复发性流产合并甲状腺疾病的诊治

甲状腺疾病所致甲状腺功能异常是引起复发性流产的一个常见内分泌因素,近年来已成为内分泌学、生殖医学及围产医学领域研究和关注的热点之一。临床上常见的甲状腺疾病主要包括甲状腺功能亢进症、临床甲状腺功能减退症、亚临床甲状腺功能减退症及甲状腺自身免疫性疾病等。对于复发性流产合并甲状腺疾病的规范化诊治在业内尚未达成共识,故普遍存在诊断标准不一、用药不规范等现象。文章就复发性流产患者合并甲状腺疾病的诊治作一阐述。     

内科内分泌疾病与复发性流产

正引起复发性流产的常见内科内分泌疾病包括甲状腺疾病、糖尿病和高泌乳素血症等,本文将分别对这3种与复发性流产有关的疾病进行讨论。1甲状腺疾病妊娠期间的甲状腺功能状态与妊娠结局直接相关,妊娠期甲状腺疾病一直以来都是内分泌学界和围生医学界的关注热点。美国甲状腺学会(ATA)2011年颁布了《妊娠和产后甲状腺疾病诊断和处理:ATA     

甲状腺疾病妇女的孕前保健

甲状腺疾病是常见的内分泌疾病之一,妊娠后可造成母婴不良结局。因此,在受孕前需作好充分准备,接受孕前保健是十分必要的。孕前保健至少应在受孕前3~6个月开始,内容包括对夫妇双方的孕前医学检查(包括详细个人、家族史的采集,系统体格检查以及相关的实验室检查),孕前医学咨询及指导(包括对疾病的治疗及妊娠时机的建议,对生活行为、营养、运动的指导及对受孕知识的指导及个体化的咨询指导)等服务。1甲状腺功能的诊断程序2诊断标准[1]甲状腺疾病诊断标准①临床甲状腺功能减退症TSH>4·8 mU/L,FT4<10·3 pmol/L亚临床甲状腺功能减退症TSH>…     

妊娠合并甲状腺功能减退症对妊娠结局影响

育龄妇女甲状腺功能异常影响妊娠的过程和结局。临床甲状腺功能减退症（甲减）及亚临床甲减可引起不孕,并与自发性流产、妊娠期高血压疾病、早产、胎盘早剥、胎儿窘迫及低体重儿的发生有关,还可导致新生儿智力低下,应当推荐孕前和孕期进行甲状腺功能检查。     

妊娠期甲状腺疾病监测与处理

妊娠期甲状腺疾病近10年来成为内分泌学界和围产医学界临床研究的热点之一。妊娠期甲状腺疾病主要包括:甲状腺功能减退症、甲状腺功能亢进症、产后甲状腺炎、妊娠合并甲状腺结节和甲状腺癌等。妊娠期甲状腺疾病可能导致流产、早产、胎盘早剥,以及胎儿畸形、胎儿生长受限、神经发育异常等母儿不良结局。妊娠期的免疫状态、内分泌水平改变对甲状腺功能和自身免疫功能有一定的影响,及时的诊断、处理以及孕期严密的随访可以显著改善母儿预后。文章对妊娠期甲状腺疾病的监测与处理予以阐述,以指导临床实践工作。     

妊娠期TPO-Ab阳性亚临床甲状腺功能减退症对妊娠结局的影响

甲状腺激素是胚胎期胎儿大脑发育所必需.妊娠期亚临床甲状腺功能减退症(简称:亚甲减)可能导致流产、早产、胎盘早剥、低出生体重儿、妊娠期糖尿病等不良妊娠结局,重度亚甲减患者发展为甲状腺功能减退症的风险较高.甲状腺过氧化酶抗体(TPO-Ab)是反映自身免疫性甲状腺疾病的特异指标,通过激活补体、抗体依赖细胞介导的细胞毒性作用和...     

