Sunday, September 14, 2008

Hypothyroidism and Pregnancy

Over at the blog, the-f-word, the author has had a series of recent posts discussing hypothyroidism. This is a topic of special importance when discussing pregnancy and postpartum issues so I thought I'd highlight it here too.

[There's no need to repeat all her information, so we'll just mention a few points particularly pertinent to pregnancy and postpartum, and then tell you to GO READ IT. ]

Many fat folk have undiscovered or undertreated hypothyroidism. Doctors often do not take hypothyroidism concerns seriously in fat people, thinking they are trying to excuse their supposed eating problems. So it can be difficult to find a care provider who is willing to take these concerns seriously or test them in any meaningful way.

Furthermore, exactly what TSH levels should be used to diagnose hypothyroidism is controversial. Newer diagnostic cutoffs favored by some medical groups tend to diagnose and treat more people; the older cutoffs miss a lot of borderline or "subclinical" cases. Yet these folks often experience typical hyothyroidism symptoms like:
  • obesity/unexplained weight gain/difficulty losing weight
  • tiredness/fatigue
  • very dry or cracked skin
  • menstrual problems/irregularity
  • dry/brittle hair and nail changes
  • muscle or joint aches and pains
  • feeling cold a lot/intolerance to temperature variations
  • depression issues
  • "brain fog"
  • constipation
  • fertility issues
If you have a combination of these symptoms you might want to consider thyroid testing. However, if you do have thyroid testing, BE SURE TO GET YOUR EXACT RESULTS AND THE DIAGNOSTIC CUTOFFS USED TO DEFINE "NORMAL." Compare your exact results to the levels considered "normal" and see where your levels fall.

Too often, people are told their results are "normal" when in fact, closer examination may show that their results are borderline (and should be watched and retested later) or are actually abnormal when using the newer, lower cutoffs.

[I really can't stress this enough. Do NOT just accept a "normal" or "abnormal" on lab tests; actually get the numerical results, the range the lab used to determine "normal" and compare them. Then request a copy of your lab results and keep a record of them so you can track them over time. Remember, lots of people who may have been diagnosed as "normal" in the past might now be considered to have "abnormal" results now under revised guidelines.]

Thyroid Tests and Pregnancy Concerns

If you are considering pregnancy at any time in the near future, you might want to have your thyroid levels checked as a precaution beforehand, even if you don't suspect a problem.

Some doctors these days recommend that ALL women have their thyroid levels checked before or during pregnancy, but it's not certain whether this broad a testing distribution is really justified by research. More study is needed before such widespread testing is implemented.

However, for women of size (and especially those with PCOS), it probably is sensible to have the thyroid levels checked before pregnancy. Although not all research agrees, some research suggests that obese people tend to have higher rates of both overt and subclinical (or "mild") hypothyroidism. Other research suggests that women with PCOS also have more subclinical hypothyroidism. Therefore, it probably makes sense for women in these two groups to have their thyroid levels checked carefully, preferably well before conception.

For some women, it also makes sense to check thyroid levels during pregnancy as well. If you have had thyroid issues in the past (or suspect them), are being treated currently for hypothyroidism, or if you have a strong family history of hypothyroidism, you should have your levels monitored regularly during pregnancy.
Even if your hypothyroidism was well-controlled beforehand, it may not stay that way during pregnancy, and can change fairly quickly. Therefore, periodic testing during pregnancy is a must for those with hypothyroidism.

Your levels should be measured about every trimester, on average. However, some women need to increase their thyroid medication dosage even early in the first trimester. If your thyroid levels historically have bounced around a lot, you may be particularly susceptible to early problems and should be closely monitored. If you haven't seen your midwife or OB yet, your family doctor/GP can help you get the tests you need until you have a care provider for your pregnancy.

Does Hypothyroidism Make a Pregnancy High-Risk?

Some women with hypothyroidism have been told that their hypothyroidism makes them "high risk" and so they are not good candidates for a birth center or home birth, or that they should only see an OB or even a perinatologist during pregnancy.

However, it's only UNTREATED or INADEQUATELY TREATED hypothyroidism that is really a risk. As long as thyroid levels are tested periodically and treated adequately, women with hypothyroidism don't need to be treated as "high-risk." Most women with adequately-treated hypothyroidism have normal, healthy pregnancies and babies. (I did, four times, and so have many other women with hypothyroidism that I know.)

Unless thyroid levels are particularly difficult to keep under control, women with hypothyroidism can see any type of provider they wish...nurse-midwife, homebirth midwife, family doctor, or OB.

