Hypothyroidism During Pregnancy

(Thyroid Deficiency During Pregnancy)

Introduction

Thyroid disease is particularly common in women of child-bearing age. As a result, it is no surprise that thyroid disease may complicate the course of pregnancy. It is
estimated that 2.5% of all pregnant women have some degree of hypothyroidism. The frequency varies among different populations and different countries. While
pregnancy itself is a natural state, and by no means should be considered a "disease," thyroid disorders during pregnancy may affect both mother and baby. This
article focuses specifically on hypothyroidism and pregnancy. After a general description of normal and abnormal thyroid function, recent data on long term
consequences in children of mothers who had hypothyroidism during pregnancy will be reviewed.

What is the thyroid gland?

The thyroid is a gland weighing about 15 grams (about half an ounce) that is located in the front of the neck just below the Adam's apple (cricoid cartilage). The thyroid
gland is responsible for the production of the body's thyroid hormone. The thyroid responds to hormonal signals from the brain to maintain a constant level of thyroid
hormone. The hormone signals are sent by specialized areas of the brain (hypothalamus and pituitary), eventually sending thyroid stimulating hormone (TSH) that
promotes thyroid hormone production by the thyroid gland.
What happens with thyroid disease?

Disease of the thyroid gland is extremely common. In some conditions, the thyroid may produce too much hormone. In other conditions, the thyroid may be damaged or
destroyed and little, if any, thyroid hormone is produced. The main thyroid hormone is called thyroxine, or T4.

Symptoms vary depending on whether there is too much or too little T4 in the blood. With an excess of T4 (hyperthyroidism), patients complain of feeling restless,
emotionally hyper, and hot and sweaty. They may have tremors, trouble concentrating, and weight loss. Frequent bowel movements and diarrhea are common.

If T4 levels are low (hypothyroidism) as a result of decreased production by the thyroid gland, patients often notice fatigue, lethargy, and weight gain. Constipation is
common and many patients with hypothyroidism report feeling excessively cold.

Hypothyroidism During Pregnancy (cont.)

 Stages of Pregnancy Slideshow Pictures

Early Pregnancy Symptoms

Take the Quiz: Early Pregnancy Symptoms

In this Article
• Introduction
• What is the thyroid gland?
• What happens with thyroid disease?
• How is hypothyroidism treated during pregnancy?
• What are the consequences of hypothyroidism during pregnancy?
• How early does the mother's thyroid hormone affect the unborn baby?
• What can be done to avoid the consequences of hypothyroidism in pregnancy?
• Hypothyroidism During Pregnancy At A Glance
• Hypothyroidism During Pregnancy Glossary
• Hypothyroidism During Pregnancy Index
• Find a local Obstetrician-Gynecologist in your town

How is hypothyroidism treated during pregnancy?

The treatment of hypothyroidism during pregnancy is relatively straightforward in most cases. A synthetic form of T4 is given to replace the missing hormone. The dose
of the medication is regularly adjusted to maintain a steady blood level of thyroid hormone within the normal range. Therefore, it is routine practice to monitor the blood
level of the thyroid stimulating hormone (TSH) while monitoring hypothyroidism during pregnancy. In many respects, the treatment of hypothyroidism in pregnancy is
similar to that in nonpregnant women. For more information, please read the article onHypothyroidism.

What are the consequences of hypothyroidism during pregnancy?

For years, physicians have known of a link between mothers with hypothyroidism during pregnancy and developmental delay in their children after birth. This was
particularly seen in mothers who came from iodine deficient areas of the country (iodine is necessary to produce thyroid hormone and is now a common component of
the salt in our foods) and was also observed in mothers with autoimmune thyroid disease, such as Hashimoto's thyroiditis.
There is a relationship between thyroid levels in the mother and brain development of her child. A large study reported in 1999 found that undetected or inadequately
treated hypothyroidism in mothers was associated with IQ changes in the infants of these women. The average IQ scores were about 4 points lower in the children of
hypothyroid mothers than in children of normal mothers. Larger IQ deficits were seen in the children of mothers who had more severe hypothyroidism. These children
had an average IQ 7 points lower than normal. In addition, almost 20% of these children had IQ scores of less than 85 compared to 5% of the children of normal
mothers. The children of hypothyroid mothers were also more likely to have difficulty in school or have repeated grades.

