Post-Partum Transient Thyrotoxicosis With Painless Thyroiditis

Ginsberg, Jody; Walfish, P. G.

doi:10.1016/s0140-6736(77)92384-4

Cited by 139 publications

(47 citation statements)

References 11 publications

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“…Post partum thyroid dysfunction (PPTD) was recognized as a clinical entity in the 1970s (1,2). The incidence of PPTD in the general population is 4-8% (3)(4)(5)(6).…”

Section: Introductionmentioning

confidence: 99%

Prediction of post partum thyroid dysfunction: can it be improved?

Kuijpens¹,

Pop

Vader³

et al. 1998

Eur J Endocrinol

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Background: Screening pregnant women for thyroid peroxidase antibodies (TPOAb) to identify those at risk for post partum thyroid dysfunction (PPTD) is controversial, mainly because of the low positive predictive value (ppv) of TPOAb. Objectives: To evaluate if the ppv of TPOAb can be enhanced, either by taking into account the time of TPOAb testing, or by combining this parameter with other putative determinants of PPTD such as smoking, family history or other autoimmune diseases. Methods: A prospective study was performed in the Kempenland region (southeastern Netherlands). Three hundred and ten unselected women were visited at 12 and 32 weeks gestation and 4, 12, 20, 28 and 36 weeks post partum. Serial thyroid stimulating hormone (TSH), free thyroxine (fT 4 ) and TPOAb testing was performed. Thyroid dysfunction (TD) was defined as abnormal TSH either in combination with abnormal fT 4 (overt TD) or without abnormal fT 4 (subclinical TD). PPTD was defined as overt TD post partum. Multivariate regression analysis was performed for determining independent risk factors for PPTD. The sensitivity and specificity of TPOAb at different time points and at different concentrations were calculated and presented in receiver operating characteristic (ROC) curves. Women who had experienced PPTD were followed for 2.5-3 years. Results: Data from 291 women were available for analysis. Serum fT 4 declined during pregnancy and returned to baseline values post partum. TD in gestation was present in 23 women (7.9%): serum TSH was transiently decreased in 13 (6 had overt gestational thyrotoxicosis (2.1%)) and increased in 10 (2 had TPOAb). Both point prevalence and concentration of TPOAb decreased during gestation and returned to baseline levels within 12 weeks post partum. TD in post partum was present in 36 women (12.4%): 21 had subclinical and 15 overt TD. Out of the 15 women with overt TD (incidence of PPTD: 5.2%) 10 were positive for TPOAb (TPOAbþ); 9 had thyrotoxicosis (4 TPOAbþ), 5 hypothyroidism (5 TPOAbþ) and 1 thyrotoxicosis followed by hypothyroidism (TPOAbþ). Independent risk factors for PPTD were TPOAb (relative risk (RR) ¼ 27.2), bottle feeding (RR ¼ 11.1) and smoking habits (ever smoked: RR ¼ 3.1; women with PPTD had smoked more cigarettes for a longer period of time). The sensitivity of TPOAb testing was highest at 12 weeks gestation (0.67). The ppv of TPOAb was 0.31-0.75 (depending on time of testing and concentration), increasing slightly to 0.38-0.80 when combined with bottle feeding or smoking habits. There appeared to be an autoimmune form of PPTD in 2/3 of cases and a nonautoimmune form; women with the autoimmune form were at risk for developing permanent hypothyroidism. Conclusions: A maximum of 2/3 of PPTD cases can be predicted from the presence of TPOAb because 1/3 remained negative for TPOAb. The most appropriate time for TPOAb testing is in the first trimester of pregnancy. The combination of TPOAb testing with anamnestic determinants of PPTD does not increase ppv substantially.

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“…Post partum thyroid dysfunction (PPTD) was recognized as a clinical entity in the 1970s (1,2). The incidence of PPTD in the general population is 4-8% (3)(4)(5)(6).…”

Section: Introductionmentioning

confidence: 99%

Prediction of post partum thyroid dysfunction: can it be improved?

Kuijpens¹,

Pop

Vader³

et al. 1998

Eur J Endocrinol

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“…Blizzard et al (1962) reported that a decrease in the size of goiters, lowering of antithyroid antibody levels, and elevation of protein-bound iodine and butanolextractable iodine to normal values were observed following steroid therapy in three patients with Hashimoto's thyroiditis. However, he also noted that with diminution or cessation of the steroid hormone administration, the goiters and biochemical abnormalities of the disease recurred and the (Papapetrou and Jackson, 1975;Gluck et al, 1975;Woolf and Daly, 1976;Dorfman et al, 1977;Gorman et al, 1978;Inada et al, 1979;Nikolai et al, 1980) or at one to three months after delivery (Ginsberg and Walfish, 1977;Amino et al, 1977;Nikolai et al, 1980), and is followed by transient hypothyroidism with eventual recovery to a euthyroid state or, in very rare cases, persistent hypothyroidism. There are reports of four cases of postpartum transient thyrotoxicosis followed by persistent hypothyroidism (Ginsberg and Walfish, 1977;Amino et al, 1977).…”

Section: Discussionmentioning

confidence: 99%

“…However, the true predisposing cause of transient thyrotoxicosis during the course of chronic lymphocytic thyroiditis has not yet been clarified. On the other hand, transient thyrotoxicosis after delivery has been suspected to emerge in relation to immunological changes and/or acute changes in steroid hormone concentrations before and after delivery (Nelson and Palmer, 1975;Amino et al, 1976;Amino et al, 1977;Ginsberg and Walfish, 1977). These findings, together with those in the present case, suggest that immunological changes enhanced by a reduction in steroid hormone concentrations might be closely related to the occurrence of transient thyrotoxicosis in chronic lymphocytic thyroiditis, but it remains to be determined what kind of immunologicol changes might play a role in the occurrence of "destructive" thyroiditis.…”