Nurse-midwives and doctors all can order thyroid tests and adjust prescriptions as needed; homebirth midwives often can order lab tests and work with consulting doctors to make prescription adjustments if needed. Any of these types of care providers can provide care for a pregnant woman with hypothyroidism.
Some women prefer to be followed by both a pregnancy care provider and an endocrinologist, as they feel their endocrinologists may pay closer attention to smaller changes in their thyroid levels. Others do not feel the need for care beyond their normal provider.

Hypothyroidism does not preclude you from birthing at home or at a birth center, nor does it necessitate a high-risk provider. Choose whatever provider you feel most comfortable with. However it's a good idea to ask your care provider about his/her plan for monitoring your thyroid levels during pregnancy; some care providers are more knowledgeable about thyroid concerns than others. Be sure they also have a plan for checking your levels postpartum.

Postpartum Thyroid Issues

After the baby is born, many women experience thyroid difficulties. Even if you've never had thyroid issues in your life, were fine during pregnancy, or were totally fine in all previous pregnancies, you may still develop postpartum thyroiditis. It is important to watch ALL women carefully for thryoid symptoms after birth.

Postpartum thyroiditis classically involves a period of hyPERthyroidism (thyroid is overactive) followed by hyPOthyroidism (thyroid is underactive). However, be aware that some women skip straight to the hypothyroidism part and never experience any real signs of hyperthyroidism first.

About 5-10% of all women develop postpartum thyroiditis, but the incidence is higher in women with a history of thyroid or autoimmune issues. Doctors often miss postpartum thyroiditis since they usually only see you briefly several weeks after the baby is born. And with a new baby, many moms tend to dismiss symptoms or don't take time to have them investigated. So postpartum thyroiditis tends to be underdiagnosed and the incidence may be higher than generally acknowledged.

Women experiencing difficulty with breastmilk production should have their thyroid levels tested (as well as testing for anemia etc.), because this can affect milk production. There are many other possible causes of low milk production, of course, but this is one that is often missed. And because thyroid levels can fluctuate widely after childbirth, repeated testing may be needed. Although most women with a history of thyroid issues can breastfeed without problems, they should be particularly watchful for possible thyroid issues.
Women who gain a lot of weight in the months after giving birth (despite normal intake and despite breastfeeding) may also be experiencing postpartum thyroid issues and should be checked.

Women who experienced severe bleeding during and after birth should also be aware of a potential for thyroid problems. Sometimes severe hemorrhage can damage the pituitary gland, which in turn can lead to hypothyroidism. This is called Sheehan's Syndrome. As one website notes:

Rarely, hypothyroidism after childbirth is caused by Sheehan's syndrome, also called postpartum hypopituitarism. This condition may occur in women who have severe blood loss during childbirth resulting in damage to the anterior pituitary gland.

Finally, women who experience thyroid issues during and after pregnancy should also be warned to watch for possible recurrence of thyroid issues during perimenopause and menopause. Advanced age is another period of time when women are particularly vulnerable to hypothyroidism too. Thus, periodic thyroid tests should become part of women's life-long care.

Thyroid Medicine and Supplements

Hypothyroid medications are generally considered safe during pregnancy and breastfeeding. Remember, these medications are simply putting back into your body what should already be there. Babies are at far greater danger from untreated hypothyroidism than they are from typical hypothyroid medications. Just make sure to monitor your thyroid levels periodically.

I know of no "official" correlation between hypothyroidism and vitamin D levels, but it's my observation that many folks with hypothyroidism also have chronically low vitamin D levels as well. Whether there's a causal connection is debatable, but they often do seem to go hand in hand. So while you are at the doctor's having your TSH etc. checked, consider asking them to run Vitamin D levels as well.

Finally, remember that many things interfere with absorption of thyroid medicines. In particular, thyroid meds should NOT be taken at the same time as prenatal vitamins. (Many doctors don't know this; mine didn't.) Iron and calcium in particular interfere with absorption of thyroid medications, and prenatals are full of iron and calcium. Take your thyroid meds and your prenatals at least 2-3 hours apart instead.

Take your thyroid meds as consistently as possible. Thyroid meds are most effective taken in the morning, on an empty stomach, with plenty of water. Avoid eating for about an hour afterwards if possible. Do not take with any other meds or vitamins, and if possible, take them about the same time each day.


Although most women will not have problems with their thyroid during their pregnancies or postpartum, the frequency with which it occurs (even in women with no prior thyroid issues) merits close attention from birth attendants.
However, because not all birth attendants are fully aware of hypothyroidism issues in pregnancy, women need to be proactive about informing and advocating about this issue for themselves, particularly women of size.


