Dear happy colleague, Do you routinely check thyroid functions in your pregnant patients? A systematic review and meta-analysis of maternal thyroid dysfunction during pregnancy and the risk of adverse outcomes in the offspring has shown both hypo and hyperthyroidism has an association with ADHD (attention deficit and hyperactivity disorder) in the child, as well as epilepsy. Hypothyroidism has also been associated with the offspring being autistic.
When would you consider or offer thyroid tests for your patients? Other than clinical features of thyroid dysfunction, offer tests for thyroid dysfunction to adults, children and young people with type 1 diabetes or other autoimmune diseases, or new-onset atrial fibrillation. Consider tests for thyroid dysfunction for adults, children and young people with depression or unexplained anxiety, or with abnormal growth, or unexplained change in behaviour or school performance. Be aware that in menopausal women symptoms of thyroid dysfunction may be mistaken for menopause – this is a new practice addition for me! Many systematised healthcare programs do not offer routine third trimester ultrasounds in pregnancy, citing low clinical requirements. Notably, suspicion of IUGR definitely does require sonographic monitoring. However have you ever considered a third trimester ultrasound to detect anomalies in the baby? For those not had previous scans, it is a requirement. Surprisingly (for me) 1 in 300 of routine third trimester ultrasounds reveals fetal anomalies previously missed.
Warning: utilise this data with your socio-economic milieu in mind! With the recent KESES online discussion and seminar, it was noted that many practitioners are not clear on treatment guidelines where PCOS is concerned. The discussion was fruitful in that many myths were busted, and attendees left having a clearer idea on how best to approach the PCOS patient. I do not want to reiterate the points put forth then – I highly recommend you attend the KESES seminars as they are beyond just educative/informative due to the quality of the presenters, they are also well worth the time spent. One small addition to the academic information is Metformin and it’s association with pregnancy outcomes in women undergoing IVF – other than a reduced risk of OHSS, there is no other than benefit (especially if BMI < 26) as per a recent systematic review and meta-analysis. Keep it up, KESES (Kenya Society of Endoscopic Specialities)! The WHO recommendations on drug treatment for non-severe hypertension in pregnancy (2020) interestingly show a move away from using calcium-channel blockers such as Nifedipine, citing research showing that these are more likely to cause pre-eclampsia. Methyldopa has stood the test of time antenatally, and the beta-blockers are getting more and more favourable. Since we routinely (I hope) test for Hepatitis B (HepBsAg) in pregnancy, what do we do once it is positive? Further testing is required, having invited the infectious disease team over to help. What is important in our field is that it has been shown (WHO, 2020) that peripartum antiviral prophylaxis is highly effective at reducing the risk of HBV MTCT, other than infant immunoprophylaxis. So be sure to prescribe tenofovir disoproxil fumarate in labour! It seems to be the season for diabetes in pregnancy, with an apparent spike in numbers of cases that we are seeing at the hospital. Albeit low-certainty evidence, diet plus exercise, metformin, myo‐inositol, and vitamin D help prevent the mother developing gestational diabetes in pregnancy. Better late than never to consider these factors in for those who are at risk of developing GDM. Warm wishes, Raj H. Dodia _/|\_ References: Ge GM, Leung MTY, Man KKC, et al. Maternal thyroid dysfunction during pregnancy and the risk of adverse outcomes in the offspring: a systematic review and meta-analysis [published online ahead of print, 2020 Aug 18]. J Clin Endocrinol Metab. 2020;dgaa555. doi:10.1210/clinem/dgaa555 https://www.nice.org.uk/guidance/ng145/chapter/Recommendations Drukker L, Elizabeth B, Rodriguez GB, Roberts NW, Impey L, Papageorghiou AT. How often do we identify fetal abnormalities during routine third-trimester ultrasound? A systematic review and meta-analysis [published online ahead of print, 2020 Aug 13]. BJOG. 2020;10.1111/1471-0528.16468. doi:10.1111/1471-0528.16468 Wu Y, Tu M, Huang Y, Liu Y, Zhang D. Association of Metformin With Pregnancy Outcomes in Women With Polycystic Ovarian Syndrome Undergoing In Vitro Fertilization: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020;3(8):e2011995. Published 2020 Aug 3. doi:10.1001/jamanetworkopen.2020.11995 Funk AL, Lu Y, Yoshida K, et al. Efficacy and safety of antiviral prophylaxis during pregnancy to prevent mother-to-child transmission of hepatitis B virus: a systematic review and meta-analysis [published online ahead of print, 2020 Aug 14]. Lancet Infect Dis. 2020;S1473-3099(20)30586-7. doi:10.1016/S1473-3099(20)30586-7 https://www.cochranelibrary.com/cca/doi/10.1002/cca.3219/full
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