Management of a pregnant woman with thyrotropinoma: a case report and review of the literature (original) (raw)

MON-LB46 Thyrotropinoma and Pregnancy

Journal of the Endocrine Society

Thyrotropinomas (TSHomas) are rare pituitary tumours, comprising 1-2% of all pituitary adenomas. Thyrotropinomas in pregnancy are exceedingly rare and management of these in pregnancy can be challenging due to the potential for maternal and foetal harm. We report the case of a 35 year old woman who was found to have a pituitary macroadenoma on imaging whilst being evaluated for headaches and sinusitis. She had felt more stressed than usual but no other overt thyrotoxic symptoms. There were no visual field abnormalities or symptoms to suggest other endocrine hypo or hypersecretion. Pituitary MRI revealed a macroadenoma and biochemistry demonstrated raised free T4 24 pmol/L and free T3 6.8 pmol/L and inappropriately elevated TSH of 4.2 mIU/L, in keeping with secondary hyperthyroidism. She was scheduled for transsphenoidal (TSA) pituitary surgery, however on review she had naturally fallen pregnant. After a multi-disciplinary discussion, it was decided that surgery should be deferred a...

Pregnancy and Autoimmune Thyroid Disease: Alternating Between Hypothyroidism and Hyperthyroidism and the Role of Thyrotropin Receptor Antibodies

AACE Clinical Case Reports, 2017

Objective: To report the case of a female patient with hypothyroidism who spontaneously developed Graves hyperthyroidism during pregnancy and then reverted back to hypothyroidism in a subsequent pregnancy. Methods: The pertinent clinical features, laboratory data, and clinical course of the case are reported, along with a brief literature review. Results: A 30-year-old female with hypothyroidism diagnosed at age 20 years unexpectedly required decreased levothyroxine dosing during her second pregnancy. She was taking levothyroxine 12.5 µg daily when she became pregnant a third time. In the first trimester, levothyroxine was discontinued, and she presented in the third trimester with clinical and biochemical hyperthyroidism and a diffusely enlarged goiter. Propylthiouracil (PTU) was initiated. Thyroid-stimulating hormone-receptor antibodies (TRAbs) were positive. After delivery, her baby developed transient neonatal Graves disease. She was continued on a stable dose of PTU for 10 months postpartum and then became pregnant a fourth time. PTU was discontinued and she remained euthyroid off medications until the second trimester, when she presented with clinical and biochemical hypothyroidism, requiring levothyroxine initiation. TRAb level was elevated. Thyroid-stimulating immunoglobulin (TSI) bioassay was elevated. Despite elevated TSI in her fourth pregnancy, her child did not develop neonatal Graves disease. She remains euthyroid on levothyroxine. Conclusion: Spontaneous transformation from hypothyroidism to hyperthyroidism during pregnancy is rare but can occur. The balance between the activity of stimulating and blocking TRAbs may impact the clinical presentation for both the mother and the fetus.

Thyrotropinoma with silent somatotroph and lactotroph adenoma during pregnancy

Endocrinology, Diabetes & Metabolism Case Reports, 2022

Thyrotropinomasareanuncommoncauseofhyperthyroidismandareexceedinglyrarelyidentifiedduringpregnancy, with limited evidence to guide management. Most commonly they present as macroadenomas and may cause symptomsofmasseffectincludingheadache,visualfielddefectsandhypopituitarism.Wepresentacaseofa35-yearold woman investigated for headaches in whom a 13 mm thyrotropinoma was found. In the lead-up to planned transsphenoidal surgery (TSS), she spontaneously conceived and surgery was deferred, as was pharmacotherapy, at her request. The patient was closely monitored through her pregnancy by a multidisciplinary team and delivered without complication. Pituitary surgery was performed 6 months post-partum. Isolated secondary hypothyroidism was diagnosed postoperatively and replacement thyroxine was commenced. Histopathology showed a double lesion with predominant pituitary transcription factor-1 positive, steroidogenic factor negative plurihormonal adenoma and co-existent mixed thyroid-stimulating hormone, growth hormone, lactotroph and follicle-stimulating hormone staining with a Ki-67 of 1%. This case demonstrates a conservative approach to thyrotropinoma in pregnancy with a successful outcome. This highlights the need to consider the timing of intervention with careful consideration of risks to mother and fetus.