Tash said...

I am a woman who has had this condition since I was about 16, and I found your information very helpful. I have one child from my previous relationship. My hubby and I are planning to have our first baby together, will start trying within the next few months, so I hope it goes well, just had my thyroid tested again 2 days ago. Great site

The Rebound Girl said...

Wish I'd read this earlier. I have a goiter and had existing nodules when I fell pregnant. When I went in for my thyroid u/s they've found one nodule has doubled in size and now I need FNA to determine if its benign or malignant. My bets are on benign. I normally do u/s twice a year but this year decided to wait it out and see if checkign once a year would be okay. Wasnt' a good idea but you live and you learn.

Anonymous said...

I am recently diagnosed with Hypothyroid. I am taking 50mcg of synthroid. b'coz I am trying to get pregnant. I missed my period and got negative hpt and blood tests. What you do suggest is the best dosage? Any suggestions please...

Summer said...

I want to Thank You for posting this. I haven't felt good since I had my baby a year ago so I went to get my thyroid tested among other tests. Just got a call today saying my test was abnormal and to make an appt with my Doc. So being nervous about this I have been looking online about it. I came across your site and it is so helpful! I wrote down a bunch of questions to ask my Doc thanks to you! And I was worried about having another baby eventually because I would be "High Risk". Thanks for calming my fears about that from what you posted. Your blog has been really helpful!

Anonymous said...

I am diagnosised with hypothyroid 8 yrs back. i am taking Levothyroxine 100MCG. Last month when I and my hubby decided on having a baby, i checked my thyroid harmones. To my surpries their( free T3 and Free T4) values were above the range and TSH is very below range. My doctor has reduced my dose to 50 mcg. What will you suggest to me? your suggestation is very valuable for me.

Well-Rounded Mama said...

Sorry, I'm not a medical professional and don't give medical advice. Talk it over with your doc. You might consider asking to have your values checked frequently, esp if you get pregnant, as folks with thyroid issues can have major changes in pregnancy.

Annette said...

I so wish I had read this so much earlier. On September 30, 2011 Our beautiful 26 year old daughter and our grandson died during the night. Cause of death "Sudden cardiac death due to hypothyroidism and pregnancy. She was in her 18th week. Shannon was hypothyroid before pregnancy, told her doctor, questioned him endlessly, and took her medication faithfully. After we received the autopsy report I requested her medical file and found that the Dr. had ordered a TSH at 5 weeks. The lab report showed "HIGH". He either overlooked or ignored this but our daughter and grandson are gone and our lives are destroyed.

Well-Rounded Mama said...

Annette, I'm so sorry for your loss. How heartbreaking.

Although outcomes like this are rare, they do show the importance of making sure this is carefully monitored. Most of the time, a pregnancy with thyroid issues is unremarkable, but once in a while, things like this show how serious the issue can potentially be.

My heart goes out to you.

Dipti said...

hey this post is very informative for pregnant women..thanks for sharing it...

Pregnancy Care

Anonymous said...

I became hypothyroid after my 2nd pregnancy. for 18months I suffered with exhaustion, cold, aches etc and just thought it was because my son was a bad sleeper and still breastfeeding. My HV kept saying i had ppst natal depression (which I knew I didnt) I had problems with my eyes and was diagnosed with episclaritus, and the opthomalgist ordered the thyroid tests and found my condition. Clearly some HV's should read your info! thanks. i hope to have another baby one day, its nice to know i wont have to be considered High risk.

Anonymous said...

Thanks for the informative article! I have had hypothyroidism for 15 years now, which began as severe hyperthyroidism from Grave's disease with an abnormally large goiter. I had I-131 ablation therapy twice and went hypo for life. My endo is wonderful but they are not always aware of the correct levels for pregnant women. My obgyn said TSH shouldn't be over 2.5 during pregnancy or it could cause miscarriage, whereas mine was 3.4 at six weeks. He upped my dose from 125 to 150mcg. The endo said it was a 'little high but not abmormal' it's important to make sure the endo informs the patient of the actual TSH level.

I'm almost 12 weeks now and all is well--healthy baby and good TSH levels. My endo is checking my levels once every four weeks to be sure since it can really affect a pregnancy. I'm looking into birthing options now and would love to use a midwife and have a home birth if possible. I have tons of food allergies (yeast, cheese, wheat, onions and eggs) and am also allergic to Sulfa drugs. I am afraid of having a severe reaction while in the hospital--from the food to the drugs, I could seriously endanger myself and the baby. I am also slightly overweight but not considered high risk, even though I'm 36. Do you know if home births are possible or recommended for hypothyroid women? I sure hope it is for my and the baby's sake!

