St Thomas University Wk 1 Advanced FNP Maternal Hypothyroidism Clinical Discussion

Elizabeth Varona-Martin

Module 1

• The most significant thing I've taken away from my clinical experience is the need for good listening and communication skills. Listening to and conversing with your patients and preceptors will vastly increase your comprehension of the illness process you are attempting to assess. This is particularly important when you are seeing patients via telemedicine. 

One of the cases I'd like to share is a 31-year-old white G2P1O female evaluated through Zoom call for a follow-up on her pregnancy and Hashimoto's thyroiditis with resultant hypothyroidism. She denies any nausea or vomiting, vaginal bleeding, or abdominal pain. The patient states she is feeling good, and pregnancy is going well. She is 22 weeks pregnant.  She denies fatigue, excessive weight gain, cold intolerance, or poor appetite.

The patient was visually inspected via Zoom teleconferencing per guidelines. No physical exam was done.

Labs 

TSH:0.407    Free T4: 1.66

Differential Diagnosis

Overt hypothyroidism, an increased TSH with a decreased free T4,  complicates pregnancy in around 0.3 to 0.5 percent of tested women. This conclusion is influenced by two factors: some hypothyroid women are anovulatory, and hypothyroidism during pregnancy is linked with an increased incidence of miscarriages in the first trimester (Ross, 2021).

Hypothyroidism has been implicated in developing multiple issues during pregnancies, including preeclampsia and gestational hypertension, abruption of the placenta, premature birth, particularly extremely premature birth (before 32 weeks), low birth weight, increased cesarean section rates, hemorrhage after childbirth, morbidity, and mortality during pregnancy, child neuropsychological and cognitive impairment (Ross, 2021).

Subclinical hypothyroidism (elevated TSH, normal free T4) is more frequent than overt hypothyroidism, affecting 2.0 to 2.5 percent of pregnant women in the United States.

Women with subclinical hypothyroidism, rather than overt hypothyroidism, had a decreased risk of pregnancy problems. On the other hand, subclinical hypothyroidism has been linked to an increased risk of severe preeclampsia, premature birth, placental abruption, newborn respiratory distress syndrome, or pregnancy loss compared to euthyroid women (Ross, 2021).

Isolated maternal hypothyroxinemia: (low T4) is characterized as a pregnant free T4 level in the lowest 2.5th to 5th percentile of the recommended ranges with a normal TSH. It is unknown what influence isolated maternal hypothyroxinemia has on perinatal and neonatal outcomes (Ross, 2021).

Impression and Plan:

Pregnancy ICD 10-CM Z34.90 

Continue taking prenatal multivitamins with Folic acid.

Minerals and vitamins, Most pregnant women's daily vitamin and mineral requirements are met by a typical prenatal multivitamin including iron and folic acid. Iron 15 to 30 mg should be included in the multivitamin to avoid iron deficiency, and folic acid 0.4 to 0.8 mg should be used to minimize the risk of open neural tube abnormalities during the neural tube closure phase (Lockwood & Magriples, 2021).

Pregnancy body mass index is used to provide suggestions for gestational weight growth. Pregnancy raises the danger of rapid weight gain, therefore enhances the risk of cardiovascular disease and diabetes in the future. Obesity and excessive weight gain have both been implicated in the development of cesarean birth and macrosomia (Lockwood & Magriples, 2021).

Hashimoto's thyroiditis  ICD10-CM E06.3  

Levothyroxine 175 mcg PO once daily, 

check TSH, Free T4  in 8 weeks

Follow up in 8-10 weeks

This week's clinical experience, I learned how to manage pregnant patients with hypothyroidism, which is crucial in our development as future primary care providers. For women with a hypothyroidism diagnosis who become pregnant or those who develop hypothyroidism during pregnancy, the provider must address numerous critical concerns. Clinical symptoms of hypothyroidism during pregnancy are comparable to those seen in nonpregnant individuals and may include tiredness, cold sensitivity, constipation, and weight gain (Ross, 2021). Because some of the symptoms of hypothyroidism are similar to those of pregnancy, symptoms may be ignored or referred to the pregnancy itself, even though cold intolerance is not a typical clinical presentation of pregnancy.

During normal pregnancy, there are thyroid physiology changes to accommodate the growing metabolic demands, evidenced in changed thyroid function tests. These adjustments include an increase in thyroxine (T4)-binding globulin (TBG), which leads to greater levels of total T4 and triiodothyronine (T3) than in nonpregnant women (Ross, 2021). Furthermore, high blood human chorionic gonadotropin (hCG) levels, particularly in the first trimester, cause a decrease in serum thyroid-stimulating hormone (TSH) concentrations.

For those women who have hypothyroidism and want to get pregnant, providers recommend optimizing their thyroid hormone dose before conception. Preconception serum TSH levels should be between the lower reference limit and 2.5 mU/L (Ross, 2021).  

Hypothyroid pregnant women should raise their levothyroxine dose by roughly 30% and tell their doctor as soon as possible. Additional dosage adjustments are performed depending on blood TSH concentrations tested every four weeks until the TSH returns to normal (Ross, 2021).

Depending on the degree of the biochemical abnormalities, hypothyroidism might harm pregnancy outcomes, causing Overt hypothyroidism, Subclinical hypothyroidism, or Maternal hypothyroxinemia.

Fetal or neonatal hypothyroidism may cause neurologic consequences such as delayed intellectual and motor development. The degree of impairment is determined by the severity and duration of neonatal hypothyroidism. Although timely treatment may mitigate the effects of postnatal hypothyroidism, the consequences of gestational hypothyroidism, particularly in the first trimester, might last a lifetime (Rubin, 2021). Maternal and newborn iodine insufficiency, which is still prevalent in some regions of Europe and elsewhere globally, is one cause of neonatal hypothyroidism.

TSH screening in the first trimester should be recommended to pregnant women with any of the following conditions: A patient living in a region with moderate to severe iodine deficiency or hypothyroidism symptoms has a family or personal history of thyroid illness. Presence of Thyroid peroxidase (TPO) antibodies in the past, Age >30 years, goiter, type 1 diabetes Irradiation of the head and neck, Recurrent miscarriage or premature birth, multiple previous pregnancies (two or more), class 3 obesity (BMI 40 kg/m2), infertility,  thyroid surgery,  the use of amiodarone, lithium, or any iodinated radiologic contrast agents (Ross, 2021).

References

• Lockwood, C. J., & Magriples, U. (2021, August 24). Prenatal care: Patient education, health promotion, and safety of commonly used drugs. UpToDate. Retrieved from https://www.uptodate.com/contents/prenatal-care-patient-education-health-promotion-and-safety-of-commonly-used-drugs?search=pregnancy&source=search_result&selectedTitle=11~150&usage_type=default&display_rank=4. 
• Ross, D. S. (2021, April 15). Hypothyroidism during pregnancy: Clinical manifestations, diagnosis, and treatment. UpToDate. Retrieved from https://www.uptodate.com/contents/hypothyroidism-during-pregnancy-clinical-manifestations-diagnosis-and-treatment?search=hypothyroidism+in+pregnancy&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. 
• Rubin, D. I. (2021, March 25). Neurologic manifestations of hypothyroidism. UpToDate. Retrieved from https://www.uptodate.com/contents/neurologic-manifestations-of-hypothyroidism?search=hypothyroidism+in+pregnancy&source=search_result&selectedTitle=8~150&usage_type=default&display_rank=8.