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Hopeful
Joined: 03 May 2007
Posts: 54
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 Posted: Sat Mar 29, 2008 2:58 am Post subject: Hypothyroidism in Pregnancy |
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Is this statement true (evidence based)
'Patients with uncomplicated hypothyroidism can be managed by GP/ M.W. with no need for consultant obstetrician input'.
Can anyone help me in evidence regarding this statement i read in one website. Thankyou |
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Nick Raine-Fenning
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Location: Nottingham
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| Posted: Sat Mar 29, 2008 7:41 am Post subject: |
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| I disagree for a start - the patient could have burnt out Grave's disease and still have LATS antibodioes for one thing! |
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Hopeful
Joined: 03 May 2007
Posts: 54
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| Posted: Sat Mar 29, 2008 9:37 am Post subject: |
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Thankyou for your reply.
This statement says uncomplicated hypothyroidism.
With burnt out graves disease there will be other system involvement mainly heart like raised pulse/BP in which case woman can be referred to hospital.
I am actually working on developing a protocol for management of hypothyroidism in community as GPs encounter thyroid problems much earlier before woman is seen in hospital and management involves changing thyroxine and checking LFTS in UNCOMPLICATED cases. obviously if complications arise they will be referred to hospital. They will be seen in hospital anyway as booking of high risk pregnancy but atleast they can be managed right from the start of problem. |
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Nick Raine-Fenning
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Location: Nottingham
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| Posted: Sat Mar 29, 2008 3:18 pm Post subject: |
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| Hopeful wrote: | | This statement says uncomplicated hypothyroidism. |
Does that necessarily exclude LATs? Not so sure and this illustrates the fact it is always best to be safe.
If it is truly uncomplicated then there is not much of an essay but don't we still need to do serial scans for IUGR etc?
Always thought hypothyroidism was insufficient for an essay unless there was a recent Grave's. Hyperthyroidism makes a much better essay! |
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Xerxes I
Century Club
Joined: 01 Mar 2007
Posts: 228
Location: Winchester
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| Posted: Sat Mar 29, 2008 8:02 pm Post subject: Re: Hypothyroidism in Pregnancy |
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| Hopeful wrote: | Is this statement true (evidence based)
'Patients with uncomplicated hypothyroidism can be managed by GP/ M.W. with no need for consultant obstetrician input'.
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I think the red bit is enough to give it a big F.
On a seperate note, what should you be guided by when treating pregnanct women with Hypo? should you up the dose in second trimester? or should you leave the patient alone if clinicaly asymptomatic and biochemically within normal range? how do you go about preconception normalisation?
Our endocrinologist likes to keep TSH low regardless of clinical symptoms and free T4. He quotes This paper.
Is he wrong? Well Cath NP certainly believes he is. See her letter to the authors of the above paper here
What is everyone's practice?
My point is that if these gurus can't agree on basic points in the management of hypo in pregnancy (like most other medical conditions!) , there is no such a thing as "uncomplicated" hypothyroidism. |
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rpwalavalkar
Teale Fenning Administrator
Joined: 20 Jul 2006
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| Posted: Sat Mar 29, 2008 8:17 pm Post subject: |
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as i understand thyroid in preg there is Increased total T4 and T3 + thyrotropic effect of hcg.
hence the logic of keeping TSH low makes sense for now, but i may be totally wrong.
r
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Dr Miss. Raj Walavalkar MBBS MRCOG
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Xerxes I
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| Posted: Sat Mar 29, 2008 9:03 pm Post subject: |
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"Secondly, there are no data to support the view that driving down the upper limit of thyroid stimulating hormone (TSH) to 2.5 mU/l is safe3 or that it helps maternal or fetal wellbeing.2 "
Girling and Nelson Piercy, BMJ 2007 |
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Hopeful
Joined: 03 May 2007
Posts: 54
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| Posted: Sat Mar 29, 2008 10:29 pm Post subject: |
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Thanks everyone for replying to my question.
As far as my question is concerned i am basically involved in designing a protocol for community based management of hypothyroidism in pregnancy. This is important as it will help GP/CMW in early diagnosis and treatment and reduces unnecessary burden on hospital OPD.
A proposed plan is as follows
Early pregnancy—
Perform TFTs
Woman euthyroid on maintenance dose------- check thyroid function every trimester-------------- Check TFTs subsequently every 3 months
Hypothyroid on maintenance dose---------- Inc dose by 50%--------- Check TFTs in 4 to 6 wks---------- Check TFTs subsequently every 3 months
Newly diagnosed hypothyroidism-------------- No heart disease--------- Start Thyroxine 100 ug/day-------------- Check TFTs in 4 to 6 wks---------- Check TFTs subsequently every 3 months |
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Xerxes I
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Location: Winchester
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| Posted: Sun Mar 30, 2008 8:56 am Post subject: |
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| What are you going to look at? TSH or free T4? |
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rpwalavalkar
Teale Fenning Administrator
Joined: 20 Jul 2006
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| Posted: Sun Mar 30, 2008 9:06 am Post subject: |
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really nice flow chart.
i would look at TSH as my deciding factor, as free T4 is dependent on TBG and rate of dissociation and kinetics of the drug will vary individually. i think TSH gives a better overall picture as opposed to T4 alone. also T3 is the more active form and hence T4 value may not be a correct representation.
r
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Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
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Nick Raine-Fenning
Course Director
Joined: 27 May 2006
Posts: 1852
Location: Nottingham
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| Posted: Sun Mar 30, 2008 9:51 pm Post subject: Re: Hypothyroidism in Pregnancy |
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[quote="Xerxes I"] | Hopeful wrote: | | My point is that if these gurus can't agree on basic points in the management of hypo in pregnancy (like most other medical conditions!) , there is no such a thing as "uncomplicated" hypothyroidism. |
I couldn't agree more and with each passing day I think your overview of this specific scenario applies to almost every clinical scenario.
It is funny in a time of super-specialisation that each camp is fighting its own corner with gloves off. The radiologists seem most at risk as their generic skills are slowly being encompassed into our own daily work.
I think CNP advice is 99.9% excellent but we have to resist accepting everything she says as unquestionably true. Guidelines and RCTs (not in that order of course) should inform us not personal opinion regardless of who the person is. However, I totally agree with her in this case.
Raj - I am not sure TSH is a good test for any assessment of thyroid disease. It is a screening test but in the presence of any clinical features or risk factors you have to go with free levels which are independent of most other parameters.
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"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997 |
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Nick Raine-Fenning
Course Director
Joined: 27 May 2006
Posts: 1852
Location: Nottingham
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| Posted: Sun Mar 30, 2008 9:56 pm Post subject: |
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| rpwalavalkar wrote: | | ... free T4 is dependent on TBG |
It is independent I thought - that's the whole point. Total T4 is dependent as are any total levels of any steroid hormone hence the need for assessment of free levels which consider the relevant binding protein.
| rpwalavalkar wrote: | | .. i think TSH gives a better overall picture as opposed to T4 alone. |
Maybe as total T4 is not a great test. However, free T4 is a good test as is free T3. The free levels are much more expensive hence the use of the pituitary stimulant hormones (TSH, FSH, LH, etc) as a screening test. |
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Hopeful
Joined: 03 May 2007
Posts: 54
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| Posted: Mon Mar 31, 2008 5:35 am Post subject: |
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| I think debate on TSH or T4 is making this post drift away from its main question. I will do both but question is about this proposed protocol. Any suggestions? |
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rpwalavalkar
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Joined: 20 Jul 2006
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| Posted: Mon Mar 31, 2008 2:15 pm Post subject: |
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well, i am going back to books, wonder now how i passed the exam.  
r
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Dr Miss. Raj Walavalkar MBBS MRCOG
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SR O&G Wessex Region |
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Nick Raine-Fenning
Course Director
Joined: 27 May 2006
Posts: 1852
Location: Nottingham
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| Posted: Tue Apr 01, 2008 11:38 am Post subject: |
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| Hopeful wrote: | | I think debate on TSH or T4 is making this post drift away from its main question. I will do both but question is about this proposed protocol. Any suggestions? |
Yes, and I think we have made this clear, there is no role for a community based service here.
If you want to draft something I would recommend the following:
1. identify risk groups / factors
2. divide your monitoring accoringly with more frequent assessments in the high risk group
3. state the clinical features (signs and symptoms) and feto-maternal complications
4. define what tests you will do for screening and in the event of clinical features occuring
NB this will include TFTs and also USS etc all based on feto-maternal risks
5. time these according to the risk group
6. discuss induction / delivery / post-partum period (incl contraception)
That, in a nutshell, is a medical disorder in pregnancy template. |
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