Thyroid gland diseases during pregnancy
In normal conditions during pregnancy there is an intensifying of function of a thyroid gland and rising of development of thyroid hormones, especially in first half of pregnancy, its early terms when the foetus thyroid gland does not function.
Thyroid hormones during pregnancy matter for a fetation, processes of its growth and a differentiation of tissues. They influence development of a pulmonary tissue, a brain myelogenesis, an ossification.
In the subsequent, in second half of pregnancy, excess of hormones contacts squirrels and passes in an inactive condition.
The foetus thyroid gland starts to function rather early - on 14-16 week, and by the moment of sorts the functional system a pituitary body - a thyroid gland is completely generated. Thyritropic hormones of a pituitary body do not pass a placental barrier, but thyroid hormones freely pass from mother to a foetus and anatropicly through a placenta (a thyroxine and a triiodothyronine).
Most often during pregnancy there is a diffusive toxic struma (from 0,2 to 8 %) which obligatory symptoms is the hyperplasia and thyroid gland hyperfunction.
During pregnancy the assessment of degree of disturbance of function of a thyroid gland represents certain difficulties at its pathology and the hyperactivity of a thyroid gland bound to pregnancy.
At a diffusive toxic struma the augmentation of the general free thyroxine, higher maintenance of the iodine bound by protein becomes perceptible. Usually sick complain of palpitation (on an electrocardiogram the sinus tachycardia, the raised voltage, augmentation of systolic indicators), fatigability, nervousness, sleep disturbance, sense of the fever, the raised diaphoresis, a tremor of arms, an exophthalmos, thyroid gland augmentation, a subfebrile condition. At a diffusive toxic struma in first half of pregnancy against hyperactivity of function of a thyroid gland at all women the disease exacerbation becomes perceptible, in second half of pregnancy in connection with blockage of excess of hormones at a part of patients with easy degree of a thyrotoxicosis there comes enriching.
But at the majority of patients enriching does not come, and in time 28 weeks in connection with haemocirculatory acclimatisation - augmentation BCM, minute volume of heart - there can come a cardiovascular decompensation: a tachycardia to 120-140 impacts in minute, disturbance of a rhythm as a ciliary arrhythmia, a tachypnea.
At pregnant women with a toxic struma pregnancy flow is the most frequent (to 50 %) becomes complicated abortion threat, especially in early terms. It is bound many thyroid hormones which break implantation, a placentation - negatively influence development of foetal egg.
The complication of flow of pregnancy second for frequency at a thyrotoxicosis is the early toxicosis of pregnant women, and its development coincides with a thyrotoxicosis exacerbation, proceeds hardly and badly gives in to treatment in this connection it is necessary to interrupt pregnancy often. Serotinal toxicoses of pregnant women arise less often, a predominant symptom is the hypertensia; flow gestosis very serious and badly gives in to treatment.
In sorts there can be a decompensation cardiovascular system, and in postnatal and early postnatal the seasons - bleedings. Therefore in sorts it is necessary to watch carefully a condition cardiovascular system, in postnatal and early postnatal the seasons to apply preventive maintenance of bleedings.
In a puerperal period the thyrotoxicosis exacerbation - palpitation, delicacy, the general tremor, diaphoresis intensifying also is often observed. The sharp exacerbation in a puerperal period of a thyrotoxicosis demands: 1) treatments Mercazole and as it passes through milk to a foetus and negatively influences they be 2) lactemia depressing.
Treatment of a toxic diffusive struma at pregnancy - very responsible problem. Only in 50-60 % at a thyrotoxicosis of easy degree it is possible to receive sufficient therapeutic effect from application of iodide preparations, in particular diiodotyrosine, against a diet, vitamin-rich, and sedatives (Valeriana, Leonurus). Treatment Mercazole is dangerous because of its damaging action on organofaction of a thyroid gland of a foetus - danger of development of a hypothyrosis at a foetus-newborn.
Therefore at a diffusive toxic moderately severe struma and a nodal struma the abortion is shown. However, if the woman does not agree an abortion, there is a surgical method of treatment which is most safe (Mercazole it is impossible to treat). To effect operation during pregnancy 14 weeks as earlier operation effecting enlarges frequency of an abortion are necessary in time.
