REVIEW ARTICLE |
https://doi.org/10.5005/jp-journals-10016-1349 |
Correlation of Transient Hyperthyroidism with the Severity of the Pregnancy Unique Quantification of Emesis Score
1,2Department of Obstetrics and Gynecology, Saveetha Medical College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India
Corresponding Author: Nishitha Gandavaram, Department of Obstetrics and Gynecology, Saveetha Medical College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India, Phone: +91 9176246945, e-mail: nishitha656@gmail.com
Received on: 12 April 2024; Accepted: 25 September 2024; Published on: 28 October 2024
ABSTRACT
During early pregnancy, many women are affected with severe sickness in the morning, that is hyperemesis gravidarum (HG), which represents extreme vomiting in pregnancy. Among HG women, about 66–73% had severe HG and the presence of elevated thyroid function. Data collected from the subjects showed the association of temporary hyperthyroidism with severe morning sickness in our Saveetha Medical Hospital. The pregnancy unique quantification of emesis (PUQE) score helps in assessing the rigorousness of nausea and vomiting during pregnancy. The total sample size was 260 antenatals, out of which 11 were hyperemesis, this is a cross-sectional study and the study period was between June and August 2023. Gestational transient hyperthyroidism prevalence was 1.92%. In our study, we have found that there is a significant relation between the rigorousness of PUQE score with hypocalcemia and we did not find any statistically significant relationship between transient hyperthyroidism and pregnancy. The level of free thyroxine (T4) and thyroid-stimulating hormone (TSH) in transient hyperthyroid women was found to be normal at 20 weeks of gestation. Thus, transient hyperthyroidism in pregnancy was not significantly linked with the rigorousness of the PUQE score. Hence, it is not necessary to test for thyroid function in pregnant women with transient hyperthyroidism unless they have a clinical presentation of hyperthyroidism.
How to cite this article: Gandavaram N, Sharma N. Correlation of Transient Hyperthyroidism with the Severity of the Pregnancy Unique Quantification of Emesis Score. Int J Infertil Fetal Med 2024;15(2):112-114.
Source of support: Nil
Conflict of interest: None
Keywords: Hyperemesis gravidarum, Hyperthyroidism, Pregnancy unique quantification of emesis score.
INTRODUCTION
About 78–89% of pregnant women are commonly affected in the early trimester with nausea and vomiting of pregnancy (NVP).1,2 In about 60% of pregnancies, these symptoms are set on at the end of the first trimester.3 Hyperemesis gravidarum (HG) is the frequent combination of symptoms such as nausea and vomiting and it results in a hospital stay due to dehydration. It results in about 0.3–3% age of pregnant women4,5 and is characterized by nausea and vomiting caused by reduced body weight of >5%, ketonuria, water loss, electrolyte imbalance, and in severe cases there are abnormalities of liver enzyme.4,6
The etiology of morning sickness is still unknown. But this may be related to the hormonal change during pregnancy. The high level of human chorionic gonadotropin (HCG) hormone causes severe morning sickness in pregnant women.
Human chorionic gonadotropin is also a thyroid-stimulating hormone (TSH). The peak level of HCG reached during the age of pregnancy at 8–14 weeks is linked with reduced TSH levels and increased free thyroxine (T4).7 The pregnant women without a diagnosis of thyroid autoimmune or clinical features of Graves disease but pregnant patients with transient hyperthyroidism (nonimmune) in the early stage will be resolved spontaneously either at the end of the first or at the initial period of the second trimester.8 HG is the known cause.8 About 66–73% of females with severe HG showed increased thyroid function.9,10 Author Goodwin et al. showed that there was a significant link between the severity of vomiting and thyroid function.10
The pregnancy unique quantification of emesis (PUQE) scoring system mainly includes three clinical manifestations, that is, nausea, vomiting, and retching.11 The PUQE score depends on symptoms produced within 12 hours while the recently revised or modified version covers the long duration of pregnancy. The modified PUQE score system is greater in assessing NVP symptoms in the first trimester of pregnancy, while the 12-hour PUQE index is an important tool to assess the effects of treatment with antiemetic drugs.12
The present study, mainly aimed to determine the correlation of transient hyperthyroidism and vomiting and nausea, and its severity based on revised PUQE scores.
MATERIALS AND METHODS
The present prevalence cross-sectional study was done among the 260 antenatals, out of which 11 were HG who were admitted to the Saveetha Medical Hospital. The study period was from June to August 2023.
The inclusion criteria include pregnant women carrying a single pregnancy with a gestation age of ≤13 weeks with the symptoms of nausea and vomiting, who were admitted to hospital.
The exclusion criteria included for this study are the pregnancy with
-
More pregnancy.
-
Hyperthyroidism pregnant women.
-
Diagnosed thyroid disease.
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Previous hospitalized for NVP.
