Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with...
Transcript of Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with...
![Page 1: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/1.jpg)
THYROID DISEASE
IN PREGNANCY
Grand Rounds
December 5, 2018
Maria Kolojeski, DO (PGY3)https://www.wddty.com/magazine/2016/june/depression-its-not-your-brain-its-your-thyroid.html
![Page 2: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/2.jpg)
REVIEW OF THYROID HORMONES
Hypothalmus
Thyroid Releasing Hormone (TRH)
Anterior Pituitary
Thyroid-Stimulating Hormone (TSH)
Thyroid
Triiodothyronine (T3)
Thyroxine (T4)
Iodine
![Page 3: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/3.jpg)
THYROID CHANGES IN PREGNANCY
Thyroid Volume: 30% larger in 3rd vs 1st trimester
Increased thyroid binding globulin
Increased in total T3 & T4 levels
Free T3 & T4 typically remain stable
Weak stimulation of TSH receptors by hCG (first 12 weeks)
Increases serum free T4
Thyrotropin (AKA: Thyroid Stimulating Hormone [TSH])
Decreases in early pregnancy
Transient subclinical hyperthyroidism, Gestational transient hyperthyroidism
Returns to baseline in second trimester
Increased in third trimester due to placental deiodinase
![Page 4: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/4.jpg)
THYROID
LABORATORY WORKUP
➢ First Trimester
➢ 0.1 - 2.5 mIU/L
➢ Second Trimester
➢ 0.2 - 3.0 mIU/L
➢ Third Trimester
➢ 0.3 - 3.0 mIU/L
➢ If TSH abnormal order free T4
➢ Rarely T3 toxicosis is the cause
➢ Consider antibody testing if
euthyroid but clinical signs presentWilliams Obstetrics 24ed. Ch. 58 – Fig.1.
❖ Universal screening not recommended
![Page 5: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/5.jpg)
THYROID HORMONES & THE FETUS
Maternal T4 crosses the placenta
Fetal brain development
Provides thyroid hormone
before 12 weeks
Fetal thyroid begins to produce own
thyroid hormone & concentrate
iodine
30% of T4 at term is estimated
to be of maternal production
![Page 6: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/6.jpg)
IODINE REQUREMENTS
Iodine deficiency in Pregnancy
Causes
Increased thyroid hormone production
Increased renal iodine loss
Fetal iodine requirement
Mild mental impairment to cretinism
Iodine Intake in Pregnancy
Reproductive age: 150mcg daily
Pregnant: 220mcg daily
Lactating: 290mcg daily
About 50% of PNV don’t contain iodine
Not to excess 500mcg daily
http://www.faqs.org/nutrition/images/nwaz_01_img0114.jpg
![Page 7: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/7.jpg)
HYPERTHYROIDISM
Prevalence: 0.2 - 0.4% pregnancies (US); studies in UK (0.7 - 1.7%), China (1%)
Causes: Graves disease (95%), trophoblastic disease, toxic multinodular goiter, toxic adenoma, thyroiditis, exogenous thyroid hormone
Diagnosis: low TSH and high free T4
Symptoms: fatigue, nervousness, frequent stools, sweating, tachycardia, tremors, weight loss, heat intolerance, insomnia, palpitations, HTN, insomnia, +/- goiter
Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy
Complications: SAB, preeclampsia, heart failure, preterm birth, low birth weight, fetal thyroid disease, infection, anemia, hearing loss
SUBCLINICAL HYPERTHYROIDISM
Prevalence in pregnancy: 1.7%
No associations with adverse pregnancy outcomes
Antithyroid medications have can have adverse effects on the fetus
![Page 8: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/8.jpg)
THYROID STIMULATING ANTIBODIES
Risk of immune-mediated fetal hypothyroidism and hyperthyroidism
Thyroid stimulating immunoglobulins (TSI) stimulate fetal thyroid
1-5% of neonates have hyperthyroidism or neonatal Grave’s disease
TSH-binding inhibitory immunoglobulins inhibit fetal thyroid
Decreased occurrence with maternal treatment during pregnancy
However – increased risk if previous maternal treatment via surgery or radioiodine ablation
Consider fetal thyrotoxicosis in all women with a history of Grave’s
American Thyroid Association and American Associate of Clinical Endocrinologists recommend antibody testing between 22-26wga in women with a history of Grave’s disease.
ACOG does not, due to no change in management.