Disturbance of function of a thyroid gland at pregnant women unfavorablely influences a foetus and development of the child - at a thyrotoxicosis in 12 % at newborns hypothyrosis signs as excess of maternal thyroid hormones inhibits development of thyritropic function of a pituitary body and function of a thyroid gland in a foetus are taped. At newborns of this bunch are observed: a dry and hydropic skin, parchmentity the skull bones, constantly open stomatic cleft, thickened tongue, a muscular hypotonus and a hyporeflexia, the slowed down peristalsis of an intestine and bent to constipations. Thus almost in 50 % replaceable therapy by thyroid hormones was required.
Tactics of the accoucheur-gynecologist and the endocrinologist at conducting pregnant women with a diffusive and nodal toxic struma the following: hospitalisation in early terms till 12 weeks for inspection and the decision of a question on possibility of a carrying of a pregnancy as in this season there are complications, specific to pregnancy (a toxicosis and discontinuing threat). Pregnancy is contraindicative at moderately severe flows diffusive strumas and a nodal struma if the woman not intended to be operated in time 14 weeks. Pregnancy probably to bear only at easy degree of a thyrotoxicosis of a diffusive struma and positive treatment by diiodotyrosine. Constant observation of the accoucheur-gynecologist and the endocrinologist will allow to tap complications of pregnancy and will estimate effect of treatment of a thyrotoxicosis. At the slightest complications hospitalisation is shown. Labours spend in specialised maternity home (regional) with the control for cardiovascular system and cardiotropic therapy, bleeding preventive maintenance in the afterbirth and postnatal seasons. Children are transferred under observation of the pediatrist-endocrinologist.
Hypothyrosis and pregnancy combination
The similar condition is observed was rather rarely as in the similar genesial function - sterility is considerably damaged. A hypothyrosis - the disease caused by depression of entering in an organism of thyroid hormones. The expressed forms of a hypothyrosis are called as a myxedema, at an athyreosis the cretinism educes.
Not compensated hypothyrosis if there comes pregnancy, leads to its discontinuing, and in case of a foetus birth - defective children: anomalies of development of a brain, the hardest disorders of function of a thyroid gland, disease of Down, further a delay of mental development. In a combination to a high perinatal mortality, of course, it is unproductive economic expenses of a society for a reproduction.
The hypothyrosis can be congenital (the most dangerous to pregnancy as causes the hardest perinatal complications) and got - after an operative measure on a thyroid gland of a cerebrally-pituitary parentage.
Pregnancy flow at a hypothyrosis becomes complicated the serious form gestosis in the form of an eclampsia and is accompanied by a high maternal mortality, pre-natal destruction of a foetus, especially at not compensated hypothyrosis. Even at the subcompensated form of a hypothyrosis frequency of an abortion sharply increases.
Pregnant women with a hypothyrosis complain of slackness, drowsiness, memory depression, a xeroderma, abaissement of a hair, fragility of a hair, persistent constipations. Pallor and puffiness of a skin, the bradycardia, the raised maintenance of cholesterol in blood becomes perceptible.
During pregnancy, especially in its second half, some enriching of flow of a hypothyrosis becomes perceptible. It is bound to rising of activity of function of a thyroid gland of a foetus (dangerously for it!) and entering of fruit thyroid hormones in an organism of mother. It is dangerous to a foetus as early including of function of a thyroid gland leads to its attrition in the subsequent.
Pregnancy probably to bear at a secondary hypothyrosis after operation on a thyroid gland under condition of its compensated flow under the influence of specific therapy. Adequate replaceable hormonal therapy is carried out by Thyreoidinum or Thyreoidinum and triiodothyronine combination. In second half of pregnancy the dose needs to be lowered a little, but not to cancel. The pregnant woman is observed by the accoucheur-gynecologist and the endocrinologist. To hospitalise at any complications of pregnancy. At congenital forms of a hypothyrosis pregnancy is contraindicative because of a birth of defective children (possibility of aberation chromosomes).
Diseases of adrenals during pregnancy
The functional role of adrenal hormones during pregnancy is various. They participate in metabolic and adaptic mechanisms during pregnancy and in sorts, accept a role in synthesis of sexual steroid hormones, development of lungs, a liver, pancreas, a brain.
