VIDEO: Collaborative effort needed for managing Graves’ disease during pregnancy
In this Healio Video Exclusive, Nicole Gomez, MD, speaks with Caroline T. Nguyen, MD, about managing Graves’ disease during pregnancy.
Nguyen, an assistant professor of clinical medicine, obstetrics and gynecology in the division of endocrinology, diabetes and metabolism at the University of Southern California (USC) Keck School of Medicine and a Healio | Endocrine Today Editorial Board Member, said managing Graves’ disease during pregnancy can be tricky for health care professionals. She and Gomez, an assistant professor of obstetrics and gynecology in the division of maternal and fetal medicine at the USC Keck School of Medicine, discuss several tips for diagnosing Graves’ disease, the need for collaboration between different specialties and why preconception planning is important.
Nguyen and Gomez are course directors for the USC Jorge H. Mestman Endocrine and Women’s Health Symposium.
You can view the full video interview above or read the Q&A transcript below.
Editor’s note: This is a three-part Healio Video Exclusive series. Check out the other videos on menopausal HT and CGM.
Video transcript
Gomez: Carolyn, we’re so excited about your talk this year, you’re talking about hyperthyroidism and Graves’ disease.
Nguyen: Yes, hyperthyroidism, Graves’ disease and pregnancy, I think it’s a topic that can be challenging for a lot of endocrinologists, obstetricians and maternal-fetal medicine specialists who are usually that team of physicians who are caring for patients during this time.
Gomez: I feel really lucky that I got to train with endocrine so much during my maternal-fetal medicine fellowship. Do you have two or three pearls for the average maternal-fetal medicine or obstetrician/gynecologist who may be treating patients with Graves’ disease in pregnancy?
Nguyen: First off is making the diagnosis itself. In pregnancy that can sometimes be challenging, because you don’t see a lot of Graves’ disease and it is pretty rare, it’s only 0.2% of pregnancies. Most physicians aren’t seeing this all the time, so making that diagnosis can be challenging because of the physiologic changes that happen in pregnancy itself, due to beta [human chorionic gonadotropin] and its effect on thyroid hormone production. Even in normal pregnancy, you can have labs that look like hyperthyroidism; thyroid-stimulating hormone can be low, thyroxine can be high. But oftentimes, this might just be physiologic changes of pregnancy itself. There can also be gestational transient thyrotoxicosis that can happen. Oftentimes, we see this with hyperemesis gravidarum. Then you find these labs, and it can be quite confusing, is this Graves’ disease or not?
I think if there’s no prior history of Graves’ disease, think [about] if this is perhaps something else. If you cannot tell by the physical exam if these are Graves’ ophthalmopathy, or a large goiter, then we do have the ability to test for the antibodies for Graves’ now. That can be done with either a TSH receptor antibody or a thyrotropin-stimulating immunoglobulin. Either one can be used in a patient that is presenting as hyperthyroid, or biochemical hyperthyroidism, but what they would reflect is if they’re elevated, those are the antibodies that lead to Graves’ disease that act on the TSH receptor and lead to increased thyroid hormone production. If you have those, then that would be more consistent with a diagnosis of Graves’ disease in pregnancy.
Gomez: I think that’s one of the pitfalls of that hyperthyroid state in early pregnancy. I get a lot of consults where, biochemically, they looked like they had hyperthyroidism. But like you’re saying, if you look at the exam, if you get the antibodies, they don’t. That’s something that I think, at least for us in OB/GYN and maternal-fetal medicine, we can get better at doing.
In general, who do you recommend manages these patients in pregnancy?
Nguyen: In an ideal scenario, it would be a collaboration between the endocrinologist, the obstetrician and maternal-fetal medicine. Luckily, where we work, that’s what we do. Each person plays a different role essentially in that care. But I think close collaboration between the three is good. Probably the endocrinologist most of the time is titrating the medication, but that’s alongside what maternal-fetal medicine is seeing on ultrasounds, how is baby doing, and then also in the more frequent obstetrician visits as well.
After delivery, the neonatologist and the pediatrician also may play a role depending on the severity of the hyperthyroidism.
Gomez: The preconception time is a really important time that doesn’t get enough screenplay. Is there anything you like to tell your patients preconceptually before they get pregnant?
Nguyen: In a patient that has Graves’ disease already preconception, the most important part is planning their pregnancy. Ideally, in that preconception time discussing how they’re going to continue with their management. If they’re on antithyroid drugs, which is what most patients are being treated with in the U.S. and around the world, does the mom want to continue this throughout the pregnancy? Or is there a role for definitive treatment prior to the pregnancy? That sometimes needs to be considered in patients who are not as well controlled already in preconception, or perhaps the timeline for mom and pregnancy is going to be sooner, and the patient doesn’t have the luxury of waiting a couple of years to be treated with antithyroid drugs. That discussion can be pretty important to see what are the wishes of the patient and the different options that the patient has in terms of choices for management, the pros and cons of each, and what it means in pregnancy itself.
For more information:
Caroline T. Nguyen, MD, will speak more about hyperthyroidism and Graves’ disease during pregnancy at the USC Jorge H. Mestman Endocrine and Pregnancy Symposium taking place in person and virtually March 1. Register for the symposium at https://keckusc.cloud-cme.com/course/courseoverview?P=0&EID=8796.
Collapse
Healio Interviews
Read more about