Gebelikte Tiroid Hastalıkları
Özet
Gebelik döneminde tiroid fonksiyon bozuklukları, hem anne hem de bebek sağlığını ciddi şekilde etkileyebilen ve sık karşılaşılan endokrin problemlerdir. Serum TSH düzeyi, tiroid fonksiyonunun değerlendirilmesinde en güvenilir parametre olup trimestere özgü referans aralıklarına göre yorumlanmalıdır. Gebelikte en sık görülen hipotiroidi nedeni kronik otoimmün tiroidittir. Aşikar hipotiroidi; erken doğum, düşük doğum ağırlığı ve çocukta nörobilişsel gelişim bozukluğu riskini artırdığı için mutlaka levotiroksin ile tedavi edilmelidir. Subklinik hipotiroidi tedavisi ise kılavuzlara ve antikor durumuna göre değişkenlik gösterir. Gebelikte tirokotoksikozun en yaygın sebebi Graves hastalığıdır; ancak gebeliğin ilk yarısında görülebilen geçici gestasyonel tirokotoksikoz ile ayrımı tedavi kararı açısından kritik önem taşır. Aşikar hipertiroidi tedavisinde, maternal ve fetal yan etkileri en aza indirmek amacıyla ilk trimesterde propiltiourasil, sonrasında ise metimazol tercih edilir. Tiroid nodülleri ve gebelikte en sık izlenen tiroid kanseri türü olan papiller kanser, ultrason ve ince iğne aspirasyon biyopsisi ile yönetilir; operasyon genellikle doğum sonrasına ertelenebilir. Doğum sonrası ilk yılda gelişen postpartum tiroidit ise genellikle geçici ve kendiliğinden düzelen bifazik (hipertiroidi ve hipotiroidi) bir seyir gösterir, semptomatik durumlarda beta bloker veya levotiroksin tedavisi uygulanır.
Thyroid dysfunction during pregnancy is a common endocrine disorder that can cause serious complications for both mother and fetus. Serum TSH level is the most reliable measure and should be interpreted using trimester-specific reference ranges. Chronic autoimmune thyroiditis is the primary cause of hypothyroidism in iodine-sufficient areas. Overt hypothyroidism increases the risk of preterm birth, low birth weight, and impaired neurocognitive development in children, and must be treated with levothyroxine. Management of subclinical hypothyroidism varies according to guidelines and antibody status. While Graves' disease is the most common cause of overt hyperthyroidism, it must be differentiated from gestational transient thyrotoxicosis, which does not require antithyroid treatment. For overt hyperthyroidism, propylthiouracil is preferred in the first trimester, followed by a switch to methimazole in later trimesters to minimize adverse outcomes. Thyroid nodules and papillary thyroid cancer, the most frequent thyroid malignancy in pregnancy, are evaluated via ultrasound and fine-needle aspiration biopsy, with surgery often postponable until postpartum. Finally, postpartum thyroiditis is an autoimmune syndrome occurring within the first year after delivery, characterized by a transient biphasic course of hyperthyroidism followed by hypothyroidism, which mostly resolves spontaneously but can be managed with beta-blockers or levothyroxine for symptom relief.
Referanslar
Glinoer D. Thyroid hyperfunction during pregnancy. Thyroid. 1998;8(9):859-64.
De Groot L, Abalovich M, Alexander EK, Amino N, Barbour L, Cobin RH, et al. Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism. 2012;97(8):2543-65.
Lazarus J, Brown RS, Daumerie C, Hubalewska-Dydejczyk A, Negro R, Vaidya B. 2014 European thyroid association guidelines for the management of subclinical hypothyroidism in pregnancy and in children. European thyroid journal. 2014;3(2):76-94.
Glinoer D, De Nayer P, Robyn C, Lejeune B, Kinthaert J, Meuris S. Serum levels of intact human chorionic gonadotropin (HCG) and its free a and β subunits, in relation to maternal thyroid stimulation during normal pregnancy. Journal of endocrinological investigation. 1993;16(11):881-8.
Baloch Z, Carayon P, Conte-Devolx B, Demers LM, Feldt-Rasmussen U, Henry J-F, et al. Laboratory medicine practice guidelines. Laboratory support for the diagnosis and monitoring of thyroid disease. Thyroid: official journal of the American Thyroid Association. 2003;13(1):3-126.