![Page 9: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/9.jpg)
HYPERTHYROIDISM MANAGEMENT
Thioamides – decrease production of T3 & T4; cross the placenta
Proplthiouracil (PTU) – first trimester
Inhibits iodination of tyrosine and conversion of T4 to T3 in peripheral tissues
Hepatotoxicity (0.1-0.2%), ANCA (20%; rare for serious vasculitis)
Methimazole (MMI) – second & third trimesters
Inhibits iodination of tyrosine
Associated with esophageal and choanal atresia, fascial dysmorphism, aplasia cutis, omphalocele
Side effects: transient leukopenia (10%), agranulocytosis (0.3 - 0.4%)
Dosage: PTU 50-150mg PO TID; MMI 10-40mg PO divided into BID or TID dosing
Surveillance: measure T4 level q2-4 weeks
Beta blockers
Used for management of tachycardia and tremors
Avoid longer than 2-6 weeks due to increased risk of IUGR, bradycardia & hypoglycemia
Dosing
Metoprolol 25-50mg daily
Propranolol 20mg q6-8hr
![Page 10: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/10.jpg)
HYPERTHYROIDISM MANAGEMENT
Thyroidectomy – rarely performed during pregnancy
Reserved for individuals with allergy to thioamides or agranulocytosis
Pretreatment with a beta-blocker and potassium iodine
Fetal Monitoring
Fetal heart rate monitoring, growth ultrasounds;
Consider fetal thyroid ultrasound if mother with Grave’s or TRAb 2-3x normal
Postpartum
Methimazole preferred due to PTU side effects
If dose >20mg daily, then infants should have thyroid function testing at 1 and 3 months of age
TSH and free T4 at 6 weeks
Not recommended
Routine thyroid antibody testing
Some recommend if require treatment with thioamides to test initially, at 18-22 and 30-34 wga
Routine fetal thyroid evaluation: fetal US, cord blood sampling
Consider in cases of IUGR, fetal tachycardia, fetal hydrops, goiter
![Page 11: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/11.jpg)
HYPERTHYROID EMERGENCIES
Thyroid StormThyrotoxic Heart Failure & Pulmonary Hypertension
Incidence: 1-2% of pregnant patients with hyperthyroidism
High risk of maternal heart failure
Abrupt onset
Diagnosis: fever, tachycardia, cardiac dysrhythmia, CNS dysfunction
If suspect, order TSH & free T4, CBC, LFTs, Ca2+
Treat underlying cause
Avoid delivery
Incidence: 8% pregnant patients with uncontrolled hyperthyroidism
Excess T4 -> high-output cardiomyopathy that can develop into dilated cardiomyopathy
Precipitating conditions: preeclampsia, anemia, sepsis
Frequently these conditions are reversible
![Page 12: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/12.jpg)
Inhibit release of T3 & T4
• PTU 1,000mg PO load, then 200mg PO q6hr
• Iodine (1-2hr after PTU)
• Sodium iodine 500-1,000mg IV q8hr OR
• Potassium iodide, 5 drops PO q8hr OR
• Lugol solution, 10 drops PO q8hr OR
• Lithium carbonate, 300mg PO q6hr (iodine allergy)
Block peripheral T4 -> T3
• Dexamethasone, 2mg IV q6hr x 4 OR
• Hydrocortisone, 100mg IV q8hr x 3
Consider beta-blocker
for tachycardia
• Caution in those with heart failure
• Propranolol, 10-40mg PO q4-6hr; (labetalol, esmolol)
MANAGEMENT of THYROID STORM or
THYROTOXIC HEART FAILURE in PREGNANCY
Don’t forget supportive care!