妊娠合并甲状腺功能减退症的诊治

目的探讨妊娠合并甲状腺功能减退症患者的临床特点及治疗方法。方法选择2014年2月~2015年2月我院收治的妊娠合并甲状腺功能减退症患者50例作为研究对象,并对其相关资料进行分析。结果 50例妊娠合并甲状腺功能减退患者的发病率为同期接受治疗的甲状腺患者总人数的1.02%,其中亚临床甲减和临床甲减患者分别为44例和6例。50例患者中检测抗甲状腺过氧化物酶抗体(TPOAb)阳性者15例,临床甲减2例(4%)。结论孕妇在妊娠过程中容易诱发甲减,造成妇妊娠期甲减的主要原因是患者一般存在隐性自身免疫性甲状腺炎,甲减诱发的主要危害是妊娠期胎儿宫内窘迫和(或)妊娠期高血压病,患者通过接受左旋甲状腺素(L-T4)替代治疗,能够维持甲状腺功能正常,确保母婴健康,提醒临床工作者重视、及时诊治此类疾病,以提高人民健康水平。     

妊娠与甲状腺功能减退症

妊娠期间甲状腺激素的合成、分泌、代谢、调节及甲状腺免疫环境均发生相应的改变,而甲状腺功能障碍亦可从月经、排卵、受孕、胚胎分化、分娩等各阶段影响妊娠结局。已发现,即使是亚临床甲状腺功能减退症,或甲状腺功能正常的自身免疫性甲状腺疾病,对妊娠亦产生不良影响。因此妊娠合并甲状腺功能减退症的早期诊断尤为重要。目前促甲状腺激素（TSH）仍作为诊断妊娠期甲状腺疾病首选的指标。推荐将2．5mU／L作为妊娠早期母体血清TSH水平的保守上限值。有自身免疫性甲状腺疾病者在妊娠期发生甲状腺功能不足的几率较高,需密切监测。     

复发性流产的内分泌因素

复发性流产是一种常见妊娠并发症,病因复杂多样,其中内分泌因素占8%～12%,文章主要就甲状腺功能异常、高催乳素血症、多囊卵巢综合征及代谢异常、糖尿病、黄体功能不全等内分泌因素进行综述,旨在为复发性流产的预防及治疗方面带来新的思考。     

妊娠与甲状腺功能减退症

妊娠期间甲状腺激素的合成、分泌、代谢、调节及甲状腺免疫环境均发生相应的改变,而甲状腺功能障碍亦可从月经、排卵、受孕、胚胎分化、分娩等各阶段影响妊娠结局.已发现,即使是亚临床甲状腺功能减退症,或甲状腺功能正常的自身免疫性甲状腺疾病,对妊娠亦产生不良影响.因此妊娠合并甲状腺功能减退症的早期诊断尤为重要.目前促甲状腺激素(TSH)仍作为诊断妊娠期甲状腺疾病首选的指标,推荐将2.5 mU/L作为妊娠早期母体血清TSH水平的保守上限值.有自身免疫性甲状腺疾病者在妊娠期发生甲状腺功能不足的几率较高,需密切监测.     

Systematik der Diagnostik und Therapie von Schilddrüsenerkrankungen

Diseases of the thyroid are very common and in Germany one out of three adults has a goiter or thyroid nodules. Thyroid dysfunction, including its subclinical forms is found in up to 6% (hyperthyroidism) and up to 10% (hypothyroidism) of the population, respectively. The aim of a structured approach to patients is to obtain a diagnosis by evaluating morphological findings, thyroid dysfunction, signs suggestive of autoimmune disease or inflammation and accompanying disorders (notably, thyroid-associated orbitopathy). Euthyroid goiter and benign thyroid nodules may benefit from supplementation with iodine and thyroxine. Differentiated thyroid carcinoma is treated by thyroidectomy and subsequent radioiodine ablation. Antithyroid drugs are the primary treatment for Graves’ disease. Many cases of autoimmune thyroid diseases require thyroxine treatment.     

Hypothyroidism and isolated hypothyroxinemia in pregnancy,from physiology to the clinic

Many changes occur in the physiology of the maternal thyroid gland to maintain an adequate level of thyroid hormones (THs) at each stage of gestation during normal pregnancy, however, some factors can produce low levels of these hormones, which can alter the onset and progression of pregnancy. Deficiency of THs can be moderate or severe, and classified as overt or clinical hypothyroidism, subclinical hypothyroidism, and isolated hypothyroxinemia. Overt hypothyroidism has been reported in 0.3–1.9% and subclinical hypothyroidism in approximately 1.5–5% of pregnancies. With respect to isolated hypothyroxinemia, the frequency has been reported in approximately 1.3% of pregnant women, however it can be as high as 25.4%. Worldwide, iodine deficiency is the most common cause of hypothyroidism, however, in iodine-sufficient countries like the United States, the most common cause is autoimmune thyroiditis or Hashimoto's thyroiditis. The diagnosis and timely treatment of deficiency of THs (before or during the first weeks of gestation) can significantly reduce some of the related adverse effects, such as recurrent pregnancy loss, preterm delivery, gestational hypertension, and alterations in the offspring. However, so far there is no consensus on the reference levels of thyroid hormones during pregnancy to establish the diagnosis and there is no consensus on universal screening of women during first trimester of pregnancy to identify thyroid dysfunction, to give treatment and to reduce adverse perinatal events, so it is necessary to carry out specific studies for each population that provide information about it.     

