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Oral exam - medical conditions > Thyroid Disease > Flashcards

Thyroid Disease Flashcards

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USMLE® Step 1 flashcards
1
Q

What are the clinical features of hyperthyroidism?

A

Heat intolerance, tachycardia, palpitations, palmar erythema, emotional lability, vomiting, goitre

Discriminatory features in pregnancy
- weight loss, tremor, persistent tachycardia, lid lag, exophthalmos

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2
Q

What is the most common cause of hyperthyroidism in pregnancy?

A

Graves (95%)

Other causes

  • toxic multinodular goitre
  • toxic adenoma
  • thyroiditis
  • iodine, Amiodarone, lithium therapy
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3
Q

What is the effect of pregnancy on hyperthyroidism?

A

T1 - exacerbation due to hCG
T2 and T3 - State of relative immunosuppression
Puerperium - exacerbations due to reversal of the fall in antibody levels

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4
Q

What is the effect of hyperthyroidism in pregnancy?

A

Maternal:

  • Miscarriage
  • IUGR
  • PTL
  • Perinatal mortality
  • Palpitations: sinus tachy, SVT, AF
  • Thyroid storm
  • Heart failure
  • If goitre: tracheal obstruction, dysphagia

Fetal:
- Fetal or neonatal thyrotoxicosis

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5
Q

What are the anti-thyroid drugs used to treat Grave’s disease and their adverse effects?

A

PTU:

  • Neutropenia, agranulocytosis
  • Liver failure
  • Fetal hypothyroidism and goitre at high doses

Carbimazole:

  • Neutropenia, agranulocytosis
  • Aplasia cutis (absent patches of skin most often on scalp)
  • Fetal hypothyroidism and goitre at high doses
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6
Q

How would you treat sympathetic symptoms of hyperthyroidism (i.e. tachycardia, sweating, tremor, palpitations)?

A

Metoprolol or propranolol (beta-blocker).
Can be discontinued after anti-thyroid drugs take effect usually within 3 weeks.

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7
Q

What is the best time to perform a thyroidectomy in pregnancy?

What are three indications for such treatment?

A

Second trimester

Dysphagia or stridor related to a large goitre
Confirmed or suspected carcinoma
Allergies to both anti-thyroid drugs

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8
Q

What is the risk of radioiodine therapy in pregnancy?

A

Fetal thyroid ablation and hypothyroidism

As the radioioidine is taken up by the fetal thyroid

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9
Q

What is the pathogenesis of neonatal / fetal thyrotoxicosis?

A

Transplacental passage of thyroid-stimulating antibodies

Most common in those with active disease in the third trimester
Can occur in mothers with a past history of Grave’s

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10
Q

What are the clinical features of neonatal / fetal thyrotoxicosis?

A

Tachycardia, irritability, jitteriness, poor feeding, goitre, hyperexcitability, hepatosplenomegaly, stare and eyelid retraction
Severe cases: congestive cardiac failure

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11
Q

What are clinical features of hypothyroidism?

A

Weight gain, lethargy, tiredness, Goitre
Hair loss, dry skin, constipation
Carpal tunnel syndrome, fluid retention

Discriminatory features in pregnancy: cold intolerance, slow pulse rate, delayed relaxation of the tendon

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12
Q

What are your differential diagnoses for hypothyroidism?

A
  • Hashimoto’s thyroiditis (most common cause)
  • Autoimmune destruction of thyroid with associated goitre.
  • Following radioactive iodine treatment for hyperthyroidism
  • Radiation exposure to thyroid
  • Previous thyroidectomy
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13
Q

What is the effect of hypothyroidism on pregnancy?

A

Miscarriage
Anaemia
Fetal loss
PET
LBW

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14
Q

What are the clinical features of cretinism?
What it its cause?

A

Deaf mutism, spastic motor disorder, hypothyroidism

Severe maternal iodine deficiency causing permanent brain damage

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15
Q

With a thyroid nodule, what are the features indicating malignancy?

A

Previous history of radiation to the neck or chest in childhood
Fixation of the lump
Rapid growth of a painless nodule
Lymphadenopathy
Voice change
Horner’s syndrome

Raised thyroglobulin titre is suggestive of malignancy, as 90% of thyroid cancers secrete thyroglobulin

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16
Q

For women with a personal history of thyroid disease or symptoms of thyroid disease, what blood tests should they have on booking?

A

TSH
Free T4

17
Q

How is overt hypothyroidism in pregnancy diagnosed?

