Postpartum thyroiditis diagnostic criteria: Difference between revisions

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Latest revision as of 17:35, 10 November 2017

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sunny Kumar MD [2]

Overview

There are no established criteria for the diagnosis of postpartum thyroiditis (PPT). However, PPT can be diagnosed on the basis of level of TSH, free T4, free T3, radio-iodine uptake, presence of anit-TPO antibodies and absence of TSH receptor antibodies.

Diagnostic Criteria

There are no established criteria for the diagnosis of PPT. The following findings may contribute to the diagnosis of PPT:^[1]

Hyperthyroid phase: Set of following laboratory values on one or more occasions

TSH: low or suppresed
Anti-TPO antibodies: Postive
TSH-receptor antibodies: Negative
Free T4: Typical raised but may be normal
Free T3: Raised or normal with or without raised FT4
Radio-iodine uptake: Decreased

Hypothyroid phase:

TSH: >3.6 mU/L
Anti-TPO antibodies: Postive
Free T4: <8 pmol/l
Free T3: <4.2 pmol/l
Radio-iodine uptake: Decreased
Thyroid gland tenderness: Non-tender but may be tender sometime^[2]
ESR: Normal^[3]

Stepwise clinical diagnosis of Postpartum thyroiditis

The clinical approach to the diagnosis of postpartum thyroiditis is given below.

Prior episode of Postpartum thyroiditis

Family history of autoimmune disease or thyroid disease or postive anti-TPO antibody

Goiter or diabetes mellitus

Symptoms or signs of thyroid dysfunction in postpartum period

Check:
• ‡TFT and
• Anti-TPO antibodies titres in postpartum period

Panel A:
•TSH>4.0
•Normal FT4
•-/+ Anti-TPO

Panel B:
•TSH>4.0
•Low FT4
•-/+ Anti-TPO

Panel C:
•TSH=0.3-4.0
•Normal FT4
•+ Anti-TPO

Subclinical
hypothyroid phase of †PPT

Possible
autoimmune thyroidits

Repeat TSH
after 3-6months

If TSH<1.0

Treat with
Levothyroxine

•TSH>4.0
•Low FT4

•TSH=0.3-4.0
•Normal FT4

Panel D:
•TSH<1.0
•+ Anti-TPO

Repeat TSH
in 3-6 months

Repeat TSH in
3-6months

FT4
high

FT4
normal

FT4
low

Consider tapering levothyroxine

Repeat TSH in
3-6months

Dignosed as
hyperthyroid
phase of †PPT

Subclinical
hyperthyroidisum
phase of †PPT

Possible hypo-pituitary hypothyroidism

•TSH>4.0
•Treat
Levothyroxine

•TSH=0.3-4.0
•Repeat TSH
3-6months

‡TFT; Thyroid function tests(TSH, T4, and T3), †PPT=Postpartum thyroiditis,. TSH units in micro-grams per deciliter

Adopted from AFP^[4]

References

↑ Stagnaro-Green A (2002). "Clinical review 152: Postpartum thyroiditis". J Clin Endocrinol Metab. 87 (9): 4042–7. doi:10.1210/jc.2002-020524. PMID 12213841.
↑ Stagnaro-Green A (2002). "Clinical review 152: Postpartum thyroiditis". J Clin Endocrinol Metab. 87 (9): 4042–7. doi:10.1210/jc.2002-020524. PMID 12213841.
↑ Stagnaro-Green A (2002). "Clinical review 152: Postpartum thyroiditis". J Clin Endocrinol Metab. 87 (9): 4042–7. doi:10.1210/jc.2002-020524. PMID 12213841.
↑ "Thyroiditis: Differential Diagnosis and Management - American Family Physician".

Template:WH Template:WS De Groot LJ, Chrousos G, Dungan K, Feingold KR, Grossman A, Hershman JM, Koch C, Korbonits M, McLachlan R, New M, Purnell J, Rebar R, Singer F, Vinik A, Lazarus J. PMID 25905287. Missing or empty |title= (help)

[pmid12213841-1] Stagnaro-Green A (2002). "Clinical review 152: Postpartum thyroiditis". J Clin Endocrinol Metab. 87 (9): 4042–7. doi:10.1210/jc.2002-020524. PMID 12213841.

[pmid122138413-2] Stagnaro-Green A (2002). "Clinical review 152: Postpartum thyroiditis". J Clin Endocrinol Metab. 87 (9): 4042–7. doi:10.1210/jc.2002-020524. PMID 12213841.

