Jurnal Anin Word

8/12/2019 Jurnal Anin Word

1/15

Hindawi Publishing Corporation

Journal of Thyroid ResearchVolume 201! "rticle #$ %&%'(&! ( pages

http)**d+,doi,org*10,11--*201*%&%'(&

Review Article

Management of Hyperthyroidism in Pregnancy:

Comparison of Recommendations of American ThyroidAssociation and Endocrine Society

Shahram Alamdari, Fereidoun Aii, Hossein !elshad, FaranehSar"ghadi, Atieh Amouegar, and #adan Mehran

Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of

Medical Sciences, Tehran 199!"#$%, Iran

Correspondence should be addressed to .hahram "lamdari/ alamdariendocrine,ac,ir

Receied % $ecember 2012/ "ccepted 1 arch 201

"cademic 3ditor) John H, 4a5arus

Copyright 6 201 .hahram "lamdari et al, This is an open access article distributed under the Creatie Commons

"ttribution 4icense! which permits unrestricted use! distribution! and reproduction in any medium! proided the

original wor7 is properly cited,

"ppropriate diagnosis and treatment of hyperthyroidism during pregnancy are of outmost importance! because hyperthyroidism

has ma8or aderse impact on both mother and fetus, .ince data on the management of thyroid dysfunction during pregnancy is

rapidly eoling! two guidelines hae been deeloped by the "merican Thyroid "ssociation and the 3ndocrine society in the last 2

years, 9e compare here the recommendations of these two guidelines regarding management of hyperthyroidism during

pregnancy, The comparison reeals no disagreement or controersy on the arious aspects of diagnosis and treatment of

hyperthyroidism during pregnancy between the two guidelines, Propylthiouracil has been considered as the first:line drug for

treatment of hyperthyroidism in the first trimester of pregnancy, #n the second trimester! consideration should be gien to switching

to methima5ole for the rest of pregnancy, ethima5ole is also the drug of choice in lactating hyperthyroid women,

$% &ntroduction

$iagnosis of hyperthyroidism which occurs in 0,0- to ,0;

of pregnancies may be difficult in these women! as the

symptoms and signs of nerousness! sweating! dys:pnea!

tachycardia! and cardiac systolic murmur are seen in most

normal pregnancies as well raes? hyperthyroidism


2/15

Therefore estimation of DT'inde+ may be employed! but

international reference ranges hae not been aailableuntil recently and only one manuscript is underpublication


3/15

2 Journal of Thyroid Research

Tabel 1) Perbandingan rekomendasi dari Asosiasi Thyroid Amerika dan Perhimpunan Endokrin pada

tatalaksana hipertiroidisme sebelum kehamilan dan pada diagnosis hipertiroidisme dan kehamilan.

Topik

Re7omendasi

"merican Thyroid "ssociation @2011A 3ndocrine .ociety @2012A

Dor oert hyperthyroidism due to >raes?disease

or thyroid nodules! antithyroid drug @"T$A

therapy should be either initiated @beforepregnancy if possible! and for those withnew

Tatala7sanasebelum 7ehamilan

.ama @R and TA

diagnosesA or ad8usted @for those with aprior

historyA to maintain the maternal thyroid

hormone leels for free T' at or 8ust aboethe

upper limit of the nonpregnant reference range!orto maintain total T' at 1,- times the upper limitofthe normal reference range or the free T' inde+in

,

#n the presence of a suppressed serum T.H inthe

Thyroid function

first trimester @T.H G0,1 m#*4A! a historyand

physical e+amination are indicated, DT'

.ame @RA

testsmeasurements should be obtained in allpatients,

easurement of TT and TR"b may be helpfulin

establishing a diagnosis of hyperthyroidism,

There is not enough eidence to recommendfor

ltrasonography

or against the use of thyroid ultrasound in

Ionedifferentiating the cause of hyperthyroidismin

pregnancy,

.canning and

Radioactie iodine @R"#A scanning orradioiodine

upta7e determination should not be performedin Ione

upta7epregnancy,

$ifferentiation of

$ifferentiation of >raes? from gestational

thyroto+icosis is supported by the presenceof

>raes disease

.ame @TAclinical eidence of autoimmunity! typicalgoiter!and gestationaland presence of T.H receptor antibodies @TR"bA,

thyroto+icosis

TPB:"b may be present in either case,

by "merican Thyroid "ssociation and 3ndocrine .ociety!