O2, IVF, telemetry, NG tube, cooling measure, avoid salicylates
![Page 13: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/13.jpg)
HYPOTHYROIDISM
Complicates 2 – 10 per1,000 pregnancies
Causes: Iodine deficiency, chronic autoimmune thyroiditis (Hashimoto’s),
prior radioiodine ablation/surgery, pituitary/hypothalamic disorders
Diagnosis: high TSH and low free T4
Consider measurement of TPO antibodies if TSH≥2.5
Symptoms: fatigue, constipation, cold intolerance, muscle cramps, dry skin,
hair loss, prolonged relaxation of DTRs, weight gain, edema, +/- goiter
Paresthesias: early symptom present in 75% of hypothyroid patients
Other: large tongue, myxedema, hoarse voice
Complications: SAB, preeclampsia, preterm birth, low birth weigh, impaired
neuropsychologic development, placental abruption, fetal death
![Page 14: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/14.jpg)
HYPOTHYROIDISM
SUBCLINICAL HYPOTHYROIDISM
Prevalence in pregnancy: 2-5%
Approximately 1/3 have TPO antibodies
Possible increased risk of NICU admission, RDS, abruption, preterm birth, GDM
No evidence that treatment improves outcomes
ISOLATED MATERNAL HYPOTHYROXINEMIA
Prevalence in pregnancy: 1.3%
No increased rates of TPO antibodies
Inconsistent data on adverse pregnancy outcomes (neurodevelopment, macrosomia)
No evidence that treatment improves outcomes
![Page 15: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/15.jpg)
ANTITHYROID ANTIBODIES
Hashimoto’s thyroiditis
glandular destruction via thyroid peroxidase (TPO) Ab & antithyroglobulin Ab (TG)
Euthyroid Autoimmune Thyroid Disease
TPO & TG antibodies are present in 6-20% of reproductive-aged women
Women with these antibodies are at an increased risk for
Early pregnancy loss (2-5 fold)
Placental abruption (3 fold)
Postpartum thyroid complications
Permanent thyroid failure
1 in 180,000 neonates will experience fetal hypothyroidism as a result of maternal TPO antibodies attacking the fetal thyroid
![Page 16: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/16.jpg)
HYPOTHYROIDISM MANAGEMENT
T4 replacement recommended
Levothyroxine 1-2mcg/kg daily
Surveillance: measure TSH levels q4-6 weeks
If preexisting hypothyroidism, need for T4 increase in 1/3 of patients
Increased T4 needs can occur as early as week 5 of gestation
Anticipatory increase in dose by 25% at pregnancy confirmation (in those with no reserve)
Adjust dosages in 25-50mcg increments
Postpartum
Return to prepregnancy dose if preexisting condition
Measure TSH at 4-6 weeks after delivery
Safe to use in breastfeeding; can improve milk production
Not recommended
Routine thyroid antibody testing
![Page 17: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/17.jpg)
MYXEDEMA COMA
Extreme/severe hypothyroidism
Mortality rate: 20%
Rare in pregnancy
Diagnosis: “think low”
Hypoventilation, hypothermia, hypotension, hyponatremia, and bradycardia
Treatment
Levothyroxine (IV/NG) 300-500mcg bolus IV, 75-100mcg IV daily
NG doses 30-50% higher than IV; PO 50-200mcg daily once stable
Liothyronine (T3 replacement) 10mcg q8hr
Hydroxycortison 100mg q8hr until cortisol level known, then titrate
Supportive: IVF, electrolyte replacement, telemetry, intubation, warming
Cardiac enzymes and cultures to further evaluate
![Page 18: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/18.jpg)
FETAL & NEONATAL EFFECTS Goitrous Thyrotoxicosis
Transfer of TSI across the placenta; increased risk if 3x normal limit
Nonimmune hydrops, heart failure, accelerated bone maturation, tachycardia, IUGR
Treatment: increase thioamide (regardless of maternal levels)
May need antithyroid drug during neonatal period
Fetal Thyrotoxicosis
Placental transfer of TSI s/p ablation or thyroidectomy
Goitrous Hypothyroidism
Due to maternal intake of thioamides
Delayed bone maturation, hydramnios, hyperextension
Treatment: decrease maternal thioamide dosage
Possible intramniotic thyroxine injection
Nongoitrous Hypothyroidism
Transfer of TSH receptor blocking antibodies
Williams Obstetrics 24ed. Ch. 58 – Fig.3.
![Page 19: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/19.jpg)
FETAL & NEONATAL MANAGEMENT
Method of diagnosis: amniotic fluid or fetal cord blood sampling
Goiter complications
Compression of trachea and/or esophagus hydramnios and/or airway compromise
Fetal neck hyperextension labor dystocia
Fetal Thyrotoxicosis
Maternal thioamides; treat mother with levothyroxine supplementation if needed
Fetal Hypothyroidism
Discontinuation of maternal thioamide (if applicable and able)
Intraamniotic levothyroxine injections
50 - 800mg q1-4 weeks (no established protocol)
![Page 20: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/20.jpg)
CONGENITAL HYPOTHYROIDISM
Prevalence: 1 in 2000 - 4000 births; female:male = 2:1
Causes
Iodine deficiency – most common
Developmental disorders – agenesis and hypoplasia
Hereditary defects in thyroid hormone production (dyshormonogenesis)
Failure of stimulation from pituitary
Complications: mental deficiencies/cognitive defects, limb length
Most treatable cause of mental deficiency
One study found that 8% of 1420 infants had other major congenital malformations
Universal newborn screening: TSH & free T4; required in US
Management: Thyroxine replacement (early & aggressive)
![Page 21: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/21.jpg)
THYROID NODULES
Present in 1-2% of reproductive aged women
15% of Chinese women at nodules >2mm – 50% multiple; mostly nodular hyperplasia
Some studies have shown 40% malignancy rate of solitary nodules
Workup
TSH
Neck ultrasound (adequate for detecting nodules >0.5cm)
Malignant characteristics: irregular margins, microcalcifications, hypoechogenic pattern
FNA
Surgery: second trimester is optimal timing
Reserved for fast going masses, compression symptoms (recurrent laryngeal nerve)
Radioiodine scanning – contraindicated in pregnancy
Recommend waiting 6 months after ablation
Recommend waiting 3 months after delivery to undergo ablation due to storage of iodide in the breast tissue
![Page 22: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/22.jpg)
THYROID CANCER
Requires multidisciplinary approach
Typically well differentiated and slow growing
Monitor with ultrasound every trimester
If discovered in 1st - 2nd trimesters, possible thyroidectomy in 3rd
trimester – otherwise delay surgery until after delivery.