Section: Discussionmentioning

confidence: 99%

“…Recently, however, several authors (Papapetrou and Jackson, 1975;Gluck et al, 1975;Woolf and Daly, 1976;Dorfman et al, 1977;Ginsberg and Walfish, 1977;Amino et al, 1977;Gorman et al, 1978;Inada et al, 1979;Nikolai et al, 1980) have described cases of chronic lymphocytic thyroiditis which showed transient thyrotoxicosis, low radioactive iodine uptake and no thyroidal pain or tenderness, and most of these cases were followed by transient hypothyroidism with spontaneous recovery to a euthyroid state. Such cases have been differentiated from subacute thyroiditis mainly on the basis of histological …”

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Transient thyrotoxicosis occurred after cessation of steroid therapy in a patient with autoimmune thyroiditis and rheumatoid arthritis.

et al. 1982

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“…MBORA AS PRIMEIRAS DESCRIÇÕES de hipotiroidismo transitório em mulheres no período de puerperio datem de 1948, durante várias décadas esta condição despertou pouca atenção da literatura (1)(2)(3). Relatos de novos casos foram sendo feitos com freqüência cada vez maior e logo começaram a aparecer diversos estudos epidemiológicos e fisiopatológicos caracterizando-se, finalmente, a tiroidite pós-parto (TPP) como entidade clínico-nosológica (4).…”

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Predizendo riscos para tiroidite pós-parto através da dosagem de anticorpo anti-tpo: exemplo de valor da pesquisa clínica

Ward

1998

Arq Bras Endocrinol Metab

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EMBORA AS PRIMEIRAS DESCRIÇÕES de hipotiroidismo transitório em mulheres no período de puerperio datem de 1948, durante várias décadas esta condição despertou pouca atenção da literatura (1-3). Relatos de novos casos foram sendo feitos com freqüência cada vez maior e logo começaram a aparecer diversos estudos epidemiológicos e fisiopatológicos caracterizando-se, finalmente, a tiroidite pós-parto (TPP) como entidade clínico-nosológica (4).Inicialmente, a doença foi considerada como uma forma de tiroidite sub-aguda sem dor (5). Atualmente, com a demonstração de associação com antígenos DR e antígenos anti-tiroidianos, pela presença de infiltração linfocitária na tiróide, com diminuição da razão linfócitos T helper / T supressores durante a gravidez e no pós-parto, associada com grande ativação das células T no puerperio, a doença é considerada como uma patologia autoimune transitória relacionada à hiperatividade imunológica do puerpério (4,6-8).Também tem ficado patente que se trata de condição relativamente comum. Estima-se que atinja 4,9% das mulheres no primeiro ano pós-parto, variando sua prevalência na literatura entre 4,2% e 19,7% (6).Neste número dos Arquivos Brasileiros de Endocrinologia e Metabologia, Barros e Vaisman (9) encontraram uma prevalência similar, diagnosticando quatro portadoras de TPP dentre 115 pacientes. Demonstraram ainda uma associação entre a presença de anticorpos antitiroidianos durante a gravidez e no período pós-parto, com o desenvolvimento de TPP e de hipotiroidismo sub-clínico. Existem, também, evidên-cias de correlação entre anticorpos anti-TPO e outros anticorpos antitiroidianos com o desenvolvimento da doença de Basedow-Graves puerperal (10). Mais ainda, um quarto das mulheres com TPP desenvolvem hipotiroidismo permanente num período de quatro anos após o parto (11). Desta forma, a TPP é um indicador de futuras disfunções tiroidianas, embora não esteja ainda claro se a gravidez inicia um processo destrutivo da glândula ou simplesmente exacerba uma lesão pré-existente. Assim, apresenta-se uma interessante oportunidade para a prevenção de disfunções que, além de freqüentes, podem ser de grande morbidade, causando inúmeros transtornos à mulher e ao seu filho, particularmente quando se associam à depressão pós-parto.Um grande mérito do artigo de Barros e Vaisman (9), reside em demonstrar como podem ser obtidos dados científicos de valor e de aplicação prática imediata, de forma simples e com custos relativamente pequenos. A pesquisa clínica tem sido relegada a um segundo plano, desmotivada e desvalorizada, particularmente nos grandes centros universitários. Ora, em nosso país mal conhecemos muitas de nossas doenças mais prevalentes. No caso das tiroidopatias, isto se torna crucial quando lembramos que ainda possuímos grandes bolsões de áreas iodoprivas. Se somarmos a esta informação as alarmantes incertezas sobre o programa de correção da carência crônica de iodo no país, é de se imaginar que possuí-

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Post-Partum Transient Thyrotoxicosis With Painless Thyroiditis

Cited by 139 publications

References 11 publications

Prediction of post partum thyroid dysfunction: can it be improved?

Prediction of post partum thyroid dysfunction: can it be improved?

Transient thyrotoxicosis occurred after cessation of steroid therapy in a patient with autoimmune thyroiditis and rheumatoid arthritis.

Predizendo riscos para tiroidite pós-parto através da dosagem de anticorpo anti-tpo: exemplo de valor da pesquisa clínica

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