This study demonstrates that uncontrolled hypothyroidism in pregnant women can have long-term effects on the children of these mothers. Also, the effects occur even if
the hypothyroidism is mild and the woman does not exhibit any symptoms. However, the more significant the hypothyroidism, the greater the likelihood of
developmental problems.

Hypothyroidism During Pregnancy (cont.)

Stages of Pregnancy Slideshow Pictures

Early Pregnancy Symptoms

Take the Quiz: Early Pregnancy Symptoms

In this Article
• Introduction
• What is the thyroid gland?
• What happens with thyroid disease?
• How is hypothyroidism treated during pregnancy?
• What are the consequences of hypothyroidism during pregnancy?
• How early does the mother's thyroid hormone affect the unborn baby?
• What can be done to avoid the consequences of hypothyroidism in pregnancy?
• Hypothyroidism During Pregnancy At A Glance
• Hypothyroidism During Pregnancy Glossary
• Hypothyroidism During Pregnancy Index
• Find a local Obstetrician-Gynecologist in your town

How early does the mother's thyroid hormone affect the unborn baby?
Before birth a baby is entirely dependent on the mother for thyroid hormone until the baby's own thyroid gland can start to function. This usually does not occur until
about 12 weeks of gestation (the end of the first trimester of pregnancy). Thus, hypothyroidism of the mother may play a role early on, before many women realize they
are pregnant! In fact, the babies of mothers who were hypothyroid in the first part of pregnancy, then adequately treated, exhibited slower motor development than the
babies of normal mothers. However, during the later part of pregnancy, hypothyroidism in the mother can also have adverse effects on the baby, as pointed out by the
research described above. These children are more likely to have intellectual impairment.

What can be done to avoid the consequences of hypothyroidism in pregnancy?

A number of medical associations and organizations have made recommendations on screening for thyroid disease. Some of the recommendations are listed below:

• All women who are planning a pregnancy should be considered for screening of thyroid disease.

• All pregnant women with a goiter (enlarged thyroid), high blood levels of thyroid antibodies, a family history of thyroid disease, or symptoms of hypothyroidism
should be tested for hypothyroidism.

• In women who are borderline, or sub-clinical, hypothyroid (for example, not in the laboratory range for true hypothyroidism, but within the low normal range) and
who also have positive antibodies (which may indicate an ongoing autoimmune thyroid destruction), therapy with low dose thyroid hormone at the onset of pregnancy
may be beneficial.

• There is some evidence that the antibodies that may contribute to hypothyroidism can play a role in pregnancy. Data suggest that selenium
supplementation may be of benefit in women with high antibody levels at the time of preconception. This should be reviewed with your doctor.

• Women who are on thyroid hormone replacement before pregnancy should also be tested to make certain that their levels are appropriate. During pregnancy,
the medication dose required may increase by up to 50%. Increases may be required as early as in the first trimester.

• Dosing is dynamic during pregnancy and should be closely monitored by regular blood testing. As the pregnancy progresses, many women require higher doses
of hormone replacement.

• The dosage of thyroid hormone replacement during and after pregnancy should be carefully monitored using the blood thyroid stimulating hormone (TSH) value.
The laboratory ranges for normal TSH are quite wide. Most clinicians like to keep women who are pregnant and on replacement in the "hyper" end of the normal range.
This usually equates to a TSH of <2.0. Many clinicians prefer TSH in the <1.0 range.

• In women with hypothyroidism before conception, most go back to their pre-pregnancy dose of thyroid hormone within a few weeks to months.
It must be stressed that these are only guidelines. The management of each woman's situation is considered individually after consultation with her physician. The
benefits of treatment extend not only to pregnant women with hypothyroidism, but also to their children.

Hypothyroidism During Pregnancy At A Glance

• Hypothyroidism, wherein the thyroid gland produces an inadequate amount of thyroid hormone, is a common disorder particularly in women of childbearing age.

• Hypothyroidism of the mother during pregnancy may result in developmental delay in the child.

• Treatment of hypothyroidism requires thyroid hormone medication.

• There may be indications to start thyroid hormone therapy in women who are borderline in thyroid function and who are either pregnant or desiring pregnancy.

• The treatment goal of hypothyroidism in pregnancy is to maintain a thyroid hormone level within high normal range.

• Pregnant women who are on thyroid hormone should have blood testing frequently during pregnancy as requirements may change.

