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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2669_Библиотеки_им_академика_М_И_Перельмана
.pdf
Pre-existing Hypothyroidism in Pregnancy
Need ~30-35% more LT4 as soon as pregnant
= take an extra LT4 pill on Saturdays and Sundays (two
extra pills/week = 9 pills/week) as soon as they are
pregnant
Ø e.g. If she is on LT4 75 mcg PO daily before pregnancy,
take LT4 75 mcg PO q M-F and 150 mcg S/S
Ø Upon delivery, go back to pre-pregnancy dose
Ø Target TSH ≤ 2.5 throughout the pregnancy
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Graves’ in Pregnancy
Special Considerations:
1. Anti-thyroidal medications are teratogenic.
Mild subclinical hyperthyroidism = monitor, does not require
automatic anti-thyroid drugs considering risk to fetus.
a) If treating for symptoms, use PTU in the first trimester
(conversion ~1mg MMZ:20mg PTU), MMZ after that (or
discontinue all ATDs if possible!)
- Patients on MMZ <10mg/d or PTU <200mg/d may try
discontinuing
b) Use the lowest possible dose (aim for T4 at high-normal range)
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Graves’ in Pregnancy
2. TSH-R Ab can cross the placenta.
Check Ab titer in second trimester. If very high (3x ULN),
need increased fetal monitoring for fetal Graves’.
3. Long-term treatment with β-blockers has been
associated with intrauterine growth restriction, fetal
bradycardia, and neonatal hypoglycemia.
4. Watch for post partum exacerbations
Could also be post partum thyroiditis.
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Gestational Transient Thyrotoxicosis
• In normal pregnancy, Thyroid Binding Globulin and
total T4 increase by 7 wks GA and peak at 16 wks GA
• hCG stimulates the TSH receptor on the thyroid gland
causing ↑thyroid hormone & ↓TSH
• The hCG effect may be even more pronounced in:
Ø Hyperemesis gravidarum
Ø Molar pregnancy
Ø Multiple gestation
Ø Choriocarcinoma
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Gestational Transient Thyrotoxicosis
• Generally self-limited, improves by 14-18 weeks
• Treat hyperemesis if present
• Use B-blockers if really necessary for symptoms
• Do NOT give PTU or methimazole
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GTT vs. Thyroid Pathology
• Differentiating thyroid pathology from GTT can be
hard, but look for:
Ø Ophthalmopathy and/or thyroid bruit (Graves)
Ø Goitre (more likely Graves)
Ø Thyroid receptor antibody positivity (Graves)
Ø Nodules (Toxic multinod. goitre or Thyroid Adenoma)
Ø History of hyperemesis (GTT)
Ø History of thyroid disease (not GTT)
Ø Possibility of molar pregnancy (GTT; get a pelvic U/S!)
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Question 3 - 2023
A 34 year-old woman with Graves disease, who has been euthyroid on
methimazole 5mg PO daily for the past year, recently tested positive
for pregnancy. She is referred for thyroid management in pregnancy.
Which of the following is NOT appropriate?
a) Discontinue all anti-thyroidal medications to avoid teratogenicity
b) Check thyroid function tests every 4 weeks during pregnancy
c) Switch to PTU 300mg PO BID and continue until GA 16 weeks
d) Check TRAb titre immediately and check again at GA 18-22 weeks
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Autoimmune diseases tend to improve / go into remission during pregnancy (and flare in the postpartum period).
This patient has stable Graves disease and has been euthyroid for a year on very low dose of ATDs (MMZ <10mg/d,
PTU <200mg/d) – it is completely safe to try discontinuation (as per ATA 2017 guidelines). Although switching to PTU
is also an option, 300mg PO BID is too high of a dose (1:20 conversion would yield ~PTU 50mg PO BID)
TRAb should be checked as Low TRAb titres in early pregnancy can help predict successful withdrawal of ATD. TRAb is
measured again at GA 18-22 weeks as high titres can cross the placenta and cause fetal Graves.
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6. Osteoporosis
Highest yield resource:
***NEW 2023 Osteoporosis Canada Guidelines (Scope of Recommendations: Community-dwelling
postmenopausal females & males aged 50 years +)
https://www.cmaj.ca/content/195/39/E1333
Recommendations for screening for 1o prevention of Fragility Fracture – Canadian Task Force on Preventative Health
Care – Theriault G et al. CMAJ 2023 195(18) E 639-E649.
American College of Endocrinology (ACE), the American Association of Clinical Endocrinologists (AACE) guidelines for the diagnosis and treatment of
Postmenopausal Osteoporosis (2020)
https://pro.aace.com/sites/default/files/2020-05/Vol%2026%20Supplement%201%20(May%202020)%20GL-2019-0524_0.pdf
Pharmacological Management of Osteoporosis in Postmenopausal Women(2019)
https://www.endocrine.org/clinical-practice-guidelines/osteoporosis-in-postmenopausal-women
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MCQ 4 - 2024
A 65 year old female with bipolar disorder on valproate and
osteoporosis on alendronate, calcium, and vitamin D presents
with leg pain after stumbling. She is found on X-ray to have an
atypical femoral fracture. Secondary osteoporosis work-up
was negative and her vitamin D level normal. Which of the
following would be the next best step?
a) Stop oral bisphosphonate and start yearly IV
bisphosphonate
b) Continue oral bisphosphonate
c) Stop alendronate and start denosumab
d) Stop alendronate and start teriparatide
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Canadian Task Force 2023
• Recommend Risk-Assessment first screening to
prevent fragility fractures in women ≥ 65
– FRAX risk assessment tool without BMD
– If preventive pharmacotherapy to be considered, then
order BMD to use with FRAX to determine fracture risk
• Recommend against screening women 40-64 and
men aged 40+ to prevent fragility fractures (Strong,
low certainty evidence)
FRAX Tool (https://frax.shef.ac.uk/)
– Age
– BMI
– Previous #?
– Parent with # hip?
– Current smoking
– Glucocorticoids
– RA
– 2
o
osteoporosis
Conditions associated with OP - type I (insulin
dependent) diabetes, osteogenesis imperfecta in adults,
untreated long-standing hyperthyroidism, hypogonadism or
premature menopause (<45 years), chronic malnutrition, or
malabsorption and chronic liver disease
– Alcohol 3 or more per day?
Generates a 10 year probability of fragility fracture (%)
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