|Year : 2013 | Volume
| Issue : 2 | Page : 56-59
Pre-conception counseling: A thyroidology perspective
Bharti Kalra1, Swati Agrawal2, Sanjay Kalra3
1 Department of Gynaecology, Bharti Hospital and BRIDE, Karnal, Haryana, India
2 Department of Gynaecology, Gajara Raja Medical College, Gwalior, Madhya Pradesh, India
3 Department of Endocrinology, Bharti Hospital and BRIDE, Karnal, Haryana, India
|Date of Web Publication||16-Apr-2013|
Department of Endocrinology, Bharti Hospital & BRIDE, Karnal, Haryana
Source of Support: None, Conflict of Interest: None
Pre-conception counseling (PCC), an integral part of obstetric care, is essential for appropriate diagnosis and management of various endocrine and non-endocrine diseases. The concept of PCC has not been adequately highlighted in thyroidology so far. This is surprising, as thyroid disorders are a common medical comorbidity in pregnancy and can potentially harm both maternal and fetal health. This article lays down a framework which can be followed by both obstetricians and endocrinologists while counseling patients planning pregnancy.
Keywords: Graves′ disease, hypothyroidism, soft skills, thyroid cancer, thyroid nodules
|How to cite this article:|
Kalra B, Agrawal S, Kalra S. Pre-conception counseling: A thyroidology perspective. Thyroid Res Pract 2013;10:56-9
| Introduction|| |
Pre-conception counseling (PCC) is accepted as an important part of obstetric care. Disease-specific PCC, related to endocrine as well as non-endocrine diseases, is imperative for achieving optimal therapeutic outcomes, both fetal and maternal, in many conditions. This concept is accepted by both obstetricians and physicians, dealing with illnesses as varied as diabetes mellitus, congenital adrenal hyperplasia, and thalassemia.
Thyroid physiology has a clinically significant impact on pregnancy. Thyroid dysfunction, both hypothyroidism and hyperthyroidism, is linked with subfertility, pregnancy loss, preterm labor, and congenital malformations.  The presence of thyroid dysfunction also implies added financial impact during pregnancy, in terms of extra investigations, and increased frequency of follow-up. There also exist potential psychosocial concerns, of the patient and her family, who worry about the possible negative effects on maternal and fetal health.
Many of these issues, biological, psychological, as well as social, can easily be addressed by adequate PCC. PCC can help minimize the negative effect of thyroid dysfunction on pregnancy. Unfortunately, this aspect of medicine has not been highlighted adequately, in both thyroidology and gynecology fora. While all relevant aspects of diagnosis and management of thyroid disease during pregnancy/postpartum have recently been covered in the exhaustive guidelines published by various professional bodies, none of them highlight the importance of PCC, except in relation to Graves' disease. Neither is the concept of patient-centered care discussed by these guidelines. ,, This is in stark contrast to the recent developments in other subspecialities of endocrinology, such as diabetology, where patient centeredness defines the professional approach to management.  This paper defines a framework for PCC from a thyroidology perspective, utilizing recent recommendations ,, and adding other patient-relevant issues.
| Benefits of PCC|| |
PCC provides multiple benefits from a thyroidology perspective. These benefits extend far beyond the therapeutic advantages that accrue to the patient planning conception.
Patient benefits: PCC ensures that patients are euthyroid prior to conception, and have optimized their medical health. This in turn optimizes pregnancy outcomes.
Provider benefits: PCC strengthens the bond between patient and health care provider (HCP) by providing the patient with the reassurance that the HCP cares for her well-being.
Family benefits: PCC includes an explanation of the investigations that will be performed, the frequency at which they be done, and the reason for ordering them. This allows the family to plan for the financial impact of these tests, which is important in a pay-from-pocket environment.
