best java barcode library F Hyperthyroidism and Pregnancy in Objective-C

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Pregnant women with hyperthyroidism are treated with methimazole or propylthiouracil in the smallest dose possible, permitting mild hyperthyroidism to occur since it is usually well tolerated These drugs do cross the placenta and rarely may induce TSH hypersecretion and fetal goiter Thyroid hormone administration to the mother does not prevent hypothyroidism in the fetus, since T4 and T3 do not freely cross the placenta Fetal hypothyroidism is rare if the mother s hyperthyroidism is controlled with small daily doses of propylthiouracil (50 150 mg/d orally) or methimazole (5 15 mg/d orally) Thyroidectomy is reserved for women who are allergic or resistant to antithyroid drugs (usually due to noncompliance) or who have very large goiters Fetal ultrasond at 32 weeks gestation can visualize any fetal goiter, so fetal thyroid dysfunction can be diagnosed and treated During lactation, women treated with propylthiouracil secrete very little of it into breast milk Methimazole is secreted in somewhat higher concentrations in breast milk However, the use of either propylthiouracil or methimazole during breast-feeding does not significantly affect the infant s thyroid hormone levels, and both drugs are approved for nursing mothers by the American Academy of Pediatrics No adverse reactions to these drugs (eg, rash, hepatic dysfunction, leukopenia) have been reported in breast-fed infants Recommended doses are 20 mg daily or less for methimazole and 450 mg daily or less for propylthiouracil It is recommended that the medication be taken just after breast-feeding
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G Other Causes of Hyperthyroidism
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Hyperthyroid symptoms from pituitary hyperplasia are treated with propranolol Definitive treatment is with RAI or thyroid surgery Treatment of type I amiodarone-induced
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propranolol is used in the interim unless there is an associated cardiomyopathy b Atrial fibrillation Electrical cardioversion is unlikely to convert atrial fibrillation to normal sinus rhythm while the patient is thyrotoxic Spontaneous conversion to normal sinus rhythm tends to occur in about 56% of patients with achievement of euthyroidism, but that likelihood decreases with age Elective cardioversion may be used for those patients in whom atrial fibrillation persists for 4 months after resolution of hyperthyroidism Hyperthyroidism must be treated immediately (see above) Other drugs, including digoxin, blockers, anticoagulants, may be required (1) Digoxin Digoxin is used to slow a fast ventricular response to thyrotoxic atrial fibrillation; it must be used in larger than normal doses because of increased clearance and an increased number of cardiac cellular sodium pumps requiring inhibition Digoxin doses are reduced as hyperthyroidism is corrected (2) -Blockers -Blockers may also reduce the ventricular rate, but they must be used with caution particularly in patients with cardiomegaly or signs of heart failure since their negative inotropic effect may precipitate congestive heart failure Therefore, an initial trial of a short-duration -blocker should be considered, such as esmolol intravenously If a blocker is used, doses of digoxin must be reduced (3) Anticoagulants Anticoagulation is indicated in the following situations: left atrial enlargement on echocardiogram, global left ventricular dysfunction, recent congestive heart failure, hypertension, recurrent atrial fibrillation, or a history of previous thromboembolism The doses of warfarin required in thyrotoxicosis are smaller than normal because of an accelerated plasma clearance of vitamin K dependent clotting factors Higher warfarin doses are usually required as hyperthyroidism subsides c Heart failure Heart failure due to thyrotoxicosis may be caused by extreme tachycardia, cardiomyopathy, or both Very aggressive treatment of the hyperthyroidism is required in either case (see Thyroid Crisis, below) The tachycardia from atrial fibrillation is treated with digoxin as above Intravenous furosemide is typically required If tachycardia appears to be the main cause of the failure, blockers are administered cautiously as described above Congestive heart failure may occur as a result of lowoutput dilated cardiomyopathy in the setting of hyperthyroidism It is uncommon and may be caused by an idiosyncratic severe toxic effect of hyperthyroidism upon certain hearts Cardiomyopathy may occur at any age and without preexisting cardiac disease -Blockers and calcium channel blockers are avoided Emergency treatment may include afterload reduction, diuretics, digoxin, and other inotropic agents while the patient is being rendered euthyroid Heart failure usually persists despite correction of hyperthyroidism d Apathetic hyperthyroidism Apathetic hyperthyroidism may present with angina pectoris Treatment is directed at reversing the hyperthyroidism as well as providing standard antianginal therapy Coronary angioplasty or bypass grafting can often be avoided by prompt diagnosis and treatment
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