Soldin O, Tractenberg R, Hollowell J, Jonklaas J, Janicic N, Soldin S. Trimester-specific changes in maternal thyroid hormone, thyrotropin, and thyroglobulin concentrations during gestation: trends and associations across trimesters in iodine sufficiency. Thyroid. 2004;14(12):1084-90.
Glinoer D. The regulation of thyroid function in pregnancy: pathways of endocrine adaptation from physiology to pathology. Endocrine reviews. 1997;18(3):404-33.
Glinoer D, Spencer CA. Serum TSH determinations in pregnancy: how, when and why? Nature Reviews Endocrinology. 2010;6(9):526-9.
Stagnaro-Green A, Abalovich M, Alexander E, Azizi F, Mestman J, Negro R, et al. Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and postpartum. Thyroid. 2011;21(10):1081-125.
Li C, Shan Z, Mao J, Wang W, Xie X, Zhou W, et al. Assessment of thyroid function during first-trimester pregnancy: what is the rational upper limit of serum TSH during the first trimester in Chinese pregnant women? The Journal of Clinical Endocrinology & Metabolism. 2014;99(1):73-9.
Brabant G, Peeters RP, Chan SY, Bernal J, Bouchard P, Salvatore D, et al. Management of subclinical hypothyroidism in pregnancy: are we too simplistic? European journal of endocrinology. 2015;173(1):P1-P11.
Medici M, Korevaar TI, Visser WE, Visser TJ, Peeters RP. Thyroid function in pregnancy: what is normal? Clinical chemistry. 2015;61(5):704-13.
Haddow JE, Palomaki GE, Allan WC, Williams JR, Knight GJ, Gagnon J, et al. Maternal thyroid deficiency during pregnancy and subsequent neuropsychological development of the child. New England Journal of Medicine. 1999;341(8):549-55.
Casey BM, Dashe JS, Wells CE, McIntire DD, Byrd W, Leveno KJ, et al. Subclinical hypothyroidism and pregnancy outcomes. Obstetrics & Gynecology. 2005;105(2):239-45.
Stagnaro-Green A. Postpartum management of women begun on levothyroxine during pregnancy. Frontiers in endocrinology. 2015;6:183.
Mannisto T, Vaarasmaki M, Pouta A, Hartikainen A-L, Ruokonen A, Surcel H-M, et al. Thyroid dysfunction and autoantibodies during pregnancy as predictive factors of pregnancy complications and maternal morbidity in later life. The Journal of Clinical Endocrinology & Metabolism. 2010;95(3):1084-94.
Cleary-Goldman J, Malone FD, Lambert-Messerlian G, Sullivan L, Canick J, Porter TF, et al. Maternal thyroid hypofunction and pregnancy outcome. Obstetrics and gynecology. 2008;112(1):85.
Negro R, Schwartz A, Gismondi R, Tinelli A, Mangieri T, Stagnaro-Green A. Universal screening versus case finding for detection and treatment of thyroid hormonal dysfunction during pregnancy. The Journal of Clinical Endocrinology & Metabolism. 2010;95(4):1699-707.
Javed Z, Sathyapalan T. Levothyroxine treatment of mild subclinical hypothyroidism: a review of potential risks and benefits. Therapeutic advances in endocrinology and metabolism. 2016;7(1):12-23.
Henrichs J, Bongers-Schokking JJ, Schenk JJ, Ghassabian A, Schmidt HG, Visser TJ, et al. Maternal thyroid function during early pregnancy and cognitive functioning in early childhood: the generation R study. The Journal of Clinical Endocrinology & Metabolism. 2010;95(9):4227-34.
Taylor P, Lacey A, Thayer D, Draman M, Tabasum A, Muller I, et al., editors. Controlled antenatal thyroid screening study; obstetric outcomes. Endocrine Abstracts; 2016: BioScientifica.
Goodwin TM. Hyperemesis gravidarum. Clinical obstetrics and gynecology. 1998;41(3):597-605.
Tan JY, Loh KC, Yeo GS, Chee YC. Transient hyperthyroidism of hyperemesis gravidarum. BJOG: an international journal of obstetrics and gynaecology. 2002;109(6):683-8.
Casey BM, Dashe JS, Wells CE, McIntire DD, Leveno KJ, Cunningham FG. Subclinical hyperthyroidism and pregnancy outcomes. Obstetrics & Gynecology. 2006;107(2):337-41.
Davis LE, Lucas MJ, Hankins GD, Roark ML, Cunningham FG. Thyrotoxicosis complicating pregnancy. American journal of obstetrics and gynecology. 1989;160(1):63-70.