respectiely, #t is the aim of this paper to compare the

recom:mendations of these two guidelines regarding

management of hyperthyroidism during pregnancy,

'% Methods

The section of thyroto+icosis in pregnancy! pages 10EF10E( of

the >uidelines of the "merican Thyroid "ssociation


4/15

fetus aspects! pages 2--0F2-- of the 3ndocrine .ociety

Clinical Practice guidelines uidelines posed 1' uestions and responses were

gathered to 1' recommendations uidelines! a total of 1 recommen:

dations were gien for the management of hyperthyroidism in

pregnancy! including - recommendations for management of

maternal aspects of hyperthyroidism! - for management of fetal

aspects! and for gestational hyperemesis and hyper:

thyroidism raes? disease

and gestational thyroto+icosis! T.H receptor antibod:ies @TR"bA

determination had been recommended,

Table 2 compares recommendations of "T" and 3ndo:

crine .ociety on the management of hyperthyroidism during

pregnancy, The use of propylthiouracil @PTA has been rec:

ommended by both organi5ations during the first trimester

of pregnancy! followed by methima5ole @#A after the first

trimester, 3ndocrine society guideline states that # may

be prescribed if PT is not aailable or if a patient cannot

tolerate or has an aderse response to PT and it alsorecommends that practitioners should use their clinical

8udgment in switching patients from one drug to another,


5/15

Journal of Thyroid Research

Table 2) Comparison of recommendations of "merican Thyroid "ssociation and 3ndocrine .ociety on the treatment of

hyperthyroidism in pregnancy,

Topic

Recommendations


PT is preferred for the treatment of

"ntithyroid @"T$A

hyperthyroidism in the first trimester! andpatients on # should be switched toPT if

treatmentpregnancy is confirmed in the firsttrimester,Dollowing the first trimester! considerationshould

be gien to switching to #,

Propylthiouracil @PTA! if aailable! is

recommended as the first:line drug for treatment ofhyperthyroidism during the first trimester of

pregnancy because of the possible association of

methima5ole @#A with specific congenital

abnormalities that occur during first trimester

organogenesis! and # may also be prescribed if

PT is not aailable or if a patient cannot tolerate

or has an aderse response to PT, Practitioners

should use their clinical 8udgment in choosing the

"T$ therapy! including the potential difficulties

inoled in switching patients from one drug to

another, #f switching from PT to #! thyroid

function should be assessed after 2 wee7s and

then at 2: to ':wee7 interals,

Combination of 4T'and

" combination regimen of T' and an "T$should

not be used in pregnancy! e+cept in the rare Ione

"T$

situation of fetal hyperthyroidism,

onitoring lierfunction

"lthough lier to+icity may appear abruptly! itis

Ione

reasonable to monitor lier function inpregnant

in women on PTwomen on PT eery :' wee7s and toencouragepatients to promptly report any new

symptoms,#n women being treated with "T$s inpregnancy!

onitoring of thyroid

DT' and T.H should be monitoredappro+imately

eery 2F( wee7s, The primary goal is a serumDT' .ame @TA

function

at or moderately aboe the normal reference

range,

.ubtotal thyroidectomy may be indicatedduringpregnancy as therapy for maternal >raes?disease

if @1A a patient has a seere aderse reactionto

.urgery .ame @R and TA

"T$ therapy @2A persistently high doses of"T$are reuired @oer 0 mg*d of # or '-0 mg*dofPTA or @A a patient is nonadherent to

