pregnant tiroid.pptx

7/27/2019 pregnant tiroid.pptx

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Fisiologi tiroid pada Kehamilan

• Kehamilan perubahan fisiologis dan

hormonal yang dapat merubah fungsi tiroid.

• Dua hormon utama yang dihubungkan dgn

kehamilan

o human chorionic gonadotropin (HCG),

hormon yang diukur dalam tes kehamilan

o estrogen, hormon wanita utama.



• hCG dan estrogen peningkatan tingkat hormon tiroid dalam

darah.• hCG dibuat oleh plasenta, serupa dengan TSH dan sedikit

menstimulasi tiroid untuk menghasilkan hormon tiroid.

• HCG : konsentrasi hCG yang tinggi pada trimester pertama

konsentrasi TSH sedikit rendah (disebut hipertiroidisme subklinis).

• TSH

sedikit menurun pada trimester pertama

kembali normal sepanjang durasi kehamilan

• Kelenjar tiroid sedikit membesar selama kehamilan, tapi tidak

cukup untuk dideteksi secara fisik.

• Pembesaran yg terlihat jelas tanda penyakit tiroid dan harus

dievaluasi



• Estrogenmeningkatkan jumlah protein yangmengikat hormon tiroid dalam serum (thyroxine-binding globulin, protein yg mentrasport hormon tiroidke dalam darah)meningkatkan total kadar hormon

tiroid dalam darah > 99% dari hormon tiroid dalamdarah terikat dengan protein tersebut.

• Pengukuran hormon bebas (yang tidak terikat padaprotein, yang mewakili bentuk aktif dari hormon)biasanya tetap normal. Tiroid berfungsi normal jikaTSH, T4 dan T3 bebas dalam konsentrasi normal selamakehamilan.



• Pada kehamilan, janin menerima yodium darisumber ibu di semua trimester. Janin menerimatiroksin dari ibu hingga 12 minggu melalui

sirkulasi plasenta tetapi tidak TSH atau FT3.Tiroksin sebagian dikonversi ke FT3 danmengkombinasikan dengan reseptor di otak janindan bertanggung jawab untuk perkembangan

otak janin. Dari minggu ke-12, perubahanplasenta menolak bagian T4 ke janin dan janinhipofisis tiroid sumbu mulai berfungsi



1. Pada kehamilan, half life Thyroxin Binding Globulin (TBG) ↑↑ dari 15 menit sampai

• 1. Pada kehamilan, setengah hidup meningkat dari 15 menit untuk 3days dan konsentrasi menjadi

• 3 kali oleh 20weeks karena efek estrogen didorong glikosilasi, yang meningkatkan tingkat T3 dan T4 membuat nonestimasi yang dapat diandalkan. Tapi FT3 dan fT4 tetap terpengaruh, dan pilihan untuk memperkirakan tiroidfungsi selama kehamilan.

• 2. HCG dan TSH karena struktural menghasilkan kesamaan sindrom spillover hormon pada trimester 1, diwujudkansebagai stimulasi reseptor TSH oleh HCG dan biokimia hipertiroidisme. Hal ini biasa terjadi dalam kehamilanganda, hiper emesis gravidarum dan penyakit trofoblas.

•

Diagnosis hipertiroidisme palsu harus dihindari dalam kasus ini.• 3. Penipisan yodium dapat terjadi karena peningkatan glomerular filtrasi dan serapan thyroidal besar karena T4

tinggi konsentrasi. Di beberapa kekurangan yodium ibu, kompensasi jika gagal dapat menyebabkan kretinismepada keturunannya.

• 4. Konsentrasi enzim deiodinase III (yang mengubah T4 ke T3 dan selanjutnya breakdown) meningkat padaplasenta dan mengurangi tiroksin transfer.

• 5 Sekitar 2 sampai 5% dari wanita hamil menderita dari berbagai gangguan tiroid dan intervensi tepat waktu dapatdilakukan jika terdeteksi early.6 Karena perubahan fisiologis nilai tiroid hormon selama kehamilan berbeda darinilai-nilai yang tidak hamil. Nilai dalam kehamilan juga bervariasi dari trimester ke trimester dan

• ada konsensus tentang nilai ini telah belum dibuat. Coutez C et al., menetapkan nilai berikut seperti yangditunjukkan dalam tabel 1.7 Pada tahun 2008, Marwaha RK et al, pertama kali disajikan trimester

• nilai fungsi tiroid tertentu di India Woman.8 ini ditunjukkan dalam tabel 2.



• Hyperthyroidism

• What causes hyperthyroidism in pregnancy?