Health care system benefits: PCC allows the health care system to plan for intensive antenatal follow-up and achieve concordance between obstetric and endocrine care providers. It also helps laboratory services understand future requirements for specific investigations such as thyroid antibodies and analytical free T4 estimation.
| PCC and Patient-Centered Professionalism|| |
PCC is a perfect example of patient-centered professionalism in action. During PCC, the HCP is able to understand the patient's values, concerns, and needs. PCC also allows the HCP to share information with the patient and her family, thus ensuring a state of equipoise and encouraging effective shared decision making (SDM).
It is widely accepted that we do not have definite answers to many vexing questions in obstetric thyroidology. In such a scenario, SDM is a practical method of planning therapy. PCC is the first step in this process.
| PCC and Therapeutic Patient Education|| |
Counseling is similar in many ways to education, and PCC incorporates the element of patient education. Though the term therapeutic patient education (TPE) was coined for other chronic diseases such as asthma and diabetes mellitus,  it is applicable to thyroid disorders as well. Explaining the natural course of the patient's condition and discussing possible plans of action, prior to executing them, helps the patient cope better with her illness. It also promotes adherence to, and concordance with, suggested therapy, thus providing a therapeutic effect.
| Thyroid Function Tests|| |
Normal values of thyroid function tests vary from trimester to trimester, from laboratory to laboratory. Most commercial laboratories do not mention pregnancy-specific reference ranges. The following thyroid stimulating hormone (TSH) values are generally taken as normal in pregnancy: ,
The upper limit of normal for T4 should be multiplied by 1.5 for use in pregnancy. In certain cases, the endocrinologist may prescribe other tests such as thyroid antibodies or FT4.
- First trimester: 0.1-2.5 mIU/L
- Second trimester: 0.2-3.0 mIU/L
- Third trimester: 0.3-3.0 mIU/L
Radioactive iodine (RAI) scanning or RAI uptake tests will not be ordered during pregnancy. If such a test has been ordered and the patient has missed her periods, she should inform her endocrinologist.
| Adverse Obstetric Outcomes|| |
Thyroid disease is one of the, but not the only, causes of subfertility, spontaneous pregnancy loss, and preterm delivery. Do not begin thyroid medicines on your own without consulting your HCP.
| Management of Hypothyroidism|| |
- Prior to conception
Management of hypothyroidism, targeting appropriate TSH levels, helps reduce adverse outcomes. Lower TSH levels are linked with better outcomes, provided they remain within normal limits. It may be necessary to order further investigations, such as free T4 and thyroid antibodies, to decide whether to initiate therapy in some treatment-naive patients.
Euthyroid status should be ensured prior to conception, with a target TSH <2.5 mIU/L. Low-dose thyroxine supplementation may be prescribed to achieve this. 
- During pregnancy
The dose of l-thyroxine may need to be increased at conception, by up to 30%, in patients already on l-thyroxine supplementation. If on treatment, a hypothyroid patient can independently increase her dose of l-thyroxine by 25-30% if she misses a menstrual period or observes a positive urine pregnancy test. A simple way of doing so is to take two extra tablets of l-thyroxine every week. ,
However, the patient should contact both her obstetrician and endocrinologist immediately after diagnosis of pregnancy to ensure overall optimal care.
Maternal serum TSH should be monitored every 4 weeks till 20 weeks gestation, and at least once between 26 and 32 weeks, to allow for dose adjustment of l-thyroxine. It is possible that the endocrinologist orders regular TSH monitoring without prescribing treatment. In such a scenario, the patient should adhere to the suggested management plan.
- After delivery
The patient can reduce her dose of l-thyroxine to preconception levels immediately after delivery. A repeat TSH test should be done 6 weeks postpartum.
| Management of Hyperthyroidism|| |
- Prior to conception
Euthyroid status should be achieved prior to conception and appropriate contraceptive measures should be taken till this is achieved. Euthyroidism may be achieved by medical means (before and during first trimester), by surgery, or by RAI.
Pregnancy should be delayed for at least 6 months after RAI intake. A pregnancy test should also be performed prior to radioablation. Ideally, RAI-based diagnostic and therapeutic interventions should be planned in the early follicular phase of the menstrual cycle to avoid inadvertent fetal exposure.
