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Thyroid Function in Pregnancy
No full textThyroid hormones are crucial for a normal pregnancy and intrauterine fetal development, particularly development of the central nervous system. In the pregnant women there is an increase in thyroxine and triiodothyronine production in response to the estrogen-stimulated rise in the thyroid hormone transport protein, thyroxine-binding globulin. Also, in the first trimester, there is a transient inhibition of thyrotropin, which is mediated, via the negative feedback system, by an increase in thyroid hormones that are stimulated by hCG. Moreover, a large plasma volume, and thus altered distribution of thyroid hormones, increased thyroid hormone metabolism, together with increased renal clearance of iodide are responsible for higher thyroid hormone requirements in pregnancy. The fetus thyroid gland starts functioning after the first trimester. The most important maternal thyroid hormone for the fetus is thyroxine, because it crosses the placental barrier and achieves the fetus. The consequent fetal consumption of maternal thyroid hormone is an additional stimulus to increase maternal thyroid hormone secretion to ensure adequate fetal thyroid hormone availability. Such a new physiological demand requires an adequate iodine intake by pregnant women. The diagnosis of thyroid disease in pregnancy is still based upon serum TSH concentration. Due to the physiological changes occurring during pregnancy, including the increase in hCG and thyroxine-binding globulin levels, TSH normal levels are lower in pregnancy than in nonpregnant women. If internal pregnancy-specific TSH reference ranges are not available, a simple clinical way for TSH reference interval in the first trimester of pregnancy could be calculated as the reference interval for the nonpregnant population decreased by 0.5 mU/L in the upper limit (for most centers ~4 mU/L). In patients with primary hypothyroidism taking levothyroxine, lowering TSH to <2.5 mU/L has been recommended not only to pregnant women but also for women planning to become pregnant
CESAREAN SECTION: PAST, PRESENT AND FUTURE
No full textCaesarean section is a surgical procedure of ancient origins: it was performed to extract the baby after the woman had died. Today, cesarean section is necessary when vaginal birth is not possible or poses the mother or the child at high risk. In the last thirty years, this procedure has been increasingly used, particularly in Western countries, with values ranging from 14% in the Scandinavian countries to 30-35% in the USA and approximately 38% of deliveries in Italy. The increase in delivery by caesarean section is due to several factors: the progress of anesthetic techniques and surgical procedures, advanced maternal age of first delivery (32 years in the third millennium), growing medical litigation and the consequent use of defensive medicine [1-3]. Furthermore, other causes include the organization of hospitals, with the Healthcare system paying higher refunds for caesarean sections compared to natural deliveries, and the right of women to avoid pain and give birth “on request” by caesarean section. In this study we analyzed the characteristics of all patients who underwent caesarean section at the Maternal University Hospital in Sassari in 2014. This hospital is a third-level of high specialization, attracting pregnant patients from central and northern areas of Sardinia. Mothers who had a caesarean section were older and had on average a higher education level (over 78% had a high school degree, a bachelor’s or master’s degree) compared to women who gave birth by vaginal delivery. Moreover, they often lived in towns of Central and Northern Sardinia referring to hospitals without a neonatal intensive care unit, and they were then admitted to our Clinic for severe diseases of prematurity needing a fast and safe delivery, namely caesarean section. In the future, particularly in industrialized countries, it will be possible to contain the prevalence of cesarean section within the current percentage (38%), but it will probably not be reduced. In fact, several factors related to global social and cultural changes will be likely to play a role, such as a very low birth rate (around 1 child per couple), an average older age of first pregnancy (related to high levels of education and career), and a greater degree of self-determination in choosing the mode of delivery compared to the past. In the present circumstances, caesarean section should not be demonized, as with its low anesthetic and surgical risk it guarantees a safe childbirth for both mother and child.
REFERENCES
[1] Capobianco G, Balata A, Mannazzu MC, Oggiano R, Pinna Nossai L, Cherchi PL, Dessole S. Perimortem cesarean delivery 30 minutes after a laboring patient jumped from a fourth-floor window: baby survives and is normal at age 4 years. Am J Obstet Gynecol. 2008;198(1):e15-6.
[2] Capobianco G, Angioni S, Dessole M, Cherchi PL. Cesarean section: to be or not to be, is this the question? Arch Gynecol Obstet. 2013;288(2):
461-2.
[3] Dessole S, Cosmi E, Balata A, Uras L, Caserta D, Capobianco G, Ambrosini G. Accidental fetal lacerations during cesarean delivery: experience in an Italian level III university hospital. Am J Obstet Gynecol. 2004;191(5):1673-7
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