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==Overview==
==Overview==
There are no established criteria for the diagnosis of [[postpartum thyroiditis]]"[[Postpartum thyroiditis|PPT]]" but it can be diagnosed on 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 depending on the phase of disease.
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==
==Diagnostic Criteria==
*There are no established criteria for the diagnosis of [[Postpartum thyroiditis|PPT]] but it can be diagnosed on 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 [[Thyrotropin receptor|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
*[[Thyroid-stimulating hormone|'''TSH''']]: low or suppresed
*[[Thyroid-stimulating hormone|'''TSH''']]: low or suppresed
*'''Anti-[[Thyroid peroxidase|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
Line 20: Line 20:
*'''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===
===Stepwise clinical diagnosis of Postpartum thyroiditis===
The following flowchart describes the clinical approach to the diagnosis of postpartum thyroiditis.
The clinical approach to the diagnosis of postpartum thyroiditis is given below.
 
{{familytree/start|summary=Sample 1}}
{{familytree/start |summary=Sample 1}}
{{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 | | | | | | | | | | | | Z01 | | | Z01=*Prior PPT episode<br>*Family history of autoimmune disease<br>*thyroid disease<br>*Postive anti-TPO<br>*DM<br>*Goiter<br>Depression<br>*symptoms/signs of thyroid dysfunction in postpartum period }}
{{familytree | | | | |!| | | | |!| | | | | |!| | | | | |!}}
{{familytree | | | | |`|-|-|-|-|^|-|-|v|-|-|^|-|-|-|-|-|'}}
{{familytree |boxstyle=text-align: left; | | | | | | | | | | | | Z01 | | | Z01=Check: <br>• ‡TFT and<br>• Anti-TPO antibodies titres in postpartum period}}
{{familytree | | | | |,|-|-|-|-|v|-|-|^|-|-|v|-|-|-|-|-|-|-|-|-|-|-|.| | | | }}
{{familytree | | | | |,|-|-|-|-|v|-|-|^|-|-|v|-|-|-|-|-|-|-|-|-|-|-|.| | | | }}
{{familytree | | | | 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 |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 | | | | |!| | | | |!| | | | | |!| | | | | | | | | | | |!}}
{{familytree | | | | |!| | | | |!| | | | | |!| | | | | | | | | | | |!}}
{{familytree | | | | B01 | | | B02 | |,|-| B03 |-| B04|-|-|-|-|-|-|(|B01=subclinical<br>[[hypothyroid]]|B02=Possible<br>AITD|B03=Repeat TSH<br>3-6months|B04=If TSH<1.0}}
{{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 | | | | |!| | | | |!| | |!| | |!| | | | | | | || | | |!| | | || |}}
{{familytree | | | | |!| | | | |!| | |!| | |!| | | | | | | || | | |!| | | || |}}
{{familytree | | | | |)|-|-|-|-|'| | |!| | |!| | | | | | | || | | |!| | | || |}}
{{familytree | | | | |)|-|-|-|-|'| | |!| | |!| | | | | | | || | | |!| | | || |}}
{{familytree | | | |C01|-|-|C02|-|'| |C03| | | | | | | | | |C04| |C01=Treat<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 | | | |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 | | | | D01 | | | | | | | ||D02 | | | | ||D03| |D04| |D05|D01=Repeat [[TSH]]<br>3-6months|D02=Repeat [[TSH]]<br>3-6months|D03=[[FT4]]<br>high|D04=[[FT4]]<br>normal|D05=[[FT4]]<br>low}}
{{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}}
{{familytree | | | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | ||!|}}
{{familytree | | | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | ||!|}}
{{familytree | | | |E01| | | | | | | | | | | | | | | | | |!| | | |!| | ||!|E01=Consider tapering [[Levothyroxine]]}}
{{familytree | | | |E01| | | | | | | | | | | | | | | | | |!| | | |!| | ||!|E01=Consider tapering [[levothyroxine]]}}
{{familytree | | | ||!|| | | | | | | | | | | | | | | | | |!| | | |!| | ||!|}}
{{familytree | | | ||!|| | | | | | | | | | | | | | | | | |!| | | |!| | ||!|}}
{{familytree | | | |F01| | | | | | | | | | | | | | | | |F02||F03| |F04|F01=Repeat TSH<br>3-6months|F02=dignosed as<br> hyperthyroid|F03=subclinical<br>hyperthyroidisum|F04=possible hypopituitary cause}}
{{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 | | | ||)|-|-|.| }}
{{familytree | | | |J01| |J02 |J01=TSH>4.0 <br>Treat<br>[[Levothyroxine]]|J02=TSH=0.3-4.0<br>Repeat [[TSH]]<br>3-6months}}
{{familytree | | | |J01| |J02 |J01=•TSH>4.0 <br>•Treat<br>[[Levothyroxine]]|J02=•TSH=0.3-4.0<br>•Repeat [[TSH]]<br>3-6months}}
{{Diagnosis and management of [[PPT]]}}
 
'''Postpartum thyroiditis'''}}
{{familytree/end}}
{{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>
<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==
==References==

Latest revision as of 17:35, 10 November 2017

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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

  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.
  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.
  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.
  4. ↑ "Thyroiditis: Differential Diagnosis and Management - American Family Physician".

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