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Thyrotoxicosis in Pregnancy

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Thyroid Disease and Reproduction

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Abstract

Thyroid disease is a common endocrinopathy seen in pregnancy with hypothyroidism being the most common followed by thyrotoxicosis. The most common etiology of thyrotoxicosis in pregnant women is Graves’ disease, followed by transient thyrotoxicosis of pregnancy. Laboratory testing, history, and physical exam can delineate the differential diagnosis in most cases. Imaging is often not required. Untreated thyrotoxicosis can lead to adverse outcomes for both the mother and fetus, and patients can present on a wide spectrum of severity of thyrotoxicosis spanning from mild subclinical hyperthyroidism to thyroid storm with multi-organ failure. Treatment of hyperthyroidism, if warranted, is typically pharmacological therapy with antithyroidals called thionamides. Frequent monitoring is crucial for successful therapy to ensure the most optimal outcomes. The following chapter is a review of these concepts covering diagnosis, maternal and fetal risks of thyrotoxicosis, treatment, and follow-up.

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References

  1. Korelitz JJ, McNally DL, Masters MN, Li SX, Xu Y, Rivkees SA. Prevalence of thyrotoxicosis, antithyroid medication use, and complications among pregnant women in the United States. Thyroid. 2013;23(6):758–65.

    Article  CAS  Google Scholar 

  2. Weetman AP. Graves’ disease. N Engl J Med. 2000;343(17):1236–48.

    Article  CAS  Google Scholar 

  3. Carle A, Pedersen IB, Knudsen N, Perrild H, Ovesen L, Rasmussen LB, Laurberg P. Epidemiology of subtypes of hyperthyroidism in Denmark: a population-based study. Eur J Endocrinol. 2011;164(5):801–9.

    Article  CAS  Google Scholar 

  4. Abraham-Nordling M, Byström K, Törring O, Lantz M, Berg G, Calissendorff J, et al. Incidence of hyperthyroidism in Sweden. Eur J Endocrinol. 2011;165(6):899–905.

    Article  CAS  Google Scholar 

  5. Laurberg P, Cerqueira C, Ovesen L, Rasmussen LB, Perrild H, Andersen S, et al. Iodine intake as a determinant of thyroid disorders in populations. Best Pract Res Clin Endocrinol Metab. 2010;24(1):13–27.

    Article  CAS  Google Scholar 

  6. Andersen SL, Olsen J, Laurberg P. Maternal thyroid disease in the Danish National Birth Cohort: prevalence and risk factors. Eur J Endocrinol. 2016;174(2):203–12.

    Article  CAS  Google Scholar 

  7. Andersen SL, Olsen J, Carlé A, Laurberg P. Hyperthyroidism incidence fluctuates widely in and around pregnancy and is at variance with some other autoimmune diseases: a Danish population-based study. J Clin Endocrinol Metab. 2015;100(3):1164–71.

    Article  CAS  Google Scholar 

  8. Cooper DS, Laurberg P. Hyperthyroidism in pregnancy. Lancet Diabetes Endocrinol. 2013;1(3):238–49.

    Article  CAS  Google Scholar 

  9. Forfar JC, Muir AL, Sawers SA, Toft AD. Abnormal left ventricular function in hyperthyroidism: evidence for a possible reversible cardiomyopathy. N Engl J Med. 1982;307(19):1165–70.

    Article  CAS  Google Scholar 

  10. Klein I, Ojamaa K. Thyroid hormone and the cardiovascular system. N Engl J Med. 2001;344(7):501–9.

    Article  CAS  Google Scholar 

  11. Kriplani A, Buckshee K, Bhargava VL, Takkar D, Ammini AC. Maternal and perinatal outcome in thyrotoxicosis complicating pregnancy. Eur J Obstet Gynecol Reprod Biol. 1994;54(3):159–63.

    Article  CAS  Google Scholar 

  12. Sheffield JS, Cunningham FG. Thyrotoxicosis and heart failure that complicate pregnancy. Am J Obstet Gynecol. 2004;190(1):211–7.

    Article  Google Scholar 

  13. Millar LK, Wing DA, Leung AS, Koonings PP, Montoro MN, Mestman JH. Low birth weight and preeclampsia in pregnancies complicated by hyperthyroidism. Obstet Gynecol. 1994;84(6):946–9.

    CAS  PubMed  Google Scholar 

  14. Männistö T, Mendola P, Grewal J, Xie Y, Chen Z, Laughon SK. Thyroid diseases and adverse pregnancy outcomes in a contemporary US cohort. J Clin Endocrinol Metabol. 2013;98(7):2725–33.

    Article  Google Scholar 

  15. van der Kaay DC, Wasserman JD, Palmert MR. Management of neonates born to mothers with Graves’ disease. Pediatrics. 2016;137(4):1–14. https://doi.org/10.1542/peds.2015-1878 originally published online March 15, 2016.