• Hyperthyroidism in pregnancy is usually caused by Graves’ disease andoccurs in about one of every 500 pregnancies.1 Graves’ disease is anautoimmune disorder. Normally, the immune system protects people frominfection by identifying and destroying bacteria, viruses, and otherpotentially harmful foreign substances. But in autoimmune diseases, theimmune system attacks the body’s own cells and organs.

• With Graves’ disease, the immune system makes an antibody calledthyroid-stimulating immunoglobulin (TSI), sometimes called TSH receptorantibody, which mimics TSH and causes the thyroid to make too muchthyroid hormone. In some people with Graves’ disease, this antibody is

also associated with eye problems such as irritation, bulging, andpuffiness.

• Although Graves’ disease may first appear during pregnancy, a womanwith preexisting Graves’ disease could actually see an improvement in hersymptoms in her second and third trimesters. Remission—a



• Graves’ disease in later pregnancy may result from the generalsuppression of the immune system that occurs during pregnancy.The disease usually worsens again in the first few months afterdelivery. Pregnant women with Graves’ disease should bemonitored monthly.2

•More information about Graves’ disease is provided by the NationalEndocrine and Metabolic Diseases Information Service (NEMDIS) inthe fact sheet, Graves’ Disease, available atwww.endocrine.niddk.nih.gov.

• Rarely, hyperthyroidism in pregnancy is caused by hyperemesisgravidarum—severe nausea and vomiting that can lead to weight

loss and dehydration. This extreme nausea and vomiting is believedto be triggered by high levels of hCG, which can also lead totemporary hyperthyroidism that goes away during the second half of pregnancy.



• health care provider’s office or commercial facility and sending the sample to a lab for analysis.Diagnostic blood tests may include

• TSH test. If a pregnant woman’s symptoms suggest hyperthyroidism, her doctor will probably firstperform the ultrasensitive TSH test. This test detects even tiny amounts of TSH in the blood and isthe most accurate measure of thyroid activity available.

• Generally, below-normal levels of TSH indicate hyperthyroidism. However, low TSH levels may alsooccur in a normal pregnancy, especially in the first trimester, due to the small increase in thyroidhormones from HCG.

• T3 and T4 test. If TSH levels are low, another blood test is performed to measure T3 and T4.Elevated levels of free T4—the portion of thyroid hormone not attached to thyroid-bindingprotein— confirm the diagnosis.

• Rarely, in a woman with hyperthyroidism, free T4 levels can be normal but T3 levels are high.Because of normal pregnancy-related changes in thyroid function, test results must be interpretedwith caution.

• TSI test. If a woman has Graves’ disease or has had surgery or radioactive iodine treatment for thedisease, her doctor may also test her blood for the presence of TSI antibodies. More informationabout testing for thyroid problems is provided by the NEMDIS in the fact sheet, Thyroid FunctionTests, available at www.endocrine.niddk.nih.gov.



• How is hyperthyroidism treated during pregnancy?

• During pregnancy, mild hyperthyroidism, in which TSH is low but free T4 is normal,does not require treatment. More severe hyperthyroidism is treated withantithyroid medications, which act by interfering with thyroid hormoneproduction.

• Radioactive iodine treatment is not an option for pregnant women because it can

damage the fetal thyroid gland. Rarely, surgery to remove all or part of the thyroidgland is considered for women who cannot tolerate antithyroid medications.

• Antithyroid medications cross the placenta in small amounts and can decreasefetal thyroid hormone production, so the lowest possible dose should be used toavoid hypothyroidism in the baby.

• Antithyroid medications can cause side effects in some people, including

• allergic reactions such as rashes and itching

• a decrease in the number of white blood cells in the body, which can lower aperson’s resistance to infection

• liver failure, in rare cases



• Question 28: How can gestational hyperthyroidism

• be differentiated from Graves’ hyperthyroidism

• in pregnancy?

• In the presence of an undetectable or very low serum TSH

• and elevated FT4, the differential diagnosis in the majority of

• cases is between Graves’ hyperthyroidism and gestational

• hyperthyroidism (70,71). In both situations, common clinical

• manifestations include palpitations, anxiety, hand tremor,

• and heat intolerance. A careful history and physical examination

• are of utmost importance in establishing the etiology.

• The findings of no prior history of thyroid disease and no

• clinical signs of Graves’ disease (goiter, endocrine ophthalmopathy)

• favor the diagnosis of gestational hyperthyroidism. In

• situations in which the clinical diagnosis is in doubt the determination

• of TSH receptor antibody (TRAb) is indicated. In

• the presence of a nodular goiter, a serum total T3 (TT3) determination

• is helpful in assessing the possibility of the ‘‘T3 toxicosis’’

• syndrome. Total T3 determinationmay also be of benefit

• in diagnosing T3 thyrotoxicosis caused by Graves’ disease.

pregnant tiroid.pptx

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