Gestational transient hyperthyroidism occurrence was 1.92%. The consent form from the selected patient was obtained and counseling was given. For all the patients, a pelvic ultrasound scan was done. The participant patient was diagnosed with thyroid disease and the rigorousness of vomiting and nausea were analyzed with the revised PUQE score system and graded rigorousness of nausea and vomiting. The graded score is shown in Table 1. The severity was classified as:
| Classification | Score |
|---|---|
| Mild | ≤6 |
| Moderate | 7–12 |
| Severe | ≥13 |
| Circle the answer that best suits your situation from the beginning of your pregnancy | ||||
| 1. On average in a day, for how long do you feel nauseated or sick to your stomach? | ||||
| Not at all | ≤1 hour | 2–3 hours | 4–6 hours | >6 hours |
| (1) | (2) | (3) | (4) | (5) |
| 2. On average in a day, how many times do you vomit or throw up? | ||||
| ≥7 times | 5–6 times | 3–4 times | 1–2 times | I did not throw up |
| (5) | (4) | (3) | (2) | (1) |
| 3. On average in a day, how many times do you have retching or dry heaves without bringing anything up? | ||||
| None | 1–2 times | 3–4 times | 5–6 times | ≥7 times |
| (1) | (2) | (3) | (4) | (5) |
Source: Jennifer R Butler, Laura E Fitzmaurice, Alpesh N Amin, Christine M Kim: OB/GYN Hospital Medicine: Principles and Practice. Copyright © McGraw-Hill Education. All rights reserved
The laboratory investigations were performed for total blood count and thyroid functions. The patient with TSH level of <0.1 mIU/L and free T4 level of >26 pmol/L are considered to be hyperthyroidism. The patient’s data like results of thyroid function tests (TFTs), electrolytes, and scores were collected.
The documented data was analyzed using the software of SPSS of the new version. The descriptive data were reported as percentage (%), median or mean with standard deviation (SD), and statistical significance with a p-value < 0.05 (Fig. 1).
Fig. 1: Flowchart for management of HG
RESULTS
A total of 260 pregnant women were included in our study. Age was between 18 and 31 years and the gestational age ranges from 8 weeks to 21 weeks (Table 2).
| Etiology | n (%) |
|---|---|
| Transient hyperthyroidism | 1.92 |
| Hypocalcemia | 0.38 |
| Hypothyroidism | 0.38 |
The total occurrence of transient hyperthyroidism in our study was 1.92% (Table 3).
| Index scores | Mild (n%) | Moderate (n%) | Severe (n%) |
|---|---|---|---|
| Transient hyperthyroidism | 5 (45) | ||
| Hypocalcemia | 1 (9) | ||
| Hypothyroidism | 1 (9) | ||
| Without complication | 5 (45) |
A total of 5 out of 11 women (45%) were found to have transient hyperthyroidism. We found that there was no significant correlation between rigorous PUQE score and transient hyperthyroidism in our study patients. Forty-five percent of pregnant women with a transient hyperthyroidism have mild scores even though only 9% of women with hypocalcemia had severe scores. Hypothyroidism was only seen in women who scored mild (9%) and without complication (45%). The total incidence of transient hyperthyroidism in our study was 1.92%. We did not find any significant association between the PUQE scoring and transient hyperthyroidism in our study but there is a major relation between PUQE score and hypocalcemia.
DISCUSSION
The PUQE score is a reliable and clinically relevant tool to assess HG during pregnancy. This score system was based on the complex Rhodes scale, which was the golden standard assessment for nausea and vomiting.13 PUQE score mainly depended on three clinical features such as nausea, vomiting, and retch, which occurred in the previous 12 hours. The PUQE score covering the 12- or 24-hour period was found to be considerably interrelated with the increased rate of hospital admission due to NVP and severity of scores.
Koren et al.14 noted that, by using the score system, separated the patients with rigorous NVP from the mild and moderate types and identified the patients who are at higher risk of water loss and imbalance of electrolytes. The author Birkeland et al.15 found no significant correlation between the PUQE score in relation to the intake of food and an increase in body weight. The author Lacasse et al.12 noted that the revised PUQE score index covers a pregnancy longer period helps in assessing the NVP in the early pregnancy.
In our study, we found an important connection between PUQE score and low potassium level. Hypocalcemia was commonly noticed in subjects with severe vomiting. Transient hyperthyroidism was more common in women with mild PUQE scores; however, there was no significant association between them.
Goodwin et al.10 noted that women with HG showed a significant association between electrolyte abnormalities and hyperthyroidism and also showed a significant correlation between thyroid stimulation and rigorous vomiting. The study showed that severe hyperemesis women have higher levels of free T4 and lower TSH than in mild and moderate groups. Our study, showed no statistically significant connection between transient hyperthyroidism and PUQE scores in women with hyperemesis.
The prevalence of transient hyperthyroidism in pregnant women with HG was 1.92% in the present study. In Singapore, a study was done on women with HG and established occurrence rate of transient hyperthyroidism was 45%.16 The prevalence difference may be due to the variation used for hyperthyroidism.
CONCLUSION
The present study showed that transient hyperthyroidism in pregnancy is not considerably associated with the severity of the PUQE score. PUQE score system is significantly linked with hypocalcemia. Women with transient hyperthyroidism in pregnancy are clinically normal so a thyroid function blood test is not needed if not presented with the features of hyperthyroidism.
ORCID
Nishitha Gandavaram https://orcid.org/0009-0000-4404-0635
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