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BusySpR MRCOG PART II
MRCOG Part 2, MRCOG II

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MRCOG 2 Past Questions Tutorial: GROUP 3: Sat 16/11 from 10:00 - Statistics. Sun 17/11 from 10:00 - Oncology 1. Group 2: Sat 16/11 from 19:00 - Contraception & STI. See DISCUSSIONS below for details.

 

 

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Forum >> ESSAY 256 - Graves disease
ESSAY 256 - Graves disease Posted by PAUL A.
Wed Jan 23, 2008 02:12 am
A 25 year old primigravida with a history of Graves disease treated with propylthiouracil has been referred to the antenatal clinic at 12 weeks gestation. (a) What will you tell her about the risks associated with Graves disease? [9 marks]. (b) Justify your modifications to her antenatal care [7 marks]. (c) Justify your post-natal care given that she had a spontaneous vaginal delivery [4 marks].
Posted by Jilly L.
Wed Jan 23, 2008 03:04 am
a) Graves disease is an autoimmune disease with autoantibodies that attack the thyroid - thyroid stimulating hormone receptor antibodies. It can cause hypo or hyperthyroidism. It is an important cause of maternal and perinatal morbidity, which can be reduced by good obstetric care. She should be given written information regarding Graves disease and pregnancy.

Propylthiouracil is an antithyroid drug used for hyperthyroidism. She should be informed that if her thyroid function is well controlled on propylthiouracil (PTU) she should continue this as there is little evidence of teratogenicity and uncontrolled hyperthyroidism is more dangerous to her and the fetus. The lowest dose possible should be used.

Pregnancy usually has little effect on Graves disease or may lead to improvements. Thyroid eye disease, such as proptosis is usually unaffected. Goitres may increase in size. There is increased risk of intrauterine growth restriction (IUGR), perinatal mortality and pre-term delivery in undertreated hyperthyroidism.

b) She should referred to a specialist obstetric clinic with an endocrinologist. Symptoms of hyperthyroidism can be similar to normal pregnancy symptoms such as tachycardia so thyroid function should be checked in every trimester - free thyroxine levels should be normal, TSH can be raised in pregnancy. Regular ultrasound scans to assess growth and liquor volume should be done as IUGR is more common. Steriods should be considered in view of the risk of preterm delivery to reduce the risk of respiratory distress syndrome. She should deliver in a unit with obstetric and anaesthetic services in case of problems such as thyroid storm. Neonatal input will be needed to assess the neonate.

c) She will need routine postnatal care, such as advice regarding contraception, assessing for thromboembolic risk, perineal care and assessment for postnatal depression. She should be advised that breastfeeding is not contraindicated on PTU. She may develop postpartum thyroiditis and will need thyroid function tests and follow up with the endocrinologist. The neonate is at risk of thyrotoxicosis due to maternal thyroid stimulating antibodies and so will need neonatal assessment and follow up. This presentation can be delayed due to PTU clearance.

Posted by Shankaralingaia N.
Wed Jan 23, 2008 05:15 am
a)Graves disease has maternal,fetal and neonatal complications due to TSH antibodies which crosses placenta.
Women can present with worsening of thyrotoxicosis symptoms such as loss of weight in spite of good appetite,history of palpitation,tremors,heat intolerance and tiredness.some of the evidence shows there could be increased rise of miscarriage.Most of the signs are difficult to diagnose as they are normally present in pregnancy.
In severe thyrotoxicosis there could be thyroid storm,hypertension and heart failure.She could have goitre with pressure symptoms.
It can also cause pre term labour,grwth restriction and still birth.
Fetal risks are mainly due to antibodies crossing the placenta and causing fetal thyrotoxicosis.This can lead to fetal tachycardia and intra uterine growth retardation.It can develop goitre and cause polyhydramnios.Very rarely it can cause hydrops and fetal death.
These effects are seen after birth with poor feeding,growth and sleep.

b)Explain the importance of close monitoring and need for frequent antenatal visits.Care plan in documented and she is seen in the joint medical clinic with the physician and obsterician.
Dating scan is done to confirm the gestation.Booking bloods include Free T3,T4,TSH and TSH antibodies.Bloods should be done every 4-6 weeks.
Propylthiouracil or carbimazol should be continued.Reassure that they are safe in pregancy and breast feeding.Fetal tachycardia needs review by the team to adjust the dosage of the medication.
Sometimes it can cause fetal hypothyroidism.If symptomatic with palpitation propanolol is the drug of choice.
Anamoly scan at 20 weeks as usual and follow up growth scan at four weekly interval will monitor fetal growth.Other treatment for goitre can be surgically treated if necessary but radioactive treatment is contraindicated.
Educating women to monitor fetal movements in vital.Letter to the neonatologist for the management after delivery is mandatory.
Induction and delivery as normal.
Leaflets are provided with care plan.

c)After delivery neonatologist should review the baby for any signs of thyrotoxicosis such as poor feeding,growth and sleep.Bloods are taken for free T3,T4,TSH and TSH antibodies one week after birth.Breast feeding is safe with both the medications.Sometimes women can present with postpartum thyroiditis so if symptoms get worse,should be reviewed by GP.

Posted by Sahathevan S.
Wed Jan 23, 2008 06:52 am
(a)What will you tell her about the risks associated with Graves disease? [9 marks].
I will tell her hyperthyroidism usually (95 %) due Graves Disease. it is essential to maintain euthyroidism in pregnancy as uncontrolled disease associated with maternal and fetal complications. Thyroid storm is life-threatening condition which is induced by excessive release of thyroid hormones. Retrosternal extension of goiter may cause tracheal obstruction and difficult intubation. Maternal Hypertension is also a risk which may be may be followed by congestive heart failure. Considering fetal risk premature labour is a recognized complication with Graves?s disease, also growth restriction and still birth are increased risk. Baby may have Exopthalmos which is bulging of the eye anteriorly out of the orbit .Fetal or neonatal thyrotoxicosis occurs in 1-10% of babies with history of maternal Graves?s disease, mortality may reach 50% if it is not treated. Antithyroid drugs (Prophythiouracil) can cause nausea, vomiting, diarrhea and agranulocytosis and so a sore throat thoroughly investigated.higher dose of this drug can cause fetal hypothyroidism and goiter. Fetal goitre can cause polyhrdamnios and obstructed delivery .The condition is also associated with craniosynostosis and intellectual impairment. I will provide written information.

(b) Justify your modifications to her antenatal care [7 marks].
Antenatal care should be Multidisciplinary management which involves physician, obstetrician, Pediatrician and GP. As she has treated for thyrotoxicosis, it is usual to aim for free T4 at the upper limit of normal. A thyroid fuction test (TFT) should be perfomed and if she is hyperthyroid control with propylthiouracil as rapid as possible and the maintain control.
TFT should to be perfomed every 4-6wks to avoid maternal hypothyroidsm patient should be warned that the development of a sore throat or mouth ulcers necessities cessation of therapy and urgent medical attention because of the risk of agranucytosis.Betablockers can be used initially if she has the symptoms of tachycardia, sweating and tremors. Serial Growth ultrasound scans should be undertaken to check for growth,heartrate and fetal neck. to monitor the growth.

(b)Justify your post-natal care given that she had a spontaneous vaginal delivery [4 marks]
.Post partum exercebation of hyperthyroidism is the risk, therefore thyroid function should be monitored and tratretment may be needed. Pediatrician should be made aware for treated cases and neonate should be assessed for goiter and hypo or hyperthyroidism. Cord blood should be taken for TFT. Breast feeding is not contraindicated as both drugs (PTU, Carbimazole) are expressed in breast milk but have little effect on thyroid function If the mother is breast feeding then it should be repeated in regular intervals. In the case of fetal thyrotoxicosis, the mother is given antithyroid drugs, combined with thyroxine .Neonate should be treated antithyroid drugs. Until maternal antibodies are cleared. A follow-up appointment should be arranged to assess the thyroid status.
Posted by Anna A.
Wed Jan 23, 2008 01:14 pm
a) Grave disease is an auto-immune disease with the presence of thyroid stimulating antibodies. She can be ensured that pregnancy is associated with disease improvement. However she should be compliance to her medication as she is at increased risk to develop thyroid storm if her thyroid hormone level is uncontrolled. She is also at increased risk to develop heart failure if she has tachycardia or if her heart beat is not regular (arythmia). She might have a retro-sternal extention of thyroid gland which could lead to airways obstruction and difficult intubation. Side effect of anti-thyroid treatment like agranulocytosis could lead to maternal sepsis and mortality if not detected earlier. Trans-placental passage of thyroid stimulating antibody can occur and lead to fetal thyrotoxicosis. The patient should now that this condition is associated with 50% neonatal mortality if left untreated. She should be made to understand that she is at higher risk of having miscarriages if her Graves disease is uncontrolled. There is also risk of fetal hypo-thyrodism if she is over treated with anti-thyroid drug. In this case the baby might have some intellectual impairment in the future. Her risk of having low birth weight baby is also higher. The risk of her having intrauterine death and preterm baby is also high. Leaflet information, futher follow up and contact detail should be provided.

b. Multi-displinary input is required involving endocrinologist and deontologist. Consultant led care is essential for optimal outcome of mother and baby. Dating scan and detail scan should be arranged to look for evidence of fetal goiter or feature of fetal thyrotoxicosis. The aim of treatment is to give minimal dose of anti-thyroid drug to achieve euthyroid condition (higher normal level of thyroid hormone). This is important to avoid fetal goiter and fetal hypo-thyrodism. Monitoring of side effect of anti-thyroid drugs is important; any evidence of agranulocytosis, vomiting or diarrhea should be noted. B blocker may be prescribed to control maternal tachycardia or presence of arthymia. The thyroid function (TFT) should be monitored monthly if just started medication. But if the TFT level has been stabilized, measurement is only required if clinically indicated. Growth scan should be arranged monthly. Mode and time of delivery is obstetric indication.
c. The risk of post partum exacerbation is higher, prompt treatment should be ubdertaken is there is evidence of exacerbation. Cord blood for TFT and neonatologist assessment should be arranged. Neonatal symptoms of hyperthyroidism may not appear up to one week. Treatment in the newborn baby may be needed until tyroid stimulating antibody is clear from her/his body. Contraception advice should be arranged until her diseases is well control. Pre-pregnancy counseling should be ensured before embark another pregnancy.
Posted by Idris O.
Wed Jan 23, 2008 04:30 pm
) I would inform her most women with well controlled graves disease have an uncomplicated pregnancy.
It often improves during pregnancy especially in the second and third trimesters as with other auto immune disease due to a state of relative immunosuppression.This leads to a lower requirement for anti-thyroid drugs. However, mild symptoms may be indistinguishable from a normal pregnancy.
Untreated grave?s disease have an increased risk of miscarriage, IUGR, preterm delivery and increased perinatal mortality.
Poorly controlled have risk of thyroid crisis in the mother and heart failure around the time of delivery.
If a goitre is present, a retrosternal extension may increase the risk of tracheal obstruction and this may be a problem when intubation is required.
Propyl thiouracil crosses the placenta and may cause fetal hypothyroidism and goitre There is also a small risk of fetal thyrotoxicosis due to transplacental passage of thyroid stimulating antibodies This causes fetal tachycardia, IUGR or goitre and is treatable with antithyroid drugs .A drug rash or urticaria may occur in some patients on PTU and this may prompt a switch to another preparation
There Is an increased risk of exacerbation in the puerperium due to a rise in TSH receptor stimulating antibodies. I would document this discussion and offer her information leaflet on grave?s disease in pregnancy.
b) This is a high risk pregnancy and would require a multidiscilplinary care in a joint obstetric and endocrine unit involving the obstetrician, consultant endocrinologist, MW and GP. The signs and symptoms of poor control of grave?s disease would be assessed such as heat intolerance, tachycardia, palpitations, emotional lability, vomiting and goitre. I would also ask of compliance with her medication as she may be afraid of teratogenesis. This would be supported with regular monitoring of her thyroid function test ( TSH, Free T4 and T3) performed
1- 2/12 depending on the control in pregnancy, and the dose of her PTU adjusted appropriately. The aim is to maintain the woman euthyroid with a free T4 at the upper end of the normal range. I would also monitor regularly her TSH receptor stimulating antibodies because this predict the risk of fetal thyrotoxicosis. I would arrange serial growth scan,every 4weeks from 24weeks due to the risk of IUGR.This would also include checking the fetal heart rate for tachycardia and neck for goitre which may be evidence of fetal thyrotoxicosis. This can also be predicted especially in poorly controlled cases with the finding of high levels of TSH receptor stimulating antibodies . Where the facility is available, the finding of high levels of TSH binding inhibiting Ig (TBI) are also strongly predictive.Treatment with antithyroid drug and or thyroxine if the mother is euthyroid will be offered with the help of the endocrinologist.
A fine needle aspiration biopsy may be safely performed in pregnancy in suspected colloid carcinoma. Thyroidectomy is rarely required in pregnancy but may be safely performed in the second trimester if there is dysphagia or stridor from a large goitre or with suspected or confirmed carcinoma and if there is allergies to antithyroid drugs. Radioiodine therapy is contraindicated in pregnancy due to the risk of fetal thyroid ablation and hypothyroidism .. Propanolol may be used safely in pregnancy for a short period of time if there is thyroid crisis as it improves sympathetic symptoms of tachycardia, sweating and tremor. A vaginal delivery would be entertained and c-section would only be offered for obstetric reasons.
C The mother\'s thyroid function test would be monitored in the puerperium because of the risk of exacerbation especially if well controlled in pregnancy. I would inform the paediatrician about this baby before the delivery due to risk of neonatal hyperthyroidism. Thyroid function would need to be checked in the cord blood and at regular intervals if the mother is breastfeeding or the disease is poorly controlled. PTU is minimally transferred through the breastmilk and is safe in breastfeeding mothers. The mother would be informed to observe in the neonate signs of neonatal hyperthyroidism which may not present up to 1wk after delivery and the need for prompt treatment to prevent neonatal mortality. The signs include weight loss, tachycardia,irritability, poor feeding and neck swelling.
Contraception would be offered to the woman before the next pregnancy.
Posted by S M.
Wed Jan 23, 2008 04:49 pm
To start with I would reassure the lady telling her that treated Graves disease carries minimal risks to the pregnancy. However, during early pregnancy and postpartum period there is a risk of flare up of the disease. Therefore I would need to repeat her thyroid function tests and thyroid stimulating antibodies and adjustment the of dose the medication she is taking if required. I would inform her that if there is a flare up of the disease it can affect herself and her baby. The Maternal outcomes of a flare, I will tell her, can be exacerbation of symptoms of thyrotoxicosis and sometimes even thyroid crisis and congestive cardiac failure. I will tell her that if there is a flare it can cause miscarriage and chromosomal anomalies. Also it can cause the baby to be smaller for its gestational age and can cause preterm labour. Very rarely , the baby can have neonatal thyrotoxicosis due to transfer of thyroid stimulating antibodies from the mother. Thus a flare can cause increased perinatal mortality and morbidity. I will make sure that the patient understands all this information and reinforce my counselling with patient information leaflets for thyrotoxicosis in pregnancy.

