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TRANSCRIPT
HIPERTIROID
TIAN&
NYNG
tian & nyng
tian & nyng
• A 32 weeks pregnant woman, 22 Y,O, G1P0A0, came for prenatal care with complaint of palpitation. The woman was very nervous and anxious. She also complaint profuse sweating and fatigue
• Additional information :On examination the woman had fine tremor, tachycardia, diffuse enlargement in her anterior neck and exopthalmus on her eyes.
Term Clarification
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– 37 weeks pregnant woman: carrying child in uterus during third semester of pregnancy.
– G1P0A0:Gravida (1) : first pregnancy.Partus/ giving birth (0) :never giving birth before.
Abortus (0) : never done an abortion before.– Prenatal care : Check up before the birth.– Palpitation : An abnormally rapid beating of the
heart when excited by violent exertion,strong emotion or disease.
– Nervous : Easily agitated or abnormal or alarmed resulting from anxiety or anticipation.
– Anxious : Experiencing worry or unease– Profuse sweating : Excessive produce of moisture
exuded through the pores especially; from heat and nervousness.
– Fatigue : The temporary loss of power to respond induce in a sensory
receptor or end motor organ by continued stimulation.
– Fine Tremor : An involuntary quivering movement– Tachycardia : Increasing of rapid heart rate.– Diffuse enlargement in her anterior neck: Diffuse goiter ;
increase in size of thyroid gland– Exophtalmus : Abnormal protrusion of eyeballs so
the eyes can’t close completely
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Problem Identification1. A 32 weeks pregnant woman, 22 years old with
G1P0A0 has complaint of palpitation, profuse sweating and fatigue.
2. She was very nervous and anxious.3. From examination, she also had:
• Fine tremor• Tachycardia• Diffuse enlargement• Exopthalmus
tian & nyng
Problem Analyze1. What are the hormones that influences in (32 weeks) pregnancy?2. What is correlation between pregnancy and hypertiroidisme ?3. What is the mechanism of exopthtalmus?4. What is the mechanism of diffuse enlargment ?5. What is the mechanism of tachycardia?6. What is the mechanism of fine tremor?7. What is the mechanism of nervous and anxious?8. What is the mechanism of fatigue ?9. What is the mechanism of palpitation?10. What is the mechanism of profuse sweating?11. What is the diagnose in this case ?12. What is the different diagnose it this case?13. What is the penatalaksanaan in this case?14. What is the complication in this case?15. What is the prognosis in this case ?16. What is the rehabilitation and prevention ?
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Hypothesis
• The Patient ( pregnant, 32 years old, G1P0A0 ) suffered from hyperthyroidism - graves disease
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SYNTHESIS
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G1P0A0– G (gravida): The number of times a
woman has been pregnant.• G1: This is the first pregnancy for
this pregnant woman.– P (para): The number of times a
woman has given birth.• P0: She has never given birth.
– A (abortus): The number of loss pregnancy (abortion and miscarriage).• A0: She has never had abortion or
miscarriage.
Flow chart…
Complaints : Physical Exam
Grave’s disease
Palpitation?
Profuse sweating ?
Fatigue?
nervous and anxious?
Fine tremor?
Tachycardia?
diffuse enlargement?
Exopthalmus?
A 32 weeks pregnant woman, G1P0A0,22 years old
growth of fetus?
Hormonal changes ?
What happen while pregnancy
• Hormonal changes• Physical changes• Immunological changes• Musculoskeletal changes
Hormonal changes
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• Hormones that influenced in gestation phase:– Hypophyses enlarge 50 %– Corticosteroid medium increase– Aldosteron increase 2x– Thyroid enlarge 50 % , increase production
( adjusted ) ????– Parathyroid enlarge
HORMONE THAT INFLUENCES IN PREGNANCY
1.Estrogen• Stimulate the growth of nipple and mammary
gland• Make ovarium become strong during partusis• Make the tissue become smooth• Estrogen increase in the beginning of pregnancy2. Progesterone• Build the ovarium’s layer• Prevent the ovarium contraction• Increase the body temperature and cause nausea• Influence the emotion• Progesterone will have low level in the beginning
of pregnancy and high level in the end of pregnancy.
3. Prolactin• Increase the breast milk production• Prolactin work antagonist to estrogen4. Oxytocin• Ovarium contraction• ASI flow effect 5. HCG (Human Charionic Gonadothropin)• End of pregnant → placenta function decrease →
estrogen and progesterone decrease → oxytocyn increase → contraction → partusis.
