بسم الله الرحمن الرحيم

Pre-conception care: very important fT4 and thyroxine levels should be measured the dose of thyroxine adjusted until TSH reaches normal level

During pregnancy : the woman should be reviewed by an endocrinologist to measure fT4 and TSH levels at the outset in order to obtain a baseline measurement The TSH level rises in pregnancy causing an increased demand for thyroxine and so the dose of therapeutic thyroxine is adjusted usually increasing by 25–50%

-Iron supplements should be taken at a different time to the thyroxine to maximize absorption -. Although a large goitre might cause complications for general anaesthesia), there are otherwise no specific issues for labour and consequently intrapartum care may be provided by the midwife

Postnatally, : -thyroxine dose is reduced to the pre-pregnancy level - fT4 and TSH levels should be measured at the 6-week follow-up or postnatal appointment. - It is important that the neonatal bloodspot screening test is undertaken as the condition can be familial and thus the midwife should provide support to the parents, who are likely to be anxious -In addition, the woman needs to be observed for signs of thyroiditis and postnatal depression

Hyperthyroidism (thyrotoxicosis) -an overactivity of the thyroid gland that affects -It usually manifests as a clinical syndrome called thyrotoxicosis

signs and symptoms : -weight loss despite having a good appetite - intolerance to heat - sweating - tachycardia -with bouncing pulse - insomnia

- agitation - tremor - exophthalmos (protrusion of the eyeballs due to the tissue behind the eye becoming oedematous and fibrous) diarrhoea and menstrual irregularities Non-pregnancy treatment is with carbimazole and propylthiouracil, which inhibit thyroid hormone synthesis)

-Thyroidectomy is reserved for cases where there is excessively large goitre and drug therapy is ineffective. - If radioiodine treatment has been used to destroy thyroid tissue to lower the thyroid levels, the woman should be counselled to delay conception for at least four months

-The main complication of hyperthyroidism : the medical emergency of thyroid crisis (or thyroid storm) there are exaggerated features of thyrotoxicosis additional hyperpyrexia cardiac dysrhythmias congestive cardiac failure altered mental state ultimately coma. Goitre may also be present.

Hyperthyroidism is treated with : IV fluids hydrocortisone propranolol, oral iodine, carbimazole and propylthiouracil If the thyrotoxicosis is autoimmune, with antibodies to the TSH receptor, it is called Graves' disease, which accounts for 95% of hyperthyroidism in pregnancy , the risk of miscarriage increases in early pregnancy, the disease otherwise tends to improve in pregnancy and women may go into remission in the latter half of pregnancy

Care in pregnancy: aims to normalize thyroid function and carbimazole and propylthiouracil are the drugs of choice with the dose adjusted aher monthly measurements of fT4 and TSH. If the control is poor the fetus is at risk of fetal thyrotoxicosis which may necessitate cordocentesis to measure fetal fT4 and TSH This is a high-risk pregnancy and the woman should consequently be referred to a specialist obstetric unit.

The midwife should ensure monthly measurements of fT4 and TSH are undertaken and organize serial fetal growth ultrasound scans. regular assessment of the fetal heart rate to detect fetal tachycardia. continuous fetal heart monitoring during labour is required and the paediatrician should be informed when labour is established -Labour can precipitate thyroid crisis/storm - so meticulous monitoring and recording of maternal observations and wellbeing is vital.

- As with hypothyroidism, should goitre be present and is large, there may be complications if general anaesthesia is warranted

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Postnatally,: - the midwife should be alert for signs of thyrotoxicosis flare in the woman and extend the period of undertaking observations with emphasis on maternal pulse. Propylthiouracil is the drug of choice if the woman chooses to breastfeed her baby. The woman's thyroid hormone levels should also be measured 6 weeks following the baby's birth and the drug dose revised accordingly. -When examining the baby, the midwife should be alert for signs of neonatal goitre and thyrotoxicosis, referring promptly to the paediatrician if these are suspected. The baby might require temporary treatment with antithyroid drugs and propanolol necessitating admission to the NICU

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