妊娠期甲状腺疾病对胎儿宫内生长发育的影响

目的 探讨妊娠期甲状腺疾病对胎儿宫内生长发育的影响.方法 采用前瞻性研究方法,随机纳入2020年1月至2020年12月在深圳市南山区妇幼保健院产科分娩的孕妇550例,并在孕妇早、中、晚期检测甲状腺素水平以及甲状腺过氧化物酶抗体,记录孕妇发生甲状腺功能减低(简称:甲低)、甲状腺功能亢进(简称:甲亢)的发生率,并进行分组,...     

Transient hyperthyroxinemia in newborns from women with autoimmune thyroid disease and raised levels of thyroid peroxidase antibodies

Objective.?Although it is well established that maternal thyroid disease and increased levels of thyrotropin receptor antibodies (TRab) during pregnancy are associated with a number of complications, is the significance of increased levels of thyroid peroxidase antibodies (TPOab) alone a matter for discussion? The aim of the present study was to examine whether transplacental passage of TPOab from women with autoimmune thyroid disease (AITD) interferes with thyroid function in the neonate.

Methods.?Pregnant women with AITD (raised levels of TPOab) and their neonates were monitored with regard to variations of thyroid hormones, thyrotropin (TSH), and TPOab. Pregnant women with non-AITD served as controls.

Results.?The neonates from mothers with AITD, independently of the presence also of TRab in the mothers, had a transient hyperthyroxinemia one week following birth. Neonatal TPOab correlated with that of the mothers at gestation and was cleared concomitantly with normalization of thyroxine. A high frequency (21%) of severe hyperbilirubinemia was observed in neonates from mothers with AITD.

Conclusion.?Children of mothers with raised levels of TPOab, have a transient hyperthyroxinemia one week after birth accompanied by a high frequency of hyperbilirubinemia suggesting that clinical examination and blood testing should be performed consecutively during the first postnatal week.     

ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 37, August 2002. (Replaces Practice Bulletin Number 32, November 2001). Thyroid disease in pregnancy

Because thyroid disease is the second most common endocrine disease affecting women of reproductive age, obstetricians often care for patients who have been previously diagnosed with alterations in thyroid gland function. In addition, both hyperthyroidism and hypothyroidism may initially manifest during pregnancy. Obstetric conditions, such as gestational trophoblastic disease or hyperemesis gravidarum, may themselves affect thyroid gland function. This document will review the thyroid-related pathophysiologic changes created by pregnancy and the maternal-fetal impact of thyroid disease.     

妊娠期甲状腺功能保护

甲状腺疾病可以导致母儿不良妊娠结局,由于妊娠期甲状腺功能发生特异性变化,用非妊娠妇女的诊断标准评估妊娠期甲状腺功能可导致妊娠期甲状腺功能减退症漏诊、甲状腺功能亢进症误诊和药物治疗剂量不足。只有正确诊断妊娠期甲状腺疾病,合理保护妊娠期甲状腺功能,才能避免不良妊娠结局的发生和减少对新生儿远期生存质量的影响,对实现我国优生优育的国策具有非常重要的意义。     

甲状腺腺瘤200例手术分析

目的:分析甲状腺腺瘤手术的方法及术后复发情况。方法:回顾性分析200例甲状腺腺瘤的一般资料,手术方法,术后复发率等情况。结果:术后随访12～36个月,其中28例一侧腺叶全切除术患者复发1例,复发率为3.6%;96例甲状腺摘除术患者复发9例,复发率为9.4%;76例甲状腺次全切术患者复发5例,复发率6.6%。结论:单纯甲状腺摘除术复发率较高,而患侧腺叶全切除术及次全切除术复发率较低,合理的选择手术方式可减少甲状腺腺瘤的术后复发率。     

Impact of first trimester and postpartum period thyroid autoantibodies on abortus incidence in Turkish pregnant women

Objective.Abortus is a common problem and is observed approximately in one third of all pregnancies. In this study, we aimed to evaluate in euthyroid pregnant population the effect of thyroid autoantibodies of both first trimester and postpartum period on abortus incidence.

Design and method.Euthyroid 128 pregnant women were included in the study. All pregnants were required having a history of maximum one abortus without any previous endocrinological, immunological disorders. Thyroid autoimmunity was defined as having serum levels of either antithyroidperoxidase or antithyroglobulin antibodies higher than 34 and 115 IU/ml, respectively.