During pregnancy → enlargement of thyroid gland up to 20% and increase the thyroxin production depend on the enlargement
Thyroid Hormone and Regulation
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Thyroid hormone
• Thyroid hormone T3 and T4 • Produced by thyroid gland in neck • It’s major effect is to increase body
metabolism more catabolic • Influence in growth and maturity, maintain
entire body function systemic effect• regulated in negative feedback fashion
Relation Between Pregnancy and Hyperthyroidsm
*hCG : Human Chorionic Gonadotropin. A human hormone made by chorionic cells in the fetal part of the placenta.
hCG
hCG has mild TSH-like activity
High free T4 during the pregnancy
Hyperthyroid
Pregnancy HCG production by placenta Acts as a weak thyrotrophic
hormone
Stimulates the maternal thyroid
gland
Noradrenalin production
Fetal adrenal gland
Diffuse enlargement
AnxietyNervousTremor
↑ Hormone production (T3 & T4)
↑ Basal metabolism
Heat intolerance
↑ Protein metabolism
↑ Cardiac output
TachycardiaFatigue Exopthalmus
Fat heap in eye orbital
Correlation all of the symptoms
MECHANISM OF DIFFUSE ENLARGEMENT
Increase of TSH (&TSI)
Increase the proliferation of Thyroid Gland
May hyperplasia / proliferation of follicles in the thyroid follicles
Enlargement of the anterior of the neck(Struma)
Patophysiology of palpitation
Metabolism increase
O2 supply increase
Cardiac output increase
Heart rate increase
Tachycardia
PaLpitation
Hyperthyroid
T3 and T4 increase
Pathophysiology of Profuse Sweating
T3 and T4 increase
Metabolism increase
Hyperthyroid
Body heat increase
Heat secretion trough the skin
Profuse sweating
Pathophysiology of fatigue
T3 and T4 increase
Metabolism increase
Hyperthyroid
Body heat increase
Vasodilataion
O2 in muscle Muscle tonus
Excessive process of Protein catabolism
Muscle weakness
FATIGUE
Pregnancy Carry the babby
Glucose level
severe case
Eye lid do not close sompletely
protrusion stretches optic nerve
Protrusion of eye ball
Exophthalmus
Degenerative changes inExtraocular muscles
Edematous swelling at retro-orbital tissue
Abnormal connective tissue accumulation of fats
immunoglobin found in eye muscle
MECHANISM EXOPHTALMUS
Increase of thyroid hormone Release from catecholamine
Level of catecholamine increases
Increases sensitivity of beta-adrenergic receptor
Dilatation artery to skeletal muscle
Oxygen increases to muscles
Muscle tone increases Fine tremor
Mechanism of Tremor
Nervous&anxiety
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T3 and T4 increase
Metabolism increase
Hyperthyroid
↑ CNS activities
↑ work adrenal
↑ epinefrin
Nervous & anxiety
Differential DiagnoseNervous and anxious
Heat intole-rance
Fatigue Tremor Tachy-cardia
Thyroid enlargement
Exop-thalmus
Graves disease √ √ √ √ √ √ √
Toxic multi-nodular goiter
- √ - √ √√
(multinodular,
not diff)
-
Toxic thyroid ade-noma
- - - - - √ -
Diagnose• Anamnesis
– family history of hyperthyroid– sign and symptoms– body weight – number of times being pregnant.– number of times she has given birth.– number of loss pregnancies (abortions and miscarriage)– kinds of food intake
• Physical examination– Thyroid palpation– Characterized of face
• fissure of palpebrae is wide and sclera can look in around of cornea• Laboratory examination : (blood test)
– Increased levels of T3– Increased levels of T4– Low levels of TSH– Presence of thyroid stimulating antibodies
Working Diagnosis• HIPERTIROIDISM :
Clinical syndrome cause by increasing of thyroid hormone in circulation.
• CAUSE BY :– GRAVES DISEASE mostly– STRUMA NODOSA TOKSIK– ADENOMA TOKSIK
• GRAVE DISEASE : ( 20 – 40 years old) man : woman = 1 : 5
Grave’s DiseaseEtiologyAutoimmune disorder → specific antibody (TSI)
– TSH receptor at follicular cells → thyroid gland stimulation →high production of T3 and T4.
