#multinodular goiter

I had my yearly biopsy of my goiter done recently.

Nodule they sampled on the right came up clear.

Nodule on the left came back with an atypical result.

New Post has been published on http://womanhealthgate.com/hyperthyroidism-pregnancy/

Hyperthyroidism in Pregnancy

Hyperthyroidism is a clinical syndrome characterized by an increase of thyroid hormones production. As much of the thyroid disease hyperthyroidism occurs more frequently in women with an estimated incidence of 3.9%.

Most frequent causes

Uncommon causes

Graves’ Disease

Toxic Multinodular Goiter

toxic adenoma (Plummer’s disease)

Thyroiditis

  assumption of thyroid extracts in diet

exogenous administration of thyroid hormones

Trophoblastic tumors

TSH-secreting pituitary tumor

Thyroid Carcinoma

Struma Ovarii

  Graves’ Disease is the most frequent cause and frequently affects under 45 women, then during reproductive age. despite being one of the causes of infertility is not uncommon its appearance during pregnancy .

The Toxic Multinodular Goiter is the second among the most frequent causes but usually affects over 50 women and generally appears in patients who already carrier a Non-Toxic Multinodular Goiter.

One of the possible consequences of Graves’ disease and hyperthyroidism is the infiltrative orbitopathy with a bulging of the eye anteriorly out of the orbit (exophthalmos also called proptosis), a particularly serious ocular complication.

Hyperthyroidism symptoms vary according to the disease seriousness and typically consist of an increase in heart rate (tachycardia) often greater than 100 beats per minute, weight loss (slimming), fatigue, irritability, anxiety, insomnia, vomiting (hyperemesis) and some typical symptoms of pregnancy can be accentuated as the tendency to tiredness, heat intolerance and perspiration. Sometimes it is very obvious a diffuse enlargement of the thyroid gland (located in the anterior region of the neck). Patients with hyperthyroidism often have eye problems (even asymmetric) ranging from eyelid retraction to Exophthalmos (protrusion of the eyeball) typical of Graves’ disease, are also frequent: nail brittleness, increased hair loss, thickening of the pretibial tissues (myxedema).

We must remember, however, that an easier tendency to fatigue, nausea especially in the morning and gagging, irritability and anxiety and some mild tachycardia may be present in many perfectly normal pregnant women so it will always very important to conduct a differential diagnosis. In initial conditions of poor pregnancy weight gain or slimming with excessive vomiting (hyperemesis) always require a thyroid evaluation.

In the family history of these women is frequently present other cases of thyroid disease. Histocompatibility complex studies (for example, those that run on the occasion of organ transplants) have also shown an association with groups HLA-B8 and HLA-DR3.

Hyperthyroidism diagnosis is based on the clinical picture and on laboratory hormonal investigations. It is in fact necessary to the blood levels determination of FT4, FT3 (free fractions of thyroid hormones circulating in the body) and TSH (small protein hormone produced by the pituitary gland). Typically, in Hyperthyroidism FT3 and FT4 will be higher than normal (in some cases may increase only the FT3) and TSH will be very low or undetectable. TSH in normal conditions has a role in thyroid stimulating but when it works too and in an uncontrolled way as occurs in hyperthyroidism its production is lowered as a result of a strong signal (feedback) negative at the pituitary level which is increased by levels of FT3 and FT4.

Gland direct palpation is a critical clinical moment because it provides information on the size, volume, achiness and surface appearance. It also is very important neck lymph nodes, lateral cervical and supraclavicular palpation.

to a number of instrumental and immunological analysis contributing significally to Hyperthyroidism identification in pregnancy:

–      Thyroid ultrasound

–      Thyroid color-doppler ultrasound

–      Searching for thyroglobulin antibodies (Tg), anti-thyroid peroxidase (TPO) and anti-TSH receptor antibodies (TRAb)

Since in most cases it is an autoimmune disease (ie triggered and maintained by a self-aggression of their own immune defense system), antibodies dosage is important not only for diagnosis but also for disease monitoring. The research of TRAb is particularly important during pregnancy because high levels may give rise to the suspicion that there is an involvement of the fetal thyroid with the consequent risk of fetal hyperthyroidism and possible future neonatal thyrotoxicosis. In some patients it is useful dosing iodine urinary excretion to exclude its excessive dieatry introduction and in other cases (subacute thyroiditis and fictitious) may be useful a dosage of serum thyroglobulin.

Thyroid is important for the entire body but hyperfunction (hyperthyroidism) in pregnancy has a lot of possible negative effects. In women whit hyperthyroid are more prevalent: Hypertension, Anemia, Heart disease, Pre-Eclampsia, Placental abruption, Miscarriage, premature birth, fetal malformations, intrauterine fetal death, low weight of babies at birth. Newborns of these patients may have altered thyroid function and also have higher incidence of pre-natal mortality. Of course everything is always related to the illness severity and duration.

