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NEONATE BORN TO MOTHER WITH GRAVE

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NEONATE BORN TO MOTHER WITH GRAVE'S DISEASE. Baby boy born at 24 weeks gestation, weight 559G. Mother 25year,G6 ... Exchange transfusions...to reduce TSI levels ... – PowerPoint PPT presentation

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Title: NEONATE BORN TO MOTHER WITH GRAVE


1
  • NEONATE BORN TO MOTHER WITH GRAVES DISEASE
  • Baby boy born at 24 weeks gestation, weight 559G
  • Mother 25year,G6 P4 Ab1 LC4.
  • Known case of Graves disease, with uncontrolled
    thyrotoxicosis since 1999non compliant on
    treatment (PTU/Inderal). No PNC.
  • With pre-eclampsia, abruption- severe
    decelerations-Emergency C-section.

2
NICU COURSE
  • Maternal TSI on Sept 2003 212
  • (Normal 0 - 129)
  • Resuscitated at birth Apgars 3,6 8.Ventilated
    .given curosurf and transferred to ICN on
    portable ventilator
  • On exam, baby 24 weeks gestation AGA
  • Systemic exam WNL. No evidence of
    goiter/exophthalmos. Initially had heart rates in
    160-170 but later normalized.

3
MANAGEMENT IN NICU
  • Hypoperfusion/hypotension/metabolic acidosis
    needing NS bolus x 2 and inotrope support.
  • D2-3 echo showed PDAtreated with Indomethacin
  • Head sonono IVH. Drug screen normal

4
THYROID CHEMISTRIES
Infant values Day -1 Day -7
T4,free (0.6-1.70) 1.26 0.45
TSH (0.4-5) 0.07 0.01
T3,total (70-204) 124 97
5
  • PRESENT CONDITION
  • Presently baby on IMV, being treated for evolving
    lung diseasediuretics and steroid nebulization
  • On TPN and NG feeds.

6
OBSTETRIC HISTORY
  • 7/96 40wks 9lbs NSVD Dallas
  • 9/97 40wks 7lbs NSVD Mexico
  • 11/01 31wks 2lbs NSVD Thomason
  • 9/03 36wks 3lbs NSVD Thomason
  • 12/00 15wks miscarriage
  • 7/04 24wks 1.2lbs CS Thomason

7
BABY WITH NEONATAL THYROTOXICOSIS
  • Baby No.3 was born at Thomason in 2001
  • Preterm 31 wks SGA , BW1130 G
  • No prenatal-care. Presented 1 hour prior to
    delivery.
  • Had fetal bradycardia/abruptio.
  • Ventilated

8
CLINICAL FEATURES/COURSE
  • IUGR. Microcephaly, Bone age noted to be
    advanced.
  • Had persistent tachycardia
  • Baby had fluctuating levels of T4 and T3.
  • Treated with Lugols iodine, Inderal and PTU

9
THYROID CHEMISTRY
2001 Day 1 Day 10 Day 14
T4 0.7 gt6 2.6
TSH lt 0.1 lt0.1 lt0.1
T3 264 570 81
10
COURSE AFTER DISCHARGE
  • Discharged at 2 m with T4 0.6 and T3 69.
    Stopped meds prior to discharge.
  • Had initially weight loss which later improved.
  • At 2 m age had seizures. F/Up thyroid tests were
    normal.
  • Head scan/MRI July 2004 showed non communicating
    hydrocephalus

11
THYROTOXICOSIS IN NEONATE
  • Typically a transient hyperthyroidism
  • 1 in 70 Graves affected pregnancies.
  • Mortality up to 25
  • Etiology
  • Placental transfer Thyroid-stimulating
    immunoglobulins. Maternal antibodies wane over
    2-3 months

12
MATERNAL TBII
  • TSH binding inhibiting immunoglobulin
  • Levels gt 70 predictive neonatal
    thyrotoxicosis
  • Role of stimulatory and inhibitory
    immunoglobulins
  • Duration of disease depends on concentration,
    degradation rate and presence or absence of
    inhibitory Ab

13
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14
BABIES AT RISK
  • Raised level of TBII in pregnancy
  • TBII not assessed
  • Thyotoxicosis in 3rd trimester
  • Thionamide required in 3rd trimester
  • Family H/O TSH receptor mutation
  • Evidence of fetal thyrotoxicosis

15
POINTS TO CONSIDER
  • Mother with Graves disease may not have
    thyrotoxicosis and may be euthyroid or
    hypothyroid.
  • Exposure to anti-thyroid drugs in-utero may delay
    symptoms
  • Newborn Screening with T4-radioimmune assay, can
    detect raised levels of T4
  • Positive assay for Thyroid stimulating
    immunoglobulins.confirmatory
  • Consider narcotic withdrawal

16
CLINICAL FEATURES OF NEONATAL THYROTOXICOSIS
  • Hyperirritability
  • Tachycardia
  • Goiter
  • Exophthalmos
  • LBW and weight loss
  • CHF
  • Craniosynostosis/ advanced bone
    age/microcephalypsychomotor retardation
  • Jaundice/thrombocytopenia

17
APPROACH TO BABY OF MOTHER WITH GRAVES DISEASE
18
  • TREATMENT
  • Should biochemical abnormality in absence of
    symptoms be treated?
  • Thionamides block hormone synthesis
  • PTU 5-10mg/kg/d in 3 divided doses
  • Carbimazole 0.5-1.5mg/kg/d
  • Lugols iodine (8mg/drop) 1-3 drops/D
  • Iopanoic acid/sodium ipodate, Propanolol,
    Prednisolonein refractory cases

19
TREATMENT (CONTINUED)
  • Exchange transfusionsto reduce TSI levels
  • Baby on treatment for thyrotoxicosis is reviewed
    weekly until stable, then every 2 weeks and drug
    dose reduced.
  • Usually treated for 4-8 weeks.
  • Thyrotoxicosis secondary to mutations of TSH
    receptor require ablative treatment with surgery.

20
SUMMARY
  • Possibility of fetal thyrotoxicosis must be kept
    in all mothers with a history of Graves disease
    regardless of thyroid status/treatment.
  • Thyroid stimulating immunoglobulins (TSI)
    persist even after thyroid surgery/radioablation
    in mother.
  • Neonatal thyrotoxicosis secondary to TSIs is a
    transient disorder, limited by clearance of
    maternal antibodies

21
SUMMARY (CONTINUED)
  • In neonates signs of thyrotoxicosis may be
    delayed due to effect of maternal anti-thyroid
    drugs or effect of blocking antibodies. Cases
    reported as late as 45 days.
  • TSH binding inhibitor Ig levels from mother and
    from neonate correlate well with neonatal
    thyrotoxicosis.

22
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