    Article  Google Scholar 

  16. Aggarawal N, Suri V, Singla R, Chopra S, Sikka P, Shah VN, Bhansali A. Pregnancy outcome in hyperthyroidism: a case control study. Gynecol Obstet Investig. 2014;77(2):94–9.

    Article  Google Scholar 

  17. Alexander EK, Pearce EN, Brent GA, Brown RS, Chen H, Dosiou C, et al. 2017 guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and the postpartum. Thyroid. 2017;27(3):315–89.

    Article  Google Scholar 

  18. Pakkila F, Männistö T, Hartikainen AL, Ruokonen A, Surcel HM, Bloigu A, et al. Maternal and child’s thyroid function and child’s intellect and scholastic performance. Thyroid. 2015;25(12):1363–74.

    Article  Google Scholar 

  19. Bernal J. Thyroid hormones and brain development. Vitam Horm. 2005;71:95–122.

    Article  CAS  Google Scholar 

  20. Korevaar TI, Muetzel R, Medici M, Chaker L, Jaddoe VW, de Rijke YB, et al. Association of maternal thyroid function during early pregnancy with offspring IQ and brain morphology in childhood: a population-based prospective cohort study. Lancet Diabetes Endocrinol. 2016;4(1):35–43.

    Article  CAS  Google Scholar 

  21. Pitcher-Wilmott RW, Hindocha P, Wood CB. The placental transfer of IgG subclasses in human pregnancy. Clin Exp Immunol. 1980;41(2):303–8.

    CAS  PubMed  PubMed Central  Google Scholar 

  22. Polak M, Legac I, Vuillard E, Guibourdenche J, Castanet M, Luton D. Congenital hyperthyroidism: the fetus as a patient. Horm Res. 2006;65(5):235–42.

    CAS  PubMed  Google Scholar 

  23. Zimmerman D. Fetal and neonatal hyperthyroidism. Thyroid. 1999;9(7):727–33.

    Article  CAS  Google Scholar 

  24. Ogilvy-Stuart AL. Neonatal thyroid disorders. Arch Dis Child Fetal Neonatal Ed. 2002;87(3):F165–71.

    Article  CAS  Google Scholar 

  25. De Groot L, Abalovich M, Alexander EK, Amino N, Barbour L, Cobin RH, et al. Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(8):2543–65.

    Article  Google Scholar 

  26. Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, et al. 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid. 2016;26(10):1343–421.

    Article  Google Scholar 

  27. Haddow JE, Knight GJ, Palomaki GE, McClain MR, Pulkkinen AJ. The reference range and within-person variability of thyroid stimulating hormone during the first and second trimesters of pregnancy. J Med Screen. 2004;11(4):170–4.

    Article  CAS  Google Scholar 

  28. Li C, Shan Z, Mao J, Wang W, Xie X, Zhou W, et al. Assessment of thyroid function during first-trimester pregnancy: what is the rational upper limit of serum TSH during the first trimester in Chinese pregnant women? J Clin Endocrinol Metab. 2014;99(1):73–9.

    Article  CAS  Google Scholar 

  29. Lockwood CM, Grenache DG, Gronowski AM. Serum human chorionic gonadotropin concentrations greater than 400,000 IU/L are invariably associated with suppressed serum thyrotropin concentrations. Thyroid. 2009;19(8):863–8.

    Article  CAS  Google Scholar 

  30. Glinoer D. The regulation of thyroid function in pregnancy: pathways of endocrine adaptation from physiology to pathology. Endocr Rev. 1997;18(3):404–33.

    Article  CAS  Google Scholar 

  31. Moleti M, Trimarchi F, Vermiglio F. Thyroid physiology in pregnancy. Endocr Pract. 2014;20(6):589–96.

    Article  Google Scholar 

  32. Lee RH, Spencer CA, Mestman JH, Miller EA, Petrovic I, Braverman LE, Goodwin TM. Free T4 immunoassays are flawed during pregnancy. Am J Obstet Gynecol. 2009;200(3):260.e1–6.

    Article  Google Scholar 

  33. Korevaar TI, Chaker L, Medici M, de Rijke YB, Jaddoe VW, Steegers EA, et al. Maternal total T4 during the first half of pregnancy: physiologic aspects and the risk of adverse outcomes in comparison with free T4. Clin Endocrinol. 2016;85(5):757–63.

    Article  CAS  Google Scholar 

  34. Wilson KL, Casey BM, McIntire DD, Cunningham FG. Is total thyroxine better than free thyroxine during pregnancy? Am J Obstet Gynecol. 2014;211(2):132.e1–6.

    Article  CAS  Google Scholar 

  35. Lazarus J, Brown RS, Daumerie C, Hubalewska-Dydejczyk A, Negro R, Vaidya B. 2014 European thyroid association guidelines for the management of subclinical hypothyroidism in pregnancy and in children. Eur Thyroid J. 2014;3(2):76–94.