Results and conclusions.One hundred of 128 pregnant women (78.1%) had no thyroid autoantibodies, whereas 28 pregnant women (21.9%) had positivity for one of thyroid autoantibodies. One hundred pregnant women (78.1%) gave healthy births, whereas 28 (21.9%) had abortus. Abortus incidence was 28.6% in autoantibody positive group, whereas it was 20% in autoantibody negative group. Serum anti-Tg levels both in first trimester and both in postpartum period were higher in pregnants abortus group when compared with healthy births group. Although, we found no correlation between abortus incidence and thyroid autoantibodies presence, first trimester serum levels of anti-Tg levels may have correlated with abortus incidence and may be an indicator of a closer follow-up. In sight of this study, it can be concluded that autoimmunity against thyroid may continue after termination of pregnancy and this was the first study evaluating the postpartum antibodies levels which may be helpful in subsequent pregnancies.     

A study to establish gestation-specific reference intervals for thyroid function tests in normal singleton pregnancy

Objective

To establish gestation-specific reference intervals for thyroid function tests in normal singleton pregnancy.

Study design

Cross-sectional observational study performed in the Obstetric and Gynaecology department, West Middlesex University Hospital. A single blood sample from 335 pregnant women at various gestations of pregnancy was analysed for thyroid function. FT4, fT3, TSH values at each gestation of pregnancy were calculated.

Results

From the fT3, fT4 and TSH results, a 95% reference interval was calculated for each hormone for each week of pregnancy.

Conclusion

We calculated gestation-specific reference intervals for thyroid function tests throughout pregnancy to facilitate clinical management of thyroid disease in pregnancy.     

妊娠合并甲状腺功能异常:子痫前期风险与防范

妊娠期甲状腺功能异常性疾病通常表现为妊娠期甲状腺功能亢进(甲亢)或妊娠期甲状腺功能减退症(甲减),未经治疗的妊娠期甲状腺功能异常可导致多种母儿并发症并引起不良妊娠结局,无论是甲亢还是甲减均可增加子痫前期的发病风险,且子痫前期合并甲状腺功能异常使病情变得更为复杂,增加母儿不良预后的风险。故在孕前和孕早期对妊娠期甲状腺功能进行筛查,通过以药物为主的治疗手段使孕期甲状腺激素水平保持在正常范围,以及严密的监护等有助于降低妊娠期子痫前期的发病风险,改善子痫前期合并甲状腺功能异常患者的妊娠结局。     

2017 ATA guidelines on the management of thyroid dysfunctions in pregnancy: what do OB/GYNs need to know?

In the past two decades, the issue of thyroid dysfunctions during pregnancy and the postpartum period received increasing attention by both endocrinologists and obstetrics/gynecologists (OB/GYNs), the latter often became the first to diagnose an impaired thyroid function in pregnant women. In this setting, a series of different clinical guidelines have been published and reviewed, the latest ones being represented by the 2017 ATA guidelines, which extensively address a wide variety of topics, including iodine supplementation, thyroid autoimmunity, hyper- and hypo-thyroidism, thyroid nodules and cancer, post-partum management, as well as the need for pre-conception screening. Aim of this editorial is to offer a practical guidance to the OB/GYN reader by focusing upon evidence-based changes introduced by the latest guidelines, with particular regard to: (a) prescribing further endocrine testing before referral; (b) providing evidence-based answers to some of the frequently asked questions.     

Thyroid cancer in pregnancy.

OBJECTIVE: To compare stage at diagnosis, treatment and survival among pregnant women with thyroid cancer to non-pregnant women with thyroid cancer, and to assess the impact of treatment on maternal and perinatal outcomes. METHODS: A database containing maternal and newborn discharge records linked to the California Cancer Registry was queried to obtain information on all thyroid cancers from 1991-1999. Women with thyroid cancer occurring during pregnancy were compared to age-matched non-pregnant women with thyroid cancer. RESULTS: 595 cases of thyroid cancers were identified (129 antepartum and 466 postpartum). About 64% of thyroid cancers were diagnosed at stage 2 among pregnant women versus 58% among non-pregnant controls. The odds of thyroid cancer were 1.5 times higher among Asian/Pacific Islanders than among Non-Hispanic White women. Pregnancy had no significant effect on mortality after diagnosis of thyroid cancer. Thyroidectomy during pregnancy was not associated with adverse maternal or neonatal outcomes. CONCLUSIONS: Thyroid cancer discovered during or after pregnancy does not appear to have a significant impact on the prognosis of the disease.     

