Special Considerations: Thyroid, Diabetes, Lupus

The pregnancy information and descriptions offered in this document thus far have assumed that we have been talking about how the prenatal pregnancy care process is likely to unfold for a relatively healthy young woman. Not every woman who gets pregnant is necessarily healthy or young, however. The following sections of this document describe ways that doctors typically modify prenatal care recommendations when various conditions are present that complicate pregnancy.

Thyroid Diseases

Hyperthyroidism. The prefix “hyper” means “over” or “above”. Hyperthyroidism occurs when a person’s thyroid gland (located at the front of the neck, and secreting hormones that regulate many metabolic processes) becomes overactive. The most common form of hyperthyroidism is known as Grave’s disease. Hyperthyroidism can start during pregnancy, triggering various symptoms to appear, including hard or fast heartbeats, nervousness, trouble sleeping, nausea, and weight loss. As most of these symptoms are likely to happen anyway during pregnancy, it can be easy to miss that they are being caused by a hyperthyroid condition.

It is important that doctors bring hyperthyroid conditions under control for pregnant women. Hyperthyroidism has a tendency to become severe in the third trimester of pregnancy, and sometimes leads to premature labor. A pregnant woman’s poorly controlled hyperthyroidism can cause her to be at increased risk for miscarriage, premature labor, pre-eclampsia (late term high blood pressure), stillbirth, low birth weight, and even heart failure.

A mother’s hyperthyroidism can affect her baby’s health as well as affecting the quality of her pregnancy. Up to 5% of babies born to women with Graves’ disease have hyperthyroidism. Symptoms of hyperthyroidism in the fetus include high fetal heart rate, poor growth, abnormal bone development, and an enlarged thyroid gland.

If you have hyperthyroidism, your doctor may measure your levels of thyroid hormone every month, and may also perform additional tests, such as prenatal sonography and fetal blood tests. Your doctor will also likely take steps to control your hyperthyroid condition. Treating maternal hyperthyroidism can be complicated as some of the medications used to treat the condition can be harmful to the fetus. For example, radioactive iodine, a common treatment for hyperthyroidism, cannot be used during pregnancy because of the likelihood that this treatment will damage the fetus’ own thyroid gland. Fortunately, several medications, including Propylthiouracil (also called PTU), Methimazole (MMI), and Propanolol, may be safely used to treat hyperthyroidism during pregnancy. Surgical removal of the thyroid gland may become necessary when a pregnant woman fails to respond to medication treatment of her hyperthyroidism.

Hypothyroidism. The prefix “hypo” means “under” or “below”. Hypothyroidism, then, is a disease characterized by an under-active thyroid. Common among women of child-bearing age, hypothyroid can be difficult to detect, as its symptoms, such as tiredness and weight gain, are similar to normal pregnancy symptoms. Fortunately, a simple blood test can detect hypothyroidism, and the condition can be treated with thyroid hormone replacement medication such as Levothyroxine. Women who had hypothyroidism prior to becoming pregnant will often need to take a higher dose of the medication during their pregnancies so as to keep their hormones at necessary levels. In general, women with hypothyroidism can expect to have blood tests done every 4 to 6 weeks in order to monitor their thyroid hormone level.

It is important to test for and treat hypothyroid conditions in pregnant women as they are otherwise associated with negative outcomes. Being hypothyroid can reduce a woman’s chances of becoming pregnant. Pregnant woman with hypothyroidism have a high chance of first trimester miscarriage. Should pregnancy continue after the first trimester, there remains a chance that the child will have congenital abnormalities, be born with a low birth weight, and demonstrate impaired psychomotor development.

Diabetes Mellitus

Diabetes mellitus is a disease affecting blood sugar metabolism. Diabetes complicates pregnancy in multiple ways. It negatively affects the pregnancy itself, causing an increased risk of spontaneous abortion (miscarriage), macrosomia (large sized fetus), preterm birth, and respiratory problems. It also negatively affects the health of the pregnant woman, who is at increased risk for hypoglycemia (low blood sugar), ketoacidosis, increased microvascular complications (such as poor circulation and retinal (eye) damage), kidney infections, and hypertension. Because of these risks, it is very important that diabetic women maintain close contact with medical personnel before and throughout their pregnancies.