    Article  CAS  Google Scholar 

  36. Practice Bulletin No. 148: thyroid disease in pregnancy. Obstet Gynecol. 2015;125(4):996–1005.

    Google Scholar 

  37. Yoshihara A, Noh JY, Mukasa K, Suzuki M, Ohye H, Matsumoto M, et al. Serum human chorionic gonadotropin levels and thyroid hormone levels in gestational transient thyrotoxicosis: is the serum hCG level useful for differentiating between active Graves' disease and GTT? Endocr J. 2015;62(6):557–60.

    Article  CAS  Google Scholar 

  38. Tan JY, Loh KC, Yeo GS, Chee YC. Transient hyperthyroidism of hyperemesis gravidarum. BJOG. 2002;109(6):683–8.

    Article  Google Scholar 

  39. Casey BM, Dashe JS, Wells CE, McIntire DD, Leveno KJ, Cunningham FG. Subclinical hyperthyroidism and pregnancy outcomes. Obstet Gynecol. 2006;107(2 Pt 1):337–41.

    Article  Google Scholar 

  40. Bartalena L. Diagnosis and management of Graves disease: a global overview. Nat Rev Endocrinol. 2013;9(12):724–34.

    Article  CAS  Google Scholar 

  41. Goldman AM, Mestman JH. Transient non-autoimmune hyperthyroidism of early pregnancy. J Thyroid Res. 2011;2011:142413.

    Article  Google Scholar 

  42. Viard JP, Gilquin J. Graves’ disease. N Engl J Med. 2017;376(2):184–5.

    Article  Google Scholar 

  43. Bahn RS. Graves’ ophthalmopathy. N Engl J Med. 2010;362(8):726–38.

    Article  CAS  Google Scholar 

  44. Ross DS. Radioiodine therapy for hyperthyroidism. N Engl J Med. 2011;364(6):542–50.

    Article  CAS  Google Scholar 

  45. Burch HB, Cooper DS. Management of Graves disease: a review. JAMA. 2015;314(23):2544–54.

    Article  CAS  Google Scholar 

  46. Watanabe N, Narimatsu H, Noh JY, Yamaguchi T, Kobayashi K, Kami M, et al. Antithyroid drug-induced hematopoietic damage: a retrospective cohort study of agranulocytosis and pancytopenia involving 50,385 patients with Graves’ disease. J Clin Endocrinol Metab. 2012;97(1):E49–53.

    Article  CAS  Google Scholar 

  47. Tajiri J, Noguchi S. Antithyroid drug-induced agranulocytosis: special reference to normal white blood cell count agranulocytosis. Thyroid. 2004;14(6):459–62.

    Article  CAS  Google Scholar 

  48. Takata K, Kubota S, Fukata S, Kudo T, Nishihara E, Ito M, et al. Methimazole-induced agranulocytosis in patients with Graves’ disease is more frequent with an initial dose of 30 mg daily than with 15 mg daily. Thyroid. 2009;19(6):559–63.

    Article  CAS  Google Scholar 

  49. Cooper DS, Goldminz D, Levin AA, Ladenson PW, Daniels GH, Molitch ME, et al. Agranulocytosis associated with antithyroid drugs. Effects of patient age and drug dose. Ann Intern Med. 1983;98(1):26–9.

    Article  CAS  Google Scholar 

  50. Andersen SL, Olsen J, Laurberg P. Antithyroid drug side effects in the population and in pregnancy. J Clin Endocrinol Metab. 2016;101(4):1606–14.

    Article  Google Scholar 

  51. Wang MT, Lee WJ, Huang TY, Chu CL, Hsieh CH. Antithyroid drug-related hepatotoxicity in hyperthyroidism patients: a population-based cohort study. Br J Clin Pharmacol. 2014;78(3):619–29.

    Article  CAS  Google Scholar 

  52. Noh JY, Yasuda S, Sato S, Matsumoto M, Kunii Y, Noguchi Y, et al. Clinical characteristics of myeloperoxidase antineutrophil cytoplasmic antibody-associated vasculitis caused by antithyroid drugs. J Clin Endocrinol Metab. 2009;94(8):2806–11.

    Article  CAS  Google Scholar 

  53. Chen M, Gao Y, Guo XH, Zhao MH. Propylthiouracil-induced antineutrophil cytoplasmic antibody-associated vasculitis. Nat Rev Nephrol. 2012;8(8):476–83.

    Article  CAS  Google Scholar 

  54. Cooper DS. Antithyroid drugs. N Engl J Med. 2005;352(9):905–17.

    Article  CAS  Google Scholar 

  55. Andersen SL, Olsen J, Wu CS, Laurberg P. Birth defects after early pregnancy use of antithyroid drugs: a Danish nationwide study. J Clin Endocrinol Metab. 2013;98(11):4373–81.