During pregnancy at the woman function of a cortex of adrenals to what appearance of stretch marks testifies, a delay On and fluids, a hypertensia - rising of a vascular tonus raises.
Adrenals at a foetus are formed and start to function before other closed glands - in the first trimester in 10-11 weeks. For synthesis of corticosteroids the foetus uses a placental progesterone. As already it became perceptible above, corticosteroids influence formation of tissues and organs at a foetus (in particular, lungs, a brain, a liver, pancreas, heart). Besides, in foetus adrenals there is a dehydroepiandrosterone synthesis - the precursor for theelol biosynthesis in a placenta, this hormone provides optimum performance of uteroplacental system.
The placenta is passed depending on concentration for corticosteroids. Therefore at disturbance of function of adrenals mother has not only complications of the pregnancy, but also complication in formation first of all adrenals at a foetus, complications in its development.
Pregnancy in a combination to disease or a Cushing's syndrome
In a Cushing's basophilism pathogenesis the raised development Adrenocorticotrophinum - releasing - the factor a hypothalamus, leading to raised production an adrenocorticotrophin pituitary body matters, and it in turn causes a hyperplasia of a cortex of adrenals and augmentation of synthesis of corticosteroids. Excess of corticosteroids also causes disease clinic. Disease can be caused disturbance of functional attitudes in system a hypothalamus - a pituitary body - an adrenal, or a basphilic adenoma of a pituitary body which meets almost in 50 % of all cases of Cushing's basophilism.
The Cushing's syndrome arises at tumours of a cortex of adrenals - glucosterome or glucoandrosterome, and also tumours of other organs producing an adrenocorticotrophin-like of material. The Cushing's syndrome causes and educes at long treatment by corticosteroids.
Against chronic adrenal insufficiency there can be the crises of acute adrenal insufficiency caused by an infection contamination, an intoxication, a mental trauma, a surgical trauma, pregnancy and sorts. In clinic of a crisis leaders are the accruing dehydration, a vascular collapse, disturbance of function of nephroses.
In treatment of chronic adrenal insufficiency the main thing in replaceable therapy by steroid hormones: glucocorticoid action - Dexamethasone and trimaciol - and mineralocorticoid actions - a type of a cortexone of an acetate (DOXO). Hidrocortizonum, dexamethazone, Prednisonum - preparations basically glucocorticoid action, but in the minimum degree possessing mineralocorticoid properties.
Before application of steroid hormones pregnancy at patients with chronic adrenal insufficiency met was rarely and was accompanied by a high maternal mortality because of a crisis.
In connection with application of steroid hormones possibility of offensive of pregnancy was enlarged, as generative function is recovered. Besides, the big bunch is compounded by women whom before pregnancy it is long were treated by steroid hormones concerning extragenital diseases that leads to a depression of function of a cortex of adrenals. The number of women after a bilaterial adrenalectomy has increased. All it enlarges a contingent of pregnant women with chronic adrenal insufficiency. During pregnancy and especially in sorts and a puerperal period the crisis of acute renal insufficiency can easily educe, especially at inadequate replaceable hormonal therapy or at is hidden proceeding chronic adrenal insufficiency.
Danger of a crisis is most probable: 1) in early durations of gestation; 2) in sorts; 3) in an early puerperal period.
In early durations of gestation the hormonal requirement of adrenals raises, besides, at sick of chronic adrenal insufficiency the early toxicosis which breaks an electrolytic exchange quite often joins, causes dehydration, a hypoglycaemia, a hyposalemia which cause a crisis.
In sorts - the maximum metabolic cost in rather short time interval demands the raised quantity of corticosteroids.
Danger consists in an early puerperal period at a distance a foetus and a placenta as they represent hormonal active complex producing steroids. Besides, the profound diuresis after sorts throughout the first days leads to introduction from an organism of water and salts.
In the specified critical terms the special attention and observation over the pregnant woman and augmentation of replaceable hormonal therapy is necessary.
In second half of pregnancy some enriching of chronic adrenal insufficiency that is bound to participation of a foetus in development of corticosteroids and influence of hormones of a placenta - progesterone and a placental lactogen becomes perceptible.
