Postpartum thyroiditis refers to
thyroid
The thyroid, or thyroid gland, is an endocrine gland in vertebrates. In humans it is in the neck and consists of two connected lobes. The lower two thirds of the lobes are connected by a thin band of tissue called the thyroid isthmus. The thy ...
dysfunction occurring in the first 12 months after
pregnancy
Pregnancy is the time during which one or more offspring develops (gestation, gestates) inside a woman, woman's uterus (womb). A multiple birth, multiple pregnancy involves more than one offspring, such as with twins.
Pregnancy usually occur ...
and may involve
hyperthyroidism
Hyperthyroidism is the condition that occurs due to excessive production of thyroid hormones by the thyroid gland. Thyrotoxicosis is the condition that occurs due to excessive thyroid hormone of any cause and therefore includes hyperthyroidis ...
,
hypothyroidism or the two sequentially. According to the National Institute of Health, postpartum thyroiditis affects about 8% of pregnancies.
There are, however, different rates reported globally. This is likely due to the differing amounts of average postpartum follow times around the world, and due to humans' own innate differences. For example, in Bangkok, Thailand the rate is 1.1%, but in Brazil it is 13.3%.
The first phase is typically hyperthyroidism. Then, the
thyroid
The thyroid, or thyroid gland, is an endocrine gland in vertebrates. In humans it is in the neck and consists of two connected lobes. The lower two thirds of the lobes are connected by a thin band of tissue called the thyroid isthmus. The thy ...
either returns to normal or a woman develops hypothyroidism. Of those women who experience hypothyroidism associated with postpartum thyroiditis, one in five will develop permanent hypothyroidism requiring lifelong treatment.
Postpartum thyroiditis is believed to result from the modifications to the
immune system
The immune system is a network of biological processes that protects an organism from diseases. It detects and responds to a wide variety of pathogens, from viruses to parasitic worms, as well as cancer cells and objects such as wood splint ...
necessary in pregnancy, and histologically is a
subacute lymphocytic thyroiditis
Subacute lymphocytic thyroiditis is a form of thyroiditis. Subacute lymphocytic thyroiditis may occur at any age and is more common in females. A variant of subacute lymphocytic thyroiditis occurs postpartum: postpartum thyroiditis. Both of these ...
. The process is normally self-limiting, but when conventional
antibodies are found there is a high chance of this proceeding to permanent hypothyroidism. Postpartum thyroiditis is a member of the group of thyroiditis conditions known as
resolving thyroiditis.
Signs and symptoms
The initial phase of hyperthyroid symptoms occurs transiently about two to six months postpartum.
Typical symptoms include irritability, nervousness,
palpitations, and heat intolerance. Hormonal disturbances during this phase tend to occur with lower intensity compared with the hypothyroid phase.
As a result, the hyperthyroid phase may pass undetected. The second phase of hypothyroid symptoms is also transient and can occur anytime within the three- to twelve-month period postpartum.
Women in this phase experience low energy, poor memory, impaired concentration, carelessness, dry skin, cold intolerance, and general aches and pains. After one year postpartum,
euthyroid
The thyroid, or thyroid gland, is an endocrine gland in vertebrates. In humans it is in the neck and consists of two connected lobes. The lower two thirds of the lobes are connected by a thin band of tissue called the thyroid isthmus. The thy ...
function resumes. Any case with hypothyroid symptoms extending beyond one year postpartum is not considered postpartum thyroiditis.
Women who test positive for thyroid antibodies may be at increased risk of developing symptoms associated with
postpartum depression
Postpartum depression (PPD), also called postnatal depression, is a type of mood disorder associated with childbirth, which can affect both sexes. Symptoms may include extreme sadness, low energy, anxiety, crying episodes, irritability, and cha ...
than women without thyroid antibodies.
Cause
During pregnancy, immunologic suppression occurs which induces tolerance to the presence of the fetus.
[Premawardhana, L.D.K.E., Parkes, A.B., & Lazarus, J.H. (2004). Thyroiditis, postpartum. In Editor-in-Chief: Luciano Martini (Ed.), ''Encyclopedia of endocrine diseases'' (pp. 509–514). New York: Elsevier. ] Without this suppression, the fetus would be rejected causing miscarriage.
