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Gestational Transient Hyperthyroidism in Hyperemesis Gravidarum Protocol of thesis Submitted for partial fulfillment of The Master Degree in Obstetrics and Gynecology By Hany Bassiony Mohammed (M.B.B.Ch) Resident of Obstetrics&Gynnecology in Heliopolis Hospital Under supervision of Prof. Dr. Ali Farid Mohamed Ali Professor of Obstetrics & Gynecology Faculty of Medicine Ain Shams University Dr. Noha Hamed Rabei Lecture of Obstetrics & Gynecology Faculty of Medicine Ain Shams University Faculty of Medicine Ain Shams University Cairo 2007 [Type text] INTRODUCTION Nausea and vomiting in pregnancy is extremely common. Studies estimate that nausea and vomiting occur in 50-90% of pregnancies. The nausea and vomiting associated with pregnancy usually begin by 9-10 weeks of gestation, peaks at 11-13 weeks, and resolves in most cases by 12-14 weeks. In 1-10% of pregnancies, symptoms may continue beyond 20-22 weeks. (Jeffrey et al., 2003) The most severe form of nausea and vomiting in pregnancy is called hyperemesis gravidarum (HEG). HEG is characterized by persistent nausea and vomiting associated with ketosis and weight loss (>5% of prepregnancy weight). HEG may cause volume depletion, electrolytes and acid-base imbalances, nutritional deficiencies, and even death. Severe hyperemesis requiring hospital admission occurs in 0.3-2% of pregnancies. (Fatum et al., 2003) The physiological basis of HEG is controversial. HEG appears to occur as a complex interaction of biological, psychological, and sociocultural factors. (Daniel Glinoer, 2006) HEG was a significant cause of maternal death before (1940). Mortality from HEG in Great Britain decreased from 159 deaths per million births from (1931- 1940) to 3 deaths per million births from (1951-1960). In the United States, 7 deaths from HEG were reported in the (1930s), but today, although HEG is still associated with significant morbidity, it is a rare cause of maternal mortality. (Dotun et al., 2006) Women with HEG who have a low pregnancy weight gain ( < 7 kg ) have increased risk for delivering neonates of low birth weight, delivering neonates who are small for gestational age, preterm delivery, and a 5-minute Apgar score of less than 7. (Dotun et al., 2006) Pregnancy induces physiological alterations in thyroid function which may make the interpretation of the result of thyroid hormone measurements difficult. A state of hyperstimulation of the thyroid gland is common in early pregnancy. In a few cases, thyroid hormone values will deviate from the normal range, which corresponds to the gestational transient thyrotoxicosis. This syndrome is closely associated with hyperemesis gravidarum. (Patrice et al., 2004). Biochemical evidence of hyperthyroidism is frequently encountered in hyperemesis gravidarum, but its relationship to the cause of hyperemesis is unknown. Hyperemesis patients had significantly greater mean free T4, total T3 and lesser serum TSH compared to controls. Hyperemesis patients with suppressed TSH had significantly greater free T4 compared to those with TSH in the normal range. The degree of biochemical hyperthyroidism varied directly with the severity of vomiting. These data show that biochemical hyperthyroidism is a common finding in patients with hyperemesis gravidarum. (Timothy, 2000). Aim of the work The aim of this work is to determine if there is relationship between gestational transient hyperthyroidism and hyperemesis gravidarum. Patients and methods This study will be carried in Ain Shams maternity Hospital from April 2007 to December 2007. The study subjects will be patients with hyperemesis gravidarum which is so sever that the patients will need to be hospitalized to be given intravenous fluid for 3 days or more compared with control subjects. The study subjects will be 80 women, 40 patients have hyperemesis gravidarum and 40 normal pregnant female with the same gestational age as a control. Inclusion criteria:- 1. Female age ranges from 20 to 30 years. 2. Duration of pregnancy ranges from 8 to 20 weeks. 3. Primigravida. Exclusion criteria:- 1. Multiple pregnancies. 2. Vesicular mole disease. 3. Past history of hyperthyroidism or present clinical manifestations of hyperthyroidism or Graves' disease. 4. Other causes of vomiting as cholecystitis or urinary tract infections. Evaluation:- The women will be evaluated by clinical picture of hyperemesis gravidarum (persistent vomiting, weight loss, volume depletion, electrolytes and acid-base imbalances) and measurements of (freeT4 and TSH) by radio immune assay technique. Radio immune assay is used for quantitation of specific protein (antigen) that can be radioactively labeled with isotope such as radioactive Iodine or radioactive Hydrogen, The test based on the Competition of the specific Antibody between the labeled (known) and unlabeled (unknown) concentration of material, the complex is then separated and the amount of radioactivity of it is measured, the more unlabeled Antigen is present the less radioactivity of the complex. (Patrick et al., 2002). The radio immune assay of T4 and TSH will be performed in Biochemistry Department, faculty of medicine, Ain Shams University. REFERANCES 1. Daniel Glinoer,(2006) : Thyroid disease manager Chapter 14 (Thyroid regulation and dysfunction in the pregnant patient). 2. Dotun A. ogunyemi, Giulia A. Michelini, (2006) : http://www.emedicine.com/med/topic1075.htm. 3. Fatum M., Abramob Y.,(2003) : Hyperemesis gravidarum an updated review Journal of Harefuah vol. 142(1):6 1-5, 77. 4. Jeffrey D. Quinlan, Ashley Hill,(2006) : Nausea and vomiting of pregnancy Journal of American family physician vol. 68/NO. 1(JULY 1, 2003). 5. Patrice Rodien, Nicola Jordan, Anne Lefèvre, Julien Royer, Claudine Vasseur, Frédérique Savagner, Aline Bourdelotand Vincent Rohmer (2004) : Abnormal stimulation of the thyrotrophin receptor during gestation. Journal of Human Reproduction Update, Vol.10, No.2 pp.95- 105. 6. Patrick R. Murrag, Ken S. Rosenthal, George S. Kopayashi, Michael A. Pfoller, (2002) : Medical microbiology fourth edition. 7. Timothy J. Caffrey, (2000) : Transient Hyperthyroidism of Hyperemesis Gravidarum. Journal of the American Board of Family Practice, vol. 13(1); 35-38.
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