"T$therapy and has uncontrolledhyperthyroidism,The optimal timing of surgery is in thesecond

trimester,

Combinations of regiment of T' with antithyroid drugs

hae not been recommended and an indication of


6/15

surgery has been described by both guidelines, Bnly

3ndocrine .ociety guide:line recommends lier function

tests in pregnant women on PT eery :' wee7s,

Comparison of two recommendations on fetalaspects of hyperthyroidism in pregnancy is almostsimilar @Table A! stressing the importance ofmeasurement of TR"b at 20F2' wee7s of gestation!consulation with and e+pert obstetrician! and followingup of fetal thyroid dysfunction,

Table ' compares the recommendations of bothorgani:5ations on the management of gestationalhyperthyroidism, They recommend supportie therapyand aoidance of antithyroid therapy, Loth guidelinesstate that subclinical hyperthyroidism duringpregnancy does not reuire any treatment,

)% !iscussion

>raes? disease is the most common cause of autoimmune

hyperthyroidism in pregnancy, #t has been reported in about

0,-; of pregnancies, #t may be the first manifestation of the

disease or may present as a recurrent episode in a woman

with past history of hyperthyroidism! or a pregnancy in a

women on antithyroid drugs ! to+ic adenoma! and facti:

tious hyperthyroidism, ore freuent than >raes? disease

as the cause of hyperthyroidism is the syndrome of

gestational hyperthyroidism or gestational transient

thyroto+icosis! diag:nosed in about F-; of pregnancies

and includes women with hyperemesis graidarum! multiple

pregnancies! and hydatidiform mole raes?

disease is e+acerbated during the f irst trimester of gestation


7/15

' Journal of Thyroid Research

Table ) Comparison of recommendations of "merican Thyroid "ssociation and 3ndocrine .ociety on the fetal aspects of


Topic

Recommendations


#f the patient has a past or present history of

TR"b should be measured by 22:wee7gestational

Thyroid receptorantibodies

age in mothers with @1A current >raes? disease/or

>raes? disease! a maternal serumdetermination

@2A a history of >raes? disease and treatmentwith

@TR"bAof TR"b should be obtained at 20F2'wee7s

11# or thyroidectomy before pregnancy/@A a

gestation,preious neonate with >raes? disease/ or@'A

preiously eleated TR"b

#n women with TR"b or thyroid:stimulating#geleated at least 2: to :fold the normal leel

and

Detal sureillance with serial ultrasoundsshould

in women treated with "T$! maternal freeT'!

and fetal thyroid dysfunction should bescreenedbe performed in women who hae

uncontrolled for during the fetal anatomy ultrasound doneinhyperthyroidism and*or women with high

TR"b the 1%thF22nd wee7 and repeated eery 'F(wee7sleels @greater than three times the upper limit

of

Detal .ureillance

or as clinically indicated, 3idence of fetalthyroid

normalA, " consultation with an e+perienced dysfunction could include thyroidenlargement!obstetrician or maternal:fetal medicine

specialist growth restriction! hydrops! presence ofgoiter!

is optimal, .uch monitoring may include adanced bone age! tachycardia! or cardiacfailure!ultrasound for heart rate! growth! amniotic

fluid if fetal hyperthyroidism is diagnosed andthought

olume! and fetal goiter, to endanger the pregnancy! treatment using#or PT should be gien with freuentclinical!

laboratory! and ultrasound monitoring,

Cordocentesis should be used in e+tremelyrare

circumstances and performed in anappropriate

mbilical bloodsampling

setting, #t may occasionally be of use whenfetal

.ame @RAgoiter is detected in women ta7ing "T$s tohelpdetermine whether the fetus is hyperthyroidor

hypothyroid,

"ll newborns of mothers wi th >raes?disease

3aluation of newborn .ame @TA @e+cept those with negatie TR"b and notreuiring "T$A should be ealuated by a


8/15

medicalcare proider for thyroid dysfunction andtreated

if necessary,

Table ') Comparison of recommendations of "merican Thyroid "ssociation and 3ndocrine .ociety on other aspects of


Topic

Recommendations


ost women with hyperemesis graidarum!clinicalhyperthyroidism! suppressed T.H! and eleatedfree

