摘要
目的 探讨甲状腺功能亢进症(简称甲亢)131I治疗后的妊娠期女性甲状腺功能(简称甲功)状态及左甲状腺素(L-T4)替代治疗策略.方法 回顾性分析2005年1月至2019年12月在南京鼓楼医院行甲亢131I治疗后至少半年、甲功正常后妊娠并顺利分娩的88例患者,治疗时年龄为(27.3±3.7)岁.分别检测患者妊娠前1～3个月、妊娠期(4～7周、8～12周、13～22周、23～28周、29周后)、产后(6周、3个月和6个月)的3项甲功指标:促甲状腺激素(TSH)、游离三碘甲状腺原氨酸(FT3)、游离甲状腺素(FT4),按2011年美国甲状腺协会指南血清TSH水平推荐标准,进行L-T4替代治疗以维持甲功正常.采用重复测量方差分析、最小显著差异t 检验分析数据.结果 妊娠前、妊娠期及产后各时间段的TSH、FT3、FT4和L-T4差异有统计学意义(F值:5.94、3.32、3.49、9.63,均P＜0.05).为维持妊娠各时间段甲功正常,同妊娠前1～3个月L-T4替代治疗剂量(64.52±34.32)μg相比,妊娠4～7周L-T4替代治疗剂量增加至(82.33±35.06)μg,妊娠8～12周持续增加至(100.75±36.77)μg(t值:7.33、10.44,均P＜0.001),妊娠13周后L-T4剂量增加趋缓,妊娠晚期(29周后)较妊娠前增幅达76.69％.同妊娠晚期[TSH:(2.99±1.42)mU/L,FT3:(3.90±0.55)pmoVL,FT4:(15.37±2.29)pmol/L]相比,产后 6周 TSH[(1.21±1.08)mU/L]下降(t=-2.48,P=0.017),FT3[(5.23±1.07)pmol/L]和FT4[(21.29±4.96)pmoVL]明显升高(t值:6.05、5.88,均P＜0.001),L-T4替代治疗剂量明显减少(t=-6.85,P＜0.001),但产后6周、3个月和6个月L-T4替代治疗剂量仍高于妊娠前(t值:4.67～4.71,均P＜0.001).结论 甲亢131I治疗后从妊娠前的1～3个月、妊娠期到产后6周要定期监测TSH、FT3和FT4,依血清TSH水平尽早调整L-T4替代治疗剂量.
Abstract
Objective To investigate the thyroid function status and levothyroxine(L-T4)replace-ment therapy strategy in pregnant women after 131I treatment of hyperthyroidism.Methods From January 2005 to December 2019,88 patients(age:(27.3±3.7)years)who received 131I treatment in Nanjing Drum Tower Hospital were retrospectively analyzed.They became pregnant at least half a year after 131I treatment with normal thyroid function and delivered successfully.Thyroid stimulating hormone(TSH),free triiodo-thyronine(FT3)and free thyroxine(FT4)were respectively detected at 1-3 months before pregnancy,4-7,8-12,13-22,23-28,≥29 weeks of pregnancy,and 6 weeks,3 months,6 months of postpartum.According to the 2011 American Thyroid Association guidelines,L-T4 replacement therapy was performed to maintain normal thyroid function.Repeated measures analysis of variance and the least significant difference t test were used to analyze data.Results There were significant differences in TSH,FT3,FT4 and L-T4 among different time periods before pregnancy,pregnancy and postpartum(F values:5.94,3.32,3.49,9.63,all P＜0.05).In order to maintain normal thyroid function in each period of pregnancy,the doses of L-T4 re-placement therapy were increased to(82.33±35.06)μg and(100.75±36.77)μg at 4-7,8-12 weeks of pregnancy compared with the dose((64.52±34.32)pg)before pregnancy(t values:7.33,10.44,both P＜0.001).The doses of L-T4 were increased slowly after 13 weeks of pregnancy.In the third trimester(≥29 weeks),the dose was 76.69％higher than that before pregnancy.There were significant changes of TSH,FT3 and FT4 at 6 weeks of postpartum compared with those in the third trimester(TSH:(1.21±1.08)vs(2.99±1.42)mU/L,FT3:(5.23±1.07)vs(3.90±0.55)pmol/L,FT4:(21.29±4.96)vs(15.37±2.29)pmol/L,t values:-2.48,6.05,5.88,P values:0.017,＜0.001,＜0.001).Compared with that in the third trimester,the dose of L-T4 was decreased significantly at 6 weeks of postpartum(t=-6.85,P＜0.001),but doses of L-T4 at 6 weeks,3 months and 6 months of postpartum were still higher than that before pregnancy(t values:4.67-4.71,all P＜0.001).Conclusions TSH,FT3 and FT4 should be regularly monitored at 1-3 months before pregnancy,gestation period and 6 weeks of postpartum in pregnant women after 131I treatment of hy-perthyroidism.The dose of L-T4 should be adjust to the serum TSH level as soon as possible.
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