Hyperthyroidism and Graves' Disease During Pregnancy

Signs, Symptoms, and Risks
By Mary Shomon, About.com Guide
Updated March 19, 2009
About.com Health's Disease and Condition content is reviewed by our Medical Review Board
See More About:
• hyperemesis gravidarum
• thyroid disease and pregnancy
• hyperthyroidism in pregnancy
• hyperthyroidism symptoms
Hyperthyroidism can be serious during pregnancy.
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Hyperthyroidism -- an excess of thyroid hormone -- can occur during pregnancy. Because of potential risks to both mother and baby, it's a condition
that needs to be taken seriously, and properly treated.

How Does Graves' Disease Affect a Pregnant Woman and Her Baby?

The autoimmune condition Graves' disease is the most common cause of hyperthyroidism during pregnancy. Hyperthyroidism due to Graves'
disease in pregnancy is not common: It's estimated that some 1 in 500 women develop it during pregnancy. It can be serious, however. Typically,
this form of hyperthyroidism persists more than several weeks and beyond the first trimester. Graves' disease typically becomes less severe as the
pregnancy progresses.
What are the Risks of Graves' Hyperthyroidism to Mother and Baby?

Uncontrolled or untreated hyperthyroidism, especially during the second half of pregnancy, can lead to a variety of serious consequences for both
mother and baby. When hyperthyroidism is not properly treated during pregnancy, a pregnant woman is at higher risk of a number of
complications, including heart problems, high blood pressure, extreme morning sickness, preeclampsia, congestive heart failure, and even a life-
threatening condition known as thyroid storm, where heart rate and blood pressure become uncontrollably high. Thyroid storm can be triggered by
labor and delivery in a woman with untreated hyperthyroidism.

The risk to the baby is also significant, as untreated hyperthyroidism in a mother can cause:

• Miscarriage
• Intrauterine growth retardation
• Prematurity
• Low birth weight
• Stillbirth
• Hyperthyroidism in the fetus or newborn

What Other Forms of Hyperthyroidism Can Occur During Pregnancy?

A hormone that develops during pregnancy --human chorionic gonadotropin (hCG) -- rises soon after fertilization, peaks at 10 to 12 weeks of
gestation, and then declines. HCG can weakly stimulate the thyroid, resulting in a milder, shorter-term form of hyperthyroidism during pregnancy.

This transient subclinical hyperthyroidism is also known as gestational transient thyrotoxicosis -- sometimes abbreviated as GTT. GTT usually
resolves during the first trimester of pregnancy, and usually does not involve treatment.

The rise of HCG is also linked to a condition known as transient hyperthyroidism of hyperemesis gravidarum, which involves hyperthyroidism,
nausea, vomiting, and loss of 5% percent or more of body weight during early pregnancy.

What are the Signs and Symptoms of Hyperthyroidism in Pregnancy?

The symptoms of hyperthyroidism in pregnancy may be hard to identify, because they are similar to those of pregnancy itself. Fatigue, anxiety,
insomnia -- all common symptoms of pregnancy -- are also symptoms of hyperthyroidism.

Neck enlargement (goiter) is seen in almost all pregnant women with Graves' disease and hyperthyroidism, as the gland usually is enlarge to two to
four times its normal size.
Other symptoms of hyperthyroidism in pregnancy include:

• Failure to gain weight during pregnancy, or weight loss, despite increased or normal appetite
• Pulse rate over 100, known as "tachycardia"
• Heart palpitations
• Irregular heart rates (arrhythmias) including atrial fibrillation
• Higher blood pressure
• Difficulty concentrating
• Excessive nausea and vomiting
• Nervousness, anxiety, restlessness, fidgety behavior
• Depression, moodiness
• Tremor
• Intolerance to heat, excessive sweating
• Diarrhea
• Arm and leg muscle pain or weakness
• Difficulty climbing stairs
• Vision problems: i.e., stare or protrusion of the eyes, blurred vision, double vision, etc. -- also known as ophthalmopathy
• High heart rate in the baby, typically a heart rate of more than 160 beats per minute
• Fatigue, exhaustion
Since women can experience a variety of symptoms during pregnancy, it may be difficult to identify hyperthyroidism symptoms compared to
normal pregnancy symptoms. Two key symptoms should be taken seriously, however: Both a rapid pulse and unexplained weight loss are not
typical in pregnancy, and likely point to hyperthyroidism.

