Graves病合并妊娠

妊娠期甲状腺激素代谢的生理性改变使Graves病的诊治更加复杂。妊娠期Graves病必须使用抗甲状腺药物（ATD）治疗,尽可能使用最低剂量的ATD维持母体游离甲状腺素（n）于非孕期的正常高值附近是最理想的选择。胎儿甲状腺功能取决于通过胎盘屏障的促甲状腺激素（TSH）受体抗体（TRAb）与ATD之间的平衡。晚孕早期母体TRAb滴度升高是胎儿发生甲状腺功能亢进的一个危险因素,此时亦应行胎儿甲状腺超声检查。临床可以通过调整孕妇ATD用量治疗胎儿甲状腺功能亢进。若妊娠期Graves病未得到控制,或孕妇曾因Graves病行放射性碘治疗或甲状腺切除术,怀孕时TRAb仍阳性者,须于分娩时检测脐带血TSH及FT4（总甲状腺素）。     

Thyroid disease in pregnancy

Thyroid diseases are common in women of childbearing age and it is well known that untreated thyroid disturbances result in an increased rate of adverse events, particularly miscarriage, preterm birth and gestational hypertension. Furthermore, thyroid autoimmunity per se seems to be associated with complications such as miscarriage and preterm delivery. While strong evidence clearly demonstrates that overt dysfunctions (hyper- or hypothyroidism) have deleterious effects on pregnancy, subclinical disease, namely subclinical hypothyroidism, has still to be conclusively defined as a risk factor for adverse outcomes. Additionally, other conditions, such as isolated hypothyroxinemia and thyroid autoimmunity in euthyroidism, are still clouded with uncertainty regarding the need for substitutive treatment.     

妊娠期间甲状腺疾病的诊断和处理

正确处理妊娠期间甲状腺疾病是优生优育的重要内容之一。本文结合2011年颁布的“妊娠和产后甲状腺疾病诊治指南”,对妊娠期间甲状腺功能的生理变化,妊娠期甲状腺功能评定,控制存在的甲状腺功能异常避免给胎儿和妊娠过程造成的不良影响做一概述。对于妊娠期Graves病的诊断,要特别强调与妊娠甲状腺功能亢进综合征相鉴别,抗甲状腺药物的选择早期为丙硫氧嘧啶,中晚期改为甲巯咪唑。妊娠期一旦确诊甲状腺功能减退,应立即选择左甲状腺素（L—T4）治疗,并尽早使得血清促甲状腺激素（TSH）水平达标,即孕早期0．1～2．5mU／L,孕中期0．2～3．0mU／L,孕晚期0-3～3．0mU／L。由于妊娠期分化型甲状腺癌的预后和非妊娠期相似,因此手术可推迟至产后施行,并给予L-T4抑制治疗,将血清TSH控制在0．1～1．5mU／L。对于孕期的良性甲状腺结节,不建议补充L-T4治疗。     

妊娠期甲状腺疾病筛查策略

鉴于妊娠期甲状腺功能异常带来的一系列产科并发症及不良妊娠结局,许多专家建议对妊娠期妇女进行甲状腺功能筛查,但各学界对此意见不一。本文就此着重探讨妊娠期妇女甲状腺功能筛查的必要性及其临床意义,以及哪种筛查策略更为合理。     

Endocrine disorders in pregnancy: physiological and hormonal aspects of pregnancy

The endocrinology of pregnancy involves endocrine and metabolic changes as a consequence of physiological alterations at the foetoplacental boundary between mother and foetus. The vast changes in maternal hormones and their binding proteins complicate assessment of the normal level of most hormones during gestation. The neuroendocrine events and their timing in the placental, foetal and maternal compartments are critical for initiation and maintenance of pregnancy, for foetal growth and development, and for parturition. As pregnancy advances, the relative number of trophoblasts increase and the foeto-maternal exchange begins to be dominated by secretory function of the placenta. As gestation progresses toward term, the number of cytotrophoblasts again declines and the remaining syncytial layer becomes thin and barely visible. This arrangement facilitates transport of compounds including hormones and their precursors across the foeto-maternal interface. The endocrine system is the earliest system developing in foetal life, and it is functional from early intrauterine existence through old age. Regulation of the foetal endocrine system relies, to some extent, on precursors secreted by placenta and/or mother.     

Endocrine oncology in pregnancy

Endocrine tumours occur rarely in pregnant women but present clinicians with unique challenges. A high index of suspicion is often required to make a diagnosis since the symptoms and signs associated with many of these tumours, including insulinoma, adrenocortical carcinoma and phaeochromocytoma, mimic those of normal pregnancy or its complications, such as pre-eclampsia. The evidence base which informs management is very limited hence decisions on investigation and therapy must be individualised and undertaken jointly by the multidisciplinary medical team and the patient. The optimal strategy will depend on the nature and stage of the endocrine tumour, gestational stage, treatments available and patient wishes. Thus, surgical intervention, appropriately timed, may be considered in pregnancy for resectable adrenocortical carcinoma or phaeochromocytoma, but delayed until the postpartum period for well-differentiated thyroid cancer. Medical therapy may be required to reduce the drive to tumour growth, control symptoms of hormone excess and to minimise the risks of surgery, anaesthesia or labour.     

妊娠早期甲状腺毒症1例分析

妊娠期甲状腺毒症是妊娠期常见的内分泌疾病,主要表现为三碘甲状腺原氨酸(T3)、甲状腺素(T4)升高,促甲状腺激素(TSH)降低。诊断为妊娠合并甲亢还是妊娠一过性甲状腺毒症(GTT),是否需要治疗,是临床医生密切关注的问题。本文通过介绍1例妊娠早期甲状腺毒症的诊治过程展开讨论。