Module 6 Unit A

Question 1

How does the size of the thyroid gland change during pregnancy?

Answer 1

Thyroid size - During pregnancy, the thyroid gland increases in size by 10% in iodine replete countries but by 20% to 40% in areas of iodine deficiency

Normal physiologic changes in thyroid and thyroid hormones during pregnancy

Thyroid gland enlarges up to 30% of its normal size by the third trimester.

Question 2

How do TSH lab values adjust during pregnancy?

Answer 2

1st Trimester Normal or Decrease
2nd Trimester Normal
3rd Trimester Normal

Question 3

How do Free T3 lab values adjust during pregnancy?

Answer 3

1st Trimester Normal
2nd Trimester Normal
3rd Trimester Normal

Question 4

How do free T4 lab values adjust during pregnancy?

Answer 4

1st Trimester Normal
2nd Trimester Normal
3rd Trimester Normal

Question 5

How do total T3 lab values adjust during pregnancy?

Answer 5

1st Trimester High
2nd Trimester High
3rd Trimester High

Question 6

How do total T4 lab values adjust during pregnancy?

Answer 6

1st Trimester High
2nd Trimester High
3rd Trimester High

Question 7

What are the clinical signs and symptoms of hypothyroidism?

Answer 7

Nonspecific clinical findings that may be indistinguishable from common s/s of pregnancy - fatigue, constipation, cold intolerance, muscle cramps, and weight gain.

Other findings include edema, dry skin, hair loss, and a prolonged relaxation phase of DTRs

Goiter may or may not be present in cases of hypothyroidism and is more likely to occur in women who have Hashimoto thyroiditis (also known as Hashimoto disease) or who live in areas of endemic iodine deficiency.

Hashimoto thyroiditis is the most common cause of hypothyroidism in pregnancy

Question 8

What are the risks of uncontrolled hypothyroidism on the birthing person?

Answer 8

Adverse perinatal outcomes such as 
spontaneous abortion
preeclampsia
preterm birth
abruptio placentae
and fetal death

Question 9

What are the risks of uncontrolled hypothyroidism on the fetus and newborn?

Answer 9

increased risk of low birth weight and impaired neuropsychological development

Rare for maternal thyroid inhibitory antibodies to cross the placenta and cause fetal hypothyroidism

Question 10

What lab tests should the nurse midwife order to diagnose hypothyroidism?

Answer 10

TSH and free T4

Question 11

How should the nurse midwife manage a patient with hypothyroidism?

Answer 11

Adequate maternal iodine intake is needed for the maternal and fetal synthesis of T4 .

Women of reproductive age should assess their diets and dietary supplements to confirm that they are meeting the recommended daily dietary intake of 150 micrograms of iodine.

Pregnant women with overt hypothyroidism - treat with adequate thyroid hormone replacement to minimize the risk of adverse outcomes.

American Thyroid Association and the American Association of Clinical Endocrinologists recommend T4 replacement therapy, beginning with

Levothyroxine in dosages of 1–2 micrograms/kg daily or approximately 100 micrograms daily

Question 12

What are the clinical signs and symptoms of hyperthyroidism question the hyperthyroidism?

Answer 12

Nervousness, tremors, tachycardia, frequent stools, excessive sweating, heat intolerance, weight loss, goiter, insomnia, palpitations, and hypertension.

Distinctive s/s of Graves - ophthalmopathy (lid lag and lid retraction) and dermopathy (localized or pretibial myxedema)

Question 13

What are the risks of uncontrolled hyperthyroidism on the birthing person?

Answer 13

Inadequately treated maternal thyrotoxicosis is associated with a greater risk of severe preeclampsia and maternal heart failure than treated, controlled maternal thyrotoxicosis

Question 14

What are the risks of uncontrolled hyperthyroidism on the fetus and newborn?

Answer 14

Inadequately treated hyperthyroidism is associated with an increase in medically indicated preterm deliveries, low birth weight, and possibly fetal loss

Abruption, hydrops, stillbirth, fetal tachycardia, goiter, transient hyper or hypothyroid

Most cases of maternal hyperthyroidism- neonate is euthyroid.

Risks associated w/Graves disease-related either to disease itself or thioamide treatment of the disease

Question 15

What lab tests should the nurse midwife order to diagnose hyperthyroidism?

Answer 15

TSH and free T4

Question 16

How should the nurse midwife manage a patient with hyperthyroidism?

Answer 16

Refer

Overt hyperthyroidism - thioamide to minimize the risk of adverse outcomes.

Either propylthiouracil or methimazole, both thioamides, can be used to treat pregnant women with overt hyperthyroidism - new studies show may not be safe

Refer

Question 17

What is hyperemesis gravidarum?

Answer 17

Excessive NVP, no standard definition exists.

Question 18

What are the diagnostic criteria for hyperemesis gravidarum?

Answer 18

Persistent vomiting present before 9 weeks

Dehydration and/or ketonuria

Weight loss + 5% of initial body weight

Electrolyte imbalance (hypokalemia)

Question 19

How should the nurse midwife assess for hyperemesis gravidarum?

Answer 19

PUQE index - score 13+ = severe NVP/HG

Hx - diet, meds, eating disorders

Elimination - stool, blood in vomit - consider peptic ulcer or esophagitis w/repeated vomiting

Fever or chills

Exposure to viral infection or contaminated food

Abd pain, hx of eating disorders

PEx - weight {compare to previous weights}, VS, skin turgor, mucous membranes, condition of tongue, abd palpation for organomegaly, tenderness or distension, bowel sounds, uterine size

Lab tests -

CBC, UA, BUN, CMP/electrolytes

LFT - to r/o hepatitis, pancreatitis and cholestasis

TSH and T4 - to r/o thyroid disease

US - confirm pregnancy and r/o multiples or hydatidiform mole

Question 20

What effect does hyperemesis gravidarum have on the birthing person?

Answer 20

Adverse psychological -concerns about economics, employment, depression, anxiety, fear about future pregnancies

Transient biochemical hyperthyroid state- doesn’t need tx, resolves spontaneously ~18-20 weeks GA

Question 21

What effect does hyperemesis gravidarum have on the fetus and newborn?

Answer 21

If maternal weight gain normalizes not associated w/ adverse outcomes.

If low weight gain - increases r/f PTL & LBW

Question 22

How should the nurse midwife manage a person with hyperemesis gravidarum?

Answer 22

Consult, and usually collaborative

Need to break cycle

IV fluids - NEVER dextrose r/t r/f Wernicke’s encephalopathy from thiamine deficiency

Usually NS

Consider adding K+, thiamine or MV daily to prevent Wernicke’s {so basically a banana bag}

IV or IM antiemetics, reglan (metoclopramide) or zofran initially

If still can’t tolerate PO fluids and PO antiemetics reconsult MD

MD may need to order corticosteroids and either parenteral or NG feeding