Physical symptoms are often the first sign of hyperthyroidism in pregnancy. This is not an easy way to diagnose the condition, however, because
some common symptoms of hyperthyroidism -- for example anxiety, fatigue, heat intolerance, and heart palpitations -- may be similar to symptoms
of normal pregnancy.
But a thorough clinical thyroid exam can help pinpoint certain symptoms that are highly suggestive of hyperthyroidism, including goiter (an
enlarged thyroid), eye symptoms like a stare, or bulging of the eyeball (known as ophthalmopathy), and weight loss.

The diagnosis of hyperthyroidism in pregnant women should be based primarily on a Thyroid Stimulating Hormone (TSH) blood test value of less
than 0.01 mU/L and also a high free T4 value. If TSH is low, and Free T4 is normal or slightly elevated, Free T3 may also be measured, as high Free
T3 can help confirm a diagnosis of hyperthyroidism.

Because hormonal changes in pregnancy can cause hyperthyroid blood tests -- without any clinical symptoms of hyperthyroidism -- borderline
hyperthyroid TSH levels in pregnancy should not automatically lead to a diagnosis of hyperthyroidism. They may in fact be indicative of other forms
of hyperthyroidism in pregnancy -- transient gestational transient thyrotoxicosis, and transient hyperthyroidism of hyperemesis gravidarum -- that
were discussed in the article on signs and symptoms of hyperthyroidism in pregnancy.
Once actual clinical hyperthyroidism is established, determining the cause in a pregnant woman can be difficult because during pregnancy, doctors
don't use the typical diagnostic tests for Graves' disease such as the radioactive iodine uptake test, or nuclear scanning, because of the serious
harm these tests potentially pose to a developing baby.

But Graves' disease is the most common cause of an overactive thyroid in a pregnant woman, so to confirm diagnosis, thyrotropin receptor-
stimulating antibodies (TSHR-SAb) -- also sometimes referred to as thyroid stimulating immunoglobulins -- should be measured. These antibodies
are positive in most patients with Graves' disease, so this blood test can be used to diagnose Graves' disease during pregnancy

Treating Hyperthyroidism and Graves' Disease During Pregnancy

If you are pregnant and have mild hyperthyroidism, you likely will not be prescribed a specific thyroid treatment to follow during your 9 months.
However, if your hyperthyroidism is moderate to severe, treatment is required to protect your health as well as the health of your unborn baby.

A common hyperthyroidism treatment choice in the United States -- radioiodine (RAI) therapy -- is not used at any time in pregnant women,
because of the risk of destroying the baby's thyroid gland with radioactive material. This leaves drugs and surgery as the treatment options for
women who are hyperthyroid during pregnancy, and drugs are likely where your physician will begin when treating you.

Antithyroid Drugs: A First Choice for Pregnant Women

The key antithyroid drugs -- also known as thionamides -- include propylthiouracil (PTU), methimazole (MMI) and carbimazole. Though effective in
pregnant women, babies of mothers taking antithyroid drugs have a high risk of goiter, hypothyroidism or even cretinism. Why are they
recommended then? The risk of hyperthyroidism in a mother and fetus itself is greater than the risk of taking a low dose of the medication.

To explain the specifics of an antithyroid drug dosing in a pregnant women, I consulted withUpToDate, the trusted online medical reference
resource used by many physicians. According to UpToDate:

"For women with moderate to severe hyperthyroidism complicating pregnancy, we suggest a thionamide as our first choice of treatment. We
suggest using PTU rather than methimazole.

"The PTU dose should be adjusted monthly to maintain serum T4 concentrations in the high-normal range and serum TSH concentrations in the low-
normal range. We typically use a dose of PTU 50 mg twice daily or less; higher doses (e.g., doses in excess of 200 mg/day) can result in fetal goiter
and hypothyroidism.

"To minimize the risk of hypothyroidism in the fetus, we give the lowest dose of thionamide necessary to control thyroid function. In patients with
severe hyperthyroidism, full initial doses may be required (PTU 100 mg three times per day) or MMI (10 to -30 mg daily) in order to normalize
thyroid function. Our goal is to maintain persistent but minimal mild hyperthyroidism in the mother in an attempt to prevent fetal hypothyroidism.
"It is possible to discontinue the thionamide during the third trimester in one-third of women; the amelioration of hyperthyroidism as pregnancy
progresses may be due to a fall in serum TSH receptor-stimulating antibody concentrations and a rise in TSH receptor-blocking antibodies."

