PRIMARY hyperparathyroidism in pregnancy Dr. Dania Hirsch

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2 PRIMARY hyperparathyroidism in pregnancy Dr. Dania Hirsch Gestational PHPT occurs rarely. Clinical : Nonspecific symptoms of pregnancy overlap with symptoms of hypercalcemia: nausea, hyperemesis, constipation, fatigue, weakness, and mental symptoms. Biochemical: The diagnosis may be confounded by the normal pregnancyrelated decrease in serum albumin and suppressed PTH. PHPT during pregnancy is under recognized and is associated with a 3 5- fold increase in miscarriage rates and with increased rates of preeclampsia. Pregnancy loss is more common as calcium levels exceed 11 4 mg/dl Need for earlier recognition and surgical cure before becoming pregnant. However, once pregnant, surgery should be offered early in the second trimester for those with calcium levels above 11 4 mg/dl. Most women with PHPT during pregnancy have only mild hypercalcemia that is generally not associated with an increased risk of abortion or any obstetrical complication

3 המלצות לצריכה של ויטמין D ד"ר פנינה רוטמן וסידן בהריון Vitamin D deficiency = 25(OH)D below 20 ng/ml (50 nmol/liter) Vitamin D insufficiency = 25(OH)D of ng/ml (50 75 nmol/liter) Vitamin D sufficiency = 25(OH)D above 30 ng/ml (75 nmol/liter) לכולן, 1000 IU ויטמין D: מינון: 600 IU מי בסיכון לחסר? לנשים בסיכון לחסר.)במולטיוויטמינים יש כ IU 400( צמחוניות, נשים שאינן חשופות לשמש, כהות עור, נשים עם הפרעות של ספיגה מהמעי, נשים עם אי ספיקת כליות או עם סינדרום נפרוטי, נשים הנוטלות תרופות אנטי אפילפטיות, נשים עם היפופרתירואידיזם סידן: תזונה + תוספים mg במולטיוויטמינים לרוב יש.250 mg ליום. יתכן וקיים קשר בין חסר בסידן לבין סיכון מוגבר לרעלת הריון.

4 Should every pregnant have a TSH screening? Dr. Tal Biron & Dr. Rinat Gabay Overt hypothyroidism )OH) TSH >2.5 miu/l + decreased FT4 TSH 10.0 miu/l irrespective of FT4 levels. Isolated hypothyroxinemia (IH) Normal TSH with FT4 at 5th -10th percentile. Subclinical hypothyroidism (SCH) TSH miu/l with normal FT4 levels. Positive antibodies Anti TPO Ab, anti TG Ab קבוצת הנשים בסיכון, מומלץ לבדוק Age > 30 years Personal history of thyroid dysfunction Prior head or neck irradiation Prior thyroid surgery Family history Symptoms Presence of Goiter TPO Ab positivity Autoimmunity Infertility Miscarriage or preterm delivery Iodine deficient population Medications and iodinated contrast media Morbid obesity (BMI > 40 kg/m2)

5 Debate s Conclusions Proved APO. Risk based testing tests >40% of the patients and misses 30% of SCH. Clinical symptoms of SCH & OH may be missed as they mimic pregnancy related complains. Screening reveals OH which clearly has APO and improves by treatment cost effective. In Israel we perform so many tests, is TSH screening will decrease pregnancy expenses? No definition no prevalence Conflicting evidence for APO Maybe it s just the Ab? Timing of screening decrease time to treat limited evidence that LT4 can improve outcomes. Over diagnosis over treatment With Ab not necessarily cheap.

6 ATA guidelines 2016 Verbal screen at initial visit If high risk TSH + reflex TPO Ab if 2.5<TSH <10 TSH < <TSH <4 4<TSH <10 TSH >10 TPO negative TPO positive TPO negative TPO positive No treatment Consider treatment Treat LT4

7 Final criteria for the diagnosis of thyroid storm Dr. Michal Kovo TS1- Thyrotoxicosis and at least one CNS manifestation and one of the following: fever (>38 0 C, tachycardia (>130bpm), CHF, or GI/hepatic manifestation CNS- restlessness, delirium, psychosis, lethargy, convulsion, coma TS1- Thyrotoxicosis and at least three combinations of fever or tachycardia, or CHF, or GI/hepatic manifestation TS2- Thyrotoxicosis and a combination of two of the following: fever or tachycardia, or CHF, or GI/hepatic manifestation TS2- Pts. who meet the diagnostic criteria of T1 but FT3 or FT4 are not available Akamizu et. al. Thyroid 2012

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9 Congenital Adrenal Hyperplasia- Take Home Message Dr. Yifat Wiener CAH is an autosomal recessive disorder. The most common form is due to mutations in the gene encoding for the enzyme 21-Hydroxylase. Adrenal androgen production increases as a result of blocked production of Cortisol and Aldosterone. 3 common presentations with a "decreased" level of severity: Salt Wasting (Classical) > Simple Virilizing ( Classical ) > Non Classsical CAH (most common form). Clinical phenotype is based on the less severe allele Fertility and pregnancy are influenced by disease type and patients may require life-long therapy with glucocorticoids and mineralocorticoids Genetic work-up for couples, carriers of a severe mutation is recommended before conception Treatment of pregnancies at high risk of CAH with prenatal DXM be considered experimental. Benefits only 1/8 high-risk pregnancies (diagnosed sick female fetus) and Is not necessary to preserve life or protect intellectual capacity and Is largely used to reduce parental stress and prevent surgery Preventing unnecessary exposure of mother and fetus to DXM and avoiding potential associated harms and a relatively lower value on minimizing the emotional toll of ambiguous genitalia on parents and patients Obstetricians, endocrinologists, geneticists, paediatric physicians and surgeons collaborate to develop a multidisciplinary guidelines for managing high-risk families Screening for 21-hydroxylase deficiency is offered to all newborns in Israel

10 Dr. Sharon maslovitz Lis Maternity Hospital Growth is uncommon (more in macro) DA s may be discontinued DA s are safe and very effective in symptomatic growth Surgery for intractable cases or compression Post-partum prognosis is excellent