Therapy in pregnancy is basically medical, surgical option is rare.

Medicines used are anti-thyroid, that is molecules that reduce the function of the gland and then the levels of its circulating hormones: Methimazole, Propylthiouracil and Carbimazole are the most commonly used molecules and belong to the group of “Thionamides.”

Therapy, when necessary, should be undertaken as early as possible and aims to Euthyroidism (normal serum levels of thyroid hormones) in the quickest time possible, however, that ranges between 2 and 6 weeks (the drugs do not affect thyroid hormones already produced and stored in the gland).

Methimazole (MMI) is the most widely used drug in Europe while Propylthiouracil (PTU) is the drug of choice in the United States. The latter also is not available in Italy, but can still be obtained with a “Galenic” prescription  in some pharmacies. Although it has been suggested that the PTU is preferable in pregnancy, many believe MMI equally safe and effective. Data that demonstrate a link between the administration of MMI with Aplasia Cutis and other infant malformations seem controversial and inconclusive. Choice of a molecule respect to another is then determined from experience, from scientific beliefs of the doctor and from availability of the drug. The “attack doses” in Hyperthyroidism are generally 20-30 mg of MMI and 200-400 mg of PTU divided into two (MMI) or three (PTU) daily doses. Then (if the clinical condition improves) we tend to always achieve the lowest effective dose that is around 5-10 mg MMI or 50-100 mg of PTU.

Medical therapy, whatever is the molecule chosen, it is very important: not only decreases the incidence of fetal malformations related to the disease but overall has a very positive influence on the  pregnancy course favoring reproductive success. 5% of women taking Thionamides have side effects such as rashes, itching, Agranulocytosis (decrease in white blood cell) which, however, does not necessarily require interruption of treatment. More rarely may occur liver changes (hepatotoxicity) and joint disorders.

The benefit / risk balance is greatly in favor of medical therapy with Thionamides.

Sometimes to control maternal heart rate symptomatology (tachycardia) and hypertension may be indispensable using beta-blockers. Propranolol is widely used, but also Atenolol is an excellent drug. These molecules are not contraindicated in pregnancy and also allow to monitor and heal tremors and anxiety often present in situations of high heart rate (eg Thyroid Storm).

Clinical monitoring of these patients and their fetus is another crucial moment. The clinical monitoring of these patients and fetus is another crucial moment. Are recommended, in addition to the common controls provided in pregnancy, frequent checks of pressure, Thyroid volume, maternal and fetal weight and heart rate. Monthly, it is also good to check blood counts and dosage of TSH, FT3, FT4. The FT4 dosage has a particular importance and the objective is to keep it within medium-high limits. Because of fetuses of hyperthyroid patients have increased risk of malformations and growth abnormalities, in addition to routine ultrasound scans it is strongly indicated a II level morphological ultrasound with Doppler flow  at the 20th week, and this will also allow to observe the fetal Thyroid.

The search for maternal anti receptor antibodies TSH (TRAb) is recommended at the 20th and at the 30th week to identify fetuses at increased risk and to adopt more stringent measures if necessary. Postnatal and breastfeeding periods require particular attention both to the mother and neonate. Mom and baby should be carefully monitored clinically and in laboratory. It is also important to look for TRAb in newborn. Usually pregnancy has a favorable effect on  Graves’ Disease and it is not uncommon to attend a clinical improvement, but in the postnatal period clinical picture may change again.

Thionamides treatment is not a contraindication to breastfeeding but the decision to keep it still requires more prudential attitudes (minimal doses of drugs, more frequent baby checks).

New Post has been published on http://womanhealthgate.com/thyroid-nodules-multinodular-goiter/

Thyroid Nodules and Multinodular Goiter

Nodular pathology is the most common thyroid disease and affects more frequently women

Clinical evaluation is the first and most important steep in thyroid pathology.

than  men; about 6.4 % of those aged between 30 and 59 years old. In fact, its incidence is probably even higher ( in the autopsy findings rises to nearly 50% of cases ), but not diagnosed by the absence of symptoms. Its prevalence in the general population increases progressively with age and sometimes is accompanied by an enlargement of the gland ( goiter ) .

Goiter is often compensatory hypertrophy of the thyroid gland particularly frequent in areas with low iodine content in the diet.

It is a round lesion , single or multiple ( multinodular goiter ) , solid or cist ( sometimes mixed ) that can reach sometimes size that can determine compression on nearby organs .