Well-Rounded Mama said...

Anonymous, homebirth is possible for women with hypothyroidism if it is well-controlled. Frequent testing and tweaking of meds is helpful if needed.

Different care providers have different levels of comfort around seeing women with hypothyroidism in low-risk settings but most don't rule it out, as long as it is well-controlled. Have it watched for carefully postpartum as well as prenatally.

I'm a believer in lower (within reason) TSH ranges, but I'm surprised your OB agrees. There is a lot of controversy over what the best TSH ranges are and when to take action, and most docs these days don't seem to take it too seriously. Nice to see someone who does.

Olivia VanBuren said...

I was diagnosed with hypothyroidism in 2007 and, after miscarrying last year, I started reading a lot about pregnancy and miscarriage and hypothyroidism. This time, as soon as I found out I was pregnant, I scheduled an appointment with an endocrinologist to have my thyroid monitored. And it's been great. I'm now 38 weeks pregnant and my dosage of thyroxine has nearly doubled since getting knocked up, but I feel good. And though my thyroid problem technically makes my pregnancy high risk, I am planning to deliver naturally with my certified nurse midwife. And my endocrinologist has been amazing. I kind of love her. Thanks for posting this information!

Patty Sanchez said...

Thank you so much for this article. I've been freaking out for the last 3 days(Found out I was pregnant on 1/10). I was diagnosed with Hypo 2 years ago (taking Levo)and thought I'd never be able to conceive but we did 5 months after getting off birth control(thank the lord). But I've been reading way too much into pregnancy/hypo and miscarriage. This is the first website that didn't make me feel like I was going to have a miscarriage within the next couple of weeks! I will have my first prenatal visit this week and I actually feel more positive about it, thank you again!

Jill said...

I've had hypothyroidism for years. Been through 5 pregnancies with it. It wasn't until I went through menopause that I finally got a handle on my diet to the point that I've been able to lose weight, sleep and not struggle with depression the way that I had for many years.

Erin Kendall said...

You have no idea how much this puts my mind at ease. I just found out yesterday that my TSH is elevated and am awaiting a visit to the endocrinologist to sort it all out. Learning that I should still be able to give birth where I please and to breastfeed while receiving treatment is the most important and comforting information I could have read today. Thank you so, so much for this post.

Leslie and Keith said...

Hi, thank you for this post. I was diagnosed with Hashimoto's disease when I was 16 and it has been treated and controlled quite easily. Pregnant with my second child (no problems with conception, pregnancy or delivery with first and just needed meds increased). My TSH is high again at 32 weeks (going to increase meds) and OB wants to do 2 fetal non stress tests a week! I didn't have to do this with my first baby even though everything is exactly the same. Although I don't want to take any risks, this approach seems very conservative and I feel somewhat unnecessary seeing as I have no other complications. When I questioned it, nurse simply handed me the guidelines that said this was high-risk, but I fail to see how it makes my pregnancy high-risk, especially since I'm being treated. I also cannot find scientific evidence to support the stress test 2x a week. Anyone else had this issue? I'm seeing a different provider with my second, and thinking this is their 'standard of care'. Any suggestions, thoughts, or research studies to support this?

Well-Rounded Mama said...

I can't really comment on this because first, I'm not a healthcare provider or medical professional; second, I don't know the details of your situation; and third, I don't know how high is "high" in this context. Really high? A little high?

It would be an unusual complication that would truly need 2 non-stress tests a week as long as you are treating the condition and baby seems well, but perhaps they are aware of some research that I'm not aware of.

Talk it over with the provider, asking for research to support their suggestions, and if the answers don't satisfy you, switch providers. (Consider a midwife.) If you hear the same thing from the next provider, then you know it's something you need to do. If not, you'll know it's more of a judgment call or a cover-your-behind move.

I really cannot tell you whether it's necessary or not, but it does seems questionable to me. You will want to do some more research. Keep an open mind to the possibility it could be necessary, though, and get a second opinion to try and get further clarity on the issue.

Dr Rita Bakshi said...

It is vital for every woman who is struggling to become a mother or has experienced miscarriages before to get a thyroid diagnosis done as soon as possible. Take care of your health and ensure that your thyroid levels are good enough to sustain a healthy pregnancy.