- During pregnancy
The treatment of choice for hyperthyroidism during pregnancy is antithyroid drugs: propylthiouracil in the first trimester, and methimazole or carbimazole later on. Regular follow-up should be maintained with the endocrinologist, who may order investigations as frequently as 2-4 weeks.
There is a slight chance of exacerbation of symptoms during early pregnancy, but this is self-limiting. Thyroid surgery is rarely indicated during pregnancy, if at all. If absolutely necessary, it may be carried out during the second trimester.
- After delivery
Antithyroid drugs are safe in lactating mothers, and will be prescribed in divided doses, to be taken immediately after a breast feed.
| Additional Investigations|| |
No additional obstetric investigations will be ordered because of thyroid disease in pregnancy. All advice given by the obstetrician should be adhered to.
| Mineral Intake|| |
Though there is no recommendation from major professional bodies, selenium therapy has been found to be of benefit in some patients.
All clinical practice guidelines recommend taking an iodine-containing multivitamin during pregnancy. A minimum of 250 μg of daily iodine intake should be ensured, preferably in the form of potassium iodide;only iodized salt should be consumed.
| Thyroid Nodules and Cancer|| |
Development of a thyroid nodule will arrant a detailed history taking and clinical examination, serum TSH testing, and a neck ultrasound. Other tests may be ordered by the endocrinologist. Fine needle aspiration cytology (FNAC) is a safe test, with no risk to the mother or fetus. However, based on clinical features, the endocrinologist may postpone FNAC till delivery has taken place. Similarly, surgery may be deferred till delivery has taken place. However, if absolutely indicated (as in a large medullary carcinoma or a medullary carcinoma with extensive lymph node metastases), surgery can safely be performed during the second trimester. Other indications of surgery may include rapid increase in nodule size (clinically or on ultrasonography), difficulty in breathing, swallowing or speaking, or growth of nodes in the neck or elsewhere in the body.
| Mode of Delivery|| |
Thyroid disease is in itself not on indication for Cesarean section. The timing and mode of delivery will be decided by the obstetrician, based on multiple obstetric and medical factors. TSH values will not influence this decision making.
| Vertical Transmission|| |
The background prevalence of thyroid dysfunction in the general population is very high. It is not true that a mother with thyroid disease will deliver a child with thyroid dysfunction. Congenital thyroid disease is usually not inherited.
| Postpartum Thyroiditis|| |
Thyroid dysfunction may occur up to 1 year after delivery. This occurs more often in women with positive antibodies, and may present with varied clinical manifestations, depending on the phase in which it is identified. Regular investigations are needed to diagnose and monitor the condition.
| Financial Impact|| |
In a pay-from-pocket environment, PCC should include discussion on costs of anticipated outdoor clinic visits and investigations. This helps the patient, and her family, plan for future expenses.
| Soft Skills in Counseling|| |
PCC is not just a recitation of the facts mentioned above. Effective PCC involves two-way communication, with the HCP trying to elicit the specific concerns and doubts of the patient, as well as answering her queries and questions. The acronym CARES has been used to describe the qualities that a counselor should try to inculcate. These include: confident competence, authentic accessibility, reciprocal respect, expressive empathy, and straightforward simplicity.  The WATER approach to counseling is a simple strategy to incorporate soft skills into this process. This suggests a Warm welcome to the patient, followed by Asking and assessing her needs, Telling the truth while Explaining with empathy, and ending with Reassurance and a request to return.  Soft skills are an essential tool for PCC to be effective.
| Conclusion|| |
Simple and effective, straightforward and efficient, PCC should be highlighted as an important part of therapy in obstetric thyroidology. Incorporating the principles of patient-centered care and TPE, PCC provides a tool to engage and empower patients, while involving them in SDM. This may help improve concordance to the suggested diagnostic and therapeutic interventions, and thus improve outcomes, for both mother and fetus.
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