甲状腺疾患 (<教育講演>合併症妊娠における胎児・新生児管理)

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The incidence of pregnant women with thyroid dysfunction has been reported to be around 0.1〜0.4%. Graves' disease accounts for more than half of these disorders. The main cause of thyroid disease in pregnancy and puerperium is autoimmune dysfunction. Whether there may be goitre or exophthalmus present, clinical signs as inappropriate weight gain, high systolic pressure, palpitation (≧110/min), emotional lability, fatigue, accerelation or suppression of the Achiles' tendon reflex should induce changes in the biochemical thyroid function tests. Parameters for the diagnosis and management for hyperthyroidism are serum levels of free T_4 and TSH, while those of T_3, reverse T_3, and TSH are for hypothyroidism. Serum anti-microsomal antibodies and anti-thyroglobulin antibodies which have no effect on the fetus are also good markers for severity. The transplacental transfer of maternal TSH receptor antibodies consisting of stimulatory and inhibitory immunoglobulins and maternal thyroid-binding inhibiting immunoglobulins play roles in the development of transient neonatal hyper- or hypothyroidism. Fetal controle is achieved by optimal maternal management. Untreated hyperthyroidism may be associated with fetal malformations. This risk may be reduced by antithyroid drug treatment of up to 150mg/day of propylthiouracil which has less chance of placental passage and less secretion into the mother's milk than methyl-mercapto-imidasol. Maternal thyroid function should be kept in the upper limit of normal range, taking into consideration the fetal dysfunction induced by over-administration of the drug which passes through placenta. Children of hypothyroid women taking inadequate replacement therapy manifested lower IQ values compared to the progeny of euthyroid or hypothyroid women taking adequate therapy. Replacement therapy can be started with T_3 10〜30μg as an initial daily dose. When the maternal function comes in the lower range of normal level, exchanged T_4 100〜300μg/day is given. If necessary, additional T_3 is considered in the second and third trimester. General condition of the neonate born of mother with thyroid dysfunction should be seriously observed with biochemical examination of TSH, free T_3 and/or T_4 levels in cord sera. Frequency of cretinism in Japan is 1 : 6,000〜8,000 babies. Congenital hypothyroidism in the baby is discovered by systematic mass screening of TSH levels. Prognosis in the offspring becomes favorable when treatment with thyroxine is initiated by age 3 weeks. Management by team approach involving obstetrician, neonatologist and internist is strongly recommended for complete care of mother, fetus and neonates. However, it should be emphasized that we, the obstetrician, should have direct control in the management of both the mother and fetus.
1990-08-01

甲状腺疾患 (<教育講演>合併症妊娠における胎児・新生児管理)

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