Hypothyroidism%20During%20Pregnancy - PowerPoint PPT Presentation

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Hypothyroidism%20During%20Pregnancy

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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 – PowerPoint PPT presentation

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Title: Hypothyroidism%20During%20Pregnancy


1
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

2
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

3
PathophysiologyReview 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)

4
Pathophysiologypregnancy 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)

5
Impact on the fetus
  • Fetus dependent on maternal T4 in 1st 10-12 weeks
  • Thyroid hormones critical for brain development
  • Contribute to maturation of retina, cochlea,
    lung, bones, thermogenesis
  • Hypothyroidism can lead to cretinism - mental
    retardation stunted physical growth

6
Clinical Manifestations
  • Widely separated sutures
  • Large fontanelles
  • Short arms/legs
  • Umbilical hernia
  • Macroglossia
  • Mental retardation
  • Hypotonia
  • Jaundice
  • Poor feeding
  • (National Library of Medicine, 2014)

7
Diagnostic Evaluation of Newborn
8
Treatment Options Maternal Hypothyroidism
Diagnosed Before Pregnancy
  • Levothyroxine adjustment for TSH lt 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).

9
Treatment OptionsMaternal Hypothyroidism
Diagnosed During Pregnancy
  • Identify high risk women by medical history
    exam
  • Goal Normalize thyroid function ASAP
  • Start Levothyroxine titrate dose for TSH lt 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).

10
Management of the Neonate
  • Thyroid hormone replacement started within 2
    weeks of age can normalize cognitive development
  • Serum T4 and TSH to confirm diagnosis
  • Levothyroxine 10-15 mcg/kg
  • Goal normalize TSH, keep T4 in upper end of age
    appropriate range
  • Thyroid scan/ultrasound to identify functional
    tissue
  • Referral to pediatric endocrinologist
  • Parent education (med administration, compliance)

11
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)

12
Implications for Family
  • Economic
  • Social
  • Follow up care/appointments conflict with
    parents work
  • Financial cost of healthcare
  • May need public assistance
  • Increased time demands on parents
  • Difficult to find childcare for disabled/sick
    child
  • Decreased participation in social events
  • (Reichman, Corman, Noonan, 2008)

13
Implications for FamilyEmotional
  • 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)

14
Summary
  • Thyroid hormones are important for the bodys
    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.

15
References
  • American 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.o
    rg/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
    hypothyroidism20pregnancy20guidelines
  • 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. doi10.1007/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.
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