41
Table 4. Risks and Guidance for Treating Graves' Disease
During Pregnancy
Graves' disease
treatment option Risks Guidance
Total
thyroidectomy
Fetal and neonatal
hyperthyroidism
• Measure serum TRAb and/or TSI at time
of surgery, and plan to repeat at 18–20
weeks and 30–34 weeks gestation if the
result is >3 times upper limit of normal.
Maternal thyroid
storm and
complications from
anesthesia
• Aim to achieve euthyroidism
preoperatively, which likely requires
ATD use and other therapies (such
as potassium iodide, glucocorticoids,
cholestyramine, plasmapheresis) if
appropriate.
Maternal
hypothyroidism
• Higher doses of thyroid hormone
replacement are required for pregnancy.
Patient should be closely monitored
with serum thyroid function testing
postoperatively.
Surgical
complications
(hypoparathyroidism,
RLN damage)
• Refer to a high-volume surgeon.
a
Serum TRAb and/or TSI should initially be measured in the first trimester, and if elevated to >3 times
the upper limit of normal, the measurement should be repeated at 18–22 weeks and 30–34 weeks
gestation to guide need for a fetal ultrasound if the elevated TRAb and/or TSI concentration is sustained.
(cont'd)
Recommendations Table 19. Fetal Hyperthyroidism
Strength
*
Level
#
Fetal hyperthyroidism may be treated with maternal ATD
therapy. In women with underlying hypothyroidism from
past I-131 or total thyroidectomy treatment of Graves'
disease where maternal ATD therapy is required for the
management or prevention of fetal hyperthyroidism,
levothyroxine is continued for maintenance of maternal
hypothyroidism, while ATD is added for management of
fetal hyperthyroidism. Outside of this setting, block and
replace therapy is not to be used in pregnancy.
Conditional Low
* Strength of Recommendation;
#
Level of Evidence; Good Practice Statement.