Schilddr��sendiagnostik und -therapie in der t?glichen Praxis

Thyroid dysfunction and structural changes of the thyroid are common diseases which affect women more often than men. A distinction is made between latent and overt thyroid dysfunction. In cases of overt dysfunction the concentrations of free thyroid hormones are altered. Both hypothyroidism and hyperthyroidism can be caused by a variety of mechanisms. A manifest failure is always an indication for therapy. In cases of fertility desire or pregnancy a latent hypothyroidism also needs therapy by thyroid hormone substitution. In Germany one third of the population have structural changes such as an enlarged thyroid or adenomatous goitre. Medicinal treatment, radioiodine therapy and thyroid surgery are available for treatment.     

Sterilität und Schilddrüse

Overt hyperthyroidism is rare in women wishing to conceive. Due to the severe manifestations conception is usually not possible and swift diagnosis and definite treatment, preferably surgical, are recommended. Subclinical hyperthyroidism does not have a significant impact on female fertility per se. In contrast both overt and subclinical hypothyroidisms impede female fertility, the most common cause being autoimmune thyroid disease. Overt hypothyroidism always requires thyroxine treatment and for subclinical hypothyroidism treatment with thyroxine may facilitate conception. An important aspect of thyroxine treatment of women with latent hypothyroidism is to avoid overt hypothyroidism in pregnancy and its deleterious maternal and fetal consequences. For the same reason iodine supplementation should be performed regularly except in cases with active hyperthyroidism or high TSH receptor antibodies. Elevated thyroid peroxidase antibody levels correlate with an increased rate of miscarriage and preterm delivery, however, a causal relationship is unclear and no intervention is possible. In subfertile men screening can only be recommended when thyroid dysfunction is clinically apparent.     

Heterogeneity of congenital primary hypothyroidism: the importance of thyroid scintigraphy

Current newborn screening programs in California and most of the U.S. depend for diagnosis of congenital primary hypothyroidism on demonstrating an elevated thyrotropin (TSH) level in infants with the lowest 5% to 10% of thyroxine (T4) levels by filter-paper bloodspot test. The diagnosis of primary congenital hypothyroidism based on low T4 with high TSH fails to distinguish between transient hypothyroidism, ectopic or hypoplastic thyroid, athyrosis, dyshormonogenesis, and transient hyperthyrotropinemia. We screened 166,300 newborn infants for primary congenital hypothyroidism for 6.5 years and confirmed the diagnosis in 46 cases; none of these patients had a goiter. Thyroid scintigraphy was performed in 40 with technetium-99m (Tc-99m) in the first eight cases tested and iodine-123 (I-123) in 29 of the last 32 cases. Fifteen infants were athyroid and seven had ectopic or hypoplastic glands; in 18 the thyroid gland appeared normal (present, normal location). Congenital hypothyroidism represents a spectrum of diseases from transient underactivity to complete absence of the thyroid gland. We recommend that, before starting treatment, a specific anatomic and functional diagnosis be confirmed by thyroid scintigraphy and other thyroid function tests.     

Thyroid disease in pregnancy: A review of diagnosis,complications and management

Malfunction of the thyroid gland is the second most common endocrine disorder encountered during pregnancy. It is well known that overt disease of the thyroid gland, either hyper or hypo can adversely affect pregnancy outcome. There is also an ongoing debate surrounding the issue of subclinical hypothyroidism and its effect on the cognitive development of the unborn child. The goal of this paper is to present a systematic review of the literature and the current recommendations for diagnosis and treatment of thyroid disease in pregnancy and postpartum.     

Thyroid disease and female reproduction

Objective: To review the menstrual function and fertility in thyroid disease, mainly in hyperthyroidism and hypothyroidism. Also to register the consequences of ¹³¹I therapy, which is used widely in the treatment of Graves’ disease and thyroid cancer, on subsequent pregnancies and on fertility in these patients.

Design: A MEDLINE computer search was used to identify relevant studies. The type of menstrual disturbances and the status of fertility were recorded from all the studies found. Also, the fertility and genetic hazard of female patients with Graves’ disease and thyroid cancer who were treated with ¹³¹I were registered.