The detection of Thyroid Nodules is done by palpation and / or visually (often during a clinical examination ) or during an ultrasound examination. Many small nodules are often completely asymptomatic and are diagnosed occasionally, large nodules as well as being visible (often see them for the first patient himself) and also create an aesthetic problem can lead to disorders compression on nearby organs such as the larynx and trachea ( dysphonia, dyspnea) and esophagus (dysphagia ) .

The nature of thyroid nodules are benign in most cases; particularly in women , only 5-6% has tumoral origin ( papillary carcinoma , the most frequent ) .

The diagnostic procedures are intended to distinguish malignant from benign thyroid nodules; describe its size and its structure, whether it belongs to a single or multinodular goiter , a chronic or subacute thyroiditis .

Pay attention to:

previous irradiation of the neck volumetric increase of the lateral cervical lymph nodes rapid growth increase of consistency compression disorders ( dysphonia, dysphagia) previous cases of thyroid cancer in the family

Rapid appearance , with sharp pain and tension

Concomitant relief of symptoms of hyperthyroidism ( tachyarrhythmia etc.).

Normally the first professional to take care of the problem is the general practitioner; he will judge whether it is necessary to consult an Endocrinologist .

The investigations that are both instrumental and possibly laboratoristiche citomorfologiche .

LABORATORY INVESTIGATIONS

Evaluation of thyroid function by determination of TSH ( a small pituitary hormone that controls the thyroid ) and thyroid hormones ( free fractions circulating ) FT3 , FT4 . The detection of increased thyroid hormones ( particularly FT3 ) may lay down for a hyperfunctioning nodule ( toxic adenoma ) and low values ​​( FT4 ) with increased TSH are more typical example of a chronic autoimmune thyroiditis with hypothyroidism. In pregnancy, the stimulation by chorionic gonadotropin (HCG) on the thyroid gland in the first weeks may result in a slight lowering of the physiological TSH ( down regulation ) not to be confused with situations of hyperthyroidism . Determination of Calcitonin : useful to identify or exclude the presence of a medullary carcinoma of the thyroid . Dosage antitireoglobulina antibody ( TgAb ) and antitireoperossidasi ( TPOAb ) : their identification and titration process helps to identify any chronic autoimmune ( thyroiditis Haschimoto ) .

IMAGING TESTS

Thyroid ultrasound has a very important role. Highlight the thyroid nodule , its size , its structure

Thyroid ultrasonography play and important diagnostic role in nodular pathology.

, and also describes the context in which it is glandular and may also describe the presence of enlarged lymph nodes ( lymph node enlargement ) locoregional ( neighbors) . The echo – Doppler Article by information on the vascularization of the nodule : an intense vascularization may be suspect but is also present in hyperfunctioning adenomas completely benign . The CT scan ( Computerized Axial Tomography ) and MRI ( Magnetic Resonance Imaging) are sometimes useful in analyzing the relationships of the Thyroid Gland with organs and vascular structures nearby as well as in the study of development in substernal goiters . The thyroid scan through the study of the uptake of a radioactive isotope of iodine helps to distinguish independently functioning nodules (lumps warm ipercaptanti ) and those not working ( cold nodules ) or isocaptanti than the rest of the gland. This exam is absolutely contraindicated in pregnancy.

CYTOLOGY

The fine-needle aspiration is a valuable investigation in the differential diagnosis between benign and malignant thyroid nodules . With a needle under ultrasound control and we proceed to the aspiration of the nodule and the cells are removed so It ‘ important that the sample ( sampling) is adequate for the purposes of cytology . Has no contraindication in pregnancy and as a rule all palpable nodules larger than 1 cm should undergo this procedure. As part of these investigations , however, elements of alarm or concern (in a tumor ) are the identification of nodules structurally solid , mixed or ipocaptanti scintigraphic examination ( cold ), fine-needle aspiration will identify those really dangerous , fortunately a small minority .

TREATMENT depends on the benign or malignant thyroid nodules , by the concurrence of a goiter , the overall clinical condition of the patient, including ( as many of the women) a possible pregnancy. A large part (up to almost 50 %) of benign nodules undergoes spontaneous regression . Benign nodules that have demonstrated a growth documented or aesthetic problems that damage or compression can be treated with the administration of levo- thyroxine ( LT4 ) : exogenous administration of thyroid hormones in fact suppresses the pituitary secretion of TSH and this leads in many cases a significant reduction in the size of the nodule , the attempt is always made with the minimum effective doses , requires a selection of patients to exclude contraindications (eg. cardiovascular disease , post-menopausal age the risk for osteoporosis) and usually in the absence of success is not persisted for more than a year . While the LT4 seems also useful in preventing the formation of additional nodules and still halt the growth was not demonstrated an ability to avoid the neoplastic transformation . Cystic nodules of secure benignity may be treated with the aspiration ( often burdened by relapse) , the ultrasound-guided percutaneous alcoholization ( sclerosed walls and is effective in 80 to 95% of cases ) , the surgery. Different and more complex is the attitude in cases of malignancy that holds obviously also the biological characteristics of the tumor ( histological type ) : surgical therapy is the first choice and ranges from lobectomy ( partial removal ) total removal of the thyroid ( thyroidectomy ) , using when necessary the adjuvant radioiodine therapy ( administration of radioactive iodine that destroys residual cells ) , chemotherapy , radiotherapy.