[pmid122138412-3] Stagnaro-Green A (2002). "Clinical review 152: Postpartum thyroiditis". J Clin Endocrinol Metab. 87 (9): 4042–7. doi:10.1210/jc.2002-020524. PMID 12213841.

[urlThyroiditis:_Differential_Diagnosis_and_Management_-_American_Family_Physician-4] "Thyroiditis: Differential Diagnosis and Management - American Family Physician".

[1]

[2]

[3]

[4]

@@ Line 2: / Line 2: @@
 {{Postpartum thyroiditis}}
-{{CMG}}; {{AE}}{{SKA}}, {{MMF}}
+{{CMG}}; {{AE}}{{SKA}}
 ==Overview==
-There are no established criteria for the diagnosis of PPT but it can be diagnosed on basis of level of TSH, free T, free T3, radio-iodine, uptake presence of anit-TPO antibodies and absence of TSH receptor antibodies depending on the phase of disease<ref name="pmid12213841" />
+There are no established criteria for the diagnosis of [[postpartum thyroiditis]] ([[Postpartum thyroiditis|PPT]]). However, PPT can be diagnosed on the basis of level of [[Thyroid-stimulating hormone|TSH]], free [[Thyroxine|T4]], free [[Triiodothyronine|T3]], radio-iodine uptake, presence of anit-[[Thyroid peroxidase|TPO]] [[antibodies]] and absence of [[TSH receptor]] antibodies.
 ==Diagnostic Criteria==
-*There are no established criteria for the diagnosis of PPT but it can be diagnosed on basis of level of TSH, free T, free T3, radio-iodine, uptake presence of anit-TPO antibodies and absence of TSH receptor antibodies depending on the phase of disease<ref name="pmid12213841">{{cite journal| author=Stagnaro-Green A| title=Clinical review 152: Postpartum thyroiditis. | journal=J Clin Endocrinol Metab | year= 2002 | volume= 87 | issue= 9 | pages= 4042-7 | pmid=12213841 | doi=10.1210/jc.2002-020524 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12213841  }}</ref>.
+*There are no established criteria for the diagnosis of [[Postpartum thyroiditis|PPT]]. The following findings may contribute to the diagnosis of PPT:<ref name="pmid12213841">{{cite journal| author=Stagnaro-Green A| title=Clinical review 152: Postpartum thyroiditis. | journal=J Clin Endocrinol Metab | year= 2002 | volume= 87 | issue= 9 | pages= 4042-7 | pmid=12213841 | doi=10.1210/jc.2002-020524 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12213841  }}</ref>
-*Hyperthyroid phase: Set of following laboratory values on one or more occasions
+'''Hyperthyroid phase''': Set of following laboratory values on one or more occasions
-*TSH: low or suppresed
+*[[Thyroid-stimulating hormone|'''TSH''']]: low or suppresed
-*Anti-TPO antibodies: Postive
+*'''Anti-[[Thyroid peroxidase|TPO]] [[antibodies]]''': Postive
-*TSH-receptor antibodies: Negative
+*'''TSH-receptor [[antibodies]]''': Negative
-*Free T4: Typical raised but may be normal.
+*'''Free T4''': Typical raised but may be normal
-*Free T3: Raised or normal with or without raised FT4.
+*'''Free T3''': Raised or normal with or without raised FT4
-*Radio-iodine uptake: Decreased.
+*'''Radio-iodine uptake''': Decreased
-*Hypothyroid phase:
+'''Hypothyroid phase:'''
-*TSH: >3.6 mU/L
+*'''TSH''': >3.6 mU/L
-*Anti-TPO antibodies: Postive
+*'''Anti-[[Thyroid peroxidase|TPO]] [[antibodies]]''': Postive
-*Free T4: <8 pmol/l
+*'''Free T4''': <8 pmol/l
-*Free T3: <4.2 pmol/l
+*'''Free T3''': <4.2 pmol/l
-*Radio-iodine uptake: Decreased.
+*'''Radio-iodine uptake''': Decreased
