Hanono Anat, Shah Bina, David Raphael, Buterman Irving, Roshan Daniel, Shah Shetal, Lam Leslie, Timor-Tritsch Ilan
Department of Pediatrics, New York University Medical Center, New York, NY 10016, USA.
J Matern Fetal Neonatal Med. 2009 Jan;22(1):76-80. doi: 10.1080/14767050802448299.
Pre-natal ultrasonography presents an opportunity for in-utero therapy of a fetal goiter. Because of the morbidity associated with a large goiter and the risks of repeated intra-amniotic injections, controversy arose about the precise indications of this mode of treatment. We describe our observations in treating a 22-week-old fetus with a large goiter because of dyshormogenesis, monitored with serial 3D high frequency, high resolution ultrasonography and amniotic hormonal measurements. Fetal hypothyroidism was confirmed by cordocentesis and amniotic hormone levels. After assessment of relevant risk factors and the criteria for in-utero intervention, including goiter volume, amniotic fluid index, polyhydramnios and tracheal compression, we determined that hormonal therapy was warranted. Levothyroxine was injected every 7-10 days, and its efficacy monitored by ultrasound changes and amniotic hormone sampling.
Reduction in goiter volume restored normal neck flexion relieving the pressure on the trachea, polyhydramnios was prevented and amniotic hormone levels were normalised. The infant was euthyroid at birth, however, by age 4 days hypothyroidism was diagnosed, and treatment with l-thyroxine started.
Advances in fetal ultrasonography permit judicious therapy of an enlarging goiter in a hypothyroid fetus, which may contribute to enhancing cognitive development. We discuss the value of amniotic hormone sampling, the objectives and risks of in-utero intervention in the light of recent literature and our own observations.
产前超声检查为胎儿甲状腺肿的宫内治疗提供了机会。由于巨大甲状腺肿相关的发病率以及重复羊膜腔内注射的风险，这种治疗方式的精确指征引发了争议。我们描述了对一名因激素合成障碍导致巨大甲状腺肿的22周龄胎儿进行治疗的观察情况，通过连续的三维高频、高分辨率超声检查和羊水激素测量进行监测。通过脐带穿刺术和羊