Non-Invasive Management of Fetal Goiter during Maternal Treatment of Hyperthyroidism in Grave’s Disease

Lembet, Arda; Eroğlu, Derya; Kinik, Sibel Tulgar; Gürakan, Berkan; Kuşçu, Esra

doi:10.1159/000085080

Cited by 18 publications

(15 citation statements)

References 17 publications

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“…Noninvasive management of maternal hyperthyroidism is essentially recommended for fetuses with goiter caused by maternal antithyroid drug. According to recent reports, some cases with fetal goiter were initially managed by dose reduction or discontinuation of the maternal PTU [12,13]. Cohen et al described that in utero ultrasonography of the fetal thyroid gland is an effective noninvasive tool for monitoring drug dosage in patients receiving antithyroid treatment for Graves' disease in pregnancy [14].…”

Section: Discussionmentioning

confidence: 99%

Successful Intrauterine Therapy for Fetal Goitrous Hypothyroidism during Late Gestation

et al. 2007

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Abstract. We experienced a case of fetal goitrous hypothyroidism in an infant delivered by a 33-year-old woman receiving 300 mg/day of propylthiouracil (PTU) for hyperthyroidism due to Graves' disease. A large fetal goiter (maximum diameter, 60 mm) was detected by magnetic resonance imaging (MRI) at 36 weeks of gestation. Initial fetal blood sampling revealed hypothyroidism with a serum thyroid-stimulating hormone (TSH) of 99 µIU/mL, free triiodothyronine (T 3 ) of 1.97 pg/mL, and free thyroxine (T 4 ) of 0.29 ng/dL. Consequently, a diagnosis of fetal goitrous hypothyroidism due to transplacental passage of maternal PTU was made. To reduce the risk of perinatal complications, 300 µg of levothyroxine sodium (L-T 4 ) was administered into the maternal amniotic fluid twice between 37 and 38 weeks of gestation. Subsequent fetal MRI showed that the size of goiter had decreased. At 38 weeks and 5 days of gestation, a 3042-g male infant was born by cesarean section. There were no severe complications at delivery, although mild tachypnea was observed and the infant's thyroid gland was slightly enlarged. He was treated with L-T 4 for two weeks. At present, his growth and neurological development are normal. This case indicates that intrauterine therapy by the intraamniotic administration of L-T 4 can be effective in treating fetal goitrous hypothyroidism even during late gestation.

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Section: Discussionmentioning

confidence: 99%

Successful Intrauterine Therapy for Fetal Goitrous Hypothyroidism during Late Gestation

et al. 2007

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“…In case 1, the foetal goitre was caused by excessive foetal TSH secretion in response to drug induced foetal hypothyroidism. Many similar cases have been published (33)(34)(35)(36)(37)(38)(39)(40)(41)(42), and often it is not necessary to perform cordocentesis to make the diagnosis.…”

Section: Casementioning

confidence: 98%

Management of Graves' hyperthyroidism in pregnancy: focus on both maternal and foetal thyroid function, and caution against surgical thyroidectomy in pregnancy

Laurberg¹,

Bournaud²,

Karmisholt³

et al. 2009

European Journal of Endocrinology

159

102

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Graves' disease is a common autoimmune disorder in women in fertile ages. The hyperthyroidism is caused by generation of TSH-receptor activating antibodies. In pregnancy both the antibodies and the antithyroid medication given to the mother pass the placenta and affect the foetal thyroid gland. Thyroid function should be controlled not only in the mother with Graves' hyperthyroidism but also in her foetus. The review includes two cases illustrating some of the problems in managing Graves' disease in pregnancy.Major threats to optimal foetal thyroid function are inadequate or over aggressive antithyroid drug therapy of the mother. It should be taken into account that antithyroid drugs tend to block the foetal thyroid function more effectively than the maternal thyroid function, and that levothyroxin (L-T 4 ) given to the mother will have only a limited effect in the foetus.Surgical thyroidectomy of patients with Graves' hyperthyroidism does not lead to immediate remission of the autoimmune abnormality, and the combination thyroidectomyCwithdrawal of antithyroid medicationCL-T 4 replacement of the mother involves a high risk of foetal hyperthyroidism. Conclusion: Antithyroid drug therapy of pregnant women with Graves' hyperthyroidism should be balanced to control both maternal and foetal thyroid function. Surgical thyroidectomy of a pregnant woman with active disease may lead to isolated foetal hyperthyroidism.