Pregnancy flow at chronic adrenal insufficiency often becomes complicated an early toxicosis of pregnant women that is bound to disturbance of metabolic processes. Serotinal toxicoses can be caused an overdosage of steroid hormones. At an overdosage of hormones there can come pregnancy prolongation for 10-12 days.
At pregnancy conducting it is necessary to consider the critical terms, dangerous crises of acute adrenal insufficiency, and also possible operative measures in sorts that demands carrying out of adequate replaceable hormonal therapy. At replaceable hormonal therapy the control over a condition sick, its weight increase, a BP, Saccharum maintenance in blood, an egestion 17-KS and 17-OKSR is necessary.
In first half of pregnancy prescribe dexamethazone of 10-15 mg a day and DOXOES of 5 mg intramusculary in 2 days; in second half of pregnancy dexamethazone reduce by 5 mg and cancel DOXOES. The diet should be vitamin-rich, especially C - to 1 gramme a day. Sodium chloridum - 10 gramme a day at potassium restriction. In sorts of their beginning C prescribe Hidrocortizonum to 75 mg, DOXOES and under the control over a condition repeat of 5 mg in 5-6 hours. At BP depression more low 110/70 dose enlarge. I.v. 500 ml of Sodium chloridum of 5 % about 1 ml of 0,6 % of Korglykonum and 10 ml of vitamin C of 5 % are driply introduced. At a planned operative delivery prescribe Hidrocortizonum for days on 50 mg 3 times, in the morning in day of operation 75 mg of Hidrocortizonum, during operation i.v. driply 75-100 mg of Hidrocortizonum on physiological solution are intramuscular.
In the first days after sorts therapy same, as well as in sorts. The overdosage of hormones shows a passing hypertonia, edemas, a dyspepsia. In the subsequent in postnatal and postoperative seasons the dose of hormones is reduced gradually under the BP control, 17-KS, by 17-Construction Departments. For 3-4th day - Hidrocortizonum of 50 mg 3 times and DOXOES of 5 mg; 5-6th day - Hidrocortizonum of 50 mg 2 times and Prednisolonum of 10-15 mg; 7-8th day - Hidrocortizonum of 50 mg and dexamethazone of 10-15 mg. Further pass to the fixed doses of dexamethazone applied earlier. In connection with high sensitivity to an infection contamination prescribe antibiotics of a wide spectrum, the lactemia is undesirable and dangerous (because of a load and mastitis possibility).
The abortion is dangerous crisis development, therefore at chronic adrenal insufficiency the abortion is effected under strict indications (obstetric), discontinuing till 12 weeks with application of the enhanced steroid therapy is the most safe.
At children born by mothers with chronic adrenal insufficiency, adrenal insufficiency in the first days of life which perishable and is caused by the answer to overwhelming action of the big doses of the steroid hormones applied in sorts can educe. It to exicosis, a collapse is expressed, to a respiratory failure. It prescribe Hidrocortizonum on 5-7,5 mg intramusculary 2 times day, isotonic solution of Sodium chloridum and a glucose. Hidrocortizonum dose decreases, and by 5-6 day the condition of the child is normalised.
Pregnant women with chronic adrenal insufficiency are observed by the accoucheur-gynecologist and the endocrinologist. Pregnancy is authorised to be born only at adequate replaceable therapy in moderate doses as appreciable doses of corticosteroids lead to a degrowth of a brain, lungs, a liver, pancreas, heart, adrenals and to pituitary body augmentation, in the subsequent - to adrenal insufficiency.
It is necessary to notice, that possibility of an occurring with latent forms of chronic adrenal insufficiency increases recently in connection with wide application of steroid hormones at various diseases, the depression of function of a cortex of adrenals thus educes. It shows during pregnancy in critical terms crises of acute adrenal insufficiency.
In summary it is necessary to notice, that the endocrine pathology in a combination to pregnancy demands extra care at the decision of a question on possibility of a carrying of a pregnancy. Danger of transfer of endocrine disease from mother to a foetus in embryo organo functio genesis by a principle "an organ - to an organ" is very high.
|
