HIPERTIROID

TIAN&

NYNG

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• 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

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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.