InternationalFederationofGynecologyandObstetrics

FIGOMission

• The International Federation of Gynecology and Obstetrics (FIGO) is a unique organization, being the only international professional body that brings together 130 obstetrical and gynecological associations from all over the world.

• FIGO is dedicated to the improvement of women’s health and rights and to the reduction of disparities in health care available to women and newborns as well as to advancing the science and practice of obstetrics and gynecology. The organization pursues its mission through advocacy, programmatic activities, capacity strengthening of member associations and education and training.

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InternationalFederationofGynecologyandObstetricsWorkingGrouponGoodClinicalPracticeinMaternal-FetalMedicine

Chair: G C Di Renzo

Expert members:E Fonseca, BrasilE Gratacos, SpainS Hassan, USAM Kurtser, RussiaF Malone, IrelandS Nambiar, MalaysiaM Sierra, MexicoK Nicolaides, UKH Yang, China

Expert members ex officio:C Fuchtner, FIGOM Hod, EAPMGH Visser, SM CommitteeE Castelazo , CBET CommitteeL Cabero, WG GDMV Berghella, SMFMY Ville, ISUOGM Hanson, DOHaD, WG NutritionPP Mastroiacovo, ClearinghouseJL Simpson, March of DimesD Bloomer, GLOWM

InternationalFederationofGynecologyandObstetricsWorkingGroupontheChallengesofLabour andDelivery

Chair: R Romero

Expert members:D Farine, CanadaMT Gervasi, ItalyJ M. Robson, IrelandT Duan, ChinaS Rosales, MexicoT Kimura, JapanL Yeo, Korea-USA

Expert members ex officio:C N Purandare, FIGOG C Di Renzo, FIGOM Stark, NESAGH Visser, SM CommitteeE Castelazo , CBET CommitteeC Lees, RCOGA Conde’ Agudelo, NIH NICHDD Bloomer, GLOWM

International Federation of Gynecology and ObstetricsMarch of DimesWorking Group on Preterm Birth Prevention

Chairs: J L SimpsonG C Di Renzo

Expert members:Ernesto CastelazoMary D’AltonEduardo FonsecaChris HowsonBo JacobssonJames MartinJane NormanT Y Leung

Expert members ex officio:CN Purandare, FIGOJ Howse, March of DimesG Visser, SM CommitteeD Bloomer, GLOWMJim Larson BCGDavid Ferrero, BCG

International Federation of Gynecology and ObstetricsGDM initiative

Chair: M Hod

Expert members:Mukesh AgarwalBlami DaoGian Carlo Di RenzoHema DivakarEran HadarAnil Kapur

Expert members ex officio:CN Purandare, FIGOGH Visser, SM CommitteeD Ayres do Campo, SM CommL Cabero, CBET CommitteeD Bloomer, GLOWMR Fabienke, Novo Nordisk

Good practice advice

• Folicacidsupplementation•Predictionandpreventionofpretermbirth

•Noninvasiveprenataldiagnosisandtesting

Good practice advice

• Thyroiddiseasesinpregnancy•MgSO4useinobstetrics•Appropriateuseofultrasoundinpregnancy

•Hyperglycemiaandpregnancy

GoodpracticeadvicefinalisedinJune2016

•AspirinUseinPregnancy• Irondeficiencyanaemia•ManagementofTwinPregnancy•MicronutrientsinPregnancy

GoodpracticeadvicetobediscussedonDecember2016

• Intrauterinegrowthrestriction•RecurrentMiscarriage•Predictionofpreeclampsia

Thyroid Gland

One of the largest endocrine gland

International Journal of Health Sciences & Research.2013;3(5):29

Located front of the neck, below the larynx

2 inch long, Butterfly shaped gland

It has two lobes (Right & Left)

Average weight 25-30g in adults (slightly more in women)

The thyroid makes two thyroid hormones• Thyroxine (T4)• Triiodothyronine (T3)

Thyroid Gland Functions

MOST OF FUNCTION DUE TO T3Growth & developmentIncreasing rate of metabolismIncrease metabolic rate in CVS → blood flowRegulating cerebral conducion in cnsSleepLipid metabolism

One of the largest endocrine glandThe thyroid makes two thyroidhormones

• Thyroxine (T4)• Triiodothyronine (T3)

When thyroid hormone levels in the blood are low, the pituitary

releases more TSH.(↓ T4 & T3 ---↑ TSH)

When thyroid hormone (T4, T3) levels are high,

the pituitary decreases TSH production.

