Thyroid in Pregnancy: Treatment in Ahmedabad, With Anaemia Care

Thyroid in Pregnancy: Effects on Baby and Brain Development

For roughly the first 10–12 weeks, until its own thyroid starts working, your baby depends entirely on your thyroid hormone. That hormone is essential for brain development. Pregnancy also increases your need for thyroid hormone by about half. This is why a low thyroid level matters most in early pregnancy, and why I prefer the dose to be right before or soon after conception.

• TSH is the main screening test; the ranges I use are set out in the next section.
• Free T4 and anti-TPO antibodies help me decide who needs treatment.
• Hashimoto's thyroiditis is the commonest cause of an underactive thyroid.
• Iodised salt is the main source of iodine in Indian diets.

TSH Level in Pregnancy, Trimester by Trimester

The normal TSH level in pregnancy is lower than outside pregnancy, because the pregnancy hormone hCG gently stimulates the thyroid, especially in the first trimester. The preferred guide is a range the laboratory has set for pregnant women. When a laboratory has none, these figures are commonly used.

A TSH that is low in the first trimester is often a normal effect of hCG, particularly with severe vomiting or twins. I check free T4 before calling it an overactive thyroid. One borderline result is repeated rather than treated in isolation.

Thyroid in Pregnancy: Symptoms, and Why I Rely on Blood Tests

The symptoms are easy to miss, because they look like ordinary pregnancy complaints.

• Underactive thyroid: tiredness, weight gain beyond the usual, constipation, feeling cold, dry skin, hair fall and low mood.
• Overactive thyroid: palpitations, a racing pulse at rest, weight loss or poor weight gain, feeling hot and sweaty, tremor of the hands, and vomiting that will not settle.

Tiredness, palpitations and breathlessness are common in any pregnancy. So I do not rely on symptoms; I rely on blood tests. TSH and haemoglobin are part of the booking blood tests at your first antenatal visit. A swelling in the neck (goitre) or a family history of thyroid disease is worth mentioning at that visit too.

Thyroid Conditions in Pregnancy and My Plan for Each

Hypothyroidism in Pregnancy: Treatment and Taking Thyroxine Correctly

Treatment means levothyroxine (thyroxine) at a dose that keeps TSH in the target range. The practical points:

• If you already take thyroxine, you will typically need about 25–30% more once the pregnancy is confirmed. A practical way to start is two extra tablets a week until the first TSH result comes back.
• I recheck TSH about every 4 weeks until 20 weeks, and at least once more in the third trimester.
• Take thyroxine in the morning on an empty stomach with water, 30–60 minutes before tea or breakfast.
• Keep at least 4 hours between thyroxine and any iron or calcium tablet.
• For an overactive thyroid, propylthiouracil is preferred in the first trimester. Carbimazole is often used later, at the lowest dose that keeps free T4 at the upper end of normal.
• Please do not change your dose on your own, and bring your latest reports to each visit.

Anaemia in Pregnancy: Why It Is So Common in India

WHO defines anaemia in pregnancy as a haemoglobin below 11 g/dL. National surveys suggest that about half of pregnant women in India are anaemic. During pregnancy your blood volume rises by about 40–50%, and the baby and placenta together need roughly 1000 mg of extra iron.

Iron deficiency is the commonest cause. Others include:

• Vitamin B12 deficiency, frequent in vegetarian diets.
• Folate deficiency
• Worm infestation
• Pregnancies spaced closely together
• Heavy periods before pregnancy

Beta-thalassaemia trait, which is not uncommon in Gujarat, produces small red cells that can look like iron deficiency on a report.

Anaemia in Pregnancy: Hb Level, Symptoms and Tests

You are anaemic in pregnancy when your haemoglobin (Hb) is below 11 g/dL. Below that, the severity is graded.

Mild anaemia often causes no symptoms. As haemoglobin falls, you may notice:

• Tiredness
• Breathlessness on the stairs
• Palpitations
• Headaches
• Pale skin and nails
• Hair fall
• Pica - a craving for ice or mud.

The tests I use:

• Complete blood count with red cell indices at booking, at 24–28 weeks and at about 36 weeks.
• Serum ferritin - below 30 µg/L suggests iron deficiency even when haemoglobin is normal.
• B12 and folate when the red cells are large or the diet is vegetarian.
• HPLC for thalassaemia trait and other haemoglobin variants, ideally at the first visit. If you carry the trait, your partner is tested too; if both of you are carriers, the baby can be tested by CVS at 11–14 weeks.
• Stool examination when worms are suspected, with deworming in the second trimester as national guidance advises.