Aggarawal N, Suri V, Singla R, Chopra S, Sikka P, Shah VN, et al. Pregnancy outcome in hyperthyroidism: a case control study. Gynecologic and obstetric investigation. 2014;77(2):94-9.
Andersen SL, Olsen J, Laurberg P. Antithyroid drug side effects in the population and in pregnancy. The Journal of Clinical Endocrinology & Metabolism. 2016;101(4):1606-14.
Bahn RS, Burch HS, Cooper DS, Garber JR, Greenlee CM, Klein IL, et al. The role of propylthiouracil in the management of Graves' disease in adults: report of a meeting jointly sponsored by the American Thyroid Association and the Food and Drug Administration. Thyroid. 2009;19(7):673-4.
HAMBURGER JI. Diagnosis and management of Graves' disease in pregnancy. Thyroid. 1992;2(3):219-24.
Rubin PC. Beta-blockers in pregnancy. New England Journal of Medicine. 1981;305(22):1323-6.
Polak M, Le Gac I, Vuillard E, Guibourdenche J, Leger J, Toubert M-E, et al. Fetal and neonatal thyroid function in relation to maternal Graves' disease. Best practice & research Clinical endocrinology & metabolism. 2004;18(2):289-302.
Matthews DC, Syed AA. The role of TSH receptor antibodies in the management of Graves' disease. European journal of internal medicine. 2011;22(3):213-6.
Alexander EK, Marqusee E, Lawrence J, Jarolim P, Fischer GA, Larsen PR. Timing and magnitude of increases in levothyroxine requirements during pregnancy in women with hypothyroidism. New England Journal of Medicine. 2004;351(3):241-9.
Obstetricians ACo, Gynecologists. Practice bulletin no. 148: thyroid disease in pregnancy. Obstetrics and gynecology. 2015;125(4):996-1005.
Horacek J, Spitalnikova S, Dlabalova B, Malirova E, Vizda J, Svilias I, et al. Universal screening detects two-times more thyroid disorders in early pregnancy than targeted high-risk case finding. European Journal of Endocrinology. 2010;163(4):645.
Laurberg P, Andersen SL, Pedersen IB, Andersen S, Carlé A. Screening for overt thyroid disease in early pregnancy may be preferable to searching for small aberrations in thyroid function tests. Clinical endocrinology. 2013;79(3):297-304.
Fitzpatrick DL, Russell MA. Diagnosis and management of thyroid disease in pregnancy. Obstetrics and Gynecology Clinics. 2010;37(2):173-93.
Casey BM, Leveno KJ. Thyroid disease in pregnancy. Obstetrics & Gynecology. 2006;108(5):1283-92.
Grubu TÇ. Tiroid Hastalıkları Tanı ve Tedavi Kılavuzu. 1. Baskı, Ankara: Aysun Yayıncılık. 2012:21-4.
Muller AF, Drexhage HA, Berghout A. Postpartum thyroiditis and autoimmune thyroiditis in women of childbearing age: recent insights and consequences for antenatal and postnatal care. Endocrine reviews. 2001;22(5):605-30.
Alexander EK, Pearce EN, Brent GA, Brown RS, Chen H, Dosiou C, et al. 2017 Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and the postpartum. Thyroid. 2017;27(3):315-89.
Stagnaro-Green A, Pearce E. Thyroid disorders in pregnancy. Nature Reviews Endocrinology. 2012;8(11):650-8.
Nguyen CT, Mestman JH. Postpartum thyroiditis. Clinical obstetrics and gynecology. 2019;62(2):359-64.
Benvenga S, Di Bari F, Vita R, Le Donne M, Triolo O, Granese R, et al. Relatively high rate of postpartum thyroiditis in the Straits of Messina area. Predictivity of both postpartum thyroiditis and permanent hypothyroidism by performing, in the first trimester of gestation, thyroid ultrasonography and measurement of serum thyroperoxidase and thyroglobulin autoantibodies. Journal of clinical & translational endocrinology. 2019;15:12-8.
Di Bari F, Granese R, Le Donne M, Vita R, Benvenga S. Autoimmune abnormalities of postpartum thyroid diseases. Frontiers in endocrinology. 2017;8:166.
Lazarus JH, Ammari F, Oretti R, Parkes AB, Richards CJ, Harris B. Clinical aspects of recurrent postpartum thyroiditis. British Journal of General Practice. 1997;47(418):305-8.
