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Pathology of the thyroid gland complicating pregnancy
OBSTETRICAL
SOCIETY
OF
PHILADELPHIA
DR. C. H. FRAZIER AKD DR. HENRS F. ULRICH a paper entitled Pathology of the Thyroid nancy. (For original article see page 870.)
presented
9‘41
(by invitation)
Gland Complicating Preg-
DISCUSSION DR. PHILIP F. WILLIAMS.-We probably see fewer thyroid cases in this area than may be seen where endemic goiter is prevalent. But only about $$ of 1 per cent of these patients show symptoms of thyrotoxicosis during pregnancy. I do not coincide entirely with the idea that pregnant women need iodine routinely as a part of prenatal care. I doubt very much if any of us feel that 10 per cent of our prenatal cases show sufficient hyperthyroidism to need this. The more marked cases of hyperthyroidism stress the point which Dr. Frazier has brought up, i.e., that marked dysfunction of the thyroid gland is really no part of the pregnancy, it is a complication of pregnancy and should be handled by a thyroid surgeon. Basal metabolism alone may be misleading; it is the whole group of symptoms that must lead us to determine whether thyroidectomy is necessary. Any woman who shows severe symptoms should be seen by a thyroid specialist. Not all cases will have to have the gland removed. Probably not all cases will go through pregnancy, but certainly very few will have to have the pregnancy interrupted. I have had three recent cases with marked thyroid disturbance. The first was a primipara, aged forty-four. She was anxious to have the child, having been sterile Her amenorrhea was thought to be due to a natural menofor a number of years. pause but she was four months pregnant when I first saw her. She had a basal metabolism rate of seventy plus and a pulse rate of 144. With rest in bed and mild sedative treatment, but no iodine, she quieted down. Thyroideetomy was not considered for fear of a miscarriage, she went to term, had a ten-pound female child delivered by cesarean section on account of a breech presentation, and stood the anesthesia well, in spite of the thyroid condition. The symptoms became worse after the pregnancy and two years after the delivery a thyroidectomy was performed. A second case, also a primipara, was one of marked exophthalmie goiter complicating pregnancy at term, she had had no rest, no treatment, no iodine during the pregnancy, and went through a normal labor. An operation was suggested but it was refused and she left the hospital in poor condition. The third ease had symptoms of a severe thyrotoxicosis. She received iodine 3 or 4 times during the five months of pregnancy during which she was observed, went through a normal labor, and showed marked improvement after delivery. Two other cases were those of women upon whom thyroidectomy had been done. One went through 2 pregnancies without any- disturbances and the other through one. DR. EDWARD ROSE.-Several questions seem to me to be deserving of special mention : 1. The importance of the administration of iodine to pregnant women with and An insufficiency of iodine may and often does result in the appearwithout goiter. ance of goiter and cretinism in the infant, even though the mother has had no apparent abnormality of the thyroid gland. This constitutes more of a problem in endemic goiter districts than in our own region. But it is a. very simple and easy matter to assure the pregnant woman of an adequate supply of iodine simply by administering 10. mg., either in liquid or tablet form every week or two throughout her pregnancy. And since 50 mg. of iodine is sticient to enable the adult thyroid gland to carry out its function during a year under normal circumstances one can easily make sure that both mother and infant have a good supply. I believe that the routine administration of iodine to pregnant women is just as important a part of prenatal care as any other, and should be a part of all prenatal routine.
943
AiMERICANJOURNALOFORSTETRICSANDGTNECOLOGT
In cases where there may exist a simple, nontoxic, diffuse goiter, the dosage of iodine and the frequency of its administration should be increased somewhat. And even in the presence of hard or nodular nontoxic goitnr, it is safe to administer iodine if it is done cautiously and the patient. is kept under strict and frequent obscrration. 2. The tendency of pregnancy to be followed by an aggravation of preexistent simple goiter, or hyperthyroidism, or by the development of simple or toxic goiter is well known. In 635 cases at the University Hospital which Dr. Frazier and I analyzed in 1930, 9.9 per cent of the women with toxic goiter, stated that pregnancy immediately preceded the onset of their symptoms, or greatly increased them. I know that there is considerable difference of opinion on this subject, but I feel that pregnancy is a very important etiologie f:tctor in both hypcrthyroidism and simple goiter. I am glad that the speakers refrained from assuming a dogmatic position on the necessity for or value of thyroidectomy in these cases. Herr again there is a very great variety of opinion. It is generally true that most pregnant patients stand thyroidectomy very well, but any operation presents a threat to the eontinuation of pregnancy which cannot be ignored. I feel t,hat discretion should be used in these cases and that a trial with iodine is often worth while. Even though the patient cannot be cured, she can often be carried along in a reduced sta.te of toxicity and have the operation performed after labor. DR. EDWARD A. SCHUMANN.--‘Until a short time ago surgeons have been reluctant to operate upon patients presenting evidences of acute thyroid toxemia during pregnancy. There is one point to which I beg to direct attention, the occasional occurrence of rapidly developing symptoms of thyroid toxemia during pregnancy, which symptoms, whether treated or not, last perha.ps a month or six weeks and then gradually decline in severity, disappearing after delivery. Patients suffering from this syndrome might readily be subjected to unnecessary thyroidectomy. DR. FRAZIER (closing).-In the discussion on the relation of thyrotoxicosis to pregnancy one question has not been touched. For how long after an operation for the relief of thyrotoxicosis should the patient be cautioned against conception. In the patient already married or in the one contemplating matrimony our opinion is frequently sought and invariably we recommend an interval of at least a year. In those cases operated upon in t,he pregnant state we recommend an interval of two years. In certain of the severe cases in our series that were operated upon during pregnancy, the induction of labor had been seriously considered. I do not believe that this should ever be considered as an appropriate way of managing a toxic thyroid during pregnancy or to put it another way, the principles underlying the treatment of toxic goiter during pregnancy differ in no respect from those in the nonpregnant state. Once the diagnosis is established it is safer for both mother and child to remove the toxic gland.
WD DR. I. ANDRUSSIER presented a paper entitled Prolapse of the Ovary, Due to Elongation of the InLigament, Its Treatment. (For original article see
DR. B. C. HIRST
Uncomplicated fundibulopelvic page 879.)
DISCUSSION DR. EDWARD upon this condition, due to subinvolution
A.
SCHUMANN.-Penrose, Baldy and Beyea laid great regarding it as frequently congenital in origin, though of the uterus following pregnancy or abortion. The left
stress often ovary
SOCIETY
OF
PHILADELPHIA
DR. C. H. FRAZIER AKD DR. HENRS F. ULRICH a paper entitled Pathology of the Thyroid nancy. (For original article see page 870.)
presented
9‘41
(by invitation)
Gland Complicating Preg-
DISCUSSION DR. PHILIP F. WILLIAMS.-We probably see fewer thyroid cases in this area than may be seen where endemic goiter is prevalent. But only about $$ of 1 per cent of these patients show symptoms of thyrotoxicosis during pregnancy. I do not coincide entirely with the idea that pregnant women need iodine routinely as a part of prenatal care. I doubt very much if any of us feel that 10 per cent of our prenatal cases show sufficient hyperthyroidism to need this. The more marked cases of hyperthyroidism stress the point which Dr. Frazier has brought up, i.e., that marked dysfunction of the thyroid gland is really no part of the pregnancy, it is a complication of pregnancy and should be handled by a thyroid surgeon. Basal metabolism alone may be misleading; it is the whole group of symptoms that must lead us to determine whether thyroidectomy is necessary. Any woman who shows severe symptoms should be seen by a thyroid specialist. Not all cases will have to have the gland removed. Probably not all cases will go through pregnancy, but certainly very few will have to have the pregnancy interrupted. I have had three recent cases with marked thyroid disturbance. The first was a primipara, aged forty-four. She was anxious to have the child, having been sterile Her amenorrhea was thought to be due to a natural menofor a number of years. pause but she was four months pregnant when I first saw her. She had a basal metabolism rate of seventy plus and a pulse rate of 144. With rest in bed and mild sedative treatment, but no iodine, she quieted down. Thyroideetomy was not considered for fear of a miscarriage, she went to term, had a ten-pound female child delivered by cesarean section on account of a breech presentation, and stood the anesthesia well, in spite of the thyroid condition. The symptoms became worse after the pregnancy and two years after the delivery a thyroidectomy was performed. A second case, also a primipara, was one of marked exophthalmie goiter complicating pregnancy at term, she had had no rest, no treatment, no iodine during the pregnancy, and went through a normal labor. An operation was suggested but it was refused and she left the hospital in poor condition. The third ease had symptoms of a severe thyrotoxicosis. She received iodine 3 or 4 times during the five months of pregnancy during which she was observed, went through a normal labor, and showed marked improvement after delivery. Two other cases were those of women upon whom thyroidectomy had been done. One went through 2 pregnancies without any- disturbances and the other through one. DR. EDWARD ROSE.-Several questions seem to me to be deserving of special mention : 1. The importance of the administration of iodine to pregnant women with and An insufficiency of iodine may and often does result in the appearwithout goiter. ance of goiter and cretinism in the infant, even though the mother has had no apparent abnormality of the thyroid gland. This constitutes more of a problem in endemic goiter districts than in our own region. But it is a. very simple and easy matter to assure the pregnant woman of an adequate supply of iodine simply by administering 10. mg., either in liquid or tablet form every week or two throughout her pregnancy. And since 50 mg. of iodine is sticient to enable the adult thyroid gland to carry out its function during a year under normal circumstances one can easily make sure that both mother and infant have a good supply. I believe that the routine administration of iodine to pregnant women is just as important a part of prenatal care as any other, and should be a part of all prenatal routine.
943
AiMERICANJOURNALOFORSTETRICSANDGTNECOLOGT
In cases where there may exist a simple, nontoxic, diffuse goiter, the dosage of iodine and the frequency of its administration should be increased somewhat. And even in the presence of hard or nodular nontoxic goitnr, it is safe to administer iodine if it is done cautiously and the patient. is kept under strict and frequent obscrration. 2. The tendency of pregnancy to be followed by an aggravation of preexistent simple goiter, or hyperthyroidism, or by the development of simple or toxic goiter is well known. In 635 cases at the University Hospital which Dr. Frazier and I analyzed in 1930, 9.9 per cent of the women with toxic goiter, stated that pregnancy immediately preceded the onset of their symptoms, or greatly increased them. I know that there is considerable difference of opinion on this subject, but I feel that pregnancy is a very important etiologie f:tctor in both hypcrthyroidism and simple goiter. I am glad that the speakers refrained from assuming a dogmatic position on the necessity for or value of thyroidectomy in these cases. Herr again there is a very great variety of opinion. It is generally true that most pregnant patients stand thyroidectomy very well, but any operation presents a threat to the eontinuation of pregnancy which cannot be ignored. I feel t,hat discretion should be used in these cases and that a trial with iodine is often worth while. Even though the patient cannot be cured, she can often be carried along in a reduced sta.te of toxicity and have the operation performed after labor. DR. EDWARD A. SCHUMANN.--‘Until a short time ago surgeons have been reluctant to operate upon patients presenting evidences of acute thyroid toxemia during pregnancy. There is one point to which I beg to direct attention, the occasional occurrence of rapidly developing symptoms of thyroid toxemia during pregnancy, which symptoms, whether treated or not, last perha.ps a month or six weeks and then gradually decline in severity, disappearing after delivery. Patients suffering from this syndrome might readily be subjected to unnecessary thyroidectomy. DR. FRAZIER (closing).-In the discussion on the relation of thyrotoxicosis to pregnancy one question has not been touched. For how long after an operation for the relief of thyrotoxicosis should the patient be cautioned against conception. In the patient already married or in the one contemplating matrimony our opinion is frequently sought and invariably we recommend an interval of at least a year. In those cases operated upon in t,he pregnant state we recommend an interval of two years. In certain of the severe cases in our series that were operated upon during pregnancy, the induction of labor had been seriously considered. I do not believe that this should ever be considered as an appropriate way of managing a toxic thyroid during pregnancy or to put it another way, the principles underlying the treatment of toxic goiter during pregnancy differ in no respect from those in the nonpregnant state. Once the diagnosis is established it is safer for both mother and child to remove the toxic gland.
WD DR. I. ANDRUSSIER presented a paper entitled Prolapse of the Ovary, Due to Elongation of the InLigament, Its Treatment. (For original article see
DR. B. C. HIRST
Uncomplicated fundibulopelvic page 879.)
DISCUSSION DR. EDWARD upon this condition, due to subinvolution
A.
SCHUMANN.-Penrose, Baldy and Beyea laid great regarding it as frequently congenital in origin, though of the uterus following pregnancy or abortion. The left
stress often ovary