Result(s): Both hyperthyroidism and hypothyroidism may result in menstrual disturbances. Menstrual abnormalities are less common now than in previous series. In a recent study, we found that only 21.5% of 214 thyrotoxic patients had some type of menstrual disturbance, compared to 50 to 60% in some older series. The most common manifestations are hypomenorrhea and oligomenorrhea. According to the results of endometrial biopsies, most thyrotoxic women remain ovulatory. Moreover, the genetic hazard incident to radioiodine therapy in Graves’ disease and thyroid carcinoma is very small; exposure to ¹³¹I does not cause reduced fecundity, and the risk of loss of fertility is not a contraindication for its use in these patients. mIn hypothyroidism, the frequency of menstrual irregularities has very recently been reported to be 23.4% among 171 hypothyroid patients studied. This is much less than that reported in previous studies, which showed that 50 to 70% of hypothyroid female patients had menstrual abnormalities. The most common manifestation is oligomenorrhea. Severe hypothyroidism is commonly associated with failure of ovulation. Ovulation and conception can occur in mild hypothyroidism. These pregnancies are, however, often associated with abortions, stillbirths, or prematurity. The latter may be of greater clinical importance in infertile women with unexplained infertility.

Conclusion(s): These new data, mainly concerning menstrual abnormalities in hyperthyroidism and hypothyroidism, are inconsistent with what is generally believed and written in the classic thyroid textbooks and indicate that such opinions should be revised.     

Overt and 'subclinical' hypothyroidism in women

Thyroid disease in general, and hypothyroidism in particular, are very common in women. In the USA, the most common cause of primary thyroid deficiency is on an autoimmune basis due to lymphocytic (Hashimoto) thyroiditis. Because there are thyroid hormone receptors in virtually every tissue of the body, the manifestations of hypothyroidism are varied, but problems with abnormal menses, conception, fertility, and pregnancy can be especially troubling in young women. The single most important diagnostic test is measurement of serum thyrotropin (TSH). The overwhelming majority of patients with hypothyroidism are treated with a single daily dose of synthetic levothyroxine with the goal of therapy being restoration of a normal metabolic state with return of the TSH level down to the range of 0.5 to 1.5 mlU/L. "Subclinical" hypothyroidism refers to those patients with early or mild thyroid hypofunction manifested as slight elevations of thyrotropin (approximately 4-10 mlU/L) although serum thyroxine (T4) and triiodothyronine (T3) levels are within their reference ranges. The entity is somewhat controversial in regard to its consequences if left untreated, and whether or not we should be screening patients, at least susceptible populations, for the condition. Reports indicate an association between subclinical hypothyroidism and poor outcomes of pregnancy, as well as dyslipidemias, atherogenesis, and increased mortality in the long term. We believe these consequences are sufficiently compelling to warrant screening and treatment with levothyroxine when found to halt progression to overt hypothyroidism, and improve symptoms, pregnancy outcomes, lipid abnormalities, and cardiovascular function. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to recall that hypothyroidism is a common disease in women, has many protean manifestations, and can be successfully diagnosed and treated; explain that the condition of subclinical hypothyroidism can be diagnosed and if treated can prevent many untoward complications; and state that there should be heightened awareness of the disease so that proper screening tests can be performed.     

Prescribing in pregnancy. Thyroid disease

When treating thyroid disease, as with other conditions in pregnancy, one is concerned with the welfare of both mother and developing child. Thyroid disease causes few maternal problems; thyrotoxicosis in fact tends to improve in pregnancy, allowing medical management with lower drug doses than usual. Relapse of thyroid disease may occur postpartum, when transient hypo- and hyperthyroidism are relatively common. In contrast, the fetus and neonate are threatened in a number of ways by drugs given to the mother and by transplacental passage of maternal antibodies capable of inducing thyroid disease. Antithyroid drugs may cause fetal goitre with airway obstruction, and are associated with mild neonatal hypothyroidism. Thyroid antibodies in primary myxoedema and Hashimoto's thyroiditis are occasionally implicated in neonatal hypothyroidism and may even cause thyroid dysgenesis. Neonatal hyperthyroidism has a high morbidity and mortality and may have long-term skeletal effects such as craniosynostosis. Fetal problems may not be apparent at birth but may emerge in the next eight to ten days, especially in hyperthyroidism when the mother has been on treatment. Close monitoring throughout pregnancy and for the first ten days postpartum is required to minimize risks to the fetus and neonate. Most pregnancies associated with thyroid disease will have a successful outcome. If the occasional at-risk fetus is to be identified and treated successfully there should ideally be close cooperation between obstetrician, endocrinologist and paediatrician.