Gestational Transient Hyperthyroidism in Hyperemesis Gravidarum by mikeholy


									Gestational Transient Hyperthyroidism in
        Hyperemesis Gravidarum
                    Protocol of thesis
           Submitted for partial fulfillment of
         The Master Degree in Obstetrics and Gynecology

            Hany Bassiony Mohammed
     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

                                                                 [Type text]
  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.,

 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.,

 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
                            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.
       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.

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) :

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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