Does Each Thionamide Carry Different Levels of Risk?

The antithyroid drug methimazole (sometimes known by the brand name Tapazole) more easily crosses the placenta, meaning that there is a
slightly greater risk to an unborn baby of side effects. In addition, rare instances of a condition called aplasia cutis, which causes scalp defects, have
been seen in babies born to mothers who took methimazole during pregnancy. These scalp defects have not been seen in babies of mothers who
took PTU.

PTU is also the more water-soluble of the antithyroid drugs, and therefore doesn't transfer from mother to baby as efficiently as the other drugs –
the reason it’s recommended for use during pregnancy. In areas where PTU is not available, or when a woman is allergic to PTU, methimazole and
carbimazole are used during pregnancy, and no particular problems have been associated with careful use of these drugs.

I’m Concerned for My Baby. How Will My Doctor Decide on My Dose?

Again, though these drugs do carry risk in pregnant women, your doctor’s mission is to use them as minimally as possible to control the
hyperthyroidism and reduce the risks it poses to you and your baby on its own.

Typically, doctors recommend the smallest possible dose that will control the condition. The goal is to keep your TSH level in the normal range, or
borderline hyperthyroid, using as little of the antithyroid drug as possible.

Since all antithyroid drugs do cross the placenta, however, it’s especially important to follow prescription instructions to the letter.

If I’m Taking One of These Drugs, What Do I Need to Do While I’m Pregnant to Make Sure Everything’s OK?

Keeping up with recommended check-ups is extremely important. The goal is to maintain good control of your thyroid levels throughout the
pregnancy, so thyroid tests – including Free T4 – should be performed every 2 weeks at the start of treatment. Once levels normalize, testing
should continue every 2 to 4 weeks. This regular monitoring is not just to ensure that thyroid levels are stabilized, but to determine if the
antithyroid drug dosage needs to be reduced -- or even eliminated entirely. Most doctors will not discontinue antithyroid drug treatment until after
the thirty-second week of pregnancy; because before that time, the risk of relapse is high.

In addition to thyroid testing, at healthcare visits, your pulse will be monitored, along with weight gain and thyroid size. Pulse should remain below
100 beats per minute. You should strive to keep your weight gain within the normal ranges for pregnancy, so speak with your doctor about proper
nutrition and what types of physical activity are appropriate for your current condition.
Fetal growth and pulse should also be monitored monthly.

Why Can’t I Just Opt for Surgery in the First Place?

Surgical removal of the thyroid -- known as thyroidectomy -- may be necessary if you are pregnant and cannot tolerate antithyroid drugs, or if your
hyperthyroidism is not being sufficiently managed with these medications. However, it’s only recommended as a first choice treatment option in
women with specific circumstances.

If thyroid surgery is recommended for a pregnant woman, it may be because she:

• has an allergy to antithyroid drugs

• experienced side effects from antithyroid drugs
• needs extremely high doses of antithyroid drugs to manage her condition (i.e. more than 300 mg of PTU)
• her condition could not be managed by antithyroid drugs
• her fetus is showing evidence of hypothyroidism due to the antithyroid drugs (typically, a slow fetal heart rate, slowed bone development)
Surgery is typically performed in the second trimester (when the greatest risk of miscarriage has past.) Surgery is not typically performed in the
third trimester, as this may pose a risk of pre-term labor and delivery.

After surgery, thyroid levels are still monitored carefully; antibody levels are also monitored during the later stages of pregnancy.

My Doctor Recommended I Take a Beta Blocker, Too. Should I Be Concerned?

Beta blockers may help with significant heart-related symptoms related to moderate-to-severe hyperthyroidism. Beta blockers are not considered
safe for use during pregnancy for more than a short period of time. Longer-term use during pregnancy is associated with various dangers to your
unborn baby. Typically, doctors recommend that women use a beta blocker no more than two weeks, and they are most often given during the time
when a woman is waiting for antithyroid drugs to take effect. They should also not be given toward the end of pregnancy, however, because they
can be associated with growth problems, breathing difficulties, and slow heart rate in newborns.
Want to learn more? See UpToDate's topic, "Diagnosis and treatment of hyperthyroidism during pregnancy," for additional in-depth, current and
unbiased medical information on name the condition/disease of relevance, including expert physician recommendations.

Source:

Ross, Douglas. "Diagnosis and treatment of hyperthyroidism during pregnancy." UpToDate. Accessed: February 2009.