THYROID DYSFUNCTION IN PREGNANCY

I.

HYPERTHYROIDISM

Definition: It is the oversecretion of thyroid hormone due to increased metabolic rate. Incidence: 2 per 100 pregnancies. Causes: 1. Thyroid stimulating antibodies is the commonest cause. 2. Goiter & trophoblastic disease. 3. Obesity 4. Family history Sign & symptoms: 1. Thyrotoxicosis 2. Increased cardiac output 3. Increased oxygen consumption 4. Patient cant sit quietly 5. Palpitations 6. There is occcurance of exopthalamus i.e: bulging eyes Major risks to mother: Cardiac failure because of dysfunction of cardiac muscles. Fetal risks include increased abortion, IUGR, stillbirth and neonatal mortality. Diagnostic evaluation: 1. Thyroid examination 2. T3, T4, TSH NORMAL RANGE OF THYROID PROFILE 1. T3- 24.3-39.0%
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2. T4- 4.5-12.0 ug/dl 3. TSH- 0.34-5.6 uIU/ml Management: Medical management: 1. T. Carbimazole 20- 60 mg initially then reduced to 5- 15 mg 2. Propyl thiouracil (300-450 mg) Surgical management: Thyroidectomy is done in 2nd trimester. Nursing management: 1. Mother is reassured. 2. Try to maintain a cool comfortable environment. 3. Give mother fresh, cool bedding and clothes. 4. Give cool baths if permitted. 5. Explain the family members about the care. 6. Give well balanced diet. 7. Give frequent meals. 8. Ask patient to avoid tea, coffee, cola, alcohol. 9. Give her a high protein diet. 10. Record weight. 11. Check fetal heart rate regularly. 12. Radioactive iodine should not be given in pregnancy. 13. Preconception counseling should be done.

II.

HYPOTHYROIDISM

Definition: In this, there is slow progression of thyroid hormone.

Types: 1. Primary hypothyroidism: in this, there is dysfunction of thyroid gland itself. 2. Secondary hypothyroidism: in this, there is dysfunction of both pituitary and thyroid gland. 3. Tertiary hypothyroidism: in this, there is inadequate TSH. Sign & symptoms: 1. Extreme fatigue 2. Hair loss 3. Brittle nails 4. Dry skin 5. Numbness & tingling in fingers 6. Voice become husky & hoarse 7. Menorrhagia, amenorrhea or loss of libido. Management: Evothyroxine is given. Poast partam thyroiditis: 10 15% women develop this condition due to autoimmune thyroid disease antimicrosomal antibodies have been detected. Nursing management: 1. Warm blanket may be given to maintain temperature. 2. Maintain nutritional status of mother. 3. Record vital signs 4. Record weight of the patient 5. Record FHS 6. Plan for the mode of delivery of patient. 7. The patient if untreated may have abortion, stillbirth or prematurity. 8. Generally the therapy is started as 0.1 mg/day and increased by 0.05 mg/day at 2 weeks interval depending upon free T4 and TSH levels.

EPILEPSY IN PREGNANCY
Definition: Seizures are sudden alterations in behavior or motor function caused by an electrical discharge from the brain. The effect of pregnancy on epilepsy is uncertain. Frequency of convulsions is unchanged in majoroity and is increased in some. Oestrogen activates seizure foci. There is also increased plasma clearance of anticonvulsant drugs during pregnancy. The adverse effect on mother are third trimester bleeding and megaloblastic anemia. Effects of epilepsy on pregnancy: Incidence of fetal malformations, IUGR, oligohydramnios and still births is increased. Birth defects is increased by two folds. The malformations includes cleft lip, cleft palate, mental retardation, cardiac abnormalities, limb defects. Sodium valproate associated with neural tube defect. There is chance of neonatal hemmorage, and related to anticonvulsant induced vitamin K dependent coaguloppathy. The risk of developing epilepsy to the offspring of epileptic mother is four fold. Preconception counseling includes: 1. To initiate monotherapy 2. To administer folic acid 1 mg daily. 3. Importance of prenatal diagnosis is discussed Management: 1. Phenobarbitone 60-180 mg daily in two or three divided doses. 2. Phenytoin 150-300mg daily in two divided doses 3. Carbamezapine 0.8 1.2 gm daily in divided doses. 4. Fits are controlled by intravenous diazepam 10- 20 mg 5. Folic acid 1 mg daily is to be continued throughout the pregnancy 6. Prenatal diagnosis with aFP at 16 weeks and detailed fetal anatomy scan at 18 weeks with real time USG. There is decreased level of most of the anticonvulsants in pregnancy. This is due to reduced absorption and at the same time increased hepatic metabolism and renal clearance. 7. Vit K 10 mg daily orally is to be given in last two weeks.
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8. Termination of pregnancy may have to be considered with consult to neurologists. 9. There is no contraindication for breast feeding. The infant may be drowsy. Readjusting of anticonvulsant dosage is necessary and to bring down the dose to the pre pregnant state by 4-6 weeks postpartum. Steroidal contraceptives are better to be avoided due to hepatic microsomal enzyme induction.