New Post has been published on http://womanhealthgate.com/hyperthyroidism-pregnancy/

Hyperthyroidism in Pregnancy

Hyperthyroidism is a clinical syndrome characterized by an increase of thyroid hormones production. As much of the thyroid disease hyperthyroidism occurs more frequently in women with an estimated incidence of 3.9%.

Most frequent causes

Uncommon causes

Graves’ Disease

Toxic Multinodular Goiter

toxic adenoma (Plummer’s disease)

Thyroiditis

  assumption of thyroid extracts in diet

exogenous administration of thyroid hormones

Trophoblastic tumors

TSH-secreting pituitary tumor

Thyroid Carcinoma

Struma Ovarii

  Graves’ Disease is the most frequent cause and frequently affects under 45 women, then during reproductive age. despite being one of the causes of infertility is not uncommon its appearance during pregnancy .

The Toxic Multinodular Goiter is the second among the most frequent causes but usually affects over 50 women and generally appears in patients who already carrier a Non-Toxic Multinodular Goiter.

One of the possible consequences of Graves’ disease and hyperthyroidism is the infiltrative orbitopathy with a bulging of the eye anteriorly out of the orbit (exophthalmos also called proptosis), a particularly serious ocular complication.

Hyperthyroidism symptoms vary according to the disease seriousness and typically consist of an increase in heart rate (tachycardia) often greater than 100 beats per minute, weight loss (slimming), fatigue, irritability, anxiety, insomnia, vomiting (hyperemesis) and some typical symptoms of pregnancy can be accentuated as the tendency to tiredness, heat intolerance and perspiration. Sometimes it is very obvious a diffuse enlargement of the thyroid gland (located in the anterior region of the neck). Patients with hyperthyroidism often have eye problems (even asymmetric) ranging from eyelid retraction to Exophthalmos (protrusion of the eyeball) typical of Graves’ disease, are also frequent: nail brittleness, increased hair loss, thickening of the pretibial tissues (myxedema).

We must remember, however, that an easier tendency to fatigue, nausea especially in the morning and gagging, irritability and anxiety and some mild tachycardia may be present in many perfectly normal pregnant women so it will always very important to conduct a differential diagnosis. In initial conditions of poor pregnancy weight gain or slimming with excessive vomiting (hyperemesis) always require a thyroid evaluation.

In the family history of these women is frequently present other cases of thyroid disease. Histocompatibility complex studies (for example, those that run on the occasion of organ transplants) have also shown an association with groups HLA-B8 and HLA-DR3.

Hyperthyroidism diagnosis is based on the clinical picture and on laboratory hormonal investigations. It is in fact necessary to the blood levels determination of FT4, FT3 (free fractions of thyroid hormones circulating in the body) and TSH (small protein hormone produced by the pituitary gland). Typically, in Hyperthyroidism FT3 and FT4 will be higher than normal (in some cases may increase only the FT3) and TSH will be very low or undetectable. TSH in normal conditions has a role in thyroid stimulating but when it works too and in an uncontrolled way as occurs in hyperthyroidism its production is lowered as a result of a strong signal (feedback) negative at the pituitary level which is increased by levels of FT3 and FT4.

Gland direct palpation is a critical clinical moment because it provides information on the size, volume, achiness and surface appearance. It also is very important neck lymph nodes, lateral cervical and supraclavicular palpation.

to a number of instrumental and immunological analysis contributing significally to Hyperthyroidism identification in pregnancy:

–      Thyroid ultrasound

–      Thyroid color-doppler ultrasound

–      Searching for thyroglobulin antibodies (Tg), anti-thyroid peroxidase (TPO) and anti-TSH receptor antibodies (TRAb)

Since in most cases it is an autoimmune disease (ie triggered and maintained by a self-aggression of their own immune defense system), antibodies dosage is important not only for diagnosis but also for disease monitoring. The research of TRAb is particularly important during pregnancy because high levels may give rise to the suspicion that there is an involvement of the fetal thyroid with the consequent risk of fetal hyperthyroidism and possible future neonatal thyrotoxicosis. In some patients it is useful dosing iodine urinary excretion to exclude its excessive dieatry introduction and in other cases (subacute thyroiditis and fictitious) may be useful a dosage of serum thyroglobulin.

