ATA Guidelines Tools

12 Maternal Disorders Î Thyroidectomy in pregnancy may be indicated for unique scenarios. If required, the optimal time for thyroidectomy is in the second trimester of pregnancy. If maternal TRAb concentration is high (>3x upper reference for the assay) the fetus should be carefully monitored for development of fetal hyperthyroidism throughout pregnancy, even if the mother is euthyroid post-thyroidectomy. (S-H) Î We concur with the American College of Obstetricians and Gynecologists' Committee on Obstetric Practice consensus guidelines (written in 2011 and revised in 2015) which state the following: 1. "A pregnant woman should never be denied indicated surgery, regardless of trimester. 2. Elective surgery should be postponed until after delivery. 3. If possible, nonurgent surgery should be performed in the second trimester when preterm contractions and spontaneous abortion are least likely." • In the setting of a patient with Graves' Disease undergoing urgent, non-thyroid surgery, if the patient is well controlled on ATD, no other preparation is needed. Beta-blockade should also be utilized if needed. (S-M) Î TRAb Measurement a. If the patient has a past history of Graves' disease treated with ablation (radioiodine or surgery), a maternal serum determination of TRAb is recommended at initial thyroid function testing during early pregnancy. (S-M) b. If maternal TRAb concentration is elevated in early pregnancy, repeat testing should occur at weeks 18–22. (S-M) c. If maternal TRAb is undetectable or low in early pregnancy, no further TRAb testing is needed. (W-M) d. If a patient is taking ATDs for treatment of Graves' hyperthyroidism when pregnancy is confirmed, a maternal serum determination of TRAb is recommended. (W-M) e. If the patient requires treatment with ATDs for Graves' disease through mid pregnancy, a repeat determination of TRAb is again recommended at weeks 18–22. (S-M) f. If elevated TRAb is detected at weeks 18–22 or the mother is taking ATD in the third trimester, a TRAb measurement should again be performed in late pregnancy (weeks 30–34) to evaluate the need for neonatal and postnatal monitoring. (S-H) Î Fetal surveillance should be performed in women who have uncontrolled hyperthyroidism in the second half of pregnancy, and in women with high TRAb levels detected at any time during pregnancy (>3x the upper limit of normal). A consultation with an experienced obstetrician or maternal-fetal medicine specialist is recommended. Monitoring may include ultrasound to assess heart rate, growth, amniotic fluid volume, and the presence of fetal goiter. (S-M)

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