I would try to minimize the risk by offering the lady multidisciplinary care in Obstetric medicine clinic and by following the hospital protocol for management of women with past history of thyrotoxicosis. I would repeat her thyroid function tests with the view of adjusting the dose of antithyroid medication if required and measure the level of thyroid stimulation antibodies in her blood. If these levels are high, I would send out a paediatric alert to watch out for neonatal thyrotoxicosis. I would inform the lady to watch out for the side effects of propylthiouracil especially sore throat indicating granulocytopenia. I will arrange for her to have regular scans to look out for IUGR. Also I would warn her of the signs and symptoms of Thyroid crisis and CHF. If any of these develop, I will manage them proactively and start beta blockers if required. Also, in the third trimester I would look out for signs of fetal tachycardia which might indicate fetal thyrotoxicosis.

The thyoid function tests need to be repeated postnatally and and dose adjustments made if require. Also I would need to inform the neonatologists to look out for signs of neonatal thyrotoxicosis or neonatal hypothyroidism due to high does of antithyroid medication. I will inform the lady that she can continue to breast feed. The baby might reqire thyroid function and thyroid stimulation antibody titre checked if it is symptomatic. I would send a letter to the GP informing him of the outcome of pregnancy and requesting him to repeat TFTs in 6 weeks time. I will also advise the lady to attend preconceptual counselling if she wishes to have more children.
Posted by hoping ..
Wed Jan 23, 2008 08:13 pm
I will inform patient that majority of pregnancies have good outcome if appropriately treated. Grave\'s disease tends to improve as pregnancy proceeds but carries risk of flareup in labour and postdelivery which carries high morbidity and mortality especially if thyroid storm. It increases risk of miscarriage. It can affect baby\'s growth. There is 10% risk of thyrotoxicosis in fetus this can lead to goitre. Rarely cardiac failure and stillbirth can occur. Anti thyroid drugs in high doses can lead to hypothyroidism in fetus.
This patient should have increased surveillance in pregnancy. She should be well informed about risks associated to her and baby. She should be told that majority will have good outcomes if good control of thyroid function is acheived.She should be reviewed ideally in joint obstetric and endocrine clinic, otherwise liase with endocrinilogist. Anaesthetic review should be arranged as enlarged thyroid can cause difficult intubation if required. Her thyroid function should be assessed clinicaly and biochemicaly at least every trimester. Her pulse and fetal heart rate should be documented at each visit.More frequent assesment may be warranted if symptoms or signs suggest worsening. Propyl thiouracil should be adjusted to minimum effective dose to reduce risk of neonatal hypothyroidism.Serial growth scans should be done to monitor fetal growth. Perinatal referal should be sent to neonatal unit so that neonatal assesment and management are planned. Plan should be documented in patients notes and alerts should be marked in labour and postnatal notes.
Staff involved in her care should be aware of high risk of flare-up as this will help early diagnosis. Sometimes irritability and aggressiveness can be mistaken for poor behaviour and delay in diagnosis and treatment. Thyroid function tests should be repeated as dose of antithyroid drugs has to be increased frequently after delivery.Any clinical features indicating thyrotoxicosis should be promptly investigated and managed .Her vitals especially pulse and blood pressure should be clearly documented to avoid risk of stroke and cardiac failure.She can breastfeed according to her wishes.Baby should be assesed by paediatricians.
Posted by Lekshmi B.
Wed Jan 23, 2008 09:46 pm
a) I will tell her that relapse of the disease can occur in early second trimester, but majority will improve in late second and third trimester, thereby requiring less medication and in 30% cases treatment can be discontinued. However there is a risk of relapse in postnatal period. Maternal risks include symptoms and signs related to thyrotoxicosis like anxiety palpitation, diarrhea, exophthalmos, tachycardia etc. Cardiac failure can occur has a result. Mother is also prone to develop pre eclampsia, placental abruption and preterm labor. Thyroid storm can develop especially in labor and is associated with a mortality rate of 25 % .Another complication is polyhydramnios and obstructed labor secondary to fetal goiter. Treatment with propyl thiouracil (PTU) can also result in side effects like agranulocytosis and hepatitis. Fetal risks include prematurity, low birth weight and growth restriction. Risk of fetal hyperthyroidism is there which can present as fetal tachycardia, cardiac failure, hydropsfetalis and still birth. Craniosynostosis, exophthalmos and fetal goitre may develop. There is also risk of neonatal thyrotoxicosis in 10% cases which has a 25% mortality rate. Placental transfer of PTU to fetus can also result in transient hypothyroidism in newborn which is self limiting. I will also give her information leaflets.
b) I will estimate her free T3, T4 levels and Thyrotropin receptor antibody status to assess her current disease status. If hyperthyroid management will be planned with the help of endocrinologist and neonatologist. Dosage of PTU will be adjusted and maintained at the minimum level to keep free T4 levels at the upper limit of normal. If thyroid stimulating antibodies (Ab) are positive risk of fetal thyrotoxicosis is high. Hence careful fetal monitoring will be done by daily fetal movement count, serial symphysio fundal height measurement and fetal heart rate recording. Ultrasound scan will be done to look for fetal goitre and also to assess cardiac function and growth of fetus. If suspicious, cordocentesis will be offered to confirm fetal thyrotoxicosis which will require maternal anti thyroid treatment. If mother is euthyroid thyroxin replacement will be given along with anti thyroid drug. Maternal symptoms of tachycardia will be treated with beta blockers after counseling about the risk of fetal growth restriction TFT will be done at 4 to 6 weekly intervals using pregnancy specific ranges to rule out hypothyroidism. Thyrotropin receptor Ab will be tested again in third trimester to predict risk of neonatal thyrotoxicosis. Failure to respond to medical therapy is an indication for surgery in second trimester
c) If the antenatal thyroid stimulating Ab in late pregnancy is high, cord blood TFT screening will be done and repeated at one week to rule out neonatal thyrotoxicosis. Drug induced hypothyroidism can also be detected by this. Detailed examination by neonatologist will be done to assess cardiac function of the new born. Maternal symptoms may worsen in the postpartum period and hence she needs careful monitoring and readjustment of drug dosage. Breastfeeding will be encouraged. Contraceptive advice will also be offered.
Posted by S M.
Wed Jan 23, 2008 11:21 pm
A 25 year old primigravida with a history of Graves disease treated with propylthiouracil has been referred to the antenatal clinic at 12 weeks gestation. (a) What will you tell her about the risks associated with Graves disease? [9 marks]. (b) Justify your modifications to her antenatal care [7 marks]. (c) Justify your post-natal care given that she had a spontaneous vaginal delivery [4 marks].

a) There are both maternal and fetal risks associated with grave\'s disease. If the disease is not well controlled she may develop goitre, throid storm or heart failure. If the goitre extends retrosternally this could lead to difficulties with intubation if she had respiratory arrest or needed a general anaesthetic. The maternal antithyroid antibodies cross the placenta and can lead to fetal thyrotoxicosis. The fetus is at risk of miscarriage, intrauterine growth restriction, premature delivery and stillbirth. I will provide her with a patient information leaflet.

b) She should be seen in a combined clinic by an obstetrician and physician because she requires specialist care and follow up since grave\'s disease in pregnancy can lead to an increase in maternal and fetal morbidity and mortality. Regular antenatal surveillance is required for early identification of problems and early intervention. Maternal blood should be taken for free T4, free T3 and TSH to determine if she is chemically euthyroid. The thyroid function test should be repeated every 6 weeks to determine whether the disease is under control or the medication needs to be altered. A detailed anomaly scan should be done at 20 weeks to identify structural anomalies. Serial ultrasound scans should be done for growth, liquor volume and dopplers. This will allow for early identification of growth restriction and change in fetal wellbeing.

c) Maternal blood for thyroid function test to determine whether the medication needs to be altered. Breast feeding can be allowed since only low doses of the propylthiouracil will appear in the breast milk. Effective contraception should be used since preconception counselling or planning is required before conceivoing again to enable good maternal and fetal outcomes. The neonate need to be seen by the paediatrician or neonatologist since there is a risk of neonatal thyrotoxicosis.
Posted by Azza S.
Thu Jan 24, 2008 02:50 am
I will tell her that with treated disease most of the pregnancies are associated with good out-come. Even with well controlled disease there is risk of thyrotoxicosis in 2 out-of 100 cases, this is due to the anti-bodies [IgG] which can cross the placenta. The drug is not teratogenic, but it reach the fetus and can cause hypothyroidism. An active disease is associated with increased risk of fetal loss, and adverse out-come, particularly miscarriage and intra-uterine growth restriction. The disease is not an indication for operative delivery, and not a contra-indication to breast-feeding. Pregnancy usually not affect the disease.
Multidisciplinary approach with involvement of endocrinologist, pediatrician and obstetrician-led care. Thyroid function test in each trimester ?more frequent if not well controlled- . The minimum needed does should be used. There no place for block and feed-back therapy. Serial ultra-sound scans are needed for follow-up of growth and fetal goiter There no place for radio-active investigations during pregnancy.
Auto-immune diseases may exacerbate in post partum . Breast-feeding is not contraindicated .Contraception should be advised. The neonate will be investigated for transient hypo or hyper-thyroidism. Pre-conception advise should be requested before next pregnancy.
Posted by Srivas  P.
Thu Jan 24, 2008 03:17 am
a) Well controlled Graves Disease is likely to be uneventful in pregnancy and natural course is a gradual improvement towards late pregnancy due to decreasing anti TSH receptor antibody levels with possible need even for decrease in dose of antithyroid drugs. I will tell her uncontrolled Grave?s disease can have severe fetal, neonatal and maternal side effects and increased perinatal and maternal mortality. There is also risk of intrapartum and post partum exacerbation in her condition.

Side effects of fetal thyrotoxicosis are IUGR, craniosynostosis, exophthalmos, heart failure, hydrops fetalis, prematurity and fetal death. The neonate has risk of thyrotoxicosis. Both neonatal and fetal thyrotoxicosis carries 25% mortality. The antithyroid drugs prescribed for her too carry risks. These include fetal hypothyroidism in 5-10% cases and Goitre. Sometimes Goitre may be big enough to cause dystocia in labor. Maternal side effects with thionamides include nausea, vomiting, diarrhea, drug rash and serious side effect like hepatitis and agranulocytosis. Rarely Aplasia Cutis can occur with PTU. Neonate is also at 10-20% risk of hypothyrodism due to excess maternal antithyroid drug and is usually transient and clears up by 1-5 days after delivery. Fetal hypothyroidism too can occur , rarely causing goiter. Percutaneous Fetal blood sampling maybe needed to assess fetal thyroid hormone levels.

Maternal risks include miscarriage, preterm labor, Preecclamsia and abruptio placenta. Serious complication include occurrence of thyroid storm, Heart failure which are more likely with uncontrolled thyrotoxicosis. Thyroid storms have 25% maternal mortality risk and more likely during intrapartum or immediate post partum periods.

b)She would need multidisciplinary care involving Physician, Senior Obstetric consultant, neonatologist, head and neck surgeon, senior midwife due to risk of increased perinatal and maternal mortality in uncontrolled cases. Aim of care is directed to controlling her hyperthyroidism with antithyroid drugs, modulating correct dose with periodic Thyroid function tests?monthly with newly diagnosed disease or every trimester in well controlled disease. Clinical signs and symptoms of hyperthyroidism overlap with pregnancy symptoms. Hence biochemical values are best used for monitoring control. FreeT4, Free T3 and TSH levels are monitored. She needs to be educated about importance of compliance with drugs. Her WBC count needs to be taken monthly and any complaints of sore throat which may suggest agranulocytosis needs to be investigated and if so the antithyroid drug stopped. LFT should also be done. Her condition may sometimes improve with pregnancy and doses of antithyroid drugs may then need to be diminished in consultation with her physician.

Fetal thyrotoxicosis can be predicted by high maternal TSH receptor antibodies in early pregnancy and should be repeated at 6 months again to predict likelihood of neonatal thyrotoxicosis. USG should be done at 20 wks at fetal medicine units as it can indicate this potentially serious condition by presence of FGR, persisting fetal heart >160/mt and Goitre. Other findings could be hydramnios, fetal hydrops, and fetal craniosynostosis. This can be treated by Block and replace regimens. This means antithyroid drugs is given to control fetal thyrotoxicosis and to keep mother euthyroid, she is given thyroxine replacements as this does not cross the placental barrier. She is also likely to have IUGR because beta blockers given to control her symptoms also may cause IUGR.

If she does not respond to medications or she has significant goiter causing dysphagia, respiratory distress she should have surgical review for possible thyroidectomy and also have senior anesthetic review as uncontrolled graves disease is a high risk for thyroid storms and heart failure.

Fetal surveillance should be meticulous due to risks of IUGR, fetal death and should be started from 24-28 weeks with biweekly BPP, CTG and fetal growth charts.

Information booklets, details of internet links like patient.uk which can educate her about her condition should be given.

c) Cord blood should be tested for FT4, FT3, TSH levels and should be repeated at 3 and 7-10 day as neonatal thyrotoxicosis can present later. Maternal antithyroid drugs clear from fetal system in 1-5 days when signs of fetal thyrotoxicosis appear as transplacentally transferred antithyroid antibodies may persist for upto 3 weeks. Hence the neonate needs careful follow up with neonatologist for this period as mortality with untreated neonatal thyrotoxicosis is up to 25-50%.