Thyroid is important for the entire body but hyperfunction (hyperthyroidism) in pregnancy has a lot of possible negative effects. In women whit hyperthyroid are more prevalent: Hypertension, Anemia, Heart disease, Pre-Eclampsia, Placental abruption, Miscarriage, premature birth, fetal malformations, intrauterine fetal death, low weight of babies at birth. Newborns of these patients may have altered thyroid function and also have higher incidence of pre-natal mortality. Of course everything is always related to the illness severity and duration.

Therapy in pregnancy is basically medical, surgical option is rare.

Medicines used are anti-thyroid, that is molecules that reduce the function of the gland and then the levels of its circulating hormones: Methimazole, Propylthiouracil and Carbimazole are the most commonly used molecules and belong to the group of “Thionamides.”

Therapy, when necessary, should be undertaken as early as possible and aims to Euthyroidism (normal serum levels of thyroid hormones) in the quickest time possible, however, that ranges between 2 and 6 weeks (the drugs do not affect thyroid hormones already produced and stored in the gland).

Methimazole (MMI) is the most widely used drug in Europe while Propylthiouracil (PTU) is the drug of choice in the United States. The latter also is not available in Italy, but can still be obtained with a “Galenic” prescription  in some pharmacies. Although it has been suggested that the PTU is preferable in pregnancy, many believe MMI equally safe and effective. Data that demonstrate a link between the administration of MMI with Aplasia Cutis and other infant malformations seem controversial and inconclusive. Choice of a molecule respect to another is then determined from experience, from scientific beliefs of the doctor and from availability of the drug. The “attack doses” in Hyperthyroidism are generally 20-30 mg of MMI and 200-400 mg of PTU divided into two (MMI) or three (PTU) daily doses. Then (if the clinical condition improves) we tend to always achieve the lowest effective dose that is around 5-10 mg MMI or 50-100 mg of PTU.

Medical therapy, whatever is the molecule chosen, it is very important: not only decreases the incidence of fetal malformations related to the disease but overall has a very positive influence on the  pregnancy course favoring reproductive success. 5% of women taking Thionamides have side effects such as rashes, itching, Agranulocytosis (decrease in white blood cell) which, however, does not necessarily require interruption of treatment. More rarely may occur liver changes (hepatotoxicity) and joint disorders.

The benefit / risk balance is greatly in favor of medical therapy with Thionamides.

Sometimes to control maternal heart rate symptomatology (tachycardia) and hypertension may be indispensable using beta-blockers. Propranolol is widely used, but also Atenolol is an excellent drug. These molecules are not contraindicated in pregnancy and also allow to monitor and heal tremors and anxiety often present in situations of high heart rate (eg Thyroid Storm).

Clinical monitoring of these patients and their fetus is another crucial moment. The clinical monitoring of these patients and fetus is another crucial moment. Are recommended, in addition to the common controls provided in pregnancy, frequent checks of pressure, Thyroid volume, maternal and fetal weight and heart rate. Monthly, it is also good to check blood counts and dosage of TSH, FT3, FT4. The FT4 dosage has a particular importance and the objective is to keep it within medium-high limits. Because of fetuses of hyperthyroid patients have increased risk of malformations and growth abnormalities, in addition to routine ultrasound scans it is strongly indicated a II level morphological ultrasound with Doppler flow  at the 20th week, and this will also allow to observe the fetal Thyroid.

The search for maternal anti receptor antibodies TSH (TRAb) is recommended at the 20th and at the 30th week to identify fetuses at increased risk and to adopt more stringent measures if necessary. Postnatal and breastfeeding periods require particular attention both to the mother and neonate. Mom and baby should be carefully monitored clinically and in laboratory. It is also important to look for TRAb in newborn. Usually pregnancy has a favorable effect on  Graves’ Disease and it is not uncommon to attend a clinical improvement, but in the postnatal period clinical picture may change again.

Thionamides treatment is not a contraindication to breastfeeding but the decision to keep it still requires more prudential attitudes (minimal doses of drugs, more frequent baby checks).

New Post has been published on http://womanhealthgate.com/thyroid-nodules-multinodular-goiter/

Thyroid Nodules and Multinodular Goiter

Nodular pathology is the most common thyroid disease and affects more frequently women

Clinical evaluation is the first and most important steep in thyroid pathology.

than  men; about 6.4 % of those aged between 30 and 59 years old. In fact, its incidence is probably even higher ( in the autopsy findings rises to nearly 50% of cases ), but not diagnosed by the absence of symptoms. Its prevalence in the general population increases progressively with age and sometimes is accompanied by an enlargement of the gland ( goiter ) .

