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Report CopyRight/DMCA Form For : Thyroid Disorders In Pregnancy Review Article
Review ARticle, Physiological changes during pregnancy in the thyroid Table 3 Causes of Hyperthyroidism in Pregnancy. gland bring in alterations in the thyroid function tests Graves s disease 85 90 of all cases. Table 2 6 As already pointed out there is 2 to 3 fold Subacute thyroiditis. increase in TBG concentrations 30 100 increase in Toxic multinodular goiter. total tri iodothyronine and thyroxine concentrations Toxic adenoma. increased serum thyroglobulin and increased renal TSH dependent thyrotoxicosis. iodide clearance Furthermore hCG has mild thyroid Exogenous T3 or T4. stimulating activity,lodine induced hyperthyroidism. Assessment of thyroid function during pregnancy Pregnancy associated associations. should be done with a careful clinical evaluation of the Hyperemesis gravidarum. patient s symptoms as well as measurement of TSH and Hydatidiform mole. free not total thyroid hormones7 Figs 1 and 2 Source Mestman et al8 and Bishnoi and Sachmechi 9. Hyperthyroidism in Pregnancy, retraction indicating ophthalmopathy and localized or. The incidence of hyperthyroidism in pregnant pretibial myxedema which suggests dermopathy. women has been estimated at 0 2 8 The causes of,Diagnosis of Graves disease can be very difficult. hyperthyroidism during pregnancy are the same as, because women with no thyroid dysfunction may also. those seen in general population and in addition one. exhibit tachycardia palpitations mild heat intolerance. should also consider pregnancy specific conditions such. emotional lability and warm moist skin It is necessary to. as hyperemesis gravidarum and hydatidiform mole, diagnose hyperthyroidism if present during pregnancy. Table 3 The most common cause of hyperthyroidism, because untreated or poorly treated hyperthyroidism. in pregnancy is Graves disease which accounts for,can lead to adverse obstetrical outcomes Clinical. 85 90 of all cases 8 9, suspicion with relevant laboratory testing and their. Clinical features of hyperthyroidism include informed interpretation assume importance. nervousness tremors tachycardia frequent stools, Laboratory testing should include the measurement of. excessive sweating heat intolerance weight loss,serum TSH It should be remembered that values for. goiter insomnia palpitations and hypertension The, total T3 and T4 will be increased in healthy pregnant. distinctive signs of Graves disease are lid lag and lid. women and instead assessment of free hormone values. Table 2 Changes in Thyroid Physiology in Pregnancy be carried out Routine laboratory tests in hyperthyroid. patients may show mild leucopenia hypocalcemia in,Physiologic change Resulting change in. thyroid activity 10 of patients increased alkaline phosphatase and. serum estrogen serum TBG occasionally mild to moderate elevation in other liver. serum TBG demand for T4 and T3, total T4 and T3 Inadequately treated hyperthyroidism is associated. hCG THS fT4 with an increase in preterm deliveries low birth weight. in dietary requirement of iodides, babies and fetal losses Inadequately treated maternal. thyrotoxicosis is associated with a greater risk of preterm. iodine clearance hormone production in iodide, deficient areas delivery severe pre eclampsia and heart failure than. in treated and controlled maternal thyrotoxicosis10 11. goiter in iodide deficient areas, type III deiodinases T3 and T4 degradation demand for. T3 and T4 Treatment,demand for T3 and T4 serum thyroglobulin. The goal of treatment of hyperthyroidism during,thyroid volume. pregnancy is to keep the patient euthyroid with the fT4. goiter in iodide deficient areas, in the upper limit of normal range so as not to cause. 476 Indian Journal of Clinical Practice Vol 20 No 6 November 2009. Review ARticle,fetal or neonatal hypothyroidism 12. Clinical signs and symptoms Medical management13 of. Weight loss hyperthyroidism in pregnancy can,Inappropriate weight gain for include. gestational age,Goiter Thioamides,Muscle weakness,Heart rate 100 Thioamides specifically propylthi. Palpitations ouracil PTU given 100 150 mg,Onycholysis every 8 hours not exceeding 450 mg. Eye changes ophthalmopathy a day depending upon the severity. of the disease is given Methimazole,15 30 mg day as a single dose. can also be used These drugs, TSH normal TSH free T4 TSH free T4 decrease thyroid hormone synthesis. Free T4 normal by blocking the organification of,iodide The described side effects are. agranulocytosis rash 5 pruritus,Thyroid disease Thyroid Secondary. unlikely stimulating IgG hyperthyroidism,hepatitis lupus like syndrome drug. fever bronchospasm and aplasia,cutis Choanal atresia esophageal. atresia could be a manifestation of,Graves hyperthyroidism Non Graves hyperthyroidism. Antithyroid medication Antithyroid medication,methimazole embryopathy. Neonatal surveillance Treat hyperemesis or gestational. trophoblastic disease if present blockers, Figure 1 Algorithm for the evaluation of hyperthyroidism during pregnancy blockers to control adrenergic. Source Fantz et al 7 symptoms Propranolol 20 40 mg. two or three times a day or atenolol,50 100 mg daily may be used if. Clinical signs and symptoms necessary 12 Prolonged therapy has been. Low energy associated with fetal growth restriction. Inappropriate weight gain for fetal bradycardia and hypoglycemia. gestational age,Constipation Iodides,Cold intolerance. Iodides such as potassium iodide,Low pulse rate 5 10 drops twice daily along with. thioamides and blockers are used,to treat thyroid storm Iodides readily. cross the placenta and may cause fetal,goiter therefore their use should. TSH normal TSH free T4 TSH normal, Free T4 normal Free T4 be minimized for only short term. Primary Thyroidectomy,Thyroid disease hypothyroidism Nonthyroid. unlikely anti TPO antibodies illness Thyroidectomy should be reserved. in 70 of patients for women in whom treatment with. Figure 2 Algorithm for the evaluation of hypothyroidism during pregnancy thioamides is unsuccessful It is best. Source Fantz et al 7 performed in the second trimester. Indian Journal of Clinical Practice Vol 20 No 6 November 2009 477. Review ARticle, Table 4 Complications of Hyperthyroidism During diagnosis but therapy should not be withheld pending. Pregnancy the results 15 Treatment of thyroid storm in pregnant. First trimester spontaneous abortions women include thioamides any of the iodine solutions. Preterm deliveries or lithium carbonate dexamethasone and blockers. Low brith weight infants Table 5 16 17 Thioamides as already described block. Still births and neonatal deaths the additional synthesis of thyroid hormone from the. Fetal and neonatal hyperthyroidism gland and PTU also blocks the peripheral conversion. Fetal growth restriction of T4 to T3 Saturated solution of potassium iodide and. Source Mestman et al8 and Bishnoi and Sachmechi 9 sodium iodide block the release of thyroid hormone. from the gland Dexamethasone decreases thyroid, Two weeks of iodine therapy given along with PTU hormone release and peripheral conversion of T4 to. will reduce the size and vascularity before surgery T3 and propranolol inhibits the adrenergic effects of. excessive thyroid hormone Phenobarbital can be used. Radioactive Iodine, to reduce extreme agitation or restlessness and may. Radioactive iodine 131iodine 131I is contraindicated increase the catabolism of thyroid hormones 17 Maternal. in pregnant women because of the risk of fetal thyroid supportive measures in the form of oxygen intravenous. ablation therefore women should avoid pregnancy for fluids electrolyte replacement and antipyretics may be. at least four months after 131I treatment Counseling needed Fetal status should be assessed with ultrasound. of women exposed to 131I in pregnancy should focus biophysical profile or non stress test depending upon. on the gestational age of exposure If the woman was the gestational age Delivery should be reserved for. 10 weeks of gestation at the time of exposure then fetal indications that outweigh the risks to the woman. it is unlikely that the fetal thyroid is ablated If the These patients should be cared for in labor and delivery. exposure occurred at or after 10 weeks of gestation in intensive care unit. one must consider the risk of induced congenital Fetal and Neonatal Thyrotoxicosis. hypothyroidism while deciding to continue pregnancy. Breastfeeding is better avoided14 for at least 120 days Fetal and neonatal thyrotoxicosis is seen in approximately. after treatment with 131I 1 of infants who are born to mothers with Graves. It may take 6 8 weeks to see a clinical change In Table 5 Treatment of Thyroid Storm During Pregnancy. these patients fT4 levels should be monitored monthly Propylthiouracil PTU 600 800 mg orally stat then 150 200. and after the mother is euthyroid the dosage of the mg orally every 4 6 hourly If oral administration is not possible. use methimazole rectal suppositories, antithyroid drug be tapered to a minimum to prevent. Starting 1 2 hours after PTU administration,fetal hypothyroidism. Saturated solution of potassium iodide SSKI 2 5 drops. Thyroid Storm orally every 8 hours or,Sodium iodide 0 5 1 0 g IV every 8 hours or. Thyroid storm during pregnancy is a medical, emergency characterized by an extreme hypermetabolic Lugol s solution 8 drops every 6 hours or. Lithium carbonate 300 mg orally every 6 hours, state It is rare seen in 1 of pregnant patients with. hyperthyroidism but has a high risk of maternal Dexamethasone 2 mg IV or IM every 6 hours for 4 doses. heart failure 10 Clinical features of thyroid storm are Propranolol 20 80 mg orally every 4 6 hours or 1 2 mg IV. tachycardia out of proportion to fever vomiting every 5 minutes for a total of 6 mg then 1 10 mg IV every. diarrhea and cardiac arrhythmias There will be, If the patient has a history of severe bronchospasm Reserpine. restlessness confusion and at times may manifest with. 1 5 mg IM every 4 6 hours guanethidine 1 mg kg orally every. seizures 12 hours diltiazem 60 mg orally every 6 8 hours. When thyroid storm is suspected serum fT3 fT4 Phenobarbital 30 60 mg orally every 6 8 hours as needed for. extreme restlessness,and TSH levels should be evaluated to confirm the. 478 Indian Journal of Clinical Practice Vol 20 No 6 November 2009. Review ARticle, disease secondary to transplacental transfer of maternal Hypothyroidism During Pregnancy. thyroid stimulating immunoglobulins TSIs 18 These,The incidence of hypothyroidism in pregnant women. antibodies can be present even after surgery or 131I. has been estimated to be 0 3 0 7 19 There is a,treatment and can activate the fetal thyroid This. well known association between hypothyroidism and, unusual situation does not necessarily correlate with. decreased fertility 20 Causes of hypothyroidism during. the presence of active disease in the mother The, earliest sign of fetal thyrotoxicosis is a tachycardia pregnancy could be iodine deficiency infiltrative. 160 bpm other features being growth retardation diseases like sarcoid or amyloidosis primary atrophic. and craniosynostosis Occasionally fetal hydrops and or TSH dependent hypothyroidism Autoimmune. death can occur Maternal TSI in excess of 300 of thyroid disease Hashimoto thyroiditis and post. control values are predictive of fetal hyperthyroidism thyroid ablation are the most common causes of. hypothyroidism 8,Neonatal features include hyperkinesis poor. weight gain vomiting arrhythmias exophthalmos The complications associated with hypothyroidism in. hepatosplenomegaly craniosynostosis and heart failure pregnancy are pre eclampsia placental abruption post. Affected neonates are treated with blockers PTU partum hemorrhage and increased frequency of low. and iodine and digoxin as needed birth weight infants 8. Clinical Recommendations Key Practice Points, The American College of Obstetricians and TSH and fT3 are useful investigations in. Gynecologists ACOG has recommended the the management of thyroid disorders during. following guidelines 15 pregnancy and not total T3 or T4. Level A recommendations are based on good Graves disease is the commonest cause of hyper. and consistent scientific evidence thyroidism in pregnancy. Levels of TSH or fT3 fTI free thyroid Thioamides PTU or methimazole are the first. index should be monitored to manage line drugs in the management of hyperthyroidism. thyroid disease in pregnancy during pregnancy, Level B recommendations are based on limited Radioactive 131I therapy is contraindicated in. or inconsistent scientific evidence the management of hyperthyroidism during. Either PTU or methimazole can be pregnancy, used to treat pregnant women with Thyroid storm is a medical emergency which. hyperthyroidism needs to be anticipated and treated aggressively. Thyroid function tests are not indicated during pregnancy. in asymptomatic pregnant women with,Hashimoto thyroiditis is the most common. slightly enlarged thyroid glands cause of hypothyroidism in pregnancy. Level C recommendations are based primarily,Thyroxine in the initial dose of 0 1 0 15 mg is. on consensus and expert opinion,the drug of choice during pregnancy. Thyroid nodules should be investigated, during pregnancy to rule out malignancy Dosage of thyroxine is adjusted every four weeks. to keep the TSH levels at the lower limit of,Indicated testing of thyroid function may. be performed in women with a personal, history of thyroid disease or symptoms of Ferrous sulfate and thyroxine dosages should be. thyroid disease spaced 4 hours apart, Pediatrician should be present at the time Thyroid nodule needs to be evaluated during. of delivery of woman with thyroid disease pregnancy. Indian Journal of Clinical Practice Vol 20 No 6 November 2009 479. Review ARticle,Thyroid Nodules Malignant, Solitary thyroid nodule normal TSH ultrasound Tumors Non toxic Goiter. Solid or semicystic,Most thyroid nodules are benign. hyperplasic or colloid nodules However, FNAB of palpable nodule between 5 20 are true neoplasms. benign adenomas or carcinomas 22,The incidence of thyroid cancer in. pregnancy is 1 1 000 23 Any thyroid,Benign Malignant or suspicion Suspicion of. of papillary cancer follicular neoplasm nodule discovered during pregnancy. should be evaluated Fig 3 24 because,malignancy will be found in upto 40. Operate post of these nodules 14 Fine needle aspiration. Reaspirate if, I or II III trimester partum biopsy FNAB is safe in pregnancy and. trimester can be performed at any stage It should,be performed on solitary and dominant. Operate in the Operate post thyroid nodule Benign lesions are best left. II trimester partum,to be kept under observation Suspicion. Figure 3 Showing the algorithm of evaluation of thyroid nodule in pregnancy of or malignant lesions diagnosed in early. Source Tan GH et al 24 pregnancy can be operated in second. trimester and for those diagnosed late, Laboratory evaluation of hypothyroidism includes any intervention can wait till delivery. measurement of TSH and an assessment of free, hormone values Total T4 and T3 measurements are References. considered unreliable due to the increase in the TBG 1 Ain KB Mori Y Refetoff S Reduced clearance rate. concentrations In hypothyroidism TSH can be of thyroxine binding globulin TBG with increased. elevated with or without suppressed levels of fT4 Anti sialation a mechanism for estrogen induced elevation. of serum TBG concentration J Clin Endocrinol Metab. TPO antibodies and anti thyroglobulin antibodies are. 1987 65 689 96, increased in most patients with Hashimoto thyroiditis. 2 Burrow GN Maternal and fetal thyroid function,and therefore may be useful in establishing this. N Engl J Med 1994 331 1072 7,diagnosis Other laboratory abnormalities include. 3 Nelson M Wickus GG Caplan RH Begui EA Thyroid, elevated creatinine phosphokinase cholesterol and gland size in pregnancy An ultrasound and clinical study. liver function tests J Reprod Med 1987 32 888 90, Treatment 4 Vulsma T Gons MH de Vijlder JM Maternal fetal. transfer of thyroxine in congenital hypothyroidism due. Treatment should begin as soon as the diagnosis of to total organification defect of thyroid agenesis N Engl. hypothyroidism21 is made Replacement of thyroxin J Med 1989 321 13 6. should begin with 0 1 mg day to 0 15 mg day The 5 Drake WM Wood DF Thyroid disease in pregnancy. Postgrad Med J 1998 74 583 6, dosage is adjusted every four weeks to keep the TSH at. the lower end of the normal TSH and fT3 levels are to 6 Brent GA Maternal thyroid function interpretation. of thyroid tests in pregnancy Clin Obstet Gynecol, be monitored every eight weeks T4 requirements most. 1997 40 3 15, likely will increase as the pregnancy progresses which. 7 Fantz CR Jack SD Ladenson JH Gronowski AM, is secondary to the increased demand for T4 during Thyroid function during pregnancy Clin Chem. pregnancy and probably the inadequate intestinal 1999 45 2250 8. absorption that is caused by ferrous sulfate During 8 Mestman J Goodwin TM Montoro MM Thyroid. pregnancy ferrous sulfate and thyroxine dosages should disorders of pregnancy Endocrinol Metab Clin N Am. be spaced at least 4 hours apart 12 1995 24 41 71,Cont d on page 514. 480 Indian Journal of Clinical Practice Vol 20 No 6 November 2009. Case report,Cont d from page 512, 2 Adler JT Meyer Rochow GY Chen H Benn DE 6 Sandur S Dasgupta A Shapiro JL Arroliga AC Mehta. Robinson BG Sippel Rs et al Pheochromocytoma AC Thoracic involvement with pheochromocytoma a. current approaches and future directions Oncologist review Chest 1999 115 2 511 21. 2008 13 7 779 93 7 Whalen RK Althausen AF Daniels GH Extra adrenal. pheochromocytoma J Urol 1992 147 1 1 10, 3 Luo A Guo X Ren H Huang Y Ye T Clinical features. and anesthetic management of multiple endocrine 8 Plouin PF Chatellier G Fofol I Corvol P Tumor. neoplasia associated with pheochromocytoma Chin recurrence and hypertension persistence after successful. Med J Engl 2003 116 2 208 11 pheochromocytoma operation Hypertension 1997 29. 4 Pacak K Linehan WM Eisenhofer G Walther MM,9 Scott HW Jr Halter SA Oncologic aspects of. Goldstein DS Recent advances in genetics diagnosis pheochromocytoma the importance of follow up. localization and treatment of pheochromocytoma Ann Surgery 1984 96 6 1061 6. Intern Med 2001 134 4 315 29,10 d Herbomez M Gouze V Huglo D Nocaudie M. 5 Menger WM Gifford RW Jr Clinical and experimental Pattou F Proye C et al Chromogranin A assay and. pheochromocytoma Cambridge MA Blackwell 131 I MIBG scintigraphy for diagnosis and follow up. Science 1996 of pheochromocytoma J Nucl Med 2001 42 7 993 7. Cont d from page 480, 9 Bishnoi A Sachmechi I Thyroid disease in pregnancy 17 Molitch ME Endocrine emergencies in pregnancy. Am Family Physician 1996 53 215 20 Baillieres Clin Endocrinol Metabol 1992 6 167 91. 10 Davis LE Lucas MJ Hankins GD Roark ML 18 Weetman AP Graves disease N Engl J Med. Cunningham FG Thyrotoxicosis complicating 2000 343 1236 48. pregnancy Am J Obstet Gynecol 1989 160 63 70, 19 Glinoer D The regulation of thyroid function in. 11 Millar LK Wing DA Leung AS Koonings PP Montoro pregnancy pathways of endocrine adaptation from. MN Mestman JH Low birth weight and pre eclampsia physiology to pathology Endocr Rev 1997 18 404 33. in pregnancies complicated by hyperthyroidism Obstet. Gynecol 1994 84 946 9 20 Peterson M Thyroid disease and fertility Immunol. Allergy 1994 14 725 38,12 Neale D Burrow G Thyroid disease in pregnancy. Obstet Gynecol Clin N Am 2004 31 893 905 21 Mulder JE Thyroid disease in women Med Clin N Am. 13 Gittoes NJ Franklyn JA Hyperthyroidism Current 1998 82 103 25. treatment guidelines Drugs 1998 55 543 53 22 Nader S Thyroid and other endocrine disorders. 14 McClellan DR Francis GL Thyroid cancer in children during pregnancy Obstet Gynecol Clin N Am. pregnant women and patients with Graves disease 2004 31 257 85. Endocrinol Metabol Clin North Am 1996 25 27 48 23 Moosa M Mazzaferri EL Outcome of differentiated. 15 ACOG practice bulletin Thyroid disease in pregnancy thyroid cancer diagnosed in pregnant women J Clin. No 37 Int J Obstet Gynecol 200 79 171 80 Endocrinol Metabol 1997 82 2862 66. 16 Ecker JL Musci TJ Thyroid function and disease 24 Tan GH Gharib H Goellner JR VanHeerden JA Bahn. in pregnancy Curr Probl Obstet Gynecol Fertil RS Management of thyroid nodules in pregnancy Arch. 2000 23 109 22 Intern Med 1996 156 2317 20, 514 Indian Journal of Clinical Practice Vol 20 No 6 November 2009.
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