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Hyperthyroidism in Pregnancy
Hyperthyroidism may present as a new diagnosis in pregnancy, affecting up to 0.1-0.4% of pregnancies. [1] More
common is relapse of previously controlled hyperthyroidism.
Epidemiology [3]
It occurs in 2/1,000 pregnancies in the UK.
The most common cause is Graves' hyperthyroidism - overactivity resulting from the presence of
TRAb.
New-onset Graves' hyperthyroidism is estimated to occur in about 0.15% of pregnancies.
Transient gestational hyperthyroidism may also occur - it has a 2-3% prevalence in Europe but is
much higher in South Asians.
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Thyrotrophin receptor activation
Presentation
See separate article Hyperthyroidism for signs and symptoms. However, in pregnancy the following warrant
TFTs:
Tachycardia
Palpitations
Heat intolerance
Systolic murmur
Bowel disturbance
Failure to gain weight
Emotional upset
Features of Graves' disease may also be seen - for example:
Eye signs
Tremor
Weight loss
Pretibial myxoedema
Differential diagnosis
Some of the symptoms may be due to pregnancy itself.
If tachycardia is present then anaemia, arrhythmias and volume depletion might need to be
considered.
More rare causes such as phaeochromocytoma might also need to be considered.
Investigations
Serum TSH can exclude primary thyrotoxicosis. Confirm diagnosis with free T4 levels. If TSH is suppressed but
free T4 levels are normal then, if not previously supplied, free T3 level is necessary (T3 toxicosis occurs in 5% of
patients). Previously successfully treated Graves' disease is not associated with abnormal TFTs during
pregnancy. [5] It is important to remember that the ranges of TSH, T3 and T4 are different in pregnancy: [6]
Page 3 of 5
0.3-3.0 mlU/L in the second trimester.
Up to 3.5 mlU/L in the third trimester.
Free T4 varies as albumin and T4-binding globulin change.
TRAb
This can cross the placenta, stimulating the fetal thyroid, so it is important to measure during pregnancy. [1] [7]
Normal values <130% (by measuring thyroid stimulating immunoglobulins) of basal activity.
Risk of fetal or neonatal hyperthyroidism is increased when >500% activity is detected.
Thyroid ultrasound scan can be requested but thyroid uptake scans are not recommended.
Fetal/neonatal:
High miscarriage rate is associated with high thyroid hormone and thyrotrophin hormone
levels (ie not due to autoimmunity).
Intrauterine growth restriction. [8]
Low birth-weight baby. [8]
Stillbirth.
Thyroid dysfunction.
Subclinical hyperthyroidism can be associated with gestational diabetes. [2] Apart from this it has not been
associated with any other adverse effects during pregnancy.
[9]
Management [3]
[11]
Hyperthyroidism during pregnancy can present as hyperemesis gravidarum or as thyroid storm - always check
the TFTs. These women need urgent admission to hospital. [12]
Note: hyperemesis gravidarum is associated with abnormal TFTs which improve once it settles. Control is
particularly important as the pregnancy progresses, especially in the third trimester. This is the result of
suppression of the fetal pituitary thyroid axis from maternal transfer of thyroxine when hyperthyroidism is poorly
controlled. Decide which of the following groups the patient belongs to:
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Postpartum [3]
Patients may continue to breast-feed - the risk of propylthiouracil and carbimazole being secreted into
breast milk is negligible. However, neonatal thyroid function should be checked regularly.
Measure TFTs in both mother (six weeks and three months) and the neonate (six hours and again a
few days later). The reason for rechecking TFTs a few days after birth is that the neonate will have
metabolised any maternal antithyroid drugs by this time.
Prognosis
Good thyroid control is associated with a normal pregnancy with good maternal and fetal health, although recent
work does suggest it to be an independent risk factor for Caesarean section. [15]
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Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical
conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its
accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions.
For details see our conditions.
Original Author:
Dr Gurvinder Rull
Current Version:
Dr Laurence Knott
Peer Reviewer:
Prof Cathy Jackson
Last Checked:
14/12/2012
Document ID:
8719 (v3)
EMIS