Goiter is often compensatory hypertrophy of the thyroid gland particularly frequent in areas with low iodine content in the diet.

It is a round lesion , single or multiple ( multinodular goiter ) , solid or cist ( sometimes mixed ) that can reach sometimes size that can determine compression on nearby organs .

The detection of Thyroid Nodules is done by palpation and / or visually (often during a clinical examination ) or during an ultrasound examination. Many small nodules are often completely asymptomatic and are diagnosed occasionally, large nodules as well as being visible (often see them for the first patient himself) and also create an aesthetic problem can lead to disorders compression on nearby organs such as the larynx and trachea ( dysphonia, dyspnea) and esophagus (dysphagia ) .

The nature of thyroid nodules are benign in most cases; particularly in women , only 5-6% has tumoral origin ( papillary carcinoma , the most frequent ) .

The diagnostic procedures are intended to distinguish malignant from benign thyroid nodules; describe its size and its structure, whether it belongs to a single or multinodular goiter , a chronic or subacute thyroiditis .

Pay attention to:

previous irradiation of the neck volumetric increase of the lateral cervical lymph nodes rapid growth increase of consistency compression disorders ( dysphonia, dysphagia) previous cases of thyroid cancer in the family

Rapid appearance , with sharp pain and tension

Concomitant relief of symptoms of hyperthyroidism ( tachyarrhythmia etc.).

Normally the first professional to take care of the problem is the general practitioner; he will judge whether it is necessary to consult an Endocrinologist .

The investigations that are both instrumental and possibly laboratoristiche citomorfologiche .

LABORATORY INVESTIGATIONS

Evaluation of thyroid function by determination of TSH ( a small pituitary hormone that controls the thyroid ) and thyroid hormones ( free fractions circulating ) FT3 , FT4 . The detection of increased thyroid hormones ( particularly FT3 ) may lay down for a hyperfunctioning nodule ( toxic adenoma ) and low values ​​( FT4 ) with increased TSH are more typical example of a chronic autoimmune thyroiditis with hypothyroidism. In pregnancy, the stimulation by chorionic gonadotropin (HCG) on the thyroid gland in the first weeks may result in a slight lowering of the physiological TSH ( down regulation ) not to be confused with situations of hyperthyroidism . Determination of Calcitonin : useful to identify or exclude the presence of a medullary carcinoma of the thyroid . Dosage antitireoglobulina antibody ( TgAb ) and antitireoperossidasi ( TPOAb ) : their identification and titration process helps to identify any chronic autoimmune ( thyroiditis Haschimoto ) .

IMAGING TESTS

Thyroid ultrasound has a very important role. Highlight the thyroid nodule , its size , its structure

Thyroid ultrasonography play and important diagnostic role in nodular pathology.

, and also describes the context in which it is glandular and may also describe the presence of enlarged lymph nodes ( lymph node enlargement ) locoregional ( neighbors) . The echo – Doppler Article by information on the vascularization of the nodule : an intense vascularization may be suspect but is also present in hyperfunctioning adenomas completely benign . The CT scan ( Computerized Axial Tomography ) and MRI ( Magnetic Resonance Imaging) are sometimes useful in analyzing the relationships of the Thyroid Gland with organs and vascular structures nearby as well as in the study of development in substernal goiters . The thyroid scan through the study of the uptake of a radioactive isotope of iodine helps to distinguish independently functioning nodules (lumps warm ipercaptanti ) and those not working ( cold nodules ) or isocaptanti than the rest of the gland. This exam is absolutely contraindicated in pregnancy.

CYTOLOGY

The fine-needle aspiration is a valuable investigation in the differential diagnosis between benign and malignant thyroid nodules . With a needle under ultrasound control and we proceed to the aspiration of the nodule and the cells are removed so It ‘ important that the sample ( sampling) is adequate for the purposes of cytology . Has no contraindication in pregnancy and as a rule all palpable nodules larger than 1 cm should undergo this procedure. As part of these investigations , however, elements of alarm or concern (in a tumor ) are the identification of nodules structurally solid , mixed or ipocaptanti scintigraphic examination ( cold ), fine-needle aspiration will identify those really dangerous , fortunately a small minority .