Sign and symptoms:• Fatigue• Tachycardia• Heat intolerance• Exophtalmus• Hand tremors• trouble getting pregnant• irritability• weight loss without dieting• increased sweating• changes in vision or how your eyes look• lighter menstrual flow
Pathogenesis Autoimmune
Reaction antibody IgG/TSI with TSH receptor
Increased stimulate of Adenilat siklase
Increased standard of Camp
Stimulate function of gland thyroid
Proliferation thyroid cell
Increased production thyroxine hipertiroid
Risk Factor • Usually occur in age 20 – 40 years old• Woman : man = 5 : 1• Predisposition familial • Be related with form endocrinenopaty the others Autoimmune • There is family history with tyroid problem, hypertyroidism• Ever has tyroid hormone therapy or anti-tiroid treatment• Done tiroidektomi surgical• Bacterial or viral infection• Stopped of anti-tiroid treatment• Excessive of iodida in the defisiensi iodida area
Treatment
Anti-Thyroid Drugs PropylthiouracylMethimazole ~ Carbimazole
Beta blockerNot indicated, main treatment is based on the etiology, since it not
indicated any dangerous signs and it also can induce fetal growth retardation when used continuously
Radioactive Iodine Can’t be used to the pregnant patient due to the ionization and
radiation effect will result to congenital anomaly Subtotal Thyroidectomy – not recommended
TreatmentDrugs Group The effects Indication
Anti thyroid DrugsPropilthiouracil (PTU) to pregnant woman
<300 mg/dayMetimazole (MMI) – aplasia cutis
(kelainan kulit kepala bayi)Carbimazole (CMZ MMI)
Inhibiting synthesis of thyroid hormone and the effects of immunosupresif (PTU inhibit convertion T4 ->T3)
The first treatment to Graves’ disease. Short time drugs pra surgery/pra-RAI
B-adrenergic-antagonistPropanolMetoprololAtenolNadolol
Decreasing effect of thyroid hormone on tissue.
Additional drugs; sometimes as a single drugs of thyroid
Materials contains of iodineCalium IodidaSolusi LugolNatrium IpodatIopanoat Acid
Inhibiting secretion T4 and T3, Inhibiting T4 and T3, extra thyroidal
Preparation for thyroidektomi, not for routine usage
Other DrugsCalium PercloratLitium PercloratGlucocorticoids
Inhibiting Iodium transport, synthesis and hormone secretion. Improve hormonal effect in tissue, also for immunology.
Not for routine indication in sub acute thyroiditis and thyroid storm.
– PTU• Less transferred through placenta and breast milk • Dosage :
– Initial : 15 – 40 mg / day– Maintenance : 5 -15 mg / day
• Side Effect rash, fever and agranulositosis
• In this case, we prefer to use PTU as chosen treatment due to lowest side effect than other treatment / drugs and its availibility
COMPLICATIONUncontrolled hyperthyroidism, especially in the second half of
pregnancy, can lead to numerous complications.• Maternal complications
– Miscarriage – Infection – Preeclampsia – Preterm delivery – Congestive heart failure – Thyroid storm – Placental abruption
• Fetal and neonatal complications– Prematurity – Small size for gestational age – Intrauterine fetal death – Toxemia – Fetal or neonatal thyrotoxicosis, including accelerated bone
maturation, goiter, and hydrops
Rehabilitation & PreventionRehabilitation :
• reduces daily activity• bed rest and do massage to
increase relaxation
Prevention :
There are several ways to prevent getting hyperthyroidism including:
• Eating a diet with an adequate amount of iodine
• Regular screening for hyperthyroidism if there is someone in your immediate family with this disease or you have another autoimmune disease
Prognosis
Dubia ad BonamThe amount of T3 and T4 must be controlled
until become normal, however the remission phase must last until the parturition to maintain the fetus safety and must be followed up after that~ due to occurrence of relapse and chance to develop into severe complication
CLINICAL COMPETENCY• Level 3 A : be able to make a clinical diagnosis based
on physical examination and supportive examination ( simple lab .test, X – ray), and to give initial treatment and to refer to the relevant specialist (not an emergency case).
PATIENT EDUCATION• The importance of compliance with medical therapy
should be stressed. • The need for frequent laboratory assessment should
be discussed. • The adverse effects of medical therapy, including the
fetal risks, should be outlined.