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in Pregnancy.
Early diagnosis and good management of maternal thyroid dysfunction is essential to ensure minimal adverse
effects on fetal development. The following are suggestions for the use of thyroid function tests in Primary Care
and are derived from the UK guidelines, modified to take into account local practice.
FT4 pmol/L
FT3 pmol/L
TSH mU/L
First trimester
1018
3.4-6.6
<0.01 3.4
Second Trimester
9-16
3.2- 6.2
1.3-3.3
Third Trimester
8-14
3.2-5.6
1.2-3.5
1. The Endocrinologist and Obstetrician should be informed of any patient with detectable TRAbs.
2. Women with detectable TRAb should be advised to deliver in hospital.
3. Further TRAbs measurements and ultrasound scans will probably be required, the frequency of which
will be advised by the Endocrinologist and Obstetrician
4. Paediatricians should be informed on the womans admission to labour ward.
5. Cord blood should be taken for TSH, FT4 and Total T3 at delivery and the baby should have a resting
heart rate checked and remain in hospital for at least 24 hours. Further repeat TSH, Free T4 and total T3
in the neonate should be carried out on the advice of the Paediatricians.
Many women will have stopped CBZ/PTU prior to delivery but if not, the babys TFTs should be
checked and the Paediatricians informed. If there are abnormalities the baby may need to remain in
hospital (unlikely at doses of CBZ<15mg or PTU<150mg daily.)
Many women will not require to return to their CBZ/PTU post-natal but all should be seen in the
Endocrine Clinic 8-12 weeks post partum or sooner if they have symptoms.
CBZ is safe in the breast feeding woman in doses at or below 15mg daily and PTU at or below 150mg
daily.
Dr R Hughes
Dr C Calderwood
Consultant Obstetrician
Consultant Obstetrician
Dr A D Toft
Consultant Endocrinologist
Dr G J Beckett Consultant Clinical Biochemist
Action Points
Hypothyroidism
Assess thyroid status:- Preferably prior to conception or at booking in the following situations
Known hypothyroidism
Type 1, Type 2 diabetes, Gestational Diabetes
Previous history of thyroid disorder
Family history of thyroid Disease
Features of thyroid disease.
Other autoimmune thyroid disorder
Hypothyroid patients should be offered an appointment with consultant obstetrician
Measure TRAbs in all patients with history of Graves disease (irrespective of thyroid status)
Patients with detectable TRAbs require special management. Inform Endocrinologist/Obstetrician as soon
as possible.
Patients with established hypothyroidism should have T4 dose increased by 25 micrograms as soon
as a positive pregnancy test is found. Further monitoring after 2 weeks and possible further changes in
T4 dose may be required to ensure FT4 is 16-21 pmol/L; TSH <2 mU/L as quickly as possible.
Further checks on thyroid function test should be made at least once in each trimester
If TFTs are not stable contact consultant obstetrician, as a growth scan may be required .
Cut back T4 dose to pre-pregnancy dose 2-6 weeks post-partum
Hyperthyroidism
All women with hyperthyroidism in pregnancy should be seen by a Consultant
Endocrinologist and a Consultant Obstetrician from early in pregnancy.
Home delivery is not appropriate for women with Hyperthyroidism
Measure TRAbs in all patients with Graves disease at booking (irrespective of thyroid status).
Patients with detectable TRAbs require special management, irrespective of their thyroid function test
profile. Inform Endocrinologist and Obstetrician as soon as possible.
The aim is for good control of hyperthyroidism on the minimum dose of carbimazole(CBZ) /
propylthiouracil (PTU) possible
Post-partum Thyroiditis
Post-partum patients should have thyroid function tests checked at 8 - 12 weeks if they have: Symptoms of hyperthyroidism or hypothyroidism
Goitre
History of post-partum thyroiditis or thyroid disease
Positive TPOAb
If a hyperthyroid profile is found (TSH <0.01 mU/L; FT4/FT3 raised) an endocrine opinion is warranted
to differentiate post-partum thyroiditis from other causes of hyperthyroidism such as Graves disease. A
TRAbs measurement will be helpful for this.
Hypothyroidism in Pregnancy
Pregnant
Hypothyroid
Newly diagnosed
hypothyroid in pregnancy
Start immediately on 100 micrograms T4 daily
Established treated
Hypothyroidism
Measure TSH/FT4
Before Conception (if possible)
Modify T4 RX - Aim
* FT4 16-21 pmol/L; TSH 0.5-2.0 mU/L
Measure TSH/FT4
2-6 weeks postpartum
Reduce T4 RX as required
* It is important to produce this test profile (especially a FT4 of 16-21 pmol/L) as soon as possible in the pregnancy and
preferably before conception
Hyperthyroidism in Pregnancy
Pregnant
Hyperthyroid?
Hyperthyroid?
TSH <0.1 mU/L
Endocrine Referal
For Management
If TRAbs positive
Seek Endocrine/Obstetric Opinion
ASAP
If TRAbs positive
Seek Endocrine/ Obstetric Opinion
ASAP