Thyroid gland size in pregnancy. An ultrasound and clinical study

We estimated the size of the thyroid gland by palpation and measured thyroid gland volume with ultrasound in the immediate postpartum period and six months after delivery in 16 women. The 13% reduction in the mean thyroid gland volume detected six months after delivery implied that the thyroid gland enlarges slightly during pregnancy. Physical examination, however, did not detect any goiters during the immediate postpartum period and did not identify a change in thyroid gland size six months after delivery. The thyroid gland enlargement that occurs during pregnancy is not large enough to be detected by physical examination. We urge physicians to discard the commonly held notion that goiter frequently develops during pregnancy.     

Schilddrüse und frühe Entwicklung

Functional alterations of maternal thyroid glands influence early fetal development. The thyroid gland hormones triiodothyronine (T₃) and thyroxine (T₄) are absolutely necessary for the development and maintenance of physiological processes. This is especially true for the central nervous system (CNS) where the thyroid gland hormones play an important role in maturation of the fetal brain during pregnancy. In addition to thyroid gland diseases, iodine deficiency is also extremely important. During pregnancy the requirements for thyroid gland hormones increase by approximately 50 % with a corresponding need for iodine. Healthy thyroid glands can cover these increased requirements as long as sufficient iodine is available. This article describes the processes of fetal and maternal thyroid hormone production and in particular the physiological alterations of maternal thyroid gland parameters during pregnancy. Particular attention is paid to disorders of thyroid gland function in the mother and fetus.     

Adverse effects of thyroid dysfunction on pregnancy and pregnancy outcome: Epidemiologic study in Slovenia

Objective.?To evaluate the consequences of maternal thyroid dysfunction for pregnancy outcome.

Methods.?A retrospective analysis involving all pregnant women who delivered in Slovenia in the 1997–1999 triennium; those having a medical history of thyroid dysfunction and/or taking thyroid medications were allotted to the study group (n = 748) and the remaining ones to the control group (n = 52 253).

Results.?Significantly higher incidences of infertility (5.5% vs. 3.7%, p < 0.05), menstrual cycle irregularities (3.2% vs. 1.9%, p < 0.05), hypertensive disorders (7.0% vs. 4.2%, p < 0.05), threatened preterm delivery (9.1% vs. 5.6%, p < 0.001), and delivery before 32 weeks (2.7% vs. 1.5%, p < 0.05) were found in the study than in the control group. There were no significant differences in the incidences of miscarriage, non-gestational diabetes mellitus, proteinuria, hyperemesis, intrahepatic cholestasis of pregnancy, intrauterine growth restriction, placental abruption, preterm delivery, small for gestational age newborns (SGA), and stillbirths.

Conclusions.?This is the first study to evaluate the incidence of thyroid dysfunction for the whole population of pregnant women in Slovenia using a retrospective analysis. Thyroid dysfunction adversely affects pregnancy and pregnancy outcome but to a lesser extent than presented in previous studies. An evaluation of thyroid function in the women who experience menstrual cycle irregularities, infertility, and complications during pregnancy, labor and delivery would be advisable.     

Onset of Graves’ disease during pregnancy in a woman with established hypothyroidism

Background: Pregnancy strongly influences the thyroid gland and its function. Thyroid guidelines recommend a 30 to 50% increase of the preconceptional levothyroxine dose in women with hypothyroidism, when pregnancy is diagnosed.

Case: A 33 year-old, 8-week pregnant woman with hypothyroidism, presents with a 2-week history of palpitations, sweating, nervousness and fatigue. Physical examination shows tachycardia (108 bpm), distal tremors and diffuse goiter. After biochemical confirmation of hyperthyroidism, her levothyroxine dose is reduced and finally interrupted. Propylthiouracil is started and maintained until after the delivery of a healthy baby at week 40. Two weeks postpartum, hyperthyroidism worsens and propylthiouracil is replaced by methimazole. Eighteen months after delivery 7.5?mCi 131Iodine was given. Two months later, hypothyroidism developed and levothyroxine was initiated.

Conclusion: Although conversion of Hashimoto's hypothyroidism into Graves' disease is exceptional in pregnancy, pregnant women with autoimmune hypothyroidism should ideally have their TSH concentrations measured before empirically increasing their levothyroxine dose.     

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。     

Maternal and placental responses before preterm birth: adaptations to increase fetal thyroid hormone availability?