(↑ T4 & T3 --- ↓ TSH)

Points to be remembered….

Increased TSH levels indicates…..Pituitary gland working extra hard

to maintain normal circulating thyroid hormones !

Early Pregnancy

Serum Thyrotropin

level decreases

Weak TSH effect of HCG‘Spill over’

Increase in free Thyroxine

1.Lazarus JH. British Medical Bulletin. 2010;1-12.2.Galofre JC. J Womens Health (Larchmt). 2009;18(11):1847-1856.3.Thyroid disease and pregnancy. American Thyroid Association website

The Nine Square Game

To evaluate our Thyroid patient

As per the AACE and ITS Guidelines

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

FREE

TH

YRO

XIN

E o

r FT

4

BASIC THYROID EVALUATION

FREE

TH

YRO

XIN

E o

r FT

4

EUTHYROID

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

BASIC THYROID EVALUATION

FREE

TH

YRO

XIN

E o

r FT

4

PRIMARYHYPOTHYROID

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

BASIC THYROID EVALUATION

FREE

TH

YRO

XIN

E o

r FT

4 PRIMARYHYPERTHYROID

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

BASIC THYROID EVALUATION

FREE

TH

YRO

XIN

E o

r FT

4

SECONDARYHYPOTHYROID

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

BASIC THYROID EVALUATION

FREE

TH

YRO

XIN

E o

r FT

4 SECONDARYHYPERTHYROID

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

BASIC THYROID EVALUATION

FREE

TH

YRO

XIN

E o

r FT

4

SUB-CLINICALHYPERTHYROID

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

BASIC THYROID EVALUATION

FREE

TH

YRO

XIN

E o

r FT

4

SUB-CLINICALHYPOTHYROID

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

BASIC THYROID EVALUATION

FREE

TH

YRO

XIN

E o

r FT

4

NON THYROIDILLNESS or NTI

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

BASIC THYROID EVALUATION

FREE

TH

YRO

XIN

E o

r FT

4 NTI or Pt.on THYROID HORMONES

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

BASIC THYROID EVALUATION

FREE

TH

YRO

XIN

E o

r FT

4

EUTHYROIDSUB-CLINICALHYPERTHYROID

NON THYROIDILLNESS - NTI

NTI or Pt.on HYROID HORMONES

SUB-CLINICALHYPOTHYROID

SECONDARYHYPERTHYROID

SECONDARYHYPOTHYROID

PRIMARYHYPERTHYROID

PRIMARYHYPOTHYROID

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

BASIC THYROID EVALUATION

THYROID HORMONES

TEST REFERENCE RANGE

TSH Normal Range 0.3 - 4.0 mU/L

Free T4 Normal Range 0.7-2.1 ng/dL

TSH upper limit has been revised to 2.5 mU/L

HYPERTHYROIDISM HYPOTHYROIDISM

SOLITARY NODULE/GOITRE

POSTPARTUMTHYROIDITIS

CONCLUSIONSPearls for Practice

HypothyroidismT4 essential for early fetal developmentLittle T4 crosses placenta after 1st

trimAdequate treatment – good outcome

HyperthyroidismCareful D/D at early weeksUntreated- poor preg. Outcomedrugs cross placenta: lowest optimal dosageCord blood - Thyroid function

Postpartum ThyroiditisOccurs 3-4 mths postpartumAutoimmune disorderPhases of hyper-hypo-recoveryAnnual thyroid function tests

Thyroid nodule & CancerDefer preg. For 1 year after trt. With radioactive iodineNodule identified beyond 20 weeks-biopsy after deliveryLarge goitre – anesthetic complications

Thyroid dysfunction

FIGOrecommendsthefollowing:

•Screeningforthyroidfunctionisrecommendedinthefirsttrimesterparticularlyincountrieswithadeficientiodinedietandinsymptomaticpatients•TSHisthesuperiormethodforscreening.FreeT4andTPOAbtestingarenotrecommendedforscreening.ThebestreliabletestsforTSHarebyC.I.Aor3rd generationR.I.A(RadioImmunoAssay).Notablynormalthyroidtestvalueschangeinpregnancy

•TreatmentforhypothyroidismisrecommendedwhenTSHlevelsare>2.5and>3,0IU/Lduringthefirstandsecond/thirdtrimestersrespectively.TheonlyreplacementtherapyisL-thyroxine.ThestartingdoesofL-thyroxinearepresentedinfig.4.Insteadtreatingsubclinicalhypothyroidism,inthepresenceofnegativethyroidauto-antibodies,isstilldebatable.Importantly,womenonL-thyroxinebeforepregnancyshouldincreasetheirdosageby30-50%whentheyfirstrecognizethepregnantstate.

•TreatmentofHyperthyroidismduetoGrave’sdiseaseisbyantithyroiddrugs(Propylthiouracil(PTU)orCarbimazole/Methimazole(MMI)).ItisnotrecommendedtochangedrugsduringpregnancySymptomatic(fig-1)treatmentwithbeta- blockersforshorttermmaybeneeded.

•Primary,preventionofhypothyroidismisbyahealthydietandIodisedfortifiedsalt(especiallyiniodinedeficientareas).

•Ifthepatienthasathyroidnodulesheshouldbeevaluatedandtreatedduringpregnancy.Thefirststepsareperfomanceofathyroidultrasonogramandafineneedleaspiration(FNA)asneeded.Surgeryshouldbepreferablydeferredtothepostpartumperiod.

FollowupandpostpartumTSHevaluationandreductionofL-thyroxinedosetopre- pregnantlevelsinpatientswithhypothyroidism.

CONCLUSIONS

FOCUSONGLOBALSTRATEGIES

AMELIORATEOURPROFESSIONOVERCOMINGTHELIMITSOFNATIONALSOCIETIESGUIDELINES:THEBESTPRACTICEADVICEGLOBALSTRATEGIESFOR:PRETERMBIRTHPREVENTIONNONCOMMUNICABLEDISEASESPREVENTINGEXPOSURETOTOXICCHEMICALS

FIGHTINGTHEINEQUITY

Gatheringdataonmaternalmortalityandmaternalhealthisnotoriouslydifficult.However,onethingisclearfromallthestatistics:althoughmaternalandperinatalmortalityandmorbidityisfallinggloballytheperspectivesforwomen-infantsinpoorresourcescountriesaremuchworstthanforthoseinindustrialisedcountries.

Accesstocare

HealthcareSystems/InsuranceCoverage

Education/Counseling

PreventivetoolsBest

Practice

Riskfactors/MarkersImplementation

Window of Opportunity

Pregnancyoffersawindowofopportunitytoprovidematernalcareservicestomotherandoffspring

Reducetraditionalmaternalandperinatalmorbidityandmortality

indicators

AddressintergenerationalpreventionofpretermbirthandNCDs,suchas

diabetes,hypertension,cardiovasculardisease,andstroke.

OnSept2015theUNGeneralAssemblyadoptedthe“Agenda2030:TransformingourWorld”,withaconsensusoftheWorldGovernmentCommunity- introduced17sustainabledevelopmentgoalsSDGs.ManyofthesuggestedSDG’shaveEnvironmentalandReproductivehealthembeddedintheirgoals

Itisasheerco-incidencethatSeptember2015witnessedthe20th anniversaryoftheBeijingWorldConferenceonWomenundertheslogan-“Planet50-50by2030:SetitupforGenderEquality”.

‘TheAgenda2030;Transformingourworld’ orPlanet50-50by2030’ i.e.SDGswillnotmaterialisewithoutthecontributionof50%ofitspopulationi.e.women- Thiscanbeachievedonlywithgenderequality,equaleducationandemploymentopportunities+providingsexualreproductivehealthandrights.

ReproductiveHealthandRightswillnotbecompleteunlessweimproveenvironmentalHealth

FIGOwasnotandwillnotbeapassiveobservertobringaboutthisrequiredchangeandwillacttomakethesedreamsrealforwomen.