TREATMENT depends on the benign or malignant thyroid nodules , by the concurrence of a goiter , the overall clinical condition of the patient, including ( as many of the women) a possible pregnancy. A large part (up to almost 50 %) of benign nodules undergoes spontaneous regression . Benign nodules that have demonstrated a growth documented or aesthetic problems that damage or compression can be treated with the administration of levo- thyroxine ( LT4 ) : exogenous administration of thyroid hormones in fact suppresses the pituitary secretion of TSH and this leads in many cases a significant reduction in the size of the nodule , the attempt is always made with the minimum effective doses , requires a selection of patients to exclude contraindications (eg. cardiovascular disease , post-menopausal age the risk for osteoporosis) and usually in the absence of success is not persisted for more than a year . While the LT4 seems also useful in preventing the formation of additional nodules and still halt the growth was not demonstrated an ability to avoid the neoplastic transformation . Cystic nodules of secure benignity may be treated with the aspiration ( often burdened by relapse) , the ultrasound-guided percutaneous alcoholization ( sclerosed walls and is effective in 80 to 95% of cases ) , the surgery. Different and more complex is the attitude in cases of malignancy that holds obviously also the biological characteristics of the tumor ( histological type ) : surgical therapy is the first choice and ranges from lobectomy ( partial removal ) total removal of the thyroid ( thyroidectomy ) , using when necessary the adjuvant radioiodine therapy ( administration of radioactive iodine that destroys residual cells ) , chemotherapy , radiotherapy.

New Post has been published on http://womanhealthgate.com/hyperthyroidism-pregnancy/

Hyperthyroidism in Pregnancy

Hyperthyroidism is a clinical syndrome characterized by an increase of thyroid hormones production. As much of the thyroid disease hyperthyroidism occurs more frequently in women with an estimated incidence of 3.9%.

Most frequent causes

Uncommon causes

Graves’ Disease

Toxic Multinodular Goiter

toxic adenoma (Plummer’s disease)

Thyroiditis

  assumption of thyroid extracts in diet

exogenous administration of thyroid hormones

Trophoblastic tumors

TSH-secreting pituitary tumor

Thyroid Carcinoma

Struma Ovarii

  Graves’ Disease is the most frequent cause and frequently affects under 45 women, then during reproductive age. despite being one of the causes of infertility is not uncommon its appearance during pregnancy .

The Toxic Multinodular Goiter is the second among the most frequent causes but usually affects over 50 women and generally appears in patients who already carrier a Non-Toxic Multinodular Goiter.

One of the possible consequences of Graves’ disease and hyperthyroidism is the infiltrative orbitopathy with a bulging of the eye anteriorly out of the orbit (exophthalmos also called proptosis), a particularly serious ocular complication.

Hyperthyroidism symptoms vary according to the disease seriousness and typically consist of an increase in heart rate (tachycardia) often greater than 100 beats per minute, weight loss (slimming), fatigue, irritability, anxiety, insomnia, vomiting (hyperemesis) and some typical symptoms of pregnancy can be accentuated as the tendency to tiredness, heat intolerance and perspiration. Sometimes it is very obvious a diffuse enlargement of the thyroid gland (located in the anterior region of the neck). Patients with hyperthyroidism often have eye problems (even asymmetric) ranging from eyelid retraction to Exophthalmos (protrusion of the eyeball) typical of Graves’ disease, are also frequent: nail brittleness, increased hair loss, thickening of the pretibial tissues (myxedema).

We must remember, however, that an easier tendency to fatigue, nausea especially in the morning and gagging, irritability and anxiety and some mild tachycardia may be present in many perfectly normal pregnant women so it will always very important to conduct a differential diagnosis. In initial conditions of poor pregnancy weight gain or slimming with excessive vomiting (hyperemesis) always require a thyroid evaluation.

In the family history of these women is frequently present other cases of thyroid disease. Histocompatibility complex studies (for example, those that run on the occasion of organ transplants) have also shown an association with groups HLA-B8 and HLA-DR3.

Hyperthyroidism diagnosis is based on the clinical picture and on laboratory hormonal investigations. It is in fact necessary to the blood levels determination of FT4, FT3 (free fractions of thyroid hormones circulating in the body) and TSH (small protein hormone produced by the pituitary gland). Typically, in Hyperthyroidism FT3 and FT4 will be higher than normal (in some cases may increase only the FT3) and TSH will be very low or undetectable. TSH in normal conditions has a role in thyroid stimulating but when it works too and in an uncontrolled way as occurs in hyperthyroidism its production is lowered as a result of a strong signal (feedback) negative at the pituitary level which is increased by levels of FT3 and FT4.

