Title:

Thyroid Disease In Pregnancy; an audit of current practice

Location:

Ayrshire Maternity Unit, CrosshouseHospital, Kilmarnock, KA2 0BE

Contributors:

Dr J. McInally, FY2; Dr J.Ramsay, Consultant

Aims:

To assess current practice in the management of thyroid disease in pregnancy and compare this to regional guideline

Methods:

Identification of women with thyroid disease who attended Ayrshire Maternity Unit from 1stJanuary 2008-31stDecember 2008. A retrospective analysis of casenotes was then performed, looking at a number of indicators.

Results:

  • 38 casenotes were included in the final data analysis
  • 80% of patients with hyperthyroid disease were reviewed in a specialist clinic (medical obstetric, medical endocrine or both) compared to 35% of those with hypothyroid disease and 42% of those with iatrogenic hypothyroid disease
  • Thyroid function tests were taken on average 5.1 times during pregnancy, 0.9 times in the first trimester, 1.5 times in the second and 2.6 times in the third.
  • In the 26 patients with autoimmune hypothyroid disease, TFTs were taken 125 times. Using the laboratory values suggested in local guidance 88% of T4 levels were low, and 52% of tests had both low T4 and high TSH
  • Thyroxine was increased a total of 16 times (in 50% of patients), 13 of these were when T4 was low and TSH raised.
  • 60% of patients with hyperthyroid disease had antithyroid antibodies checked (TPOAb and TRAb) compared to 58% of those with iatrogenic hypothyroid disease and 31% of those with autoimmune hypothyroid disease

Discussion:

These results suggest that we are not following local policy with regards to our management of thyroid disease in pregnancy. In particular, all patients with hyperthyroid disease or previous treatment with radioiodine or thyroidectomy should be reviewed at a specialist clinic. Only 42% of those in the latter category were, highlighting the importance of establishing the type of hypothyroid disease prior to and during the booking process. Thyroid function tests were taken appropriately in the majority of patients. In patients with hypothyroid disease, the majority of results were suggestive of undertreated hypothyroid disease, using the lab values recommended in the guidelines. As changes in thyroxine dosing did not follow these results, it may imply a lack of knowledge of the reference ranges recommended in local protocol. All hyperthyroid patients who attended a medical obstetric clinic had antibodies checked as per protocol, the 40% who did not have these checked had not attended this clinic. This may again imply a lack of knowledge of the current recommendations for these tests.