Audit of investigation and management of babies born to mothers with thyroid disease Dr. Ambika Rajesh May 2007

Introduction Hypothyroidism is one among the most common endocrine disease Incidence of Congenital Hypothyroidism in UK is 1 in every 4000 babies Evidence from retrospective studies suggest that low circulating maternal thyroid hormone concentrations are associated with impaired neurointellectual performance in early childhood Maternal autoimmune thyroid disease can result in foetal and neonatal hyperthyroidism by transplacental passage of TSI

Aim To draft a baseline on existing practice in the investigation and management of babies born to mothers with thyroid disease

Standards Existing protocol within the deapartment of Paediatrics at JPH

Material and Methods All babies who came for repeat bloods between the period April 2006-January 2007 were identified using the postnatal ward admission book Subsequently, those babies whose mothers had been diagnosed to have thyroid problems antenatally were then selected to be included for the study

Data collection Case notes were reviewed by Paediatric SHO and data collected in a set proforma

Standards set for management of babies with maternal thyroid disease All babies of mothers with hypothyroidism (Hashimoto`s disease) are to be reviewed at days and thyroid function tests taken Babies born to mothers with hypothyroidism secondary to congenital aplasia or hypoplasia of the thyroid gland have no significant increased risk of hypothyroidism. So a Guthrie test alone should suffice.

Standards set for management of babies with maternal thyroid disease (contd.) Babies born to mothers with hypothyroidism secondary to treatment (surgery or radioiodine) for Grave`s disease are at increased risk of neonatal thyrotoxicosis.They should have their cord bloods tested for T4,TSH,TSI (if not done in pregnancy) and examined. The high risk babies should be kept in for 4 days with repeat bloods taken for T4 and TSH. Both high and low risk babies should have their bloods tested for T4 and TSH on days and managed depending on the results.

Results Total number of babies identified- 24 List of maternal thyroid problems 2 cases - Antithyroid peroxidase antibodies positive 2 cases - Hashimotos thyroiditis 1 case - Non toxic nodular goitre 1 case - Autoimmune hypothyroid (no record of any trimester bloods) 18 cases - Mentioned to be having underactive thyroid and were on thyroxine

Results Since there were no cases specifically mentioned to have hypothyroidism secondary to treatment for Grave`s disease or due to congenital aplasia or hypoplasia of the thyroid gland in maternal notes - All babies were assessed as per the standard set up for babies born to mothers with hypothyroidism (Hashimoto`s disease)

Results Review Between days (recommended protocol) - 8 cases (33.3%) At a later date -1 case (4.2%) At an earlier date - 1 case (4.2%) Not reviewed - 14 cases (58.3%)

Results Thyroid function tests undertaken Between days (recommended protocol) – 17 cases (70.8%) At a later date – 5 cases (20.8%) At an early date – 2 cases (8.4%)

Results Follow up protocol based on thyroid function test results Normal TSH and hence no follow up needed- 14 cases Increased TSH – 9 cases Decreased TSH – 1 case

Cases with increased TSH Values normalised on follow up 4 cases Follow up awaiting1 case Did not attend follow up 1 case No follow up arranged3 cases

Case with decreased TSH Follow up was not complete for this baby

Discussion Overall there is satisfactory adherence to existing protocol in the department in the management of babies born to mothers with thyroid problems

Recommendations Areas that need further improvement are: Review of babies between days Follow up of babies with abnormal thyroid function tests, in particular increased TSH Also keeping a separate record for mothers with thyroid problem detailing their thyroid status in postnatal ward should be considered