Anaemia in Pregnancy Treatment: Iron Tablets, IV Iron and More

Treatment depends on the cause and on how far along you are.

Thalassaemia trait is not treated with extra iron unless iron deficiency has also been proven.

Iron Injection in Pregnancy: When I Suggest IV Iron

Today, an iron injection usually means an intravenous (IV) infusion, given into a vein over a short time. The painful injections into the buttock used in the past are no longer the usual choice. I suggest IV iron when:

• Tablets have not raised your haemoglobin after a fair trial.
• Tablets cause side effects you cannot tolerate.
• Anaemia is moderate or severe in the second or third trimester.
• Delivery is close and there is not enough time for tablets to work.

Preparations such as ferric carboxymaltose or iron sucrose are given in hospital, where you are observed during and after the infusion. With ferric carboxymaltose, one or two sittings are often enough. Iron sucrose is given in smaller doses over several sittings. IV iron is not used in the first trimester. Common, mild effects include a headache, a metallic taste, joint aches or a brief flushing. Allergic reactions are uncommon, and the observation period exists for that reason. Iron that leaks under the skin can leave a brown mark, so tell the nurse at once if the drip site hurts. I recheck haemoglobin and ferritin a few weeks later.

Iron-Rich Foods for Anaemia in Pregnancy: Indian Choices

Food alone rarely corrects anaemia once it has set in, but it supports treatment and helps stop it coming back. Iron from plants is absorbed less well than iron from meat. Eating it with vitamin C improves absorption.

• Greens: methi, palak, sarson, drumstick leaves, rajgira (amaranth) leaves
• Pulses: rajma, chana, moong, masoor and sprouted grains
• Millets: bajra, ragi and jowar rotlas in place of some of the wheat.
• Snacks: jaggery, dates, dried figs, raisins, roasted chana
• With meals for vitamin C: lemon, amla, guava, orange
• If you eat them: eggs, fish, chicken
• For B12: dahi and paneer

Keep tea and coffee at least an hour away from meals and from iron tablets.

How Thyroid Problems and Anaemia Affect Mother and Baby

• Anaemia. Moderate-to-severe anaemia is linked with preterm birth, low birth weight, and a greater need for transfusion if there is heavy bleeding after delivery. Anaemic mothers also recover more slowly and find breastfeeding more tiring. Bringing your haemoglobin up to at least 11 g/dL before term is one of the simpler steps that lowers the risks of birth.
• Underactive thyroid. Untreated overt hypothyroidism is linked with miscarriage, pre-eclampsia, preterm birth and effects on the baby's brain development.
• Overactive thyroid. Uncontrolled hyperthyroidism can affect the baby's growth and, rarely, cause a thyroid storm.

With treatment and regular checks, outcomes can come close to those of other pregnancies. For every woman at delivery, active management of the third stage of labour and readiness for bleeding are standard.

Thyroid and Iron After Your Baby Arrives

• Thyroxine is usually brought back to your pre-pregnancy dose, and TSH is rechecked at about 6 weeks after the birth.
• About 5–10% of women develop postpartum thyroiditis within the first year - more often if anti-TPO was positive. It may start with an overactive phase followed by an underactive one. Unexplained tiredness or low mood after the birth deserves a TSH test.
• Continue iron and folic acid for at least 3 months after delivery to rebuild your stores.
• Leave at least 18 months before the next pregnancy, and if you have thyroid disease, have your TSH checked before trying again.

Five Steps in My Thyroid and Anaemia Plan

1. Baseline tests at the first visitTSH, haemoglobin and ferritin, plus free T4, antibodies, B12 and HPLC as indicated.
2. Early correctionthyroxine adjusted and iron started or increased as soon as results arrive, with written instructions.
3. Regular rechecksTSH about every 4 weeks in early pregnancy and haemoglobin each trimester; IV iron arranged in hospital if needed.
4. A target before birthhaemoglobin of at least 11 g/dL, with the hospital's 24×7 labour and emergency cover.
5. After the birththyroxine dose reviewed, TSH at 6 weeks, iron continued.

Reasons to See Me About Thyroid or Anaemia

• Hypothyroidism or hyperthyroidism, whether you are pregnant or planning.
• A TSH above the pregnancy range.
• Haemoglobin below 11 g/dL, or unusual tiredness, breathlessness or dizziness.
• You or your partner carry thalassaemia trait, or there is a family history.
• Side effects from iron, or haemoglobin that is not improving.
• Unusual tiredness, anxiety or low mood in the months after delivery.

Thyroid and Iron Myths I Hear Often

Questions Patients Often Ask Me About Thyroid and Anaemia in Pregnancy