Gland direct palpation is a critical clinical moment because it provides information on the size, volume, achiness and surface appearance. It also is very important neck lymph nodes, lateral cervical and supraclavicular palpation.

to a number of instrumental and immunological analysis contributing significally to Hyperthyroidism identification in pregnancy:

–      Thyroid ultrasound

–      Thyroid color-doppler ultrasound

–      Searching for thyroglobulin antibodies (Tg), anti-thyroid peroxidase (TPO) and anti-TSH receptor antibodies (TRAb)

Since in most cases it is an autoimmune disease (ie triggered and maintained by a self-aggression of their own immune defense system), antibodies dosage is important not only for diagnosis but also for disease monitoring. The research of TRAb is particularly important during pregnancy because high levels may give rise to the suspicion that there is an involvement of the fetal thyroid with the consequent risk of fetal hyperthyroidism and possible future neonatal thyrotoxicosis. In some patients it is useful dosing iodine urinary excretion to exclude its excessive dieatry introduction and in other cases (subacute thyroiditis and fictitious) may be useful a dosage of serum thyroglobulin.

Thyroid is important for the entire body but hyperfunction (hyperthyroidism) in pregnancy has a lot of possible negative effects. In women whit hyperthyroid are more prevalent: Hypertension, Anemia, Heart disease, Pre-Eclampsia, Placental abruption, Miscarriage, premature birth, fetal malformations, intrauterine fetal death, low weight of babies at birth. Newborns of these patients may have altered thyroid function and also have higher incidence of pre-natal mortality. Of course everything is always related to the illness severity and duration.

Therapy in pregnancy is basically medical, surgical option is rare.

Medicines used are anti-thyroid, that is molecules that reduce the function of the gland and then the levels of its circulating hormones: Methimazole, Propylthiouracil and Carbimazole are the most commonly used molecules and belong to the group of “Thionamides.”

Therapy, when necessary, should be undertaken as early as possible and aims to Euthyroidism (normal serum levels of thyroid hormones) in the quickest time possible, however, that ranges between 2 and 6 weeks (the drugs do not affect thyroid hormones already produced and stored in the gland).

Methimazole (MMI) is the most widely used drug in Europe while Propylthiouracil (PTU) is the drug of choice in the United States. The latter also is not available in Italy, but can still be obtained with a “Galenic” prescription  in some pharmacies. Although it has been suggested that the PTU is preferable in pregnancy, many believe MMI equally safe and effective. Data that demonstrate a link between the administration of MMI with Aplasia Cutis and other infant malformations seem controversial and inconclusive. Choice of a molecule respect to another is then determined from experience, from scientific beliefs of the doctor and from availability of the drug. The “attack doses” in Hyperthyroidism are generally 20-30 mg of MMI and 200-400 mg of PTU divided into two (MMI) or three (PTU) daily doses. Then (if the clinical condition improves) we tend to always achieve the lowest effective dose that is around 5-10 mg MMI or 50-100 mg of PTU.

Medical therapy, whatever is the molecule chosen, it is very important: not only decreases the incidence of fetal malformations related to the disease but overall has a very positive influence on the  pregnancy course favoring reproductive success. 5% of women taking Thionamides have side effects such as rashes, itching, Agranulocytosis (decrease in white blood cell) which, however, does not necessarily require interruption of treatment. More rarely may occur liver changes (hepatotoxicity) and joint disorders.

The benefit / risk balance is greatly in favor of medical therapy with Thionamides.

Sometimes to control maternal heart rate symptomatology (tachycardia) and hypertension may be indispensable using beta-blockers. Propranolol is widely used, but also Atenolol is an excellent drug. These molecules are not contraindicated in pregnancy and also allow to monitor and heal tremors and anxiety often present in situations of high heart rate (eg Thyroid Storm).

Clinical monitoring of these patients and their fetus is another crucial moment. The clinical monitoring of these patients and fetus is another crucial moment. Are recommended, in addition to the common controls provided in pregnancy, frequent checks of pressure, Thyroid volume, maternal and fetal weight and heart rate. Monthly, it is also good to check blood counts and dosage of TSH, FT3, FT4. The FT4 dosage has a particular importance and the objective is to keep it within medium-high limits. Because of fetuses of hyperthyroid patients have increased risk of malformations and growth abnormalities, in addition to routine ultrasound scans it is strongly indicated a II level morphological ultrasound with Doppler flow  at the 20th week, and this will also allow to observe the fetal Thyroid.

The search for maternal anti receptor antibodies TSH (TRAb) is recommended at the 20th and at the 30th week to identify fetuses at increased risk and to adopt more stringent measures if necessary. Postnatal and breastfeeding periods require particular attention both to the mother and neonate. Mom and baby should be carefully monitored clinically and in laboratory. It is also important to look for TRAb in newborn. Usually pregnancy has a favorable effect on  Graves’ Disease and it is not uncommon to attend a clinical improvement, but in the postnatal period clinical picture may change again.

Thionamides treatment is not a contraindication to breastfeeding but the decision to keep it still requires more prudential attitudes (minimal doses of drugs, more frequent baby checks).