Pregnancy & Endocrinology-no pics

Pregnancy & Endocrinology-no pics - Pregnancy...

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William Harper Hamilton General Hospital McMaster University www.drharper.ca
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Objectives Objectives Postpartum thyroid dysfunction Gestational DM Type 1 & Type 2 DM & Pregnancy
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Case 1 Case 1 31 year old female Somalia Canada 3 years ago G2P1A0, 11 weeks pregnant Well except fatigue Hb 108 , ferritin 7 (Fe and LT4 interaction?) TSH 0.2 mU/L, FT4 7 pM Started on LT4 0.05 TSH < 0.01 mU/L FT4 12 pM, FT3 2.1 pM
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Case 1 Case 1 1. How would you characterize her hypothyroidism? 2. What are the ramifications of pregnancy to thyroid function/dysfunction?
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TSH Low High FT4 Low 1° Hypothyroid Low Central Hypothyroid TRH Stim. If equivocal MRI, etc. High 1° Thyrotoxicosis High 2° thyrotoxicosis Endo consult FT3, rT3 MRI, α-SU RAIU
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Case 1 Case 1 GH, IGF-1 normal LH, FSH, E2, progesterone, PRL normal for pregnancy 8 AM cortisol 345, short ACTH test normal MRI: normal pituitary TGAB, TPOAB negative Normal pregnancy, delivery, baby, lactation
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Increased estrogen increased TBG (peaks wk 15-20) normal FT4 & FT3 if normal thyroid fn. and good assay many automated FT4 assays underestimate true FT4 level (except Nichols equilibrium dialysis free T4 assay) if suspect your local FT4 assay is underestimating FT4 can check total T4 & T3 instead (normal pregnant range ~ 1.5x nonpregnant) hCG peak end of 1 st trimester, hCG has weak TSH agonist effect so may cause: slight goitre mild TSH suppression (0.1-0.4 mU/L) in 9% of preg mild FT4 rise in 14% of preg
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Fetal thyroid starts working at 12-14 wks Cross placenta well: MTZ > PTU TSH-R Ab (stim or block) Fetal goitre (can compress trachea after birth) MTZ aplasia cutis scalp defects Other MTZ reported embryopathy: choanal atresia, esophageal atresia, tracheo-esophageal fistula Therefore do NOT use MTZ during pregnancy, use PTU instead
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No TSH at end of 1 st trimester as expected from hCG effect Requirement to increase LT4 dose occurred between weeks 4 -20 Despite exponential rise in estradiol throughout pregnancy (note y-axis units) TBG levels plateau at 20 wks
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LT4 dose requirement tied to rising TBG levels (THBI inversely proportional to TBG level) By 10 wks need average increase of 29% LT4 dose By 20 wks need average increase of 48% LT4 dose No increase of dose beyond 20 wks required
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* Regardless of cause of hypothyroidism (Hashimoto’s, thyroidectomy) initial LT4 dose increase is usually required early (~ week 8), before 1 st prenatal visit!
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Pregnancy &amp; Endocrinology-no pics - Pregnancy...

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