Injury or inadvertent removal of parathyroid glands
Injury to recurrent laryngeal nerve
Persistent disease s/p radioiodine treatment
Pregnancy has does not lead to recurrence, however progression can occur
Follow with US and thyroglobulin levels
Continue levothyroxine
![Page 23: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/23.jpg)
POSTPARTUM THYROIDITIS
➢ Thyroid dysfunction within 12 months of delivery
➢ Transient autoimmune thyroiditis account for 5-10% of cases
➢ Approximately 50% of women with TPO antibodies in first trimester developed
postpartum thyroiditis
➢ Most cases will resolve spontaneously➢ One third develop overt hypothyroidism
Thyrotoxicosis
Release of excess thyroid hormone
Abrupt onset
Small, painless goiter
Lasts a few months
Fatigue, irritability, weight loss,
palpitations, heat intolerance
Thioamides ineffective
Consider beta-blocker if severe
Hypothyroidism
Thyromegaly more common
Typically 4-8 months postpartum
Fatigue, cold intolerance, weight
gain, constipation, depression
T4 replacement for 6-12 months
![Page 24: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/24.jpg)
REFERENCES1. American College of Obstetrics and Gynecology. “Practice Bulletin No. 148: Thyroid Disease in Pregnancy.” Obstetrics and
Gynecology. 2015;125:996-1005.
2. Cunningham, F. Gary,, et al. Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014.
3. Foley, F. Michael,, et al. Obstetric Intensive Care Manual. 5th edition. New York: McGraw-Hill Education, 2018.
4. Lafranchi, Stephen and Maynika Rastogi. “Familial Thyroid Dyshormonogenesis.” Orphanet Encyclopedia, August, 2010,https://www.orpha.net/consor/cgi-bin/OC_Exp.php?lng=en&Expert=95716. Accessed 2 December 2018.
5. National Library of Medicine (US). Genetics Reference [Internet]. Bethesda, MD: The Library; 27 November 2018. Congenital Hypothyroidism; [reviewed 2015 September]. Available from: https://ghr.nlm.nih.gov/condition/congenital-hypothyroidism#inheritance. Accessed 2 December 2018.
6. Newborn screening for congenital hypothyroidism. Journal of Clinical Research in Pediatrtic Endocrinology vol. 5 Suppl 1,Suppl 1 (2013):8-12.
7. Ross, S. Douglas. (2018). Hyperthyroidism during pregnancy: treatment. In J. E. Mulder (Ed.), UpToDate. https://www-uptodate-com.proxy.kumc.edu/contents/hyperthyroidism-during-pregnancy-treatment?search=hyperthyroidism%20in%20pregnancy&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H17 . Accessed 4 December 2018.
8. Ross, S. Douglas. (2018). Hypothyroidism during pregnancy: clinical manifestation, diagnosis, and treatment. In J. E. Mulder (Ed.), UpToDate. https://www-uptodate-com.proxy.kumc.edu/contents/hypothyroidism-during-pregnancy-clinical-manifestations-diagnosis-and-treatment?search=hypothyroid%20in%20pregnancy&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Accessed 4 December. 2018.
9. Ross, S. Douglas. (2018). Overview of Thyroid Disease in Pregnancy. In J. E. Mulder (Ed.), UpToDate. https://www-uptodate-com.proxy.kumc.edu/contents/overview-of-thyroid-disease-in-pregnancy?search=thyroid%20diseases%20and%20pregnancy&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Accessed 11 November 2018.
![Page 25: Thyroid disease in pregnancy - wesley ob/gyn · 2018-12-05 · Additional symptoms associated with Grave’s Disease: ophthalmopathy, dermopathy Complications: SAB, preeclampsia,](https://reader033.fdocuments.in/reader033/viewer/2022060500/5f1a5f680093877bfe2e2cdc/html5/thumbnails/25.jpg)
QUESTIONS?
THYROID DISEASE IN PREGNANCY