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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 - PowerPoint PPT Presentation
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Hypothyroidism During Pregnancy
Rosa CarranzaUniversity of Texas Medical Branch at Galveston
GNRS 5631: NNP1Debra Armentrout, RN, MSN, NNP-BC, PhD
Leigh Ann Cates, MSN, RN, NNP-BC, RRT-NPSMarch 20, 2014
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
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)
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)
Impact on the fetus
Clinical Manifestations
Widely separated suturesLarge fontanellesShort arms/legsUmbilical hernia
MacroglossiaMental retardation
HypotoniaJaundice
Poor feeding
(National Library of Medicine, 2014)
Diagnostic Evaluation of Newborn
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).
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).
Management of the Neonate
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)
Implications for Family
Economic
Follow up care/appointments conflict with parent’s work
Financial cost of healthcare
May need public assistance
Social
Increased time demands on parents
Difficult to find childcare for disabled/sick child
Decreased participation in social events
(Reichman, Corman, & Noonan, 2008)
Implications for Family
Emotional
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)
SummaryThyroid 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.
ReferencesAmerican 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.