As a result, following delivery, the immune system rebounds causing levels of thyroids antibodies to rise in susceptible women.
[Stagnaro-Green, A. (2000). Recognizing, understanding, and treating postpartum thyroiditis. ''Endocrinology & Metabolism Clinics of North America'', 29(2), 417–430. ]
Specifically, the immunohistological features of susceptible women are indicated by:
* antibodies to
thyroglobulin (TgAb)
* antibodies to
thyroid peroxidase (TPOAb)
* increase in TPOAb subclasses IgG
1-IgG
3
* lymphocyte infiltration and follicle formation within thyroid gland (
Hashimoto's thyroiditis
Hashimoto's thyroiditis, also known as chronic lymphocytic thyroiditis and Hashimoto's disease, is an autoimmune disease in which the thyroid gland is gradually destroyed. Early on, symptoms may not be noticed. Over time, the thyroid may enlarg ...
)
* T-cell changes (increased
CD4:
CD8
CD8 (cluster of differentiation 8) is a transmembrane glycoprotein that serves as a co-receptor for the T-cell receptor (TCR). Along with the TCR, the CD8 co-receptor plays a role in T cell signaling and aiding with cytotoxic T cell-antigen int ...
ratio)
* TSH-receptor antibodies (TSH-R Abs)
Diagnosis
This condition is commonly undiagnosed by physicians due to either unfamiliarity with the disease, the subtlety of symptoms, or the attribution of the symptoms to the stresses of having a newborn.
Usual screening begins with assessing the
thyroid stimulating hormone
Thyroid-stimulating hormone (also known as thyrotropin, thyrotropic hormone, or abbreviated TSH) is a pituitary hormone that stimulates the thyroid gland to produce thyroxine (T4), and then triiodothyronine (T3) which stimulates the metabolism of ...
(TSH) level. A suppressed TSH could represent the hyperthyroid phase, but warrants further testing to investigate for possible
Graves' disease.
A normal TSH with persistent symptoms could represent the shift between phases and requires repeat testing 4–6 weeks later; an elevated TSH at this time could indicate the hypothyroid phase.
Treatment
For most women, the hyperthyroid phase presents with very mild symptoms or is asymptomatic; intervention is usually not required. If symptomatic cases require treatment, a short course of
beta-blockers would be effective.
Assessing treatment for the hypothyroid is more complex. Women with symptoms or a very high TSH level, or both, are usually prescribed a course of
levothyroxine
Levothyroxine, also known as -thyroxine, is a manufactured form of the thyroid hormone thyroxine (T4). It is used to treat thyroid hormone deficiency (hypothyroidism), including a severe form known as myxedema coma. It may also be used to tre ...
.
Asymptomatic women with slightly elevated TSH levels who are planning subsequent pregnancies, should consider a course of treatment until completion of the family to avoid possible developmental complications in future children.
Otherwise, treatment could be discontinued after one year postpartum.
Prevalence
Women with
type I diabetes mellitus
Type 1 diabetes (T1D), formerly known as juvenile diabetes, is an autoimmune disease that originates when cells that make insulin (beta cells) are destroyed by the immune system. Insulin is a hormone required for the cells to use blood sugar for ...
have a threefold increase in the prevalence of postpartum thyroiditis than non-diabetic women in the same region.
According to
Johns Hopkins, 3 in 100 women develop postpartum thyroiditis. Some risk factors include antithyroid antibodies, type 1 diabetes, history of thyroid problems, and family history of thyroid problems. According to the
National Institute of Health
The National Institutes of Health, commonly referred to as NIH (with each letter pronounced individually), is the primary agency of the United States government responsible for biomedical and public health research. It was founded in the late ...
, postpartum thyroiditis is especially common in Pakistan because it is an iodine-deficient country.
References
Further reading
*"Postpartum Thyroiditis." Johns Hopkins Medicine, www.hopkinsmedicine.org/health/conditions-and-diseases/postpartum-thyroiditis. Afzal, Rafia. "Thyroid disorders in pregnancy: An overview of literature from Pakistan." Indian journal of endocrinology and metabolism vol. 17,5 (2013): 943–5. doi:10.4103/2230-8210.117202
{{Pathology of pregnancy, childbirth and the puerperium
Thyroid disease
Pathology of pregnancy, childbirth and the puerperium