The appropriate management of womenwith

T' do not reuire "T$ treatment, Clinical8udgment

should be followed in women who appeargestational hyperthyroidism andhyperemesis

significantly thyroto+ic or who hae inaddition

anagement of

graidarum includes supportie therapy!serum total T alues aboe the reference rangefor

management of dehydration! andhospitali5ation pregnancy, Leta bloc7ers such as metoprolol maybe

gestational

if needed,helpful and may be used with obstetricalagreement,

hyperthyroidism "T$s are not recommended for themanagement 9omen with hyperemesis graidarum and

of gestational hyperthyroidism,diagnosed to hae >raes? hyperthyroidism @freeT'

.ame @TAaboe the reference range or total T' M1-0; oftopnormal pregnancy alue! T.H G0,01 m#*liter!andpresence of TR"bA will reuire "T$ treatment!as

clinically necessary,There is no eidence that treatment ofsubclinical

.ubclinical hypothyroidism .ame @TA

hyperthyroidism improes pregnancy outcome!and

treatment could potentially adersely affectfetal

outcome,


9/15


and decreased during the latter half of pregnancy! to

be e+ac:erbated again shortly after deliery or late in

the postpartum period concentration! and hC> thyroid stimulation withsuppression of serum T.H! may pause difficulties inthe diagnosis of maternal hyperthy:roidism raes? disease

reen! , "baloich! 3, "le+ander et al,!>uide:lines of the "merican Thyroid "ssociation for the

diagnosis and management of thyroid disease during

pregnancy and postpartum!K Thyroid! ol, 21! no, 10! pp,

10%1F112-! 2011,

[11] 4, $e >root! , "baloich! 3, O, "le+ander et al,!anagement of thyroid dysfunction during pregnancy and

postpartum) an endocrine society clinical practice guideline!K

ournal of ClinicalEndocrinolo(y ' Meta)olis*! ol, E&! no, %! pp,

2-'F2-(-! 2012,

[12] O, Patil:.isodia and J, H, estman! >raeshyperthyroidism and pregnancy) a clinical update!K

Endocrine &ractice! ol, 1(! no, 1! pp, 11%F12E! 2010,

[13] J, N, 4, Tan! O, C, 4oh! >, ., H, Neo! and N, C,Chee! Transient hyperthyroidism of hyperemesis

graidarum!KAn Internationalournal of -)stetrics and

.ynaecolo(y! ol, 10E! no, (! pp, (%F(%%! 2002,

[14] I, "mino! B, Tani5awa! H, ori et al,! "ggraation


10/15

of thy:roto+icosis in early pregnancy and after deliery

in >raes? disease!K ournal of Clinical Endocrinolo(y

' Meta)olis*! ol, --! pp, 10%F112! 1E%2,

[15] J, H, 4a5arus! Thyroid disorders associated withpregnancy) etiology! diagnosis! and management!K

Treat*ents in Endo"crinolo(y! ol, '! no, 1! pp, 1F'1! 200-,


11/15

(

[16] $, >linoer! Thyroid hyperfunction duringpregnancy!K Thyroid! ol, %! no, E! pp, %-EF%('! 1EE%,

[17] 4, O, illar! $, ", 9ing! ", ., 4eung! P, P, Ooonings! , I,ontoro! and J, H, estman! 4ow birth weight and preeclamp:

sia in pregnancies complicated by hyperthyroidism!K -)stetrics

and .ynecolo(y! ol, %'! no, (! pp, E'(FE'E! 1EE',

[18] P, Papendiec7! ", Chiesa! 4, Prieto! and 4, >runeiro:Papendiec7! Thyroid disorders of neonates born to mothers

with >raes? disease!K ournal of &ediatric Endocrinolo(y and

Meta)olis*! ol, 22! no, (! pp, -'&F--! 200E,

[19] , Phoo8aroenchanachai! ., .riussadaporn! T,Peerapatdit et al,! 3ffect of maternal hyperthyroidism

during late pregnancy on the ris7 of neonatal low birth

weight!K Clinical Endocrinolo(y! ol, -'! no, ! pp, (-F&0!