Background: During pregnancy, maternal thyroid hormone supply is crucial for fetal development. Preterm infants often present with hypothyroxinemia. Preterm birth, either spontaneous or medically indicated, is always the result of a complicated pregnancy. We hypothesized that in preterm birth, the maternal transplacental thyroid hormone supply is influenced by the pregnancy complication and we questioned whether maternal and placental compensatory mechanisms are activated to increase thyroid hormone transfer.

Methods: Observational case-control study in mother–infant-dyads with complicated pregnancies ending in spontaneous preterm birth (n?=?31) or indicated preterm birth due to vascular complications (n?=?45) and normal pregnancies (healthy term controls; n?=?41). At delivery, maternal and cord blood and placenta samples were collected. Cord and maternal plasma concentrations of thyroid stimulating hormone (TSH), total T4, fT4/FTI, total T3, and T4 binding globulin (TBG), and maternal serum concentrations of thyroid peroxidase (TPO)-antibodies were measured. Placental maturity was evaluated histologically and mRNA and/or protein levels of thyroid hormone deiodinases (DiO) 1, 2 and 3, and transporters (MCT8, MCT10, and OATP1c1) were quantified.

Results: In indicated and spontaneous preterm births, cord plasma T4 concentrations were lower than in healthy term controls (p?≤?.001), whereas T3 was only decreased in spontaneous preterm birth (p?≤?.001). Compared with spontaneous preterm births and healthy term controls, indicated preterm birth was characterized by higher maternal plasma TSH (p?≤?.05), earlier placental maturation, higher placental DiO2 gene and MCT10 protein levels and lower DiO3 gene levels (all p?≤?.01).

Conclusions: Low T4 was observed in preterm infants irrespective of the cause of preterm birth, while maternal (TSH) and placental (DiO2, DiO3, and MCT10) compensatory responses were only activated in indicated preterm birth due to vascular complications. This may have mediated the normal fetal T3 availability in preterm infants born after indicated preterm birth but not after spontaneous preterm birth.     

妊娠期合并甲亢危象诊治

甲亢危象是罕见的妊娠期合并症,病情凶险,可危及母儿生命。早期诊断并及早开始以抗甲状腺药物治疗为主的联合治疗是抢救成功的关键。孕前及孕早期开展甲状腺功能筛查是降低甲状腺疾病患者孕期不良结局的重要手段。     

Recurrence of phaeochromocytoma in pregnancy in a patient with multiple endocrine neoplasia 2A: a case report and review of literature

Multiple endocrine neoplasia type 2A (MEN 2A) is an autosomal dominant inherited condition with a prevalence of one in 40?000 individuals. It causes the development of tumours in endocrine glands, such as medullary thyroid cancer, pheochromocytomas, as well as primary hyperparathyroidism. MEN 2A in pregnancy is very rare with only 29 cases reported in the literature. The presence of pheochromocytoma is a rare cause of hypertension during pregnancy with an incidence of 0.007% of all pregnancies. This has severe implications on both mother and the foetus. This case report describes a 22-year-old nulliparous Caucasian woman with known MEN2A syndrome, who underwent thyroidectomy for medullary thyroid carcinoma in childhood and excision of left sided pheochromocytoma at the age of 19. She was found to have a recurrence of pheochromocytoma in the right adrenal gland during pregnancy at 16 weeks of gestation and was oddly normotensive. Catecholamine effects were blocked with phenoxybenzamine and she delivered by an uneventful elective caesarean section at 36 weeks gestation. She underwent a laparoscopic right adrenalectomy six weeks postpartum, followed by lifelong corticosteroid replacement.     

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。     

13例妊娠合并Graves病的临床分析

目的 分析Graves病治疗后妊娠时机及其母儿预后。方法 采用回顾性分析的方法,将13例妊娠前诊断为Graves病患者,按妊娠期间是否服用抗甲状腺药物分两组:甲组:妊娠期未服用抗甲状腺药物;乙组:妊娠期使用了抗甲状腺药物。对比研究其母儿合并症及并发症。结果 甲、乙两组妊娠前甲亢病程无差异,甲组停药至此次妊娠间隔明显短于乙组,乙组早产率,产后出血率及小于胎龄儿发生率明显高于甲组(P<0.05)。结论 Graves病在病情稳定后即可妊娠,妊娠后需严密监测母体及胎儿甲状腺功能;对于应用内基硫嘧啶治疗后需用甲状腺素片部分替代的孕妇.其胎儿甲状腺功能情况需严密监测。