CME INDIA Case Presentation by Dr. Sunetha, Gynaecologist, Coimbatore.

CME INDIA Case Study

How to manage a 29 year-old-female in early pregnancy? Weight-72 kg on Thyroxine 75, TSH 9.8 and Anti-TPO >1000

Question asked in CME INDIA Group

  • 29 year-old-female in early pregnancy, weight-72 kg
  • On Thyroxine 75,
  • TSH 9.8,
  • Anti-TPO >1000
  • Are steroids needed?

CME INDIA Discussion

Dr. Murugananth, Coimbatore:

  • Is it new onset hypothyroidism or pre-existent Madam?

Dr. Sunetha, S DGO, Coimbatore:

  • Pre-Existing.

Dr Vivek Ranjan Gupta, Surat:

  • Anti-TPO antibody is the autoimmunity marker. It determines whether there is autoimmune thyroiditis in the thyroid gland; this is important in pregnancy. In pregnancy if there is subclinical hypothyroidism, and TSH is in the range of 5–9miU/L, but the TPO antibody is positive, treatment is required. In pregnancy if TPO is positive and there is a slight elevation of TSH (more than 4mIU/L), treatment is required.
  • Increase dose of thyroxine to 125 to maintain TSH below 2.5 (Remember for pregnancy normal is not less than 5 but it should be less than 2.5 in first trimester).
  • Anti tpo antibody comes positive in both hypo and hyperthyroidism.
  • So, if the presentation is thyroiditis or sub-acute thyroiditis then we can think of steroids and other options. But in this case, it is hypothyroidism.

How to manage a 29 year-old-female in early pregnancy? Weight-72 kg on Thyroxine 75, TSH 9.8 and Anti-TPO >1000

Dr. N. K. Singh:

  • ATS 2019 is most commonly followed.
  • Treatment of subclinical hypothyroidism is recommended for TPO (thyroid peroxidase)- positive women with thyrotropin levels greater than the pregnancy-specific range and TPO-negative women with thyrotropin levels greater than 10 mIU/L and can be considered for women with lower thyrotropin.

Dr. Om Lakhani, DNB Endo, Ahmedabad:

  • No indication for steroids.
  • Increase dose of LT4 to 125 mcg… make sure the timing and compliance of medications is correct.
  • Repeat thyroid function after 1 month.
  • Anti-TPO is a widely-misused test.
  • It has very limited indications and it’s use in clinical decision making is declining.
  • For example, in this patient there is no indication for Anti TPO since the patient is already having established hypothyroidism. Anti-TPO is not going to change the management in this case. So, the test was not indicated.
  • See these experts from https://endocrinology.co.in/FOR+DOCTORS/THYROID/Thyroid+disorders+in+Pregnancy/2.+Hypothyroidism+in+pregnancy

How to manage a 29 year-old-female in early pregnancy? Weight-72 kg on Thyroxine 75, TSH 9.8 and Anti-TPO >1000

Dr. S. K. Gupta, MBBS MD (Med) CFM (France), Senior Consultant Physician, Delhi:

  • In pregnancy:
    • Treat in first TM (Trimester)treat if TSH is more than 4.
    • I remember TSH values as 1.5 for First Tm.
  • 2.5 for Second TM.
  • 3.5 for Third TM.
  • (Though actual values are slightly different).
  • If TSH value is between 2.5 and 4 than only Anti TPO should be advised if positive these patients may need treatment with low dose thyroxin.
  • Steroids not to be used in this case.
  • Anti TPO is non-specific marker which can present in number of conditions.

Dr. Ronak Shah, Senior Physician, Anand:

  • Also, avoid iron & calcium supplements at the same time with thyroxine.
  • TPO is useful in decision making for treatment of subclinical hypothyroidism.
  • How TPO is useful in decision making.
  • If TPO is significantly high and TSH between 4.5 to 10, we may start treatment.
  • If TPO is negative, we may wait.
  • This is for the most common cause of primary hypothyroidism i.e. Hashimoto’s thyroiditis.

Dr. Om Lakhani, DNB Endo, Ahmedabad:

  • While this is true and accepted notion for a while this concept is now being challenged in the endocrine community.
  • For people age less than 70 with TSH between 5 to 7 – Anti TPO can be used for decision making on whether to treat or not
  • For people age less than 70 with TSH between 7 to 10 – Anti TPO is not required and treatment must be given since data has suggested that treatment in this group is associated with reduced CV disease.
  • But always remember to repeat the thyroid function in non-pregnant individual with subclinical hypothyroidism before taking a decision, it is not uncommon to see lab errors with regards to TSH very commonly.
  • A patient is established to have SCH only if she/he has elevated TSH on repeated measurements.

CME INDIA Learning Points

  • Antithyroid antibodies, which include thyroid-stimulating hormone receptor antibodies (TRAbs), thyroid peroxidase antibodies (TPOAbs), and thyroid globulin antibodies (TgAbs), are widely known for their tight association with thyroid autoimmune diseases.
  • The variation in all three kinds of antibodies also showed different trends during and after pregnancy
  • Autoimmunity increases with age and is often commonly evaluated in women of the reproductive age group. Prevalence of thyroid antibodies is common even in euthyroid pregnant women
  • Assays for anti–thyroid peroxidase (anti-TPO) and antithyroglobulin (anti-Tg) antibodies may be helpful in determining the etiology of hypothyroidism or in predicting future hypothyroidism.
  •  However, once a patient has been found to be antibody positive, repeated antibody testing adds little to the clinical picture and thus is not recommended.
  • Assays for anti–thyroid peroxidase (anti-TPO) and antithyroglobulin (anti-Tg) antibodies may be helpful in determining the etiology of hypothyroidism or in predicting future hypothyroidism.
  • Anti-TPO antibodies have been associated with increased risk of infertility and miscarriage; whether levothyroxine (LT4) treatment can lower this risk is controversial.

CME INDIA Tail Piece

  • Thyroid peroxidase (TPO), a membrane-bound enzyme, catalyzes the oxidation of iodide and the iodination of the tyrosyl residues of thyroglobulin.
  • TPOAbs can bind to TPO and then damage the thyrocytes and cause hypothyroidism.
  • Among the three kinds of antibodies, the TgAb is the earliest-discovered and it is mainly composed of IgG. It mainly attacks different antigenic determinants of thyroglobulin, which is located in the colloid of thyroid follicles.
  • TPOAb and TgAb are frequently present in the same individual.

How to manage a 29 year-old-female in early pregnancy? Weight-72 kg on Thyroxine 75, TSH 9.8 and Anti-TPO >1000

The variation in TPOAbs before, during, and after pregnancy. The curve is a set of data from one patient. The patient suffered from Hashimoto’s thyroiditis. (Courtsey: C.Lie et al.The Clinical Value and Variation of Antithyroid Antibodies during Pregnancy Volume 2020 |Article ID 8871951 | https://doi.org/10.1155/2020/8871951)

How to manage a 29 year-old-female in early pregnancy? Weight-72 kg on Thyroxine 75, TSH 9.8 and Anti-TPO >1000
  • Both the American Thyroid Association (ATA) and American Association of Clinical Endocrinology (AACE) recommend starting levothyroxine therapy under the following scenarios:
    • TSH is >10 mIU/l or;
    • Presence of hypothyroid symptoms or;
    • Presence of cardiovascular risk factors or;
    • Positive TPO antibody.

References:

  1. Levothyroxine in Women with Thyroid Peroxidase Antibodies before Conception.
  2. N Engl J Med.  2019; 380(14):1316-1325 (ISSN: 1533-4406)
  3. https://pro.aace.com/sites/default/files/2021-01/AACE%20TRC%20Interpretation%20of%20TFTs%20Part%203-FINAL.pdf
  4. https://endocrinology.co.in/FOR+DOCTORS/THYROID/Thyroid+disorders+in+Pregnancy/2.+Hypothyroidism+in+pregnancy
  5. C.Lie et al.The Clinical Value and Variation of Antithyroid Antibodies during Pregnancy Volume 2020 |Article ID 8871951 | https://doi.org/10.1155/2020/8871951


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