Thyroid Disease During Pregnancy

Reading for this module should include Chapters 14 in Thyroid Disease Manager, or alternative sources. These could include chapter in Endocrinology, Edition III, comparable chapters in Endocrinology Edition IV (when released), or appropriate chapters in “The Thyroid”. Please note that many questions have more than one correct answer among the multiple possible responses offered.

Anticipated study and testing time for this module is 3 hours. After reading the material, print out his page, complete the test, fill in required personal information, and send the page with payment to

Center for Continuing Medical Education, 950 E 61^st St., University of Chicago, Chicago, IL 60637., with payment of $45. After satisfactory completion of the examination, a certificate will be returned by mail.

1. Thyrotoxicosis due to Graves’ disease in a pregnant woman usually tends to improve spontaneously during gestation :
	A. Because less iodine is available for the maternal thyroid gland to produce excess thyroid hormones ?
	B. Because the hormone binding capacity of the serum is markedly increased ?
	C. Because of an immunosuppressive state, characteristic of pregnancy, with less TSH-Receptor antibodies produced ?
	D. Because maternal thyroid hormones are transferred to the feto-placental unit in great amounts ?
	E. All of the above responses are correct ?

2. To treat thyrotoxicosis due to Graves’ disease during pregnancy, you would recommend :
	A. The administration of radioactive iodine ?
	B. The administration of antithyroid drugs at the dosage needed to completely block the organification of iodide ?
	C. The association of antithyroid drugs and thyroxine ?
	D. The administration of beta-adrenergic blocking agents only, because the use of antithyroid drugs is strictly contra-indicated ?
	E. The smallest possible dose of antithyroid drugs needed to control thyrotoxicosis ?

3. Clinical symptoms and signs of thyrotoxicosis occurring during the first trimester of gestation indicate that you should assess :
	A. The presence of a hydatiform mole ?
	B. The presence of associated symptoms of hyperemesis gravidarum ?
	C. Serum hCG levels ?
	D. The presence of TSHT-Receptor antibodies ?
	E. The occurrence of a twin pregnancy ?

4. During a normal pregnancy, what are the changes observed in the serum levels of free thyroid hormones :
	A. Free T4 and Free T3 usually remain unchanged throughout gestation ?
	B. Free T4 may transiently increase during the first trimester of gestation ?
	C. Free T4 goes up and free T3 goes down, as gestation progresses towards term ?
	D. Both Free T4 and Free T3 tend to decrease progressively, as gestation progresses towards term ?
	E. All of the above responses are correct ?

5. During pregnancy, “classical” thyroid autoimmunity (that is positive TG-antibodies and/or TPO-antibodies) may be associated with :
	A. An increased risk of hypothyroidism ?
	B. An increased risk of hyperthyroidism ?
	C. An increased risk of spontaneous miscarriage ?
	D. An increased risk of abnormal fetal development ?
	E. An increased risk of having postpartum thyroiditis ?

6. During pregnancy, in order to diagnose thyroid autoimmunity, you should primarily advocate the measurement of :
	A. TG-antibodies alone ?
	B. TPO-antibodies alone ?
	C. TSH-Receptor antibodies alone ?
	D. All three auto-antibodies, in the second half of gestation ?
	E. All of the above responses are correct

7. When a thyroid nodule is discovered during pregnancy, would you recommend :
	A. To perform a thyroid scintiscan ?
	B. To perform an ultrasonography followed by fine needle aspiration ?
	C. To refer the patient immediately to the thyroid surgeon ?
	D. To measure serum calcitonin and thyroglobulin levels ?
	E. To postpone the nodule’s work-up until after parturition ?

8. When a goiter is discovered in a euthyroid pregnant subject, it may indicate :
	A. Only Graves’ disease ?
	B. Only Hashimoto’s thyroiditis ?
	C. Iodine deficiency ?
	D. Intumescence (vascular swelling) of the thyroid gland ?

9. If a pregnant woman, who has previously been cured of Graves’ disease by radioiodine administration or thyroid surgery, is presently taking replacement thyroid hormones, do you recommend to determine the presence of TSH-Receptor antibodies ?
	A. Never during gestation ?
	B. In all cases, preferably in the early stages of gestation ?
	C. Only if maternal thyroid dysfunction is suspected ?
	D. Only if fetal development does not progress normally ?
	E. Only if the obstetrician suspects fetal hyperthyroidism at 7-8 months of gestation?

10. If a woman with active Graves’ disease needs to continue taking propylthiouracil during breastfeeding, would you recommend to her :
	A. To stop breastfeeding and switch to bottle feeding ?
	B. To continue breastfeeding, but stop taking PTU ?
	C. To continue both breastfeeding and PTU treatment, but add levothyroxine to the treatment of the lactating mother, in order to avoid perinatal hypothyroidism ?
	D. That it is safe to breastfeed and take PTU, as long as the required daily dosage remains moderate ?
	E. All of the above responses are correct ?

11. *What is the evidence to link hCG with thyroid function ?*
	A. Human chorionic gonadotropin (hCG) resembles the TSH molecule and, hence, may mimic its activity, through binding to the TSH receptor on thyroid follicular cells ?
	B. Elevated hCG levels (>100.000 UI/L) are found in association with gestational thyrotoxicosis ?
	C. Molar disease can be found in association with hyperthyroidism ?
	D. In normal pregnancy, serum TSH is frequently suppressed transiently near the end of the first trimester of gestation when hCG is elevated?
	E. All of the above responses are correct ?

12. In a pregnant hypothyroid woman, taking daily levothyroxine already before she becomes pregnant :
	A. Do you maintain the same daily l-T4 dosage throughout pregnancy ?
	B. Do you verify free T4 and TSH levels only in the second half of gestation, in order to adjust treatment’s adequacy ?
	C. Do you systematically monitor thyroid hormones and serum TSH levels as needed throughout gestation ?
	D. Do you monitor thyroid function tests already in the early part of gestation, and adjust the daily dosage of levothyroxine ?
	E. Do you expect neonatal hypothyroidism ?

13. If a hypothyroid pregnant woman is not adequately treated (i. e. remains hypothyroid during gestation), what are the obstetrical risks associated with hypothyroidism?
	A. Preeclampsia ?
	B. Intrauterine fetal demise ?
	C. A poor perinatal outcome ?
	D. Cesarian section will be needed ?
	E. Athyreosis in the neonate ?

14. What is the differential diagnosis of suspected thyrotoxicosis during pregnancy :
	A. Subacute thyroiditis ?
	B. Graves’ disease ?
	C. Thyrotoxicosis factitia ?
	D. Gestational transient thyrotoxicosis due to high hCG ?
	E. Iodine induced thyrotoxicosis ?

15. When a pregnant woman has known features of thyroid immunity (that is positive antibodies), what tests or clinical information will help you predict her chances to develop postpartum thyroiditis ?
	A. An abnormal serum TSH value at five months gestation ?
	B. Micronodules observed at ultrasonography during pregnancy ?
	C. An elevated serum TG value at mid-gestation ?
	D. The requirement for levothyroxine administration during pregnancy ?
	E. A personal history of postpartum thyroiditis following a previous pregnancy ?

Answer Sheet
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Do you believe the presentations contained pharmaceutical industry bias? Yes __ No __ Comments:

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CME QUESTIONS- THYROID DISEASE DURING PREGNANCY BACK PREPARED BY DANIEL GLINOER, MD

CME QUESTIONS- THYROID DISEASE DURING PREGNANCY BACK
PREPARED BY DANIEL GLINOER, MD