Mother may have postnatal flare of antibody levels and the drug if decreased or stopped will need to be restarted. TFT should be repeated and watch for signs and symptoms of thyroid storms. After discharge, any palpitation, disorientation, fever should need to be immediately reported. She should have follow up appointment at 1-2 months to see persisting hyperthyroidism which may need to be distinguished from postpartum thyroiditis. She should also be emphasized the importance of neonatal follow up.

She can be encouraged to give breast feeding as the antithyroid drugs cross breast milk in low levels.
Posted by Reiaz M.
Thu Jan 24, 2008 09:12 am
Most women with Graves disease will have an uncomplicated pregnancy with good outcome.
Patients who are symptomatic may experience an alleviation in their symptoms in the third trimester with an exacerbation in the post partum period. She should be counseled that uncontrolled hyperthyroidism can lead to cardiac failure and death and the importance of complaince with medications should be emphasised.
The size of the goitre may increase in pregnancy and may be associated with airway obstruction and dysphagia.
Propylthiouracil crosses the placenta and can result in fetal hypothyoidism in about 10% of cases. The maternal risks of propylthiouracil include rash, gastrointestinal disturbances and agranulocytosis. She should be advised to report any sore throat immediately.
Even if the patient is euthyroid there is still the risk of fetal hyperthyroidism of about 10%. This is because anti TRH antibodies are present in maternal plasma and can cross the placenta. Fetal hyperthyroidism can result in fetal gitre, exomphthalos and cardiac failure resulting in hydrops. Craniosyntosis is also a recognised complication of fetal hyperthroidism.
There is an increased risk of fetal growth restriction and still birth.
The neonate is at risk of developing hyperthyroidism.

b)
This patient will be managed in conjuction with an endocrinologist.
Free T3 and T4 levels are measured at least monthly to assess biochemical thyroid status. This ensures that antithyroid medications are used at appropriate doses.
Propythiouracil shoul be continued to attain biochemical euthyroidism. The lowest dose required should be used to decrese the risk of fetal hypothyroidism.
If the patient experiences symptoms of hyperthyroidism a beta blocker eg propranolol can be used once the patient is counseled about the increased risk of fetal growth restriction.
Patients with exopthalmos should be referred to the opthamologist for eye care.
At each antenatal appointment she is assesed for symptoms of hyperthyroidism. Fetal tachycardia may be an indication of fetal hyperthyroidism. She should have serial USS to assess growth and to rule out any fetal anomalies such as fetal goitre.
She should be referred to the anesthesist prior to labour as there may be difficulty in obtaining an airway if general anesthesia is needed. A cesarean section may be needed in cases of ffetal gitre resulting in hyperextension of the fetal neck.
The neonatologist should be made aware of the possibility of neonatal hyperthyroidism.

c) There is a risk of thyroid storm and vigilance should be kept for signs of fever, tachycardia, hypertension. Propylthiouracil should be continued and although it is present in small amounts in breast milk the effects are minimal and breast feeding should be encouraged. The neonate should be monitored for signs of hyperthyroidism which can develop up to a week after delivery. She is advised on contraception and of continuing risks in future pregnancy.
Posted by M M A.
Thu Jan 24, 2008 01:19 pm
(a)
We inform her that this is an autoimmune disease and it has maternal and fetal implications, the risks depend on her state and they occur more often if the disease is inadequately controlled.

The mother is at increase risk of fetal loss (miscarriage), fetal intrauterine growth restriction and preterm labour.

We tell her that the disease may deteriorate in the first trimester because of similarity of a- subunit of HCG and TSH, also due to poor absorption of drugs.

PTU is safe in pregnancy but there are risk of developing agranulocytosis which require discontinuation of the drug.

Thyroid storm can occur at time of stress like labour , operative delivery or infection , it has low incidence but if occur it can lead to maternal heart failure and even maternal death.

We explain to her that pregnancy has no effect on the disease, still she may have obstructive symptoms that require surgery with risk of anaesthesia and thyroid storm also.

We inform her that there are fetal risks like low birth weight and still birth. The fetus can develop hyperthyroidism even if the mother has the disease previously because of the persistence of thyroid stimulating antibodies which can pass tranplacental. Fetal hyperthyroidism can cause fetal goiter and heart failure.

Fetal hypothyroidism can occur also due to over treatment and can cause goiter with or without fetal mental retardation.

We reassure her that generally the prognosis is good in well controlled patients.

(b)
The aim is to achieve good maternal and fetal well being.

If she is already on PTU , there is no need to discontinue the drug but it should be kept to the minimum dose that keep the patient clinically well and biochemically euthyroid. We advise her to report early if she develop sore throat or mouth ulceration as these are features of agranulocytosis and drug should be stopped or changed.

Clinical assessment is usually of limited value because many of the symptoms of hyperthyroidism can occur normally in pregnancy like palpitation, sweating and heat intolerance. Also signs like persistent tachycardia , tremor, lid-lag and exophthalmos do not necessary reflect current hyperthyroidism.

Thyroid function test also has limitations in pregnancy because of increase TBG, we need to measure free T4 and free T3 and to adapt levels specific to each trimester in pregnancy, we do TFTs every 4-6 weeks in uncontrolled cases. If the disease is controlled , we repeated it in each trimester.

We also do serial general assessment for her including her weight , pulse, tremor with eyes and neck examination.

Serial US examination is needed to detect fetal goiter and fetal growth, this is usually after 24 weeks of gestation because the thyroid stimulating antibodies cross placenta after that time.

Also the fetus monitored for signs of hyperthyroidism like increase fetal movement and fetal tachycardia, we do regular auscultation for fetal heart.
We may need to increase the dose of maternal Anti-Thyroid drugs with addition of thyroxin.

We involve an endocrinologist, pediatrician , fetal medicine specialist and anaesthetist in her care.

Beta blockers can be used to control symptoms of anxiety and tremor, propranolol is the drug of choice.

Radioactive iodine is contraindicated because of risk of fetal thyroid destruction.

If surgery needed, it can be done in the second trimester to minimize risk to the fetus.

Frequency of antenatal visit will be as normal antenatal care but it should be more frequent if the disease is uncontrolled.

Provide patient information leaflet.


(c)
Breast feeding is not contraindicated. The fetus will need regular TFTs because small amount of PTU can pass into breast milk.

Evaluation of the neonate by neonatologist for goiter, hypo- or hyperthyroidism development

In addition, the mother will need re-evaluation and re-adjustment of medication.

We give advice about contraception and planning of future pregnancy.
Posted by Hala T.
Fri Jan 25, 2008 01:00 am
Graves? disease is an autoimmune disorder caused by TSH receptor-stimulating antibodies and often improves during pregnancy, especially in the second& third trimesters. In first trimester, possibly related to HCG production exacerbation may occur. Thyroid stimulating antibodies may cause, fetal or neonatal thyrotoxicosis .also the mother with poorly controlled thyrotoxicosis may lead to a thyroid crisis (storm) &heart failure, particularly at time of delivery. Rarely retrosternal extension of goiter may cause tracheal obstruction which is a particular problem if the patient need to be intubated .PTU cross the placenta in high dose & may cause fetal hypothyroidism and goiter but not grossly teratogenic. The risk also may develop low birth weight, preterm delivery and still birth, craniosynostosis to the fetus.
Antenatal care should monitor free T3&T4 to avoid maternal hypothyroidism and the dose of anti thyroid drugs should be reduced to lowest effective dose-ensure biochemically&clinically euthyroid with TFT/1-3 month. Serial fetal ultrasound to asses fetal growth, F.H.R, fetal goiter. Thyroidectomy is rarely indicated in pregnancy, but if required, is best performed in the second trimester.
Post natal care to monitor and treat postpartum exacerbation and evaluate neonate for goiter, hyper or hypothyroidism by pediatertian. Breast feeding not contra-indicated as PTU secreted in very low concentration in breast- milk
Posted by Dr seema jain J.
Fri Jan 25, 2008 04:31 pm
a) I will inform this lady that though Grave?s disease being an autoimmune disease entails maternal as well as fetal risks,if well controlled she can expect a good outcome of the pregnancy.The chances of miscarriage are increased.Pregnant mothers can develop hypertension (mainly systolic) and can also go into preterm labour.Though there is a chance of it being ameliorated in the 2nd and 3rd trimester,it can exacerbate postpartum.Complications like cardiac failure and thyroid storm can be life threatening.
The main concern with Grave?s disease is of fetal thyrotoxicosis since the antibodies cross the placenta.I will impress upon her the fact that sometimes inspite of normal thyroid levels in the mother ,the baby can be affected.Though there are no reported cases of any congenital anomalies because of the disease,chance of prematurity and stillbirth is increased.Intrauterine growth retardation of the baby can occur.Due to advanced bone maturation,craniosynostosis(fusion of skull bones) can occur.Babies can develop hydrops and in some cases may even succumb.On the other hand,the drug used for the treatment (PTU) is non teratogenic but can cause fetal hypothyroidism and fetal goitre.Neonatal thyrotoxicosis also is a known complication.Postpartum thyroiditis is common in women with Grave?s disease.

b)Since she is already on treatment,I will do her thyroid function tests every 4-6 weeks with the aim of using the least possible dose to maintain the values within the normal reference range for pregnancy.I will emphasise to her the importance of being compliant with the treatment to ensure the best outcome.In case she is symptomatic(tachycardia\\tremors),I will use beta blockers(propranolol 20 mg 8hrly).If there are any clinical findings suggestive of intrauterine growth retardation,I will do serial growth scans while also looking out for fetal goiter ,fetal tachycardia or hydrops.Cordocentesis will be recommended if fetal hypothroidism or thyrotoxicosis is suspected.Her complete pregnancy care will be done in liaision with an endocrinologist and an expert in fetal medicine.
c)Women with Grave?s disease tend to have exacerbation of the disease postnatally so I will warn her about it and ask her to get back if symptoms like palpitations,tremors occur.In such a situation I will treat her with beta blockers.I will check her thyroid function tests after 4 weeks to check for euthyroid status.Very rarely women can develop thyroid storm for which she will be transferred to an intensive care unit.Adequate hydration,thermoregulation,treatment of anemia and infection,beta blockers and steroids form the cornerstone of management of thyroid storm.Breastfeeding will be encouraged since very little amount of PTU is secreted in breast milk.The newborn?s thyroid function status will be checked immediately after delivery and after a week-these babies are best managed by a neonatologistPostpartum thyroiditis will be looked out for and treated with beta blockers if needed.



Posted by Farina A.
Fri Jan 25, 2008 11:23 pm
I would like to reassure her that most of the pregnancies with this disease have good outcome, however uncontrolled disease can lead to thyroid storm, cardiac failure and arrythmias. If there is enlargement of the gland it can obstruct airways and may need surgical intervention. I would also like to tell her about the 1% risk of fetal, neonatal thyrotoxicosis, specially in those who have active disease in pregnancy. Propylthiouracil can cross the placenta but is not harmful to the baby and she should continue her treatment if she feels well on it. Graves disease can deteriorate in first trimester not due to pregnancy but due to excessive nausea vomiting and decrease compliance to treatment due to fear of teratogenesis. The disease usually improves during the second and third trimester. Uncontrolled disease can result in miscarriage, IUGR, preterm birth and low birth wt. Well controlled disease has a good pregnancy outcome. She should be provided with written information.

During her antenatal care her TFT should be check in each trimester and if normal there is no need of increasing frequency of her antenatal visits. However more frequent testing may be required in poorly controlled cases. Pulse tachecardia, palpitation, tremours, lid lag, exophthalamous and goitre are features distinct from a normal pregnancy which should be checked at each visit. Keeping in view the 1% risk of fetal thyrotoxicosis, excessive fetal movements, fetal tachecardia and fetal goiter at ultrasound, maternal propylthiouracil may be increased to a dose reaching to treat the fetus along with maternal supplementation of thyroxin (if needed). Otherwise lowest possible dose of propylthiouracil is adjusted according to the results of TFT (adjusted according to the normal ranges in pregnancy). Prescription of beta blockers for palpitations is safe. Regular growth assessment (every 4wks) of the fetus from 24wks of gestation, and earlier detection and treatment of fetal thyrotoxicosis improves the outcome. Surgical intervention is safe in second trimester, however radioactive iodine is contraindicated whether therapeutic or diagnostic due to its risks of fetal congenital anomalies. Corticosteroid administration for a preterm labour is beneficial. Multidisciplinary approach with an obstetrician, physician, paediatrician and fetal physician may be required to manage the disease. The disease rarely effects the timing and mode of delivery unless there are signs of fetal compromise.

Postnataly woman is at risk of a relapse, as pregnancy induced immunosupressed state is over and the antithyroid antibodies can activate the disease again. Her physical sense of well being and TSH, fT3, fT4 levels can give an idea about alteration in therapy. Neonate may not show the features of thyrotoxicosis in one to two weeks of life. The woman should be informed about the signs of poor feeding, jitterreness and tachecardia in the neonate to consult earlier with the paediatrician. Breast feeding is encouraged as only 0.07% of the drug is secreted in the breast milk. Adequate contraception is advised hormonal contraception not contraindicated.
Posted by PAUL A.
Fri Jan 25, 2008 11:23 pm
a) Graves disease is an autoimmune disease with autoantibodies that attack the thyroid - thyroid stimulating hormone receptor antibodies. It can cause hypo or hyperthyroidism. It is an important cause of maternal and perinatal morbidity, which can be reduced by good obstetric care. She should be given written information regarding Graves disease and pregnancy (1) .

Propylthiouracil is an antithyroid drug used for hyperthyroidism. She should be informed that if her thyroid function is well controlled on propylthiouracil (PTU) she should continue this as there is little evidence of teratogenicity and uncontrolled hyperthyroidism is more dangerous to her and the fetus. The lowest dose possible should be used (1) .