A

TSH above reference range with a decreased T4
OR
TSH > 10mIU / L (regardless of T4)

18
Q

What are the maternal risks in overt hypothyroidism?

A

PET
Anaemia
PPH

Anovulation + Miscarriage

19
Q

What are the fetal risks in overt hypothyroidism?

A

Placental abruption
Prematurity
Perinatal mortality

Developmental delay

20
Q

Outline your management of a woman with overt hypothyroidism in pregnancy:

A

Pre-pregnancy:
- TFTs

Antenatal:

  • Thyroid peroxidase (TPO) antibodies if TSH >2.5 mU/L.
  • Thyroid replacement therapy with thyroxine if TSH > than reference range with decreased free T4 OR TSH >10 mIU/L regardless of free T4 level. Approx 100-200 mcg/day.
  • Explain low risk of fetal hyperthyroidism as very little thyroxine crosses placenta.
  • Monitor TSH level at least once per trimester. Maintain maternal serum TSH within lower half of trimester specific pregnancy ranges.
  • Recheck TSH 4-6 weeks after any thyroid dose changes.

Postpartum:
- Check TSH; if thyroxine dose increased in pregnancy at risk of hyperthyroidism/overreplacement.

21
Q

What are the adverse effects of overt hypothyroidism on fetal development?

A

• Neuro cretinism
• Low IQ
• Low BW
• Neurodevelopment delays
Myxedematous cretinism

22
Q

How do you identify pregnancies at risk of fetal thyrotoxicosis?

A

Previous or current maternal Graves’ disease with high TRab titres or levels that do not fall with advancing gestation.

Maternal TRab levels should be performed each trimester and at risk fetuses should undergo serial USS for assessment of fetal growth, fetal heart rate and fetal neck for goitre.

23
Q

How long should neonatal thyrotoxicosis be treated?
How long should treatment continue for and why?

A

Neonatal thyrotoxicosis should be treated with anti-thyroid drugs ASAP. These are continued for a few weeks as maternal TRab are cleared the thyrotoxicosis will resolve.

24
Q

Explain to a woman what Graves disease is, its effects on pregnancy and the effects of pregnancy on Graves disease:

A

Graves disease is an autoimmune condition where antibodies stimulate the TSH receptors on the thyroid causing excessive production of thyroid hormone.

Maternal effects of Graves disease:

  • Miscarriage
  • Cardiac arrhythmias: sinus tachy, SVT, AF.
  • Thyroid crisis and heart failure
  • If significant goitre: mass effect symptoms such as tracheal obstruction and difficulties swallowing.

Fetal and neonatal effects:

  • Growth restriction
  • PTL
  • Perinatal mortality
  • Fetal and neonatal thyrotoxicosis associated with increased fetal and neonatal mortality.

Effect of pregnancy on Graves disease:

  • Severity often improves in 2nd and 3rd trimesters due to relative immunosuppression so lower requirements for antithyroid treatment.
  • Can be worse in the first trimester due to hCG cross-reactivity and postpartum.
25
Q

Outline your management of a woman with Graves disease in antenatal, intrapartum and postpartum:

A

Pre-pregnancy:

  • Contraception/avoid pregnancy for 4 months following radio-iodine tx.
  • Counsel risks to fetus: hyperthyroidism/goitre, IUGR, preterm birth, stillbirth.
  • Counsel risks to mum: miscarriage, goitre complications, cardiac arrhythmias (sinus tachy, SVT, AF), thyroid storm.
  • May need less medication during pregnancy.

Antepartum:

  • Existing Graves: continue same antithyroid.
  • New dx Graves: start PTU; start with high doses 450-600 mg daily for 4-6 weeks then reduce, aiming for clinical euthyroidism.
  • Beta-blockers for sympathetic symptoms; can stop after 3 weeks of antithyroid tx.
  • Monthly review if new dx, perform TFTs every 4-6 weeks.
  • Thyroidectomy: ideally 2nd trimester; if mass symptoms, malignancy or unable to take both antithyroid meds.
  • Check TRab levels in 1st trimester; if elevated repeat at 18-22 weeks and 30-34 weeks.
  • Serial ultrasounds: fetal growth, FHR and fetal goitre. Refer to MFM if worried about fetal hyperthyroidism

Intrapartum:
- Nil

Postpartum:

  • Paediatric check of baby if suspicious of neonatal hyperthyroidism.
  • Check TFTs 2-4 months after delivery.
  • If stopped antithyroid meds in pregnancy may need to restart.

Oral exam - medical conditions (21 decks)

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