-*Thyroid gland tenderness: Non-tender but may be tender sometime.<ref name="pmid122138413">{{cite journal| author=Stagnaro-Green A| title=Clinical review 152: Postpartum thyroiditis. | journal=J Clin Endocrinol Metab | year= 2002 | volume= 87 | issue= 9 | pages= 4042-7 | pmid=12213841 | doi=10.1210/jc.2002-020524 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12213841  }}</ref>
+*'''[[Thyroid gland]] tenderness''': Non-tender but may be tender sometime<ref name="pmid122138413">{{cite journal| author=Stagnaro-Green A| title=Clinical review 152: Postpartum thyroiditis. | journal=J Clin Endocrinol Metab | year= 2002 | volume= 87 | issue= 9 | pages= 4042-7 | pmid=12213841 | doi=10.1210/jc.2002-020524 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12213841  }}</ref>
-*ESR: Normal<ref name="pmid122138412">{{cite journal| author=Stagnaro-Green A| title=Clinical review 152: Postpartum thyroiditis. | journal=J Clin Endocrinol Metab | year= 2002 | volume= 87 | issue= 9 | pages= 4042-7 | pmid=12213841 | doi=10.1210/jc.2002-020524 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12213841  }}</ref>
+*'''ESR''': Normal<ref name="pmid122138412">{{cite journal| author=Stagnaro-Green A| title=Clinical review 152: Postpartum thyroiditis. | journal=J Clin Endocrinol Metab | year= 2002 | volume= 87 | issue= 9 | pages= 4042-7 | pmid=12213841 | doi=10.1210/jc.2002-020524 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12213841  }}</ref>
 ===Stepwise clinical diagnosis of Postpartum thyroiditis===
-The following flowchart describes the clinical approach to the diagnosis of thyroiditis.
+The clinical approach to the diagnosis of postpartum thyroiditis is given below.
-{{familytree/start |summary=Sample 1}}
+{{familytree/start|summary=Sample 1}}
-{{familytree | | | | | | | | | | | | A01 | | |A01=Neck pain}}
+{{familytree | | | | X01 | | | X02 | | | | X03 | | | | X04 |X01=Prior episode of [[Postpartum thyroiditis]]|X02=Family history of [[autoimmune]] disease or [[thyroid]] disease or postive [[anti-TPO antibody]]|X03=[[Goiter]] or [[diabetes mellitus]]|X04=Symptoms or signs of [[thyroid dysfunction in postpartum period]]}}
-{{familytree | | | | | | |,|-|-|-|-|-|^|-|-|-|-|-|-|.| | | | }}
+{{familytree | | | | |!| | | | |!| | | | | |!| | | | | |!}}
-{{familytree | | | | | | B01 | | | | | | | | | | | B02 | | |B01=Yes|B02=No}}
+{{familytree | | | | |`|-|-|-|-|^|-|-|v|-|-|^|-|-|-|-|-|'}}
-{{familytree | | | | | | |!| | | | | | | | | | | | |!| }}
+{{familytree |boxstyle=text-align: left; | | | | | | | | | | | | Z01 | | | Z01=Check: <br>• ‡TFT and<br>• Anti-TPO antibodies titres in postpartum period}}
-{{familytree | | | | | | C01 | | | | | | | | | | | C02 |C01=RAIU*|C02=Presenting symptoms and TFTs‡}}
+{{familytree | | | | |,|-|-|-|-|v|-|-|^|-|-|v|-|-|-|-|-|-|-|-|-|-|-|.| | | | }}
-{{familytree | | | | |,|-|^|-|-|.| | | | | | | |,|-|^|-|-|-|v|-|-|-|.| }}
+{{familytree |boxstyle=text-align: left; | | | | A01 | | | A02 | | | | A03 | | | | | | | | | | |!|A01='''Panel A:'''<br>•TSH>4.0<br>•Normal FT4 <br>•-/+ Anti-TPO|A02='''Panel B:'''<br>•TSH>4.0 <br>•Low FT4 <br>•-/+ Anti-TPO|A03='''Panel C:'''<br>•TSH=0.3-4.0 <br>•Normal FT4 <br>•+ Anti-TPO}}
-{{familytree | | | | D01 | | | D02 | | | | | | D03 | | | | D04 | |D05|D01=Increased|D02=Decreased|D03=Hyperthyroid|D04=Hypothyroid|D05=Euthyroid}}