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“…4,5 In addition, fetal/neonatal hyperthyroidism as a consequence of maternal thyroid disease has been well described. However, reports of the fetus and infant being affected by both hypo-and hyperthyroidism are rare.…”

Section: Maternal Thyrotoxicosis and Fetal Goitre Requiring In Utero mentioning

confidence: 99%

Maternal thyrotoxicosis and fetal goitre requiring in utero therapy for hypothyroidism and subsequent neonatal therapy for hyperthyroidism

Groom

Snowise

Wheeler

et al. 2013

J Paediatrics Child Health

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Thyroid hormones are produced by the fetus from 11 weeks gestation 1 and are essential for normal fetal and neonatal development. Maternal autoimmune thyroid disease (Graves' disease) or its treatment may adversely affect this normal development by causing hypo-or hyperthyroidism in utero and/or in the early neonatal period. This case demonstrates that the fetus/ infant may be susceptible to both mechanisms of disruption of thyroid function.A 35-year-old woman in her fifth pregnancy with known Graves' disease presented with thyrotoxicosis at 7 weeks gestation (thyroid stimulating hormone (TSH) 0.01 mIU/L (0.3-4), fT 3 50 pmol/L (3.5-6.5), fT4 95.3 pmol/L (10-23)) with positive thyroid antibodies (anti-thyroid peroxidase antibodies 190 IU/mL (<10) and thyroid stimulating immunoglobulin (TSI) >40 U/L (0-1). She was transferred from carbimazole to propylthiouracil (PTU) daily dose 150 mg. This was reduced to 100 mg by the end of the first trimester. Low TSH and high fT3 levels persisted throughout the second trimester (fT3 8.2-29.3 pmol/L) but levels of fT4 returned to the normal range.On ultrasound at 26 weeks gestation, a fetal goitre was identified. The goitre appeared to have a uniform increase in vascularity, fetal growth, heart rate and skeletal ossification appeared normal. By 31 weeks, maternal thyroid function remained unchanged but the fetal goitre had enlarged with a circumference of 9.4 cm, >95th centile (95th centile by biparietal diameter 6.5 cm and by gestational age 5.2 cm).2 Referral was made to a tertiary fetal therapy unit for fetal blood sampling (FBS) to determine fetal thyroid function and to assess the potential obstructive effect of the fetal neck mass and possible need for ex utero intrapartum treatment procedure.The trachea appeared patent, fetal swallowing was observed and liquor volume was normal, and there was no significant change in the size of the goitre (Fig. 1). FBS revealed fT3 3.5 pmol/L (3.9-6.8), fT4 6.7 pmol/L (12-22) and TSH of >100 mIU/L (0.3-4), confirming severe fetal hypothyroidism. Treatment with 60 mcg intra-amniotic tri-iodothyronine (Liothyronine sodium, Goldshield Pharmaceuticals, Croydon UK) was given and maternal PTU decreased to 50 mg daily. By 35 +3 weeks, maternal clinical and biochemical status was increasingly thyrotoxic (TSH 0.01 mU/L, fT3 19.1 pmol/L and fT4 22.9 pmol/L). Despite administration of propanolol, the woman was increasingly symptomatic and so a decision was made to proceed with delivery. A healthy male infant weighing 2850 g (63rd customised birthweight centile) was delivered by an uncomplicated lower segment caesaren section. There were no concerns with the neonate's airway and no palpable goitre. On day one, the infant's thyroid function was normal (TSH 11 mIU/L (0.01-10.5), fT3 5.5 pmol/L (3.4-7.2), fT4 15.3 pmol/L (10-40)). However, from day 10, the infant was thyrotoxic (TSH 0.09 mIU/L, fT4 61.1 pmol/L, fT3 14.7 pmol/L) with TSI level >40 U/L (0-1). Carbimazole (1.25 mg bd) and propranolol (1 mg tds) were commenced due to tachycardia and fre...

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Non-Invasive Management of Fetal Goiter during Maternal Treatment of Hyperthyroidism in Grave’s Disease

Cited by 18 publications

References 17 publications

Successful Intrauterine Therapy for Fetal Goitrous Hypothyroidism during Late Gestation

Successful Intrauterine Therapy for Fetal Goitrous Hypothyroidism during Late Gestation

Management of Graves' hyperthyroidism in pregnancy: focus on both maternal and foetal thyroid function, and caution against surgical thyroidectomy in pregnancy

Maternal thyrotoxicosis and fetal goitre requiring in utero therapy for hypothyroidism and subsequent neonatal therapy for hyperthyroidism

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