Pregnant diabetic women will undergo a battery of blood and urine tests early in pregnancy. They may also be asked to have an electrocardiogram (a measure of heart rhythm) and a comprehensive eye exam to measure retinopathy (eye tissue damage). Throughout the course of their pregnancies, they may be asked to consult with a diverse team of health care professionals, including nutritionists, nurses, diabetic educators, social workers, and their doctor, to help them remain healthy and motivated throughout their pregnancy. They will need to touch base with their health care team and doctor so that appropriate monitoring of their health and the health of their pregnancies can take place at least every two weeks until 32 weeks of gestation and then every week until delivery to monitor the baby’s development.

Research has demonstrated that good glycemic (sugar) control can lower diabetic’s pregnancy risks substantially, particularly during the first seven weeks of fetal development when organs are being formed. Maintaining good sugar control requires that pregnant women adhere to a strict personalized meal plan and diabetic diet, monitor their glucose levels on a regular basis, and carefully document their blood sugar levels and insulin dosages throughout their pregnancies. They must also strictly adhere to their medication regimen. Insulin is completely safe to use during pregnancy (so long as it is used appropriately). However, other medications that may have been prescribed prior to the pregnancy may not be safe to take during pregnancy.

Though they require a great deal of discipline to act on, the dietary and medical treatments described above are capable of reducing and even eliminating many of the problems associated with diabetic pregnancy. Paying attention to glycemic control, careful blood sugar monitoring, insulin dosing, diet modifications, and regular doctor visits help to increase the likelihood of an uncomplicated pregnancy.

Lupus

Lupus is a chronic autoimmune disease in which a person’s own immune system attacks and inflames that person’s own body tissues resulting in symptoms including fatigue, swollen joints, rashes and other serious symptoms. Pregnant women with Lupus are at risk for pregnancy complications, including high blood pressure, diabetes, hyperglycemia, blood clots in the placenta, toxemia, preterm delivery, and sudden emergent need for cesearian birth. Of these various risks, the largest is that of premature delivery, which can result in the baby having difficulty breathing, being jaundiced and anemic. The majority of babies born to women with Lupus do not develop the disease themselves. However, about 3% of babies born to mothers who have Lupus develop Neonatal Lupus. The symptoms of Neonatal Lupus are a transient rash, transient blood count abnormalities, and rare but treatable heart beat abnormalities. Babies who experience Neonatal Lupus without heart beat abnormalities are generally symptom free by six months of age.

Women with Lupus who desire to get pregnant should put off conception until they have been symptom free for at least six months if possible. Once pregnant, women with Lupus have different symptom experiences. While some women experience a flare of symptoms during pregnancy, others actually improve. Often, it is difficult for doctors to determine which symptoms during a Lupus pregnancy are caused by the pregnancy itself and which are symptoms of the disease.

Lupus is a serious and chronic disease that continues to avoid cure. Only several decades ago, doctors used to counsel women with Lupus to avoid having children of their own. Today, approximately 75% of Lupus pregnancies are successful, thanks to the application of carefully developed research-based medical treatments (approximately 25% of pregnancies still result in miscarriage). Ongoing prenatal care and careful medical planning are vital parts of a Lupus pregnancy. Because of the complications that can arise in pregnant women who have Lupus, all Lupus pregnancies are considered high risk. All pregnant women with Lupus should plan to deliver in a health care facility with a neonatal intensive care unit in case of premature delivery.

If you have Lupus and plan to become pregnant, or are already pregnant, it is important that you discuss your treatment options with your doctor at your earliest convenience. Your doctor will likely need to adjust your medications, for one thing, and will want to follow your progress closely throughout your pregnancy so as to best insure your health. As with other conditions, some medications will be safe to continue during pregnancy, while others may harm your developing fetus. More information about pregnancy and Lupus can be found at the Lupus Foundation of America website.

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