    Article  CAS  Google Scholar 

  56. Yoshihara A, Noh J, Yamaguchi T, Ohye H, Sato S, Sekiya K, et al. Treatment of Graves' disease with antithyroid drugs in the first trimester of pregnancy and the prevalence of congenital malformation. J Clin Endocrinol Metab. 2012;97(7):2396–403.

    Article  CAS  Google Scholar 

  57. Andersen SL, Olsen J, Wu CS, Laurberg P. Severity of birth defects after propylthiouracil exposure in early pregnancy. Thyroid. 2014;24(10):1533–40.

    Article  CAS  Google Scholar 

  58. Yoshihara A, Noh JY, Watanabe N, Mukasa K, Ohye H, Suzuki M, et al. Substituting potassium iodide for methimazole as the treatment for Graves’ disease during the first trimester may reduce the incidence of congenital anomalies: a retrospective study at a single medical institution in Japan. Thyroid. 2015;25(10):1155–61.

    Article  CAS  Google Scholar 

  59. Laurberg P, Krejbjerg A, Andersen SL. Relapse following antithyroid drug therapy for Graves’ hyperthyroidism. Curr Opin Endocrinol Diabetes Obes. 2014;21(5):415–21.

    Article  CAS  Google Scholar 

  60. Momotani N, Noh JY, Ishikawa N, Ito K. Effects of propylthiouracil and methimazole on fetal thyroid status in mothers with Graves’ hyperthyroidism. J Clin Endocrinol Metab. 1997;82(11):3633–6.

    CAS  PubMed  Google Scholar 

  61. Hamburger JI. Diagnosis and management of Graves’ disease in pregnancy. Thyroid. 1992;2(3):219–24.

    Article  CAS  Google Scholar 

  62. Erbil Y, Ozluk Y, Giriş M, Salmaslioglu A, Issever H, Barbaros U, et al. Effect of lugol solution on thyroid gland blood flow and microvessel density in the patients with Graves’ disease. J Clin Endocrinol Metab. 2007;92(6):2182–9.

    Article  CAS  Google Scholar 

  63. Amino N, Tanizawa O, Mori H, Iwatani Y, Yamada T, Kurachi K, et al. Aggravation of thyrotoxicosis in early pregnancy and after delivery in Graves’ disease. J Clin Endocrinol Metab. 1982;55(1):108–12.

    Article  CAS  Google Scholar 

  64. Mandel SJ, Cooper DS. The use of antithyroid drugs in pregnancy and lactation. J Clin Endocrinol Metab. 2001;86(6):2354–9.

    Article  CAS  Google Scholar 

  65. Azizi F, Amouzegar A. Management of hyperthyroidism during pregnancy and lactation. Eur J Endocrinol. 2011;164(6):871–6.

    Article  CAS  Google Scholar 

  66. Sarlis NJ, Gourgiotis L. Thyroid emergencies. Rev Endocr Metab Disord. 2003;4(2):129–36.

    Article  Google Scholar 

  67. Angell TE, Lechner MG, Nguyen CT, Salvato VL, Nicoloff JT, LoPresti JS. Clinical features and hospital outcomes in thyroid storm: a retrospective cohort study. J Clin Endocrinol Metab. 2015;100(2):451–9.

    Article  CAS  Google Scholar 

  68. Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin N Am. 1993;22(2):263–77.

    Article  CAS  Google Scholar 

  69. Chiha M, Samarasinghe S, Kabaker AS. Thyroid storm: an updated review. J Intensive Care Med. 2015;30(3):131–40.

    Article  Google Scholar 

  70. Cooper DS, Laurberg P. Hyperthyroidism in pregnancy. Lancet Diabetes Endocrinol. 2013;1:239–49.

    Article  Google Scholar 

  71. Glinoer D, de Nayer P. Regulation of maternal thyroid during pregnancy. J Clin Endocrinol Metab. 1990;71(2):276–87.

    Article  CAS  Google Scholar 

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Authors and Affiliations

  1. Duke University Medical Center, Division of Endocrinology, Metabolism, and Nutrition, Department of Medicine, Durham, NC, USA

    Wilburn D. Bolton III & Jennifer M. Perkins

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  1. Wilburn D. Bolton III
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  2. Jennifer M. Perkins
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Correspondence to Jennifer M. Perkins .

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  1. Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA

    Jennifer L. Eaton

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Bolton, W.D., Perkins, J.M. (2019). Thyrotoxicosis in Pregnancy. In: Eaton, J. (eds) Thyroid Disease and Reproduction. Springer, Cham. https://doi.org/10.1007/978-3-319-99079-8_7

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  • DOI: https://doi.org/10.1007/978-3-319-99079-8_7

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