2001,

[20] $, 4uton! #, 4e >ac! 3, Vuillard et al,! anagement of>raes? disease during pregnancy) the 7ey role of fetal

thyroid gland monitoring!K ournal of Clinical Endocrinolo(y

and Meta)olis*! ol, E0! no, 11! pp, (0EF(0E%! 200-,[21] I, omotani! J, Ioh! and H, Byanagi! "ntithyroid

drug therapy for >raes? disease during pregnancy)

optimal regimen for fetal thyroid status!K /ew En(land

ournal of Medicine! ol, 1-! no, 1! pp, 2'F2%! 1E%(,

[22] $, Peleg! ., Cada! ", Peleg! and , Len:"mi! Therelationship between maternal serum thyroid:stimulating

immunoglobulin and fetal and neonatal thyroto+icosis!K -)stetrics

and .ynecol"o(y! ol, EE! no, (! pp, 10'0F10'! 2002,

[23] I, Qwaeling:.oonawala! P, an Trotsenburg! andT, Vulsma! Central hypothyroidism in an infant born to

an adeuately treated mother with >raes? disease) an

effect of maternally deried thyrotrophin receptor

antibodiesK Thyroid! ol, 1E! no, (! pp, ((1F((2! 200E,[24] D, "5i5i! Treatment of post:partum thyroto+icosis!K ournal of

Endocrinolo(ical Investi(ation! ol, 2E! no, ! pp, 2''F2'&! 200(,

[25] D, "5i5i and , Hedayati! T hyroid function in breast:fed infants whose mothers ta7e high doses of

methima5ole!K ournalof Endocrinolo(ical Investi(ation!

ol, 2-! no, (! pp, 'EF'E(!2002,

[26] D, "5i5i! , Lahrainian! , 3, Ohamseh! and , Ohoshniat!#ntellectual deelopment and thyroid function in children who

were breast:fed by thyroto+ic mothers ta7ing methima5ole!K

ournal of &ediatric Endocrinolo(y and Meta)olis*! ol,1(! no,E! pp, 12EF12'! 200,

[27] D, "5i5i! Thyroid function in breast:fed infants is notaffected by methima5ole:induced maternal hypothyroidism)results of a retrospectie study!K ournal of Endocrinolo(ical

Investi(ation! ol, 2(! no, '! pp, 01F0'! 200,

[28] D, "5i5i and , Hedayati! T hyroid function in breast:fed infants whose mothers ta7e high doses of

methima5ole!K ournalof Endocrinolo(ical Investi(ation!

ol, 2-! no, (! pp, 'EF'E(!2002,



12/15

The Scientific

World JournalHindawi PublishingCorporation

http)**www,hindawi,com Volume 201'

LehaiouralIeurology

Hindawi PublishingCorporation

Volume

201'http)**www,hindawi,com

PPARR e s e a r c h

HindawiPublishing Corporation

http)**www,hindawi,com

Volu

me201

'


13/15

MED

IATO

RS

of

INFLAMMAT

ION

>astroenterology

Research andPractice


Volume 201'http)**www,hindawi,com

"#$.Research and Treatment


Volum

e201'http)**www,hindawi,com

BioMed ResearchInternational

.ubmit

your

manuscripts at

http)**www,hindawi,com


14/15


http://www.hindawi.com

Volume 2!"


15/15

Journal of

Bbesity

.tem

Cells

3idence:Lased

Journal of

Complementaryand Journal of

Bphthalmology#nternational

"lternatieedicine

Bncology


Volume 201'


Volume 201'


Volume 201'


Volume 201'


Volume201'http)**www,hindawi,com http)**www,hindawi,com http)**www,hindawi,com http)**www,hindawi,com http)**www,hindawi,com

Computationaland International Journal ofathematicalethods

Par7inson?s

$isease

Journal of Endocrinology

#$idati%e Medicineand

in edicine

#mmunologyResearch

Cellular

&onge%it'


Volume201'


Volume201'


Volume201' Hindawi PublishingCorporation

Volume201

Hindawi Publishing Corporation

http)**www,hindawi,com http)**www,hindawi,com http)**www,hindawi,com http)**www,hindawi,com Volume 201'

http!""www#hindawi#com

Documents

Jurnal Anin Word