Fetal Hypothyroidism Complicating Medical Treatment of Thyrotoxicosis in Pregnancy

Clinical Endocrinology, 1975

Two women with thyrotoxicosis were treated with antithyroid drugs during pregnancy. One women had inadvertently received a therapeutic dose of radioiodine at 21 weeks gestation and the other suffered from severe thyrotoxicosis with a serum LATS level of 1850%. In both patients, the serum triiodothyronine was maintained above 500 ng/dl by the concurrent oral administration of this hormone. Despite this precaution, cord serum thyrotrophin levels were markedly elevated and both infants showed clinical signs of hypothyroidism at birth. This experience indicates that triiodothyronine does not prevent fetal hypothyroidism when given to the mother in pharmacological amounts.

Hyperthyroidism in Pregnancy: The Delicate Balance between Too Much or Too Little Antithyroid Drug

Journal of Clinical Medicine

Overt hyperthyroidism (HT) during pregnancy is associated with a risk of maternal–fetal complications. Antithyroid drugs (ATD) have a potential risk for teratogenic effects and fetal–neonatal hypothyroidism. This study evaluated ATD treatment and thyroid function control during pregnancy, and pregnancy outcome in women with HT. Patients and methods: A retrospective analysis of 36 single fetus pregnancies in 29 consecutive women (median age 30.3 ± 4.7 years) with HT diagnosed before or during pregnancy; a control group of 39 healthy euthyroid pregnant women was used. Results: Twenty-six women had Graves’ disease (GD, 33 pregnancies), 1 had a hyperfunctioning autonomous nodule, and 2 had gestational transient thyrotoxicosis (GTT). Methimazole (MMI) was administered in 22 pregnancies (78.5%), Propylthiouracil (PTU) in 2 (7.1%), switch from MMI to PTU in 4 (14.2%), no treatment in 8 pregnancies (3 with subclinical HT, 5 euthyroid with previous GD remission before conception). In the 8 p...

Pregnancy with Hypothyroid Secondary to Treatment of Thyroid Carcinoma: A Case Report

Diponegoro International Medical Journal

Background: Thyroid malignancy is one of the most common malignancies in women of reproductive age. One of the normal physiological change in pregnancy is an increase in total maternal thyroid levels. According to 2015 DATIN information, the prevalence of hypothyroidism in women of reproductive age was 2.2%. Method of delivery in patients with thyroid disorders are mostly by cesarean section due to complications of the mother and/or fetus. Fetal outcome usually associated with low birth weight and poor APGAR Score.Objective : Reporting a case of pregnancy with hypothyroidism secondary to thyroid carcinoma treatmentCase: A 37-year-old woman Gravida 3 Parity 2 Abortion 0 with 18 weeks pregnancy after thyroid ablation treatment with a history of Papillary Thyroid Carcinoma – Follicular Variant, following a complete thyroidectomy in August 2016. The patient was given 6-dose ablation therapy, the last therapy was performed in April 2019. On clinical examination, the patient have no sign ...

Autoimmune Thyroid Disease in Pregnancy: A Review

Journal of Women's Health, 2009

The maternal physiological changes that occur in normal pregnancy induce complex endocrine and immune responses. During a normal pregnancy, thyroid gland volume may enlarge, and thyroid hormone production increases. Hence, the interpretation of thyroid function during gestation needs to be adjusted according to pregnancy-specific ranges. The elevated prevalence of gestation-related thyroid disorders (10%-15%) and the important repercussions for both mother and fetus reported in multiple studies throughout the world denote, in our opinion, the necessity for routine thyroid function screening both before and during pregnancy. Once thyroid dysfunction is suspected or confirmed, management of the thyroid disorder necessitates regular monitoring in order to ensure a successful outcome. The aim of treating hyperthyroidism in pregnancy with antithyroid drugs is to maintain serum thyroxine (T 4) in the upper normal range of the assay used with the lowest possible dose of drug, whereas in hypothyroidism, the goal is to return serum thyroid-stimulating hormone (TSH) to the range between 0.5 and 2.5 mU=L.

Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and Postpartum

Thyroid, 2011

INTRODUCTION P regnancy has a profound impact on the thyroid gland and thyroid function. The gland increases 10% in size during pregnancy in iodine-replete countries and by 20%-40% in areas of iodine deficiency. Production of thyroxine (T 4 ) and triiodothyronine (T 3 ) increases by 50%, along with a 50% increase in the daily iodine requirement. These physiological changes may result in hypothyroidism in the later stages of pregnancy in iodine-deficient women who were euthyroid in the first trimester. The range of thyrotropin (TSH), under the impact of placental human chorionic gonadotropin (hCG), is decreased throughout pregnancy with the lower normal TSH level in the first trimester being poorly defined and an upper limit of 2.5 mIU/L. Ten percent to 20% of all pregnant women in the first trimester of pregnancy are thyroid peroxidase (TPO) or thyroglobulin (Tg) antibody positive and euthyroid. Sixteen percent of the women who are euthyroid and positive for TPO or Tg antibody in the first trimester will develop a TSH that exceeds 4.0 mIU/L by the third trimester, and 33%-50% of women who are positive for TPO or Tg antibody in the first trimester will develop postpartum thyroiditis. In essence, pregnancy is a stress test for the thyroid, resulting in hypothyroidism in women with limited thyroidal reserve or iodine deficiency, and postpartum thyroiditis in women with underlying Hashimoto's disease who were euthyroid prior to conception.

The Incidence of Gestational Hyperthyroidism and Postpartum Thyroiditis in Treated Patients with Graves' Disease

Thyroid, 2007

Graves' disease (GD) is one of the most common thyroid diseases that cause hyperthyroidism. Gestational transient thyrotoxicosis (GTT) is nonautoimmune hyperthyroidism that occurs in women with a normal pregnancy. Postpartum transient thyroiditis (PTT) is a destructive thyroiditis induced by autoimmune mechanism in the postpartum period. Hyperthyroidism due to GD usually tends to improve during the course of gestation and exacerbate after delivery. When the patient with treated GD presents with thyrotoxicosis in the early pregnancy or in the postpartum period, differential diagnosis of exacerbation of GD with GTT or PTT is important because the latter disorders are fundamentally transient. To evaluate the incidence of GTT and PTT in a GD population, we investigated the thyroid functions, thyrotropin receptor antibodies (TRAb), and human chorionic gonadotropin (hCG) during pregnancy and for 1 year after delivery for 39 pregnancies in 34 women with GD. The incidence of GTT was 26% (10=39) of pregnancies. The peak value of hCG in the GTT group ([23.7 ± 14.5] Â 10 4 IU=mL, n ¼ 9) was significantly higher than that in the non-GTT group ([13.3 ± 4.7] Â 10 4 IU=mL, n ¼ 19). The incidence of PTT was 44% (17=39) of deliveries. The free triiodothyronine (FT 3)=free thyroxine (FT 4) ratio of the exacerbation group of GD (3.1 ± 1.0, n ¼ 10) at the time of thyrotoxicosis after delivery was significantly higher than that of the PTT group (2.5 ± 0.4, n ¼ 16). The peak TRAb value of the exacerbation group of GD (72.5 ± 121.7 IU=L, n ¼ 10) at the time of thyrotoxicosis after delivery was also significantly higher than that of the PTT group (1.4 ± 0.8 IU=L, n ¼ 16). In conclusion, the high peak value of hCG is valuable for suspecting GTT, and the high FT 3 =FT 4 ratio is valuable for suspecting recurrence in the patients with GD. In both situations, changes of TRAb were also valuable in differentiating the recurrence of GD from GTT or PTT.

Thyrotoxicosis of pregnancy

Journal of Clinical & Translational Endocrinology, 2014

Thyrotoxicosis presenting during pregnancy is a common clinical problem and can be challenging to differentiate between physiologic patterns of thyroid dysfunction during gestation and intrinsic hyperthyroidism. This review provides a summary of the differential diagnosis, clinical presentation, diagnostic options, potential adverse effects of maternal thyrotoxicosis to the fetus, and treatment recommendations for thyrotoxicosis arising in pregnancy.