+{{familytree | | | | |!| | | | |!| | | | | |!| | | | | | | | | | | |!}}
-{{familytree | | | | |!| | | | |!| | | | | | | |!| | | | | |!| | | |!|}}
+{{familytree | | | | B01 | | | B02 | |,|-| B03 |-| B04|-|-|-|-|-|-|(|B01=Subclinical<br>[[hypothyroid]] phase of †[[PPT]]|B02=Possible<br>[[autoimmune thyroidits]]|B03=Repeat TSH<br> after 3-6months|B04=If TSH<1.0}}
-{{familytree | | | | |!| | | | |!| | | | | | | H01 | | | | |!| | | |!|H01=RAIU*}}
+{{familytree | | | | |!| | | | |!| | |!| | |!| | | | | | | || | | |!| | | || |}}
-{{familytree | | | | |!| | | | |!| | | | | |,|-|^|-|.| | | |!| | | |!|}}
+{{familytree | | | | |)|-|-|-|-|'| | |!| | |!| | | | | | | || | | |!| | | || |}}
-{{familytree | | | | E01 | | | E04 | | | | E02 | | E03 | | E04 | | |E06 |E01=Suppurative thyroiditis|E02=Increased|E03=Decreased|E04=Hashimoto's thyroiditis|E06=Riedel's thyroiditis††}}
+{{familytree | | | |C01|-|-|C02|-|'| |C03| | | | | | | | | |C04| |C01=Treat with<br>[[Levothyroxine]]|C02=•TSH>4.0 <br>•Low FT4|C03=•[[TSH]]=0.3-4.0 <br>•Normal FT4|C04='''Panel D:'''<br>•[[TSH]]<1.0 <br>•+ Anti-TPO}}
-{{familytree | | | | | | | | | | | | | | | |!| | | |!| }}
+{{familytree | | | | |!| | | | | | | | || |!|| | | | | | | |,|-|-|+|-|-|-|.| }}
-{{familytree | | | | | | | | | | | | | | | F01 | | F02 |F01=Graves disease†|F02=
+{{familytree | | | | D01 | | | | | | | ||D02 | | | | ||D03| |D04| |D05|D01=Repeat [[TSH]]<br>in 3-6 months|D02=Repeat [[TSH]] in <br>3-6months|D03=[[FT4]]<br>high|D04=[[FT4]]<br>normal|D05=[[FT4]]<br>low}}
-Silent thyroiditis
+{{familytree | | | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | ||!|}}
+{{familytree | | | |E01| | | | | | | | | | | | | | | | | |!| | | |!| | ||!|E01=Consider tapering [[levothyroxine]]}}
+{{familytree | | | ||!|| | | | | | | | | | | | | | | | | |!| | | |!| | ||!|}}
-Postpartum thyroiditis}}
+{{familytree | | | |F01| | | | | | | | | | | | | | | | |F02||F03| |F04|F01=Repeat TSH in<br>3-6months|F02=Dignosed as<br> hyperthyroid<br>phase of †[[PPT]]|F03=Subclinical<br>hyperthyroidisum<br>phase of †[[PPT]]|F04=Possible hypo-pituitary [[hypothyroidism]]}}
+{{familytree | | | ||)|-|-|.| }}
+{{familytree | | | |J01| |J02 |J01=•TSH>4.0 <br>•Treat<br>[[Levothyroxine]]|J02=•TSH=0.3-4.0<br>•Repeat [[TSH]]<br>3-6months}}
 {{familytree/end}}
-<small>‡TFT; Thyroid function tests(TSH, T4, and T3), †Grave's disease is not a thyroiditis, *RAIU; Radioiodine uptake.††One third of Riedel's thyroiditis presents with hypothyroidism.</small>
+<small>‡TFT; Thyroid function tests(TSH, T4, and T3), †PPT=[[Postpartum thyroiditis]],.</small>
 <small>
-<br>
+TSH units in micro-grams per deciliter<br>
-Table modified from <ref name="urlThyroiditis: Differential Diagnosis and Management - American Family Physician">{{cite web |url=http://www.aafp.org/afp/2000/0215/p1047.html#afp20000215p1047-b7 |title=Thyroiditis: Differential Diagnosis and Management - American Family Physician |format= |work= |accessdate=}}</ref></small>
+Adopted from AFP<ref name="urlThyroiditis: Differential Diagnosis and Management - American Family Physician">{{cite web |url=http://www.aafp.org/afp/2000/0215/p1047.html#afp20000215p1047-b7 |title=Thyroiditis: Differential Diagnosis and Management - American Family Physician |format= |work= |accessdate=}}</ref></small>
 ==References==