Pregnancy usually has little effect on Graves disease or may lead to improvements. Thyroid eye disease, such as proptosis is usually unaffected. Goitres may increase in size. There is increased risk of intrauterine growth restriction (IUGR) , perinatal mortality and pre-term delivery in undertreated hyperthyroidism (1) ? risk of fetal / neonatal thyroid disease .

b) She should referred to a specialist obstetric clinic with an endocrinologist. Symptoms of hyperthyroidism can be similar to normal pregnancy symptoms such as tachycardia so thyroid function should be checked in every trimester (1) - free thyroxine levels should be normal, TSH can be raised in pregnancy is TSH raised or lower in pregnancy? . Regular ultrasound scans to assess growth and liquor volume (1) should be done as IUGR is more common. Steriods should be considered in view of the risk of preterm delivery to reduce the risk of respiratory distress syndrome this type of prophylactic treatment is totally inappropriate. At what gestation age will you administer and why? (-1) . She should deliver in a unit with obstetric and anaesthetic services in case of problems such as thyroid storm. Neonatal input will be needed to assess the neonate what should be assessed? .

c) She will need routine postnatal care, such as advice regarding contraception, assessing for thromboembolic risk, perineal care and assessment for postnatal depression. She should be advised that breastfeeding is not contraindicated (1) on PTU. She may develop postpartum thyroiditis (1) and will need thyroid function tests and follow up with the endocrinologist. The neonate is at risk of thyrotoxicosis due to maternal thyroid stimulating antibodies and so will need neonatal assessment and follow up (1) . This presentation can be delayed due to PTU clearance.
Posted by PAUL A.
Sat Jan 26, 2008 12:46 am
a)Graves disease has maternal,fetal and neonatal complications due to TSH antibodies which crosses placenta.
Women can present with worsening of thyrotoxicosis symptoms such as loss of weight in spite of good appetite,history of palpitation,tremors,heat intolerance and tiredness.some of the evidence shows there could be increased rise risk of miscarriage.Most of the signs are difficult to diagnose as they are normally present in pregnancy.
In severe thyrotoxicosis there could be thyroid storm,hypertension and heart failure (1) you need to make it clear this is in poorly controlled disease .She could have goitre with pressure symptoms (1) .
It can also cause pre term labour,grwth restriction and still birth (1) .
Fetal risks are mainly are IUGR, stillbirth ? not fetal risks? due to antibodies crossing the placenta and causing fetal thyrotoxicosis (1) .This can lead to fetal tachycardia and intra uterine growth retardation restriction .It can develop goitre and cause polyhydramnios.Very rarely it can cause hydrops and fetal death.
These effects are seen after birth with poor feeding,growth and sleep.

you started with a good structure ? maternal, fetal, neonatal risks. However, you did not stick to this plan

b)Explain the importance of close monitoring and need for frequent antenatal visits.Care plan in documented and she is seen in the joint medical clinic with the physician and obsterician.
Dating scan is done to confirm the gestation you were asked about modification ? every woman should have a dating scan .Booking bloods include Free T3,T4,TSH and TSH antibodies (1) . Bloods should be done every 4-6 weeks which ones? .
Propylthiouracil or carbimazol ?? is she on carbimazole? You should answer the question asked should be continued.Reassure that they are safe in pregancy and breast feeding.Fetal tachycardia needs review by the team to adjust the dosage of the medication ?? will you adjust drug dose based on fetal heart rate? .
Sometimes it can cause fetal hypothyroidism.If symptomatic with palpitation propanolol is the drug of choice.
Anamoly scan at 20 weeks as usual and follow up growth scan at four weekly interval will monitor fetal growth (1) .Other treatment for goitre can be surgically treated NO ? avoid surgery during pregnancy if necessary but radioactive treatment is contraindicated.
Educating women to monitor fetal movements in vital.Letter to the neonatologist for the management after delivery is mandatory.
Induction and delivery as normal.
Leaflets are provided with care plan.

c)After delivery neonatologist should review (1) the baby for any signs of thyrotoxicosis such as poor feeding,growth and sleep.Bloods are taken for free T3,T4,TSH and TSH antibodies one week after birth.Breast feeding is safe (1) with both the medications.Sometimes women can present with postpartum thyroiditis (1) so if symptoms get worse,should be reviewed by GP.
Posted by PAUL A.
Sat Jan 26, 2008 01:46 am
(a)What will you tell her about the risks associated with Graves disease? [9 marks].
I will tell her hyperthyroidism usually (95 %) due Graves Disease the question tells you she has Graves but you are telling her there is a 5% chance she does not?? . it is essential to maintain euthyroidism in pregnancy as uncontrolled disease associated with maternal and fetal complications. Thyroid storm is life-threatening condition which is induced by excessive release of thyroid hormones (1) . Retrosternal extension of goiter (1) may cause tracheal obstruction and difficult intubation. Maternal Hypertension is also a risk which may be may be followed by congestive heart failure. Considering fetal risk premature labour is a recognized complication with Graves?s disease, also growth restriction and still birth (1) are increased risk. Baby may have Exopthalmos which is bulging of the eye anteriorly out of the orbit .Fetal or neonatal thyrotoxicosis (1) occurs in 1-10% of babies with history of maternal Graves?s disease, mortality may reach 50% if it is not treated. Antithyroid drugs (Prophythiouracil) can cause nausea, vomiting, diarrhea and agranulocytosis and so a sore throat thoroughly investigated.higher dose of this drug can cause fetal hypothyroidism and goiter. Fetal goitre can cause polyhrdamnios and obstructed delivery .The condition is also associated with craniosynostosis (1) and intellectual impairment. I will provide written information (1) .

(b) Justify your modifications to her antenatal care [7 marks].
Antenatal care should be Multidisciplinary management which involves physician, obstetrician, Pediatrician and GP. As she has treated for thyrotoxicosis, it is usual to aim for free T4 at the upper limit of normal. A thyroid fuction test (TFT) should be perfomed and if she is hyperthyroid control with propylthiouracil as rapid as possible and the maintain control ?? meaning. The question says she is on PTU .
TFT should to be perfomed every 4-6wks (1) to avoid maternal hypothyroidsm patient should be warned that the development of a sore throat or mouth ulcers necessities cessation of therapy and urgent medical attention because of the risk of agranucytosis (1) .Betablockers can be used initially if she has the symptoms of tachycardia, sweating and tremors. Serial Growth ultrasound scans (1) should be undertaken to check for growth,heartrate and fetal neck. to monitor the growth.

(b)Justify your post-natal care given that she had a spontaneous vaginal delivery [4 marks]
.Post partum exercebation of hyperthyroidism (1) is the risk, therefore thyroid function should be monitored and tratretment may be needed. Pediatrician should be made aware for treated cases and neonate should be assessed for goiter and hypo or hyperthyroidism (1) . Cord blood should be taken for TFT. Breast feeding is not contraindicated as both drugs (PTU, Carbimazole) is she taking carbimazole? are expressed in breast milk but have little effect on thyroid function If the mother is breast feeding then it should be repeated in regular intervals. In the case of fetal thyrotoxicosis POST-NATAL care: do you have a FETUS postnatally??? , the mother is given antithyroid drugs, combined with thyroxine .Neonate should be treated antithyroid drugs. Until maternal antibodies are cleared. A follow-up appointment should be arranged to assess the thyroid status.
Posted by Azza Shawky E.
Sat Jan 26, 2008 05:03 am
a)what you tell her about the risk assocaited with Graves disease. (9)m
.Iwill inform her about Graves diease is autoimmune disorder caused by autoimmune thyroid stimulating antibodies(IgG antibodies).This disease typically can be remite in second and third timister and flare may occur after delivary. frist trimester disease excerbated by high level of HCG. Graves disease associated with hyperplastic goiter and exophthalmos.. Iwill explain to her maternal and fetal complication assocaited with uncontrolled disease . this disease can cause maternal hypertension,heart failure and thyroid storm(25%maternal mortality )espscailly if ocur after delivary. Retrostenal extension may cause tracheal obstrction and diffcult intubation . Graves disease can be assocaited with premature labour, growth restriction and still birth Propylthiouracil(PTU) most commen used drug for treatment of Graves disease it reduce the titer of TSH receptor antibodies and direct influence the aetiology of greves disease and most patient need treatment for 12-18 months . PTU can cross the placenta and has minimal teratogenic effect and the relationship previously found between aplasia cutis of scalp and this drug is unlikly exit. Iwill tell her about side effect of PTU as vomiting, diarrhoea agranulocytosis,fetal and neonatal thyrotoxicosis 1-10%of babies of mother with current or previous Graves disease,Transplacental passage of thyroid stimulating antibodies present with fetal tachycardia,IUGR.,fetal , neonatal goiter and mortality increase to 50%. Patient should warned that if she develop sore throat or mouth ulceration at any time to stop the antithyroid drug immediatlly and urgent medical attention because the risk of thyrotoxicosis. woman should given leaflet and written information.
b)Justify your modification of her antinatal care.(7)m
Antenatal care of this woman should be every month and thyroid function test T4-T3-TSH should done every 4-6weeks to avoid maternal hypothyroidism. Serial ultrasound scan should undertaken to check for growth , heart rate and fetal neck . the dose of antithyroid drug should reduced to lowest effective dose. Beta blocker can be used initially to improve symptom of tachycardia , sweating and tremors. thyroidectomy rarely required but if required it is safely performed in second trimister. It is usually done for woman with obstructive symptom as dysphagia or stridor and those with proven malignancy. Radio iodine therapy is contraindicated during pregnancy and post partum. Multidisplinary team should be invoved in antenatal care of this patient as obstetrcain, endocrinologest, neonatologist. In case of fetal thyotoxicosis the mother is given antithyroid drug combind with thyroxine if she is euthyroid.
c)Justify your postnatal care given that she had spontanous vaginal delivary(4m)
This patient should have routine postnatal care . Postpartum thyroiditis can occur up to one year after delivary and can manifest by high or low T4 level and this need to be follow up with endocrinologist. Neonatologist should be informed to evaluate the neonate for goiter,hyperthyroidism or hypothyroidism and thyroid function test on cord blood at regular interval if breast feeding.Iodine treatment is contrandicated during breast feeding also radio iodine scan contraindicated but may be undertaken if breast feeding stop for 24 hours,. contraception should be used for 4 months after radio iodine treatment. Breast feeding is not condraindicated as very low concentration PTU in breast milk.
Posted by PAUL A.
Sat Jan 26, 2008 11:08 pm
a) Grave disease is an auto-immune disease with the presence of thyroid stimulating antibodies. She can be ensured ? reassured that pregnancy is associated with disease improvement. However she should be compliance to her medication as she is at increased risk to develop thyroid storm if her thyroid hormone level is uncontrolled (1) . She is also at increased risk to develop heart failure if she has tachycardia or if her heart beat is not regular (arythmia). She might have a retro-sternal extention of thyroid gland which could lead to airways obstruction and difficult intubation (1) . Side effect of anti-thyroid treatment like agranulocytosis (1) could lead to maternal sepsis and mortality if not detected earlier. Trans-placental passage of thyroid stimulating antibody can occur and lead to fetal thyrotoxicosis (1) . The patient should now that this condition is associated with 50% neonatal mortality if left untreated. She should be made to understand that she is at higher risk of having miscarriages if her Graves disease is uncontrolled (1) . There is also risk of fetal hypo-thyrodism if she is over treated with anti-thyroid drug. In this case the baby might have some intellectual impairment in the future. Her risk of having low birth weight baby is also higher. The risk of her having intrauterine death and preterm baby is also high what is ?high?? Why not ?higher?, which is a relative assessment? . Leaflet information (1) , futher follow up and contact detail should be provided.

b. Multi-displinary input is required involving endocrinologist and deontologist . Consultant led care is essential for optimal outcome of mother and baby. Dating scan and detail scan should be arranged to look for evidence of fetal goiter or feature of fetal thyrotoxicosis what are the ultrasound features? . The aim of treatment is to give minimal dose of anti-thyroid drug to achieve euthyroid condition (1) (higher normal level of thyroid hormone). This is important to avoid fetal goiter and fetal hypo-thyrodism. Monitoring of side effect of anti-thyroid drugs is important; any evidence of agranulocytosis, vomiting or diarrhea should be noted. B blocker may be prescribed to control maternal tachycardia or presence of arthymia. The thyroid function (TFT) should be monitored monthly if just started medication. But if the TFT level has been stabilized, measurement is only required if clinically indicated NO ? should be measured in every trimester . Growth scan should be arranged monthly (1) . Mode and time of delivery is obstetric indication ? meaning .
c. The risk of post partum exacerbation is higher (1) , prompt treatment should be ubdertaken is there is evidence of exacerbation. Cord blood for TFT and neonatologist assessment should be arranged (1) . Neonatal symptoms of hyperthyroidism may not appear up to one week. Treatment in the newborn baby may be needed until tyroid stimulating antibody is clear from her/his body. Contraception advice should be arranged until her diseases is well control. Pre-pregnancy counseling should be ensured before embark another pregnancy.
Posted by PAUL A.
Sat Jan 26, 2008 11:21 pm

) I would inform her most women with well controlled graves disease have an uncomplicated pregnancy (1) .
It often improves during pregnancy especially in the second and third trimesters as with other auto immune disease due to a state of relative immunosuppression.This leads to a lower requirement for anti-thyroid drugs. However, mild symptoms may be indistinguishable from a normal pregnancy (1) .
Untreated grave?s disease have an increased risk of miscarriage, IUGR, preterm delivery and increased perinatal mortality (1) .
Poorly controlled have risk of thyroid crisis in the mother and heart failure around the time of delivery (1) .
If a goitre is present, a retrosternal extension may increase the risk of tracheal obstruction and this may be a problem when intubation is required (1) .
Propyl thiouracil crosses the placenta and may cause fetal hypothyroidism and goitre There is also a small risk of fetal thyrotoxicosis due to transplacental passage of thyroid stimulating antibodies (1) This causes fetal tachycardia, IUGR or goitre and is treatable with antithyroid drugs .A drug rash or urticaria may occur in some patients on PTU and this may prompt a switch to another preparation
There Is an increased risk of exacerbation in the puerperium due to a rise in TSH receptor stimulating antibodies. I would document this discussion and offer her information leaflet on grave?s disease in pregnancy (1) .
b) This is a high risk pregnancy and would require a multidiscilplinary care in a joint obstetric and endocrine unit involving the obstetrician, consultant endocrinologist, MW and GP. The signs and symptoms of poor control of grave?s disease would be assessed such as heat intolerance, tachycardia, palpitations, emotional lability, vomiting and goitre. I would also ask of compliance with her medication as she may be afraid of teratogenesis. This would be supported with regular monitoring of her thyroid function test ( TSH, Free T4 and T3) performed
1- 2/12 ? meaning depending on the control in pregnancy (1) , and the dose of her PTU adjusted appropriately. The aim is to maintain the woman euthyroid with a free T4 at the upper end of the normal range (1) . I would also monitor regularly her TSH receptor stimulating antibodies because this predict the risk of fetal thyrotoxicosis. I would arrange serial growth scan (1) ,every 4weeks from 24weeks due to the risk of IUGR.This would also include checking the fetal heart rate for tachycardia and neck for goitre which may be evidence of fetal thyrotoxicosis. This can also be predicted especially in poorly controlled cases with the finding of high levels of TSH receptor stimulating antibodies . Where the facility is available, the finding of high levels of TSH binding inhibiting Ig (TBI) are also strongly predictive.Treatment with antithyroid drug and or thyroxine if the mother is euthyroid will be offered with the help of the endocrinologist.
A fine needle aspiration biopsy may be safely performed in pregnancy in suspected colloid carcinoma. Thyroidectomy is rarely required in pregnancy but may be safely performed in the second trimester if there is dysphagia or stridor from a large goitre or with suspected or confirmed carcinoma and if there is allergies to antithyroid drugs. Radioiodine therapy is contraindicated in pregnancy due to the risk of fetal thyroid ablation and hypothyroidism .. Propanolol may be used safely in pregnancy for a short period of time if there is thyroid crisis as it improves sympathetic symptoms of tachycardia, sweating and tremor. A vaginal delivery would be entertained and c-section would only be offered for obstetric reasons.

You will have a limited amount of time / space. You should look at the number of marks on offer and focus on the ?modifications? to her antenatal care. The question was not about the antenatal management of Graves disease

C The mother\'s thyroid function test would be monitored in the puerperium (1) because of the risk of exacerbation especially if well controlled in pregnancy. I would inform the paediatrician about this baby before the delivery due to risk of neonatal hyperthyroidism. Thyroid function would need to be checked in the cord blood and at regular intervals (1) if the mother is breastfeeding or the disease is poorly controlled. PTU is minimally transferred through the breastmilk and is safe in breastfeeding mothers (1) . The mother would be informed to observe in the neonate signs of neonatal hyperthyroidism which may not present up to 1wk after delivery and the need for prompt treatment to prevent neonatal mortality. The signs include weight loss, tachycardia,irritability, poor feeding and neck swelling.
Contraception would be offered to the woman before the next pregnancy.

good answer but you would have run out of space / time.
Posted by maha G.
Sun Jan 27, 2008 01:17 am
{a}
Grave?s disease is an autoimmune thyrotoxicosis and constitute about 95% of causes of thyrotoxicosis.
I would reassure her that the outcome would be good for her and her baby if the disease is well controlled,furthermore remission may happen in 2nd and 3rd trimestersand about one third of patients would not need treatment,however exacerbation may happen in the 1st trimester due to high hCG levels and pos-tdelivery also.
Grave?disease has maternal and fetal implication,if uncontrolled may be complicated with thyroid storm,maternal hypertension and heart failure,furthermore if the goiter is big it will be complicated with obstructive airway,stridor ,dysphagia and difficult intubation if genereal anaesthia is warrented.
Fetal effects such as prematurity,intrauterine growth restriction and stillbirth may happen if disease uncontrolled.
Fetal and neonatal thyrotoxicosis may happen even in eutyroid in about 1 to 10 %due to passage of thyroid stimulating hormone receptor antibodies to the fetus ,if untreated the mortality rate in fetal and neonatal thyrotoxicosis is 50% and 15% recpectively.Fetal thyrotoxicosis with big goiter may lead to obstructive labour and may lead to craniosynostosis.
Proplthiouracil{PTU}cross the placenta however it is not treatogenic,also it is secreted in breast milk however its effect on thyroid function of baby is little,overtreatment may lead to fetal hypothyroidism ,however if happen,neurodevolpment is preserved,furthermore,neonatal hypothyroidism and goitre may happen but it is small and unimportant.I would advise her if she devolps sore throat or mouth ulcer to review her doctor as this is an indicative for agranulocytosis.
{b}
I would involve in her care senior obstetrician,endocrinologist,an ophthalmologist,fetal medicine doctor and senior midwife.
I would request thyroid function tests{TFTS} especially free T3,T4,TSH receptor antibodies and to be compared with previos tests to check any exacerbation,TFTS would be done every 4 to 6 weeks however if well controlled can be done every trimester.
I would explain to her that it is crucial to continue her treatment with PTU and be vigilant for any symptoms of agranulocytosis,also beta blockers as propranolol can be used to control tachycardia.
Regular ultrasound and fetal growth charts are essential to detect any IUGR,fetal goitre,hydropos or tachycardia.
In case of fetal thyrotoxicosis,treatment should be started either to consider delivery if near term,or use PTU and thyroxine even if mother is euthyroid.
Delivery should be in the hospital with continous fetal monitoring,aiming to vaginal delivery and C.S.preserved only for obstetric indications.
I would involve senior paedetercian at time of delivery,take cord blood for TFTS,also neonatal TFTS within one week.
{c}
I would be aware for postpartum flare as adjustment of treatment may be warrented.
I would consider care of the newborn by senior paedetercian
Iwould discuss with her the contraceptive methods and find the most appropriate for her,also I would tell her that treatment for thyrotoxicosis may be completed in 12 to 18 months so before contemplating new pregnancy ,better to review preconception clinc.
I would encourage breast feeding ,although PTU is secreted in milk ,it has little effect on neonatal thyroid function.


Posted by PAUL A.
Sun Jan 27, 2008 01:38 am
To start with I would reassure the lady telling her that treated Graves disease carries minimal risks to the pregnancy (1) . However, during early pregnancy and postpartum period (1) there is a risk of flare up of the disease. Therefore I would need to repeat her thyroid function tests and thyroid stimulating antibodies and adjustment the of dose the medication she is taking if required. I would inform her that if there is a flare up of the disease it can affect herself and her baby. The Maternal outcomes of a flare, I will tell her, can be exacerbation of symptoms of thyrotoxicosis and sometimes even thyroid crisis (1) and congestive cardiac failure. I will tell her that if there is a flare it can cause miscarriage and chromosomal anomalies there is some concern about congenital anomalies but NOT chromosomal anomalies . Also it can cause the baby to be smaller for its gestational age and can cause preterm labour (1) these are related to poorly treated / untreated disease . Very rarely , the baby can have neonatal thyrotoxicosis what about hypothyroidism? due to transfer of thyroid stimulating antibodies from the mother. Thus a flare can cause increased perinatal mortality and morbidity. I will make sure that the patient understands all this information and reinforce my counselling with patient information leaflets (1) for thyrotoxicosis in pregnancy.

I would try to minimize the risk by offering the lady multidisciplinary care in Obstetric medicine clinic and by following the hospital protocol for management of women with past history of thyrotoxicosis. I would repeat her thyroid function tests when & how often? with the view of adjusting the dose of antithyroid medication if required and measure the level of thyroid stimulation antibodies in her blood. If these levels are high, I would send out a paediatric alert to watch out for neonatal thyrotoxicosis (1) . I would inform the lady to watch out for the side effects of propylthiouracil especially sore throat indicating granulocytopenia (1) . I will arrange for her to have regular scans to look out for IUGR (1) how often? . Also I would warn her of the signs and symptoms of Thyroid crisis and CHF. If any of these develop, I will manage them proactively and start beta blockers if required. Also, in the third trimester I would look out for signs of fetal tachycardia which might indicate fetal thyrotoxicosis.

The thyoid function tests need to be repeated postnatally and and dose adjustments made if require. Also I would need to inform the neonatologists to look out for signs of neonatal thyrotoxicosis or neonatal hypothyroidism due to high does of antithyroid medication (1) . I will inform the lady that she can continue to breast feed (1) . The baby might reqire thyroid function and thyroid stimulation antibody titre checked if it is symptomatic will you only do this if the neonate was symptomatic? Patients complain of symptoms ? how will a neonate?? . I would send a letter to the GP informing him of the outcome of pregnancy and requesting him to repeat TFTs in 6 weeks time. I will also advise the lady to attend preconceptual counselling if she wishes to have more children.
Posted by PAUL A.
Sun Jan 27, 2008 01:59 am
I will inform patient that majority of pregnancies have good outcome if appropriately treated (1) . Grave\'s disease tends to improve as pregnancy proceeds but carries risk of flareup in labour and postdelivery (1) which carries high morbidity and mortality especially if thyroid storm. It increases risk of miscarriage is this the case with adequately treated disease? . It can affect baby\'s growth. There is 10% risk of thyrotoxicosis in fetus this can lead to goitre. Rarely cardiac failure and stillbirth can occur (1) . Anti thyroid drugs in high doses can lead to hypothyroidism in fetus (1) .
This patient should have increased surveillance in pregnancy. She should be well informed about risks associated to her and baby. She should be told that majority will have good outcomes if good control of thyroid function is acheived.She should be reviewed ideally in joint obstetric and endocrine clinic, otherwise liase with endocrinilogist. Anaesthetic review should be arranged as enlarged thyroid can cause difficult intubation if required why did you not mention this as a risk in (a)? . Her thyroid function should be assessed clinicaly and biochemicaly at least every trimester (1) . Her pulse and fetal heart rate should be documented at each visit.More frequent assesment may be warranted if symptoms or signs suggest worsening. Propyl thiouracil should be adjusted to minimum effective dose to reduce risk of neonatal hypothyroidism (1) .Serial growth scans should be done to monitor fetal growth (1) . Perinatal referal should be sent to neonatal unit so that neonatal assesment and management are planned (1) . Plan should be documented in patients notes and alerts should be marked in labour and postnatal notes.
Staff involved in her care should be aware of high risk of flare-up (1) as this will help early diagnosis. Sometimes irritability and aggressiveness can be mistaken for poor behaviour and delay in diagnosis and treatment. Thyroid function tests should be repeated (1) as dose of antithyroid drugs has to be increased frequently after delivery majority do not require any adjustments .Any clinical features indicating thyrotoxicosis should be promptly investigated and managed .Her vitals especially pulse and blood pressure should be clearly documented to avoid risk of stroke and cardiac failure.She can breastfeed according to her wishes (1) . Baby should be assesed by paediatricians all babies are assessed ? what should they look for specifically? .
Posted by PAUL A.
Sun Jan 27, 2008 02:38 am
a) I will tell her that relapse of the disease can occur in early second trimester why should the disease relapse in early second trimester?? , but majority will improve in late second and third trimester, thereby requiring less medication and in 30% cases treatment can be discontinued it is not clear how you came up with this figure. This is not a feature of Graves disease (-1) However there is a risk of relapse in postnatal period (1) . Maternal risks include symptoms and signs related to thyrotoxicosis like anxiety palpitation, diarrhea, exophthalmos, tachycardia etc there are no marks for this so it is pointless writing it . Cardiac failure can occur has a result. Mother is also prone to develop pre eclampsia, placental abruption and preterm labor. Thyroid storm can develop especially in labor and is associated with a mortality rate of 25 % you must make it clear that this is a feature of untreated / poorly treated disease otherwise the woman will think she has a 25% risk of death . Another complication is polyhydramnios and obstructed labor secondary to fetal goiter these are extremely rare features ? you are expected to discuss more common ones . Treatment with propyl thiouracil (PTU) can also result in side effects like agranulocytosis what will you tell the woman about this? and hepatitis. Fetal risks include prematurity, low birth weight and growth restriction (1) . Risk of fetal hyperthyroidism is there which can present as fetal tachycardia, cardiac failure, hydropsfetalis and still birth. Craniosynostosis, exophthalmos and fetal goitre may develop (1) . There is also risk of neonatal thyrotoxicosis in 10% cases which has a 25% mortality rate is this in all cases, treated cases or untreated cases? . Placental transfer of PTU to fetus can also result in transient hypothyroidism (1) in newborn which is self limiting. I will also give her information leaflets (1) You need to be precise when you quote figures. Giving a patient mortality figures for untreated disease when her disease is, or could be well treated is inappropriate .
b) I will estimate her free T3, T4 levels and Thyrotropin receptor antibody status to assess her current disease status. If hyperthyroid management will be planned with the help of endocrinologist and neonatologist Are there no additional risks if she is euthyroid? Are there no fetal / neonatal risks? . Dosage of PTU will be adjusted and maintained at the minimum level to keep free T4 levels at the upper limit of normal (1) . If thyroid stimulating antibodies (Ab) are positive risk of fetal thyrotoxicosis is high. Hence careful fetal monitoring will be done by daily fetal movement count ? evidence that this is of use??? , serial symphysio fundal height measurement and fetal heart rate recording do you not do this in normal pregnancies? . Ultrasound scan will be done to look for fetal goitre and also to assess cardiac function and growth of fetus (1) . If suspicious, cordocentesis will be offered to confirm fetal thyrotoxicosis which will require maternal anti thyroid treatment. If mother is euthyroid thyroxin replacement will be given along with anti thyroid drug you were asked about modifications to her antanatal care, NOT the management of Graves disease in pregnancy . Maternal symptoms of tachycardia will be treated with beta blockers after counseling about the risk of fetal growth restriction TFT will be done at 4 to 6 weekly intervals using pregnancy specific ranges to rule out hypothyroidism (1) . Thyrotropin receptor Ab will be tested again in third trimester to predict risk of neonatal thyrotoxicosis. Failure to respond to medical therapy is an indication for surgery in second trimester
c) If the antenatal thyroid stimulating Ab in late pregnancy is high, cord blood TFT screening will be done and repeated at one week to rule out neonatal thyrotoxicosis. Drug induced hypothyroidism can also be detected by this (1) . Detailed examination by neonatologist will be done to assess cardiac function of the new born. Maternal symptoms may worsen in the postpartum period (1) and hence she needs careful monitoring and readjustment of drug dosage. Breastfeeding will be encouraged (1) . Contraceptive advice will also be offered.
Posted by PAUL A.
Sun Jan 27, 2008 02:47 am
a) There are both maternal and fetal risks associated with grave\'s disease. If the disease is not well controlled she may develop goitre, throid storm or heart failure (1) . If the goitre extends retrosternally this could lead to difficulties with intubation (1) if she had respiratory arrest or needed a general anaesthetic. The maternal antithyroid antibodies cross the placenta and can lead to fetal thyrotoxicosis what about hypothyroidism? . The fetus is at risk of miscarriage, intrauterine growth restriction, premature delivery and stillbirth (1) . I will provide her with a patient information leaflet (1) .

b) She should be seen in a combined clinic by an obstetrician and physician because she requires specialist care and follow up since grave\'s disease in pregnancy can lead to an increase in maternal and fetal morbidity and mortality. Regular antenatal surveillance do you not do this in normal pregnancies? is required for early identification of problems and early intervention. Maternal blood should be taken for free T4, free T3 and TSH to determine if she is chemically euthyroid. The thyroid function test should be repeated every 6 weeks (1) to determine whether the disease is under control or the medication needs to be altered. A detailed anomaly scan should be done at 20 weeks to identify structural anomalies do you not do this in normal pregnancies? . Serial ultrasound scans should be done for growth (1) , liquor volume and dopplers. This will allow for early identification of growth restriction and change in fetal wellbeing.

c) Maternal blood for thyroid function test to determine whether the medication needs to be altered you need to make it clear you recognise the risk of post-partum relapse . Breast feeding can be allowed (1) since only low doses of the propylthiouracil will appear in the breast milk. Effective contraception should be used since preconception counselling or planning is required before conceivoing again to enable good maternal and fetal outcomes. The neonate need to be seen by the paediatrician or neonatologist since there is a risk of neonatal thyrotoxicosis what about hypothyroidism?

You need a more detailed answer. Routine care is not part of ?modifications? to your care
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Posted by PAUL A.
Sun Jan 27, 2008 04:26 am
I will tell her that with treated disease most of the pregnancies are associated with good out-come (1) . Even with well controlled disease there is risk of thyrotoxicosis in 2 out-of 100 cases, this is due to the anti-bodies [IgG] which can cross the placenta. The drug is not teratogenic, but it reach the fetus and can cause hypothyroidism (1) . An active disease is associated with increased risk of fetal loss, and adverse out-come, particularly miscarriage and intra-uterine growth restriction (1) . The disease is not an indication for operative delivery, and not a contra-indication to breast-feeding. Pregnancy usually not affect the disease.
Multidisciplinary approach with involvement of endocrinologist, pediatrician and obstetrician-led care. Thyroid function test in each trimester ?more frequent if not well controlled (1) - . The minimum needed does should be used. There no place for block and feed-back therapy. Serial ultra-sound scans are needed for follow-up of growth and fetal goiter (1) There no place for radio-active investigations during pregnancy.
Auto-immune diseases may exacerbate in post partum so what will you do? . Breast-feeding is not contraindicated (1) .Contraception should be advised. The neonate will be investigated for transient hypo or hyper-thyroidism (1) . Pre-conception advise should be requested before next pregnancy.

You need a more detailed answer and have not made use of all the space / time provided
Posted by PAUL A.
Sun Jan 27, 2008 04:44 am

a) Well controlled Graves Disease is likely to be uneventful in pregnancy (1) and natural course is a gradual improvement towards late pregnancy due to decreasing anti TSH receptor antibody levels with possible need even for decrease in dose of antithyroid drugs. I will tell her uncontrolled Grave?s disease can have severe fetal, neonatal and maternal side effects and increased perinatal and maternal mortality. There is also risk of intrapartum and post partum exacerbation in her condition.

Side effects diseases do not have side-effects of fetal thyrotoxicosis are IUGR, craniosynostosis, exophthalmos, heart failure, hydrops fetalis, prematurity and fetal death do not write a list . The neonate has risk of thyrotoxicosis. Both neonatal and fetal thyrotoxicosis carries 25% mortality is this irrespective of treatment? . The antithyroid drugs prescribed for her too carry risks. These include fetal hypothyroidism in 5-10% cases and Goitre (1) . Sometimes Goitre may be big enough to cause dystocia in labor. Maternal side effects with thionamides include nausea, vomiting, diarrhea, drug rash and serious side effect like hepatitis and agranulocytosis what will you tell her about this? . Rarely Aplasia Cutis can occur with PTU. Neonate is also at 10-20% risk of hypothyrodism due to excess maternal antithyroid drug and is usually transient and clears up by 1-5 days after delivery. Fetal hypothyroidism too can occur , rarely causing goiter you have already mentioned this . Percutaneous Fetal blood sampling maybe needed to assess fetal thyroid hormone levels.

Maternal risks include miscarriage, preterm labor, Preecclamsia and abruptio placenta do not write a list . Serious complication include occurrence of thyroid storm, Heart failure which are more likely with uncontrolled thyrotoxicosis (1) . Thyroid storms have 25% maternal mortality risk and more likely during intrapartum or immediate post partum periods.

b)She would need multidisciplinary care involving Physician, Senior Obstetric consultant are there junior consultants?? , neonatologist, head and neck surgeon why??? , senior midwife due to risk of increased perinatal and maternal mortality in uncontrolled cases. Aim of care is directed to controlling her hyperthyroidism with antithyroid drugs, modulating correct dose with periodic Thyroid function tests?monthly with newly diagnosed disease or every trimester in well controlled disease (1) . Clinical signs and symptoms of hyperthyroidism overlap with pregnancy symptoms. Hence biochemical values are best used for monitoring control. FreeT4, Free T3 and TSH levels are monitored. She needs to be educated about importance of compliance with drugs. Her WBC count needs to be taken monthly and any complaints of sore throat which may suggest agranulocytosis needs to be investigated and if so the antithyroid drug stopped will you leave her untreated? . LFT should also be done. Her condition may sometimes improve with pregnancy and doses of antithyroid drugs may then need to be diminished in consultation with her physician.

Fetal thyrotoxicosis can be predicted by high maternal TSH receptor antibodies in early pregnancy and should be repeated at 6 months again to predict likelihood of neonatal thyrotoxicosis. USG should be done at 20 wks at fetal medicine units as it can indicate this potentially serious condition by presence of FGR, persisting fetal heart >160/mt and Goitre (1) . Other findings could be hydramnios, fetal hydrops, and fetal craniosynostosis. This can be treated by Block and replace regimens. This means antithyroid drugs is given to control fetal thyrotoxicosis and to keep mother euthyroid, she is given thyroxine replacements as this does not cross the placental barrier. She is also likely to have IUGR is this the same as FGR? Why are you using different abbreviations? because beta blockers given to control her symptoms also may cause IUGR.

If she does not respond to medications or she has significant goiter causing dysphagia, respiratory distress she should have surgical review for possible thyroidectomy and also have senior anesthetic review as uncontrolled graves disease is a high risk for thyroid storms and heart failure.

Fetal surveillance should be meticulous due to risks of IUGR, fetal death and should be started from 24-28 weeks with biweekly BPP, CTG based on what evidence??? and fetal growth charts.

Information booklets, details of internet links like patient.uk which can educate her about her condition should be given.

c) Cord blood should be tested for FT4, FT3, TSH levels and should be repeated at 3 and 7-10 day as neonatal thyrotoxicosis can present later (1) . Maternal antithyroid drugs clear from fetal system in 1-5 days when signs of fetal thyrotoxicosis appear as transplacentally transferred antithyroid antibodies may persist for upto 3 weeks. Hence the neonate needs careful follow up with neonatologist for this period as mortality with untreated neonatal thyrotoxicosis is up to 25-50%.

You would have run out of space / time here.

You consistently write long answers because you fail to focus on the question asked. Doing unnecessary / unproven investigations is just as dangerous as not doing relevant ones and you will lose marks.


Mother may have postnatal flare of antibody levels and the drug if decreased or stopped will need to be restarted. TFT should be repeated and watch for signs and symptoms of thyroid storms. After discharge, any palpitation, disorientation, fever should need to be immediately reported. She should have follow up appointment at 1-2 months to see persisting hyperthyroidism which may need to be distinguished from postpartum thyroiditis. She should also be emphasized the importance of neonatal follow up.

She can be encouraged to give breast feeding as the antithyroid drugs cross breast milk in low levels.
Posted by PAUL A.
Sun Jan 27, 2008 07:16 pm

Most women with Graves disease will have an uncomplicated pregnancy with good outcome (1) .
Patients who are symptomatic may experience an alleviation in their symptoms in the third trimester with an exacerbation in the post partum period (1) . She should be counseled that uncontrolled hyperthyroidism can lead to cardiac failure and death (1) and the importance of complaince with medications should be emphasised.
The size of the goitre may increase in pregnancy and may be associated with airway obstruction (1) and dysphagia.
Propylthiouracil crosses the placenta and can result in fetal hypothyoidism in about 10% of cases. The maternal risks of propylthiouracil include rash, gastrointestinal disturbances and agranulocytosis. She should be advised to report any sore throat immediately.
Even if the patient is euthyroid there is still the risk of fetal hyperthyroidism of about 10% (1) . This is because anti TRH antibodies are present in maternal plasma and can cross the placenta. Fetal hyperthyroidism can result in fetal gitre, exomphthalos and cardiac failure resulting in hydrops. Craniosyntosis is also a recognised complication of fetal hyperthyroidism (1) .
There is an increased risk of fetal growth restriction and still birth (1) .
The neonate is at risk of developing hyperthyroidism.

b)
This patient will be managed in conjuction with an endocrinologist.
Free T3 and T4 levels are measured at least monthly to assess biochemical thyroid status (1) . This ensures that antithyroid medications are used at appropriate doses.
Propythiouracil shoul be continued to attain biochemical euthyroidism. The lowest dose required should be used to decrese the risk of fetal hypothyroidism.
If the patient experiences symptoms of hyperthyroidism a beta blocker eg propranolol can be used once the patient is counseled about the increased risk of fetal growth restriction.
Patients with exopthalmos should be referred to the opthamologist for eye care.
At each antenatal appointment she is assesed for symptoms of hyperthyroidism. Fetal tachycardia may be an indication of fetal hyperthyroidism. She should have serial USS to assess growth (1) and to rule out any fetal anomalies such as fetal goitre .
She should be referred to the anesthesist prior to labour as there may be difficulty in obtaining an airway if general anesthesia is needed. A cesarean section may be needed in cases of ffetal gitre resulting in hyperextension of the fetal neck.
The neonatologist should be made aware of the possibility of neonatal hyperthyroidism (1) .

c) There is a risk of thyroid storm relapse is more common and vigilance should be kept for signs of fever, tachycardia, hypertension. Propylthiouracil should be continued and although it is present in small amounts in breast milk the effects are minimal and breast feeding should be encouraged (1) . The neonate should be monitored for signs of hyperthyroidism which can develop up to a week after delivery what about hypothyroidism? . She is advised on contraception and of continuing risks in future pregnancy.
Posted by PAUL A.
Sun Jan 27, 2008 07:33 pm
(a)
We inform her that this is an autoimmune disease and it has maternal and fetal implications, the risks depend on her state and they occur more often if the disease is inadequately controlled.

The mother is at increase risk of fetal loss (miscarriage) is this the case with well treated disease? , fetal intrauterine growth restriction and preterm labour (1) .

We tell her that the disease may deteriorate in the first trimester because of similarity of a- subunit of HCG and TSH, also due to poor absorption of drugs.

PTU is safe in pregnancy but there are risk of developing agranulocytosis which require discontinuation of the drug.

Thyroid storm can occur at time of stress like labour , operative delivery or infection , it has low incidence but if occur it can lead to maternal heart failure and even maternal death you need to make it clear that this is a risk ONLY in poorly treated / untreated disease .

We explain to her that pregnancy has no effect on the disease how is this consistent with your statement above that the disease DETERIORATES in the first trimester because of HCG?? , still she may have obstructive symptoms that require surgery with risk of anaesthesia and thyroid storm also.

We inform her that there are fetal risks like low birth weight is this different from IUGR mentioned in your second paragraph? and still birth. The fetus can develop hyperthyroidism even if the mother has the disease previously you are told that she currently has the disease and is being treated because of the persistence of thyroid stimulating antibodies which can pass tranplacental. Fetal hyperthyroidism can cause fetal goiter and heart failure.

Fetal hypothyroidism can occur (1) also due to over treatment and can cause goiter with or without fetal mental retardation.

We reassure her that generally the prognosis is good in well controlled patients (1)
If you use so many paragraphs in the exam, you will run out of space. You have not followed an answer plan and have repeated yourself on several occasions.
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(b)
The aim is to achieve good maternal and fetal well being.

If she is already on PTU , there is no need to discontinue the drug but it should be kept to the minimum dose that keep the patient clinically well and biochemically euthyroid. We advise her to report early if she develop sore throat or mouth ulceration as these are features of agranulocytosis and drug should be stopped or changed (1) .

Clinical assessment is usually of limited value because many of the symptoms of hyperthyroidism can occur normally in pregnancy like palpitation, sweating and heat intolerance. Also signs like persistent tachycardia , tremor, lid-lag and exophthalmos do not necessary reflect current hyperthyroidism.

Thyroid function test also has limitations in pregnancy because of increase TBG, we need to measure free T4 and free T3 and to adapt levels specific to each trimester in pregnancy, we do TFTs every 4-6 weeks (1) in uncontrolled cases. If the disease is controlled , we repeated it in each trimester (1) .

We also do serial general assessment for her including her weight , pulse, tremor with eyes and neck examination.

Serial US examination (1) is needed to detect fetal goiter and fetal growth, this is usually after 24 weeks of gestation because the thyroid stimulating antibodies cross placenta after that time.

Also the fetus monitored for signs of hyperthyroidism like increase fetal movement and fetal tachycardia, we do regular auscultation for fetal heart.
We may need to increase the dose of maternal Anti-Thyroid drugs with addition of thyroxin why?? .

We involve an endocrinologist, pediatrician , fetal medicine specialist and anaesthetist in her care (1) .

Beta blockers can be used to control symptoms of anxiety and tremor, propranolol is the drug of choice.

Radioactive iodine is contraindicated because of risk of fetal thyroid destruction.

If surgery needed, it can be done in the second trimester to minimize risk to the fetus.

Frequency of antenatal visit will be as normal antenatal care but it should be more frequent if the disease is uncontrolled.

Provide patient information leaflet should be in (a) .


(c)
Breast feeding is not contraindicated (1) . The fetus is there a FETUS after delivery?? will need regular TFTs because small amount of PTU can pass into breast milk.

Evaluation of the neonate by neonatologist for goiter, hypo- or hyperthyroidism development (1)

In addition, the mother will need re-evaluation how? and re-adjustment of medication.

We give advice about contraception and planning of future pregnancy.
Posted by PAUL A.
Sun Jan 27, 2008 07:40 pm
Graves? disease is an autoimmune disorder caused by TSH receptor-stimulating antibodies and often improves during pregnancy, especially in the second& third trimesters. In first trimester, possibly related to HCG production exacerbation may occur. Thyroid stimulating antibodies may cause, fetal or neonatal thyrotoxicosis .also the mother with poorly controlled thyrotoxicosis may lead to a thyroid crisis (storm) &heart failure, particularly at time of delivery (1) . Rarely retrosternal extension of goiter may cause tracheal obstruction (1) which is a particular problem if the patient need to be intubated .PTU cross the placenta in high dose & may cause fetal hypothyroidism (1) and goiter but not grossly teratogenic. The risk also may develop low birth weight, preterm delivery and still birth, craniosynostosis to the fetus (1) .
Antenatal care should monitor free T3&T4 to avoid maternal hypothyroidism and the dose of anti thyroid drugs should be reduced to lowest effective dose (1) -ensure biochemically&clinically euthyroid with TFT/1-3 month. Serial fetal ultrasound to asses fetal growth, F.H.R, fetal goiter (1) . Thyroidectomy is rarely indicated in pregnancy, but if required, is best performed in the second trimester.
Post natal care to monitor and treat postpartum exacerbation and evaluate neonate for goiter, hyper or hypothyroidism by pediatertian (1) . Breast feeding not contra-indicated (1) as PTU secreted in very low concentration in breast- milk

You have not used all the space / time allocated. With a more detailed answer, you are likely to have obtained a pass mark.
Posted by PAUL A.
Mon Jan 28, 2008 12:19 am
a) I will inform this lady that though Grave?s disease being an autoimmune disease entails maternal as well as fetal risks,if well controlled she can expect a good outcome of the pregnancy (1) .The chances Risk ? risk refers to ?negative? outcomes: Chances of success, risks of failure of miscarriage are increased.Pregnant mothers can develop hypertension (mainly systolic) and can also go into preterm labour.Though there is a chance of it it is not clear what IT refers to ? the subject of your previous sentence was ?pregnant mothers?. being ameliorated in the 2nd and 3rd trimester,it can exacerbate postpartum. Complications like cardiac failure and thyroid storm can be life threatening you must make it clear these occur in poorly treated disease .
The main concern with Grave?s disease is of fetal thyrotoxicosis since the antibodies cross the placenta.I will impress upon her the fact that sometimes inspite of normal thyroid levels in the mother ,the baby can be affected.Though there are no reported cases of any congenital anomalies because of the disease, chance you were asked to tell her about RISKS ? not CHANCES of prematurity and stillbirth is increased.Intrauterine growth retardation (1) RESTRICTION of the baby can occur.Due to advanced bone maturation,craniosynostosis(fusion of skull bones) can occur (1) .Babies can develop hydrops and in some cases may even succumb is this different from stillbirth mentioned above? Will the woman know what this means? .On the other hand,the drug used for the treatment (PTU) is non teratogenic but can cause fetal hypothyroidism and fetal goitre (1) .Neonatal thyrotoxicosis also is a known complication.Postpartum thyroiditis is common in women with Grave?s disease (1) .

b)Since she is already on treatment,I will do her thyroid function tests every 4-6 weeks with the aim of using the least possible dose to maintain the values within the normal reference range for pregnancy (1) .I will emphasise to her the importance of being compliant with the treatment to ensure the best outcome.In case she is symptomatic(tachycardia\\tremors),I will use beta blockers(propranolol 20 mg 8hrly).If there are any clinical findings suggestive of intrauterine growth retardation,I will do serial growth scans will you wait for clinical evidence of IUGR before doing serial scans? while also looking out for fetal goiter ,fetal tachycardia or hydrops. Cordocentesis will be recommended if fetal hypothroidism or thyrotoxicosis is suspected.Her complete pregnancy care will be done in liaision with an endocrinologist and an expert in fetal medicine.
c)Women with Grave?s disease tend to have exacerbation of the disease postnatally so I will warn her about it and ask her to get back if symptoms like palpitations,tremors occur.In such a situation I will treat her with beta blockers.I will check her thyroid function tests (1) after 4 weeks to check for euthyroid status.Very rarely women can develop thyroid storm for which she will be transferred to an intensive care unit.Adequate hydration,thermoregulation,treatment of anemia and infection,beta blockers and steroids form the cornerstone of management of thyroid storm.Breastfeeding will be encouraged (1) since very little amount of PTU is secreted in breast milk.The newborn?s thyroid function status will be checked immediately after delivery and after a week-these babies are best managed by a neonatologist (1) Postpartum thyroiditis will be looked out for and treated with beta blockers if needed.
Posted by PAUL A.
Mon Jan 28, 2008 12:31 am

I would like to reassure her that most of the pregnancies with this disease have good outcome (1) , however uncontrolled disease can lead to thyroid storm, cardiac failure and arrythmias (1) . If there is enlargement of the gland it can obstruct airways and may need surgical intervention (1) . I would also like to tell her about the 1% risk of fetal, neonatal thyrotoxicosis ? risk of hypothyroidism , specially in those who have active disease in pregnancy. Propylthiouracil can cross the placenta but is not harmful to the baby and she should continue her treatment if she feels well on it. Graves disease can deteriorate in first trimester not due to pregnancy but due to excessive nausea vomiting and decrease compliance to treatment due to fear of teratogenesis. The disease usually improves during the second and third trimester. Uncontrolled disease can result in miscarriage (1) , IUGR, preterm birth and low birth wt (1) . Well controlled disease has a good pregnancy outcome. She should be provided with written information (1) .

During her antenatal care her TFT should be check in each trimester and if normal there is no need of increasing frequency of her antenatal visits. However more frequent testing may be required in poorly controlled cases (1) . Pulse tachecardia, palpitation, tremours, lid lag, exophthalamous and goitre are features distinct from a normal pregnancy which should be checked at each visit. Keeping in view the 1% risk of fetal thyrotoxicosis, excessive fetal movements how does the woman know that the movements are excessive? , fetal tachecardia and fetal goiter at ultrasound, maternal propylthiouracil may be increased to a dose reaching to treat the fetus along with maternal supplementation of thyroxin (if needed) ? meaning . Otherwise lowest possible dose of propylthiouracil is adjusted according to the results of TFT (adjusted according to the normal ranges in pregnancy). Prescription of beta blockers for palpitations is safe. Regular growth assessment (1) (every 4wks) of the fetus from 24wks of gestation, and earlier detection and treatment of fetal thyrotoxicosis improves the outcome. Surgical intervention is safe in second trimester, however radioactive iodine is contraindicated whether therapeutic or diagnostic due to its risks of fetal congenital anomalies. Corticosteroid administration for a preterm labour is beneficial ? evidence in women with Graves disease?? At what gestation age will you give it and why? . Multidisciplinary approach with an obstetrician, physician, paediatrician and fetal physician ?? may be required to manage the disease (1) . The disease rarely effects the timing and mode of delivery unless there are signs of fetal compromise.

Postnataly woman is at risk of a relapse, as pregnancy induced immunosupressed state is over and the antithyroid antibodies can activate the disease again. Her physical sense of well being and TSH, fT3, fT4 levels can give an idea about alteration in therapy (1) . Neonate may not show the features of thyrotoxicosis in one to two weeks of life. The woman should be informed about the signs of poor feeding, jitterreness and tachecardia in the neonate to consult earlier with the paediatrician will you wait for these symptoms before assessing the baby? . Breast feeding is encouraged (1) as only 0.07% of the drug is secreted in the breast milk. Adequate contraception is advised hormonal contraception not contraindicated.
Posted by Mahmud  K.
Mon Jan 28, 2008 07:19 am
(a)Graves disease is an autoimmune disorder caused by thyroid stimulating hormone receptor ?stimulating antibodies Maternal and fetal outcome is usually good with previously treated graves disease in remission or well controlled hyperthyroidism before conception and during pregnancy. It often improves during pregnancy especially in the second and third trimester but may flare up postpartum. Exacerbation may also occur in 1st trimester .There is high risk of relapse after completion of antithyroid traement . Thyrotoxicosis complicate about 1 in 500 pregnancy .Poorly controlled thyrotoxicosis may lead to thyroid crisis in the mother and congestive heart failure ,especially at the time of delivery.Presence of thyroid stimulating antibody is an independent risk factor for adverse pregnancy outcome including miscarriage. Thyroid auto antibodies cross the placenta and may stimulate fetal thyroid and cause fetal and neonatal thyrotoxicosis in 2.6% cases. Fetal thyrotoxicosis causes premature labour , intrauterine growth retardation, fetal goiter,fetal tachycardia and severe cases heart failure , hydrops occur..Without treatment the mortality rate may reach 50%. In the neonatal thyrotoxicosis features include weight loss, tachycardia ,irritability, poor feeding ,goiter and severe untreated cases congestive cardiac failure. Without treatment mortality rate is about 15%.Pregnancy has no effect on Graves opthalmopathy. Rarely retrosternal extention of a goiter cause tracheal obstruction .
(b) Many of the clinical features of hyperthyroidism are found in normal pregnancy (tachycardia, tiredness, heat intolerance, dyspnea) and the diagnosis may easily overlooked. So thyroid function should be tested at booking .Treatment with antithyroid drugs should be recommended in case of raised T3 and free T4 and low TSH with liase with the endocrinologist and obstetricians special interest in medical problem during pregnancy. Carbimazole and propyl thiourcil are the most commonly used drugs.If she had a history of well compliance with propylthiouracil it is the first choice of drug. Beta blocker can be used at short term if required for control of thyrotoxic symptoms. Transvaginal ultrasound at booking and transabdominal ultrasound at anomaly scan allows the early detection of an enlarged fetal thyroid and correlated with maternal status and treatment. Serial ultrasound to check fetal growth, heart rate and goiter and hydropic change is indicated especially in those mothers with poorly controlled when thyroid stimulating antibody levels rises.Fetal blood sampling through cordocentesis for assessment of fetal thyroid function is accurate but carries inherent risk. In the case of fetal thyrotoxicosis the mother is given antithyroid drugs combind with thyroxin if she is euthyroid.Thyroidectomy rarely indicated in pregnancy but if required for dysphagia or stridor due to enlarged goiter may be safely performed in the second trimester .Radioiodin therapy is contraindicated in pregnancy.
(c) Breastfeeding is safe even in mothers who continue with treatment . The neonate should be examined carefully after birth and the neonates thyroid function should be assessed. It is possible to predict neonate at risk by measuring rising titre of thyroid stimulating antibody although the test is not universally available.Invovement of pediatrician is important.
Posted by K P.
Mon Jan 28, 2008 10:32 pm
I would explain to her that most women with well managed Graves Disease will be fine but there is an increase in maternal, fetal and neonatal morbidity. I would explain that symptoms of hyperthroidism often are similar to normal symptoms in pregnancy such as irritability, weight loss, increase appetite, heat intolerance and palpitations but she should report these sypmtoms as they could be suggestive of an overactive thyroid and would require assessment and treatment. Other risks to the mother include cardiac failure and thyroird storm although very rare carriers a significant (25%) mortality. If she developed a goite there is risk of retrosternal goite which could impaired her breathing and have implications if she required an intubation for general anaesthesia. There is also an exacerbation of the conditon in the pueperium. I would explain that the thyroid antiboides can cross the placenta and in 10% of women there is a risk of fetal hyperthyroidism. This can cause intrauterine growth restriction, and if severe can cause fetal tachycardia, cardiac failure, This can result in hydrops and polyhydramnios which can cause preterm delivery. The fetus is also at risk of hypothyroidism due to the maternal drugs. This is usually transient and can cause fetal goitre. However I would empahsise that continuing her medication far outweighs the risks of stopping them. The neonate may present with thyrotoxicosis, this may present late (as long as one week). Symptoms in the neonate such as poor feeding, difficulty breathing and goitre are signs.

Antenatally she should be managed by a multidisciplinary team. This should include a endocrinologists and a feto-maternal obstetrician and neopnatologists.We would monitor the mother and the fetus. We should treat maternal symptoms and she may require B blockers for palpitations or tremor. She should be managed with the lowest effective dose of medication and this should be titrated according to her clinical and biochemical indices. She should have regular bloods measuring TSH, T4 and T3 every month. If she develops a goite an ultrasould assessment of her thyroid is warranted and an anaesthetic review. With regards to the fetus, apart from the routine screening and anomaly scans a cardiac scan would pick up early cardiac failure. She would need regular ultrasound for growht, liquor volume and dopplers at 4 weekly intervals looking for IUGR, polyhydramnios and potential hydrops. Features of hyperthyrodism in the fetus may require an increase in maternal antithyroid drugs and potentially thyroxine replacement in the mother.

Again I would monitor the baby and the mother. She is at increase risk of exacerbation of her condition and may require an increase in medication. I would titrate this according to biochemical and clinical symtoms. I would explain to her that breatfeeding is not contraindicated as the antithyroid drugs a present in very small amounts in breat milk. The neonate would require TFT\'s checking in the cord blood and also at regular intervals as adviced by the neonatologists (especially if she is breat feeding) I would advice her to look out for symptoms in the neonate as explained previously. I would talk to her about contraception and advice that there are no contraindications to any form of contrceptives however if she is breat feeding the COCP should not be started until 3 months.
Posted by PAUL A.
Tue Jan 29, 2008 02:18 am

a)what you tell her about the risk assocaited with Graves disease. (9)m
.Iwill inform her about Graves diease is autoimmune disorder caused by autoimmune thyroid stimulating antibodies(IgG antibodies).This disease typically can be remite in second and third timister and flare may occur after delivary (1) . frist trimester disease excerbated by high level of HCG. Graves disease associated with hyperplastic goiter and exophthalmos.. Iwill explain to her maternal and fetal complication assocaited with uncontrolled disease . this disease can cause maternal hypertension,heart failure and thyroid storm(25%maternal mortality )espscailly if ocur after delivary (1) . Retrostenal extension may cause tracheal obstrction and diffcult intubation (1) . Graves disease can be assocaited with premature labour, growth restriction and still birth (1) Propylthiouracil(PTU) most commen used drug for treatment of Graves disease it reduce the titer of TSH receptor antibodies and direct influence the aetiology of greves disease and most patient need treatment for 12-18 months . PTU can cross the placenta and has minimal teratogenic effect are there ANY terratogenic effects? and the relationship previously found between aplasia cutis of scalp and this drug is unlikly exit ? meaning ?? . Iwill tell her about side effect of PTU as vomiting, diarrhoea agranulocytosis how will this affect her? , fetal and neonatal thyrotoxicosis 1-10%of babies of mother with current or previous Graves disease ? meaning?? ,Transplacental passage of thyroid stimulating antibodies present with fetal tachycardia,IUGR.,fetal , neonatal goiter and mortality increase to 50% is this different from IUGR / stillbirth mentioned earlier? . Patient should warned that if she develop sore throat or mouth ulceration at any time to stop the antithyroid drug immediatlly and urgent medical attention because the risk of thyrotoxicosis are these features of thyrotoxicosis or agranulocytosis? . woman should given leaflet and written information (1) .
b)Justify your modification of her antinatal care.(7)m
Antenatal care of this woman should be every month even women with normal pregnancy need to be seen more often in the third trimester and thyroid function test T4-T3-TSH should done every 4-6weeks to avoid maternal hypothyroidism what about avoiding hyperthyroidism? . Serial ultrasound scan should undertaken to check for growth , heart rate and fetal neck (1) . the dose of antithyroid drug should reduced to lowest effective dose (1) . Beta blocker can be used initially to improve symptom of tachycardia , sweating and tremors. thyroidectomy rarely required but if required it is safely performed in second trimister. It is usually done for woman with obstructive symptom as dysphagia or stridor and those with proven malignancy. Radio iodine therapy is contraindicated during pregnancy and post partum. Multidisplinary team should be invoved in antenatal care of this patient as obstetrcain, endocrinologest, neonatologist. In case of fetal thyotoxicosis the mother is given antithyroid drug combind with thyroxine if she is euthyroid.
c)Justify your postnatal care given that she had spontanous vaginal delivary(4m)
This patient should have routine postnatal care . Postpartum thyroiditis can occur up to one year after delivary and can manifest by high or low T4 level and this need to be follow up with endocrinologist will you check TFT? When? . Neonatologist should be informed to evaluate the neonate for goiter,hyperthyroidism or hypothyroidism and thyroid function (1) test on cord blood at regular interval if breast feeding.Iodine treatment is contrandicated during breast feeding also radio iodine scan contraindicated but may be undertaken if breast feeding stop for 24 hours,. contraception should be used for 4 months after radio iodine treatment. Breast feeding is not condraindicated (1) as very low concentration PTU in breast milk.
Posted by PAUL A.
Tue Jan 29, 2008 02:43 am
{a}
Grave?s disease is an autoimmune thyrotoxicosis and constitute about 95% of causes of thyrotoxicosis.
I would reassure her that the outcome would be good for her and her baby if the disease is well controlled (1) ,furthermore remission may happen in 2nd and 3rd trimestersand about one third of patients would not need treatment do you discontinue treatment in 1/3 of treated patients? ,however exacerbation may happen in the 1st trimester due to high hCG levels and pos-tdelivery also.
Grave?disease has maternal and fetal implication,if uncontrolled may be complicated with thyroid storm,maternal hypertension and heart failure (1) ,furthermore if the goiter is big it will be complicated with obstructive airway,stridor ,dysphagia and difficult intubation if genereal anaesthia is warranted (1) .
Fetal effects such as prematurity,intrauterine growth restriction and stillbirth may happen if disease uncontrolled (1) .
Fetal and neonatal thyrotoxicosis may happen even in eutyroid in about 1 to 10 %due to passage of thyroid stimulating hormone receptor antibodies to the fetus ,if untreated the mortality rate in fetal and neonatal thyrotoxicosis is 50% and 15% recpectively.Fetal thyrotoxicosis with big goiter may lead to obstructive labour and may lead to craniosynostosis (1) .
Proplthiouracil{PTU}cross the placenta however it is not treatogenic,also it is secreted in breast milk however its effect on thyroid function of baby is little,overtreatment may lead to fetal hypothyroidism (1) ,however if happen,neurodevolpment is preserved,furthermore,neonatal hypothyroidism and goitre may happen but it is small and unimportant.I would advise her if she devolps sore throat or mouth ulcer to review her doctor as this is an indicative for agranulocytosis (1) .
{b}
I would involve in her care senior obstetrician,endocrinologist,an ophthalmologist,fetal medicine doctor and senior midwife.
I would request thyroid function tests{TFTS} especially free T3,T4,TSH receptor antibodies and to be compared with previos tests to check any exacerbation,TFTS would be done every 4 to 6 weeks (1) however if well controlled can be done every trimester.
I would explain to her that it is crucial to continue her treatment with PTU and be vigilant for any symptoms of agranulocytosis,also beta blockers as propranolol can be used to control tachycardia.
Regular ultrasound and fetal growth charts are essential to detect any IUGR (1) ,fetal goitre,hydropos or tachycardia.
In case of fetal thyrotoxicosis,treatment should be started either to consider delivery if near term,or use PTU and thyroxine even if mother is euthyroid.
Delivery should be in the hospital with continous fetal monitoring,aiming to vaginal delivery and C.S.preserved only for obstetric indications.
I would involve senior paedetercian at time of delivery will you wait till delivery before involving them? , take cord blood for TFTS,also neonatal TFTS within one week ? is this antenatal care? .
{c}
I would be aware for postpartum flare as adjustment of treatment may be warrented.
I would consider care of the newborn by senior paedetercian what does this involve? You mentioned this in (b)
Iwould discuss with her the contraceptive methods and find the most appropriate for her,also I would tell her that treatment for thyrotoxicosis may be completed in 12 to 18 months so before contemplating new pregnancy ,better to review preconception clinc.
I would encourage breast feeding (1) ,although PTU is secreted in milk ,it has little effect on neonatal thyroid function.
Posted by PAUL A.
Wed Jan 30, 2008 01:21 am
(a)Graves disease is an autoimmune disorder caused by thyroid stimulating hormone receptor ?stimulating antibodies Maternal and fetal outcome is usually good with previously treated graves disease in remission or well controlled hyperthyroidism before conception and during pregnancy (1) . It often improves during pregnancy especially in the second and third trimester but may flare up postpartum (1) . Exacerbation may also occur in 1st trimester .There is high risk of relapse after completion of antithyroid traement . Thyrotoxicosis complicate about 1 in 500 pregnancy .Poorly controlled thyrotoxicosis may lead to thyroid crisis in the mother and congestive heart failure ,especially at the time of delivery (1) .Presence of thyroid stimulating antibody is an independent risk factor for adverse pregnancy outcome including miscarriage. Thyroid auto antibodies cross the placenta and may stimulate fetal thyroid and cause fetal and neonatal thyrotoxicosis in 2.6% cases. Fetal thyrotoxicosis causes premature labour , intrauterine growth retardation, fetal goiter,fetal tachycardia and severe cases heart failure , hydrops occur (1) ..Without treatment the mortality rate may reach 50%. In the neonatal thyrotoxicosis features include weight loss, tachycardia ,irritability, poor feeding ,goiter and severe untreated cases congestive cardiac failure. Without treatment mortality rate is about 15%.Pregnancy has no effect on Graves opthalmopathy. Rarely retrosternal extention of a goiter cause tracheal obstruction (1) .
(b) Many of the clinical features of hyperthyroidism are found in normal pregnancy (tachycardia, tiredness, heat intolerance, dyspnea) and the diagnosis may easily overlooked. So thyroid function should be tested at booking . Treatment with antithyroid drugs should be recommended the question tells you she is already on treatment in case of raised T3 and free T4 and low TSH with liase with the endocrinologist and obstetricians special interest in medical problem during pregnancy. Carbimazole and propyl thiourcil are the most commonly used drugs the question tells you which drug she is taking .If she had a history of well compliance with propylthiouracil it is the first choice of drug. Beta blocker can be used at short term if required for control of thyrotoxic symptoms. Transvaginal ultrasound at booking and transabdominal ultrasound at anomaly scan allows the early detection of an enlarged fetal thyroid will you expect an enlarged fetal thyroid at booking? From what gestation age is the gland active? and correlated with maternal status and treatment. Serial ultrasound to check fetal growth, heart rate and goiter (1) and hydropic change is indicated especially in those mothers with poorly controlled when thyroid stimulating antibody levels rises.Fetal blood sampling through cordocentesis for assessment of fetal thyroid function is accurate but carries inherent risk. In the case of fetal thyrotoxicosis the mother is given antithyroid drugs combind with thyroxin if she is euthyroid.Thyroidectomy rarely indicated in pregnancy but if required for dysphagia or stridor due to enlarged goiter may be safely performed in the second trimester .Radioiodin therapy is contraindicated in pregnancy.
(c) Breastfeeding is safe (1) even in mothers who continue with treatment . The neonate should be examined carefully after birth and the neonates thyroid function should be assessed (1) . It is possible to predict neonate at risk by measuring rising titre of thyroid stimulating antibody although the test is not universally available.Invovement of pediatrician is important.
Posted by PAUL A.
Wed Jan 30, 2008 01:31 am
I would explain to her that most women with well managed Graves Disease will be fine (1) but there is an increase in maternal, fetal and neonatal morbidity. I would explain that symptoms of hyperthroidism often are similar to normal symptoms in pregnancy such as irritability, weight loss is this a feature of normal pregnancy?? , increase appetite, heat intolerance and palpitations but she should report these sypmtoms as they could be suggestive of an overactive thyroid and would require assessment and treatment. Other risks to the mother include cardiac failure and thyroird storm although very rare carriers a significant (25%) mortality only in poorly treated disease . If she developed a goite there is risk of retrosternal goite which could impaired her breathing and have implications if she required an intubation for general anaesthesia (1) . There is also an exacerbation of the conditon in the pueperium (1) . I would explain that the thyroid antiboides can cross the placenta and in 10% of women there is a risk of fetal hyperthyroidism (1) . This can cause intrauterine growth restriction, and if severe can cause fetal tachycardia, cardiac failure, This can result in hydrops and polyhydramnios which can cause preterm delivery (1) . The fetus is also at risk of hypothyroidism due to the maternal drugs. This is usually transient and can cause fetal goitre. However I would empahsise that continuing her medication far outweighs the risks of stopping them. The neonate may present with thyrotoxicosis, this may present late (as long as one week). Symptoms in the neonate such as poor feeding, difficulty breathing and goitre are signs.

Antenatally she should be managed by a multidisciplinary team. This should include a endocrinologists and a feto-maternal obstetrician and neopnatologists.We would monitor the mother and the fetus. We should treat maternal symptoms and she may require B blockers for palpitations or tremor. She should be managed with the lowest effective dose of medication (1) and this should be titrated according to her clinical and biochemical indices. She should have regular bloods measuring TSH, T4 and T3 every month (1) . If she develops a goite an ultrasould assessment of her thyroid is warranted and an anaesthetic review. With regards to the fetus, apart from the routine screening and anomaly scans a cardiac scan would pick up early cardiac failure how do you detect early cardiac failure on scan? . She would need regular ultrasound for growth (1) , liquor volume and dopplers at 4 weekly intervals looking for IUGR, polyhydramnios and potential hydrops. Features of hyperthyrodism in the fetus may require an increase in maternal antithyroid drugs and potentially thyroxine replacement in the mother.

Again I would monitor the baby and the mother how? . She is at increase risk of exacerbation of her condition and may require an increase in medication. I would titrate this according to biochemical and clinical symtoms. I would explain to her that breatfeeding is not contraindicated (1) as the antithyroid drugs a present in very small amounts in breat milk. The neonate would require TFT\'s checking in the cord blood and also at regular intervals as adviced by the neonatologists (especially if she is breat feeding) (1) I would advice her to look out for symptoms in the neonate as explained previously. I would talk to her about contraception and advice that there are no contraindications to any form of contrceptives however if she is breat feeding the COCP should not be started until 3 months.
Posted by PAUL A.
Wed Jan 30, 2008 02:05 am
A good candidate should

(a)
Maternal risks
? Explain that adequately treated Graves disease is associated with minimal maternal risks. However, there is a risk of relapse in the puerparium (1) .
? Poorly treated Graves disease associated with cardiac failure and thyroid storm, especially during labour (1)
? Symptoms of hyperthyroidism may be confused with symptoms of normal pregnancy (1)
? Thyroid enlargement may cause tracheal obstruction and difficult intubation (1)

Fetal / neonatal risks
? Poorly treated disease associated with increased risk of miscarriage (1)
? Explain increased risk of low birth weight, pre-term delivery and stillbirth (1)
? Explain risk of fetal / neonatal thyrotoxicosis & hypothyroidism / goitre (1)
? Explain risk of craniosynostosis and exopthalmos (1)
? Provide written information (1)


(b) With respect to antenatal care

? Know that the aim is to ensure the woman is clinically and biochemically euthyroid on the minimum dose of anti-thyroid drug by managing in a maternal medicine clinic with physician / endocrinologist (1)
? Monitor thyroid function by TSH, free T3 & T4 in each trimester, and monthly if drug dose is changed (2)
? Discuss drug side-effects and indications for changing therapy (1)
? Liaise with neonatologist as risk of neonatal hypo / hyper-thyroidism (1)
? Serial fetal growth scans + fetal heart rate + thyroid enlargement (1)


(c ) With respect to post-natal care

? Know that there is a risk of relapse ? therefore monitor for symptoms / signs of hyperthyroidism and check TFTs (1) .
? Also need to review drug dose as higher dose might have been required during pregnancy to compensate for increased plasma volume (1)
? Know that there is a risk of neonatal goitre, hypo / hyperthyroidism. Examine neonate for goitre; TFT on cord blood (1)
? Breast-feeding not contra-indicated ? very low levels of PTU in breast milk (1)
s Posted by PAUL A.
Mon May 7, 2012 01:41 am

s