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Current knowledge about the in utero and peripartum management of fetal goiter associated with maternal Graves' disease. Eur J Obstet Gynecol Reprod Biol X 2019; 3:100027. [PMID: 31404446 PMCID: PMC6687382 DOI: 10.1016/j.eurox.2019.100027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 04/09/2019] [Accepted: 04/18/2019] [Indexed: 11/20/2022] Open
Abstract
Maternal Graves’ disease is the most common cause of fetal goiter. Fetal goiter can cause complications attributable either to the physical effects of the goiter itself or to thyroid dysfunction, which can be life-threatening and cause neurological impairment. Determining whether a goiter is caused by fetal hyperthyroidism or hypothyroidism is the main clinical problem, and in utero evaluations and management are essential. Ultrasonography combined with color Doppler and magnetic resonance imaging are helpful for the initial diagnosis and monitoring, but these imaging techniques have a limited ability to discriminate between fetal hyperthyroidism and hypothyroidism. To determine the fetal thyroid status, fetal blood sampling using cordocentesis is reliable but hazardous, and the indications must be considered carefully. Amniocentesis is an easier and safer alternative, but the correlations between the amniotic fluid and fetal serum thyroid hormone levels remain unclear. If a fetal goiter is accompanied by hypothyroidism, administering thyroid hormone intra-amniotically may be effective and relatively safe. However, the wide variety of approaches to treatment exemplifies the lack of guidelines, and no systematic studies have been conducted to date. Therefore, intrauterine treatment should be reserved for selected patients at a high risk of complications. Moreover, when intrauterine treatment fails and a fetal goiter can cause airway obstruction, intrapartum management, such as ex utero intrapartum treatment, may be required; however, reports describing the use of this procedure for fetal goiter are limited. This review summarizes the current knowledge about fetal goiter associated with maternal Graves’ disease and evaluates the most significant new findings regarding its in utero and peripartum management.
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Kobayashi M, Yagasaki H, Saito T, Nemoto A, Naito A, Sugita K. Fetal goitrous hypothyroidism treated by intra-amniotic levothyroxine administration: case report and review of the literature. J Pediatr Endocrinol Metab 2017; 30:1001-1005. [PMID: 28771438 DOI: 10.1515/jpem-2017-0094] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 07/03/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Fetal goitrous hypothyroidism is mainly caused by maternal treatment of Graves' disease. Fetal goiter sometimes compresses the trachea and esophagus and may cause polyhydramnios, preterm labor, complications of labor and delivery, and neonatal respiratory disorder. CASE PRESENTATION We report a case of fetal goitrous hypothyroidism in which the mother had Graves' disease, which was treated with propylthiouracil. Intra-amniotic levothyroxine (L-T4) administration was performed, and the fetal goiter decreased in size. A female infant was delivered without goiter and complications. Thyroid function was within the normal range. CONCLUSIONS Previous reports on fetal goitrous hypothyroidism that was treated with intra-amniotic L-T4 showed that patients who had intra-amniotic L-T4 administration were likely to have a good outcome compared with patients who did not have L-T4. Thyroid function of the mother and fetus should be carefully monitored and treated appropriately.
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Intra-amniotic thyroxine to treat fetal goiter. Obstet Gynecol Sci 2016; 59:66-70. [PMID: 26866040 PMCID: PMC4742480 DOI: 10.5468/ogs.2016.59.1.66] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 07/06/2015] [Accepted: 07/30/2015] [Indexed: 11/08/2022] Open
Abstract
A 35-year-old pregnant woman visited our department and had been treated with 100 µg of daily oral levothyroxine for hypothyroidism. An ultrasonography screening was performed at 25 weeks gestation and revealed a fetal goiter and an increased amniotic fluid volume. Fetal hypothyroidism was confirmed by cordocentesis and amniotic hormone levels at 26 weeks gestation. We treated the mother with 200 µg of daily oral levothyroxine to optimize the transplacental transfer. A total of four intra-amniotic injections of levothyroxine were administered, resulting in progressive reduction in the fetal thyroid volume of goiter as measured by 3D ultrasonography and increased amniotic fluid volume. Following birth, neonatal serum thyroid stimulating hormone level was within the normal range, but free T4 was reduced. Based on this case, we suggest that monitoring amniotic fluid thyroid hormone concentration and intra-amniotic levothyroxine injection can be used to reduce the thyroid volume of goiters and to prevent polyhydramnios.
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Mastrolia SA, Mandola A, Mazor M, Hershkovitz R, Mesner O, Beer-Weisel R, Besser L, Shelef I, Loewenthal N, Golan A, Gruzman I, Erez O. Antenatal diagnosis and treatment of hypothyroid fetal goiter in an euthyroid mother: a case report and review of literature. J Matern Fetal Neonatal Med 2014; 28:2214-20. [PMID: 25363013 DOI: 10.3109/14767058.2014.983062] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Fetal goiter is an extremely rare complication of pregnancy. Its incidence is 1 in 40,000 deliveries. Antithyroid maternal therapy is responsible for 10-15% of fetal congenital hypothyroidism and can be considered as the most frequent underlying cause for this condition. The frequency of fetal goiter that is associated with fetal hypothyroidism and normal maternal thyroid function, as in our case, is even less frequent. Fetal goiter is associated with increased rate of perinatal complications and long-term morbidity, due to peripartum complications including labor dystocia due to its mass effect, as well as neonatal airway obstruction that may lead to hypoxic-ischemic brain injury and death. We present, in this study, a case report of late antenatal fetal goiter in an euthyroid woman and a literature review of the diagnosis and treatment of these cases.
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Affiliation(s)
- Salvatore Andrea Mastrolia
- a Department of Obstetrics and Gynecology , Azienda Ospedaliera-Universitaria Policlinico di Bari, School of Medicine, University of Bari "Aldo Moro" , Bari , Italy
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- h Department of Anesthesiology and Critical Care, Faculty of Health Sciences , Soroka University Medical Center, School of Medicine, Ben Gurion University of the Negev , Beer Sheva , Israel
| | - Offer Erez
- c Department of Obstetrics and Gynecology
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Fetal magnetic resonance imaging and three-dimensional ultrasound in clinical practice: Applications in prenatal diagnosis. Best Pract Res Clin Obstet Gynaecol 2012; 26:593-624. [DOI: 10.1016/j.bpobgyn.2012.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 06/08/2012] [Indexed: 01/09/2023]
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Corbacioglu Esmer A, Gul A, Dagdeviren H, Turan Bakirci I, Sahin O. Intrauterine diagnosis and treatment of fetal goitrous hypothyroidism. J Obstet Gynaecol Res 2012; 39:720-3. [DOI: 10.1111/j.1447-0756.2012.02003.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - Ahmet Gul
- Department of Obstetrics and Gynecology, Istanbul Kanuni Sultan Suleyman Research and Teaching Hospital, Istanbul, Turkey
| | - Hediye Dagdeviren
- Department of Obstetrics and Gynecology, Istanbul Kanuni Sultan Suleyman Research and Teaching Hospital, Istanbul, Turkey
| | - Isil Turan Bakirci
- Department of Obstetrics and Gynecology, Istanbul Kanuni Sultan Suleyman Research and Teaching Hospital, Istanbul, Turkey
| | - Orhan Sahin
- Department of Obstetrics and Gynecology, Istanbul Kanuni Sultan Suleyman Research and Teaching Hospital, Istanbul, Turkey
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Fetal thyroid in two-dimensional ultrasonography: nomograms according to gestational age and biparietal diameter. Eur J Obstet Gynecol Reprod Biol 2012; 162:131-8. [DOI: 10.1016/j.ejogrb.2012.02.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Revised: 01/10/2012] [Accepted: 02/09/2012] [Indexed: 11/22/2022]
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Bliddal S, Rasmussen AK, Sundberg K, Brocks V, Feldt-Rasmussen U. Antithyroid drug-induced fetal goitrous hypothyroidism. Nat Rev Endocrinol 2011; 7:396-406. [PMID: 21403664 DOI: 10.1038/nrendo.2011.34] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Maternal overtreatment with antithyroid drugs can induce fetal goitrous hypothyroidism. This condition can have a critical effect on pregnancy outcome, as well as on fetal growth and neurological development. The purpose of this Review is to clarify if and how fetal goitrous hypothyroidism can be prevented, and how to react when prevention has failed. Understanding the importance of pregnancy-related changes in maternal thyroid status when treating a pregnant woman is crucial to preventing fetal goitrous hypothyroidism. Maternal levels of free T(4) are the most consistent indication of maternal and fetal thyroid status. In patients with fetal goitrous hypothyroidism, intra-amniotic levothyroxine injections improve fetal outcome. The best way to avoid maternal overtreatment with antithyroid drugs is to monitor closely the maternal thyroid status, especially estimates of free T(4) levels.
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Affiliation(s)
- Sofie Bliddal
- Department of Medical Endocrinology, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
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Slapa RZ, Jakubowski WS, Slowinska-Srzednicka J, Szopinski KT. Advantages and disadvantages of 3D ultrasound of thyroid nodules including thin slice volume rendering. Thyroid Res 2011; 4:1. [PMID: 21211056 PMCID: PMC3024985 DOI: 10.1186/1756-6614-4-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Accepted: 01/07/2011] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The purpose of this study was to assess the advantages and disadvantages of 3D gray-scale and power Doppler ultrasound, including thin slice volume rendering (TSVR), applied for evaluation of thyroid nodules. METHODS The retrospective evaluation by two observers of volumes of 71 thyroid nodules (55 benign, 16 cancers) was performed using a new TSVR technique. Dedicated 4D ultrasound scanner with an automatic 6-12 MHz 4D probe was used. Statistical analysis was performed with Stata v. 8.2. RESULTS Multiple logistic regression analysis demonstrated that independent risk factors of thyroid cancers identified by 3D ultrasound include: (a) ill-defined borders of the nodule on MPR presentation, (b) a lobulated shape of the nodule in the c-plane and (c) a density of central vessels in the nodule within the minimal or maximal ranges. Combination of features provided sensitivity 100% and specificity 60-69% for thyroid cancer.Calcification/microcalcification-like echogenic foci on 3D ultrasound proved not to be a risk factor of thyroid cancer.Storage of the 3D data of the whole nodules enabled subsequent evaluation of new parameters and with new rendering algorithms. CONCLUSIONS Our results indicate that 3D ultrasound is a practical and reproducible method for the evaluation of thyroid nodules. 3D ultrasound stores volumes comprising the whole lesion or organ. Future detailed evaluations of the data are possible, looking for features that were not fully appreciated at the time of collection or applying new algorithms for volume rendering in order to gain important information. Three-dimensional ultrasound data could be included in thyroid cancer databases. Further multicenter large scale studies are warranted.
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Affiliation(s)
- Rafal Zenon Slapa
- Department of Diagnostic Imaging, Second Faculty of Medicine with the English Division and the Physiotherapy Division, Medical University of Warsaw, ul, Kondratowicza 8, 03-242 Warsaw, Poland.
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Marín RC, Bello-Muñoz JC, Martínez GV, Martínez SA, Moratonas EC, Roura LC. Use of 3-dimensional sonography for prenatal evaluation and follow-up of fetal goitrous hypothyroidism. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2010; 29:1339-1343. [PMID: 20733190 DOI: 10.7863/jum.2010.29.9.1339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE Fetal goitrous hypothyroidism is a rare and potentially lethal condition. Consequently, its early diagnosis and treatment improve prognosis. Thyroid hormone measurement in either fetal serum or amniotic fluid implies important risks. Here we present a fetal goiter and the follow-up procedure, both done by the traditional method and by using 3-dimensional power Doppler (3DPD) imaging and virtual organ computer-aided analysis (VOCAL). METHODS A single well-documented case of fetal goiter was followed weekly from 22 weeks until delivery. Amniocentesis for thyrotropin (TSH) and free thyroxine (T(4)) measurement as well as levothyroxine injections were performed at every control. In addition to amniocentesis, every control involved a sonographic evaluation, which included standard measurements of the gland and the capture of volume image sets in gray scale and 3DPD. Volume calculation of the gland was done using VOCAL software. Vascularization of the gland was evaluated by the vascularization index (VI) included in the software. RESULTS With treatment, TSH levels decreased progressively until normalization. Free T(4) levels increased toward the end of gestation. Sonographic measurements of the gland volume to estimated fetal weight ratio decreased across treatment as levels of TSH did. The VI clearly depicted the vascular regression of the goiter, decreasing throughout treatment in a consistent way until 24 hours before delivery. CONCLUSIONS Gray scale and 3DPD evaluations of the thyroid gland have been validated under similar circumstances and might be reliable complements to the invasive methods used in the management of this fetal condition.
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Affiliation(s)
- Rodrigo Cuevas Marín
- Fetal Medicine Unit, Vall d'Hebron University Hospital, Universidad Autónoma de Barcelona, Barcelona, Catalunya, Spain
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Huel C, Guibourdenche J, Vuillard E, Ouahba J, Piketty M, Oury JF, Luton D. Use of ultrasound to distinguish between fetal hyperthyroidism and hypothyroidism on discovery of a goiter. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2009; 33:412-420. [PMID: 19306478 DOI: 10.1002/uog.6315] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVES To determine whether sonography can be used to distinguish hyperthyroidism from hypothyroidism in pregnancies with fetal goiter. METHODS This was a retrospective study of 39 cases of fetal goiter. The majority of the mothers had Graves' disease. Fetuses were scanned for the existence of a hypertrophic thyroid gland (goiter) beginning at 22 gestational weeks. Once a goiter was diagnosed, different echographic features were analyzed and the effect of chosen treatment on fetal thyroid development was monitored. RESULTS On color Doppler, 68.8% of hypothyroid goiters had a peripheral vascular pattern vs. 20% in cases of fetal hyperthyroidism (P = 0.0574). No hypothyroid goiter presented central vascularization whereas half the hyperthyroid goiters did (P = 0.0013). Fetal tachycardia was a good indicator of hyperthyroidism (57.1% v.s 6.3%; P = 0.0055). Delayed bone maturation was seen in hypothyroid goiters (46.9% vs. 0%; P = 0.0307), while advanced bone maturity was specific to hyperthyroid goiters (85.7% vs. 0%; P < 0.0001). Lastly, an increase in fetal movement was observed in cases of fetal hypothyroidism (43.8% vs. 0%; P = 0.0364). CONCLUSION Based on the color Doppler pattern of goiter, fetal heart rate, bone maturation and fetal mobility, we established an ultrasound score to predict fetal thyroid function in cases of fetal goiter.
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Affiliation(s)
- C Huel
- Department of Perinatology, Robert Debré Hospital, Paris, France
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Mayor-Lynn KA, Rohrs HJ, Cruz AC, Silverstein JH, Richards D. Antenatal diagnosis and treatment of a dyshormonogenetic fetal goiter. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2009; 28:67-71. [PMID: 19106359 DOI: 10.7863/jum.2009.28.1.67] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Kathleen A Mayor-Lynn
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Florida College of Medicine, Gainesville, FL 32610-0294, USA.
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Reynolds BC, Simpson JH, Macara L, Watt AJB, Kubba H, Donaldson MDC, Pohlen J. Goitrous congenital hypothyroidism in a twin pregnancy causing respiratory obstruction at birth: implications for management. Acta Paediatr 2006; 95:1345-8. [PMID: 17062458 DOI: 10.1080/08035250600711074] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
We report a twin pregnancy complicated by fetal goitrous hypothyroidism secondary to dyshormonogenesis caused by thyroglobulin deficiency. Antenatal treatment with intra-amniotic thyroxine was considered but not performed, given the late gestational age at diagnosis and the multiple nature of the pregnancy. Both twins developed airway obstruction at delivery, requiring intubation and ventilation. We review the literature and describe the practical issues relating to the antenatal assessment and perinatal management of fetal goitre.
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Current awareness in prenatal diagnosis. Prenat Diagn 2005; 25:971-6. [PMID: 16270411 DOI: 10.1002/pd.1024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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