected in a string, shaped like grapes, also known as vesicular blocks (HM).
Prevention
Pregnancy with hyperthyroidism prevention
Pre-pregnancy counseling and obstetric treatment
1, pre-pregnancy and pregnancy consultation: It is recommended that women diagnosed as hyperthyroidism, first treatment of hyperthyroidism, try to wait for recovery, after a period of pregnancy.
Hyperthyroidism is stable, pregnant, and not ready for pedestrians, it is recommended to use a non- teratogenic risk, through the placenta less drugs, such as PTU, should not be 131 Iodine diagnosis and treatment, such as 131 iodine treatment before pregnancy, to contraception after half a year In order to be pregnant.
Pregnant women are currently in a hypothyroidism situation. In the supplementary treatment of thyroid hormone, thyroid hormone has no effect on the baby. After the pregnancy, the drug can not be stopped, and the withdrawal will cause miscarriage.
2. Fetal monitoring and prenatal care during pregnancy
Hyperthyroidism due to hypermetabolism, can not provide sufficient nutrition for the fetus, affect fetal growth and development, prone to fetal growth restriction (FGR), neonatal birth weight is low, check: pay attention to mother weight, palace height, abdominal circumference growth, each 1 to 2 months of fetal B-ultrasound, estimate fetal weight, usually strengthen nutrition, pay attention to rest, take the left lateral position, found FGR, timely hospitalization.
Hyperthyroidism pregnant women taking ATD may cause fetal hypothyroidism: fetal goiter, slow weight gain, fetal heart rate 110~120 beats / min, fetal movements decreased, amniotic fluid is less, congenital hypothyroidism, may have a poor prognosis, how to diagnose, Some people have suggested that the umbilical cord puncture can be taken, and the cord blood is taken to check the thyroid function for diagnosis. How to treat the fetus has little experience.
Pregnant women with hyperthyroidism are prone to premature birth. If there is a threatened premature birth, they should actively prevent miscarriage. Avoid -receptor stimulants during treatment, try to stay in bed, use magnesium sulfate, Turinal, procaine and other miscarriage drugs.
Hyperthyroidism in pregnant women is likely to cause pregnancy-induced hypertension, pay attention to early calcium, low-salt diet, nutritional guidance, checkup attention: weight changes, edema, urinary protein and blood pressure, 37 to 38 weeks of pregnancy should be admitted to the hospital, weekly Fetal heart monitoring, pay attention to fetal distress, pregnant women for ECG, to understand whether there is heart damage, if necessary, for echocardiography.
3. Labor and childbirth
B-ultrasound observation of fetal thyroid size, whether there is thyroid enlargement, resulting in over-extension of the fetal head, if abnormal, may cause dystocia, consider cesarean section, choice of delivery mode, in addition to obstetric factors, generally vaginal delivery, most successful.
Hyperthyroidism in pregnant women is generally strong, the fetus is small, the labor process is relatively short, there are reports of high neonatal asphyxia rate, energy should be added during the labor process, encourage eating, appropriate infusion, oxygen inhalation and fetal heart monitoring, blood pressure measurement q2~4h , pulse, body temperature 1 time, pay attention to psychological care in the labor process.
If the maternal heart is insufficiency, the progress of the labor is not smooth, the fetal position is not correct, the fetal head is stretched, the fetal head can not enter the plate, etc., the indication for cesarean section can be relaxed, and antibiotics can be prevented from postpartum to prevent infection.
At the time of birth, the pediatrician should be present to prepare for neonatal resuscitation, leaving the cord blood to check for thyroid function.
4, postpartum observation of newborns and mothers
After the newborn is born, pay special attention to whether there is hypothyroidism or signs and symptoms of hyperthyroidism.
Neonatal hypothyroidism: large tongue, frog belly, skin hair, body temperature is not rising, poor response, low tension, less eating, delayed bowel movements, weight is not long, individual lungs are immature, hyaline membrane disease.
Neonatal hyperthyroidism (rare): occurs in a few days after delivery (5-10 days), manifested as: small head, goiter, double eyeballs protruding or large, sputum, high skin temperature, severe hyperthyroidism accompanied by high fever , heart rate breathing acceleration and other manifestations of hyperthyroidism, there are still crying troubles, large amounts of milk, frequent bowel movements, weight and other symptoms of hyperthyroidism.
Therefore, it is recommended to extend the length of hospital stay for newborns in order to observe, and if the family members are discharged from the hospital, they will come to the hospital for examination and follow-up.
5, postpartum breastfeeding
Patients with Graves' disease have aggravated postpartum conditions. To continue taking the drug, most of them should increase the dose. PTU is better than MMI. For example, mothers take PTU200mg, tid, and newborns get PTU99g per day, so it is safe for mothers to take PTU infants.
Complication
Pregnancy complicated with hyperthyroidism Complications, abortion, premature anaemia, pregnancy-induced hypertension, placental abruption, type I diabetes, fetal distress
Mother's complications: miscarriage, premature delivery, anemia, pregnancy-induced hypertension, placental abruption, heart failure, hyperthyroidism, intermittent infection, type I diabetes.
Complications of the fetus and newborn: premature infant, stillbirth, stillbirth, malformation, fetal growth restriction (FGR), small for gestational age (SGA), fetal distress, new postpartum ventricular, fetal and/or neonatal hyperthyroidism , hypothyroidism, etc.
Symptom
Pregnancy with hyperthyroidism symptoms Common symptoms Hyperthyroidism face thyroid enlargement Heart rate increased mucinous edema tachycardia metabolism strong fear of enthusiasm, weakness, fatigue
Normal pregnancy due to changes in maternal thyroid morphology and function, in many ways similar to the clinical manifestations of hyperthyroidism, such as tachycardia, increased cardiac output, increased thyroid, warm skin, hyperhidrosis, heat, appetite, etc., in pregnancy And are common in hyperthyroidism.
Mild hyperthyroidism had no significant effect on pregnancy, but moderate, severe hyperthyroidism and abortion rate in patients with uncontrolled symptoms, prevalence of pregnancy-induced hypertension, preterm birth rate, incidence of full-term infants and perinatal mortality, hyperthyroidism for pregnancy The cause of the effect is still unclear. It may be caused by excessive consumption of nutrients by hyperthyroidism and high incidence of pregnancy-induced hypertension, which may affect the function of placenta.
Due to the placental barrier during pregnancy, only a small amount of T3, T4 can pass through the placenta, so it does not cause neonatal hyperthyroidism, pregnancy has little effect on hyperthyroidism, on the contrary, pregnancy often causes hyperthyroidism to have different degrees of relief, but pregnancy Combined with severe hyperthyroidism, because pregnancy can aggravate the burden of the heart, and increase the original heart disease in patients with hyperthyroidism, individual patients due to childbirth, postpartum bleeding, infection can induce hyperthyroidism crisis.
Examine
Pregnancy combined with hyperthyroidism
Pregnancy hyperthyroidism should pay attention to:
1, gestational thyroid hormone tuberculosis increased, causing serum TT4 and TT3 increased, so the diagnosis of hyperthyroidism during pregnancy should rely on serum FT4, FT3 and TSH.
2, transient vomiting thyroid hyperthyroidism when the chorionic promoting hormone (HCG) peaks in the third trimester, it has the same alpha subunit, similar beta subunit and receptor subunit, excessive HCG or variant HCG can stimulate TSH receptors to produce hyperthyroidism in pregnancy, including transient vomiting and hyperthyroidism.
Diagnosis
Diagnosis and differentiation of pregnancy complicated with hyperthyroidism
diagnosis
Normal pregnancy due to changes in maternal thyroid morphology and function, in many respects similar to the clinical manifestations of hyperthyroidism, so it is difficult to diagnose pregnancy with hyperthyroidism. When symptoms and signs of hyperthyroidism are found during prenatal examination, further thyroid should be done. Functional determination to confirm the diagnosis, the diagnostic criteria for hyperthyroidism in pregnancy: high metabolic syndrome, serum total thyroxine (TT4) 180.6nmol / L (14g / dl), total triiodothyronine (TT3) 3.54 Nmol/L (230 ng/dl), free thyroxine index (FT4I) 12.8, hyperthyroidism with TT4 highest level <1.4 times normal upper limit for mild hyperthyroidism, >1.4 times normal upper limit for moderate hyperthyroidism, Crisis, hyperthyroidism and heart failure, myopathy, etc. are severe hyperthyroidism.
Symptoms similar to normal pregnancy: symptoms of hyperthyroidism during normal pregnancy: increased heart rate, increased heart rate, increased thyroid 30%, -40%, hyperhidrosis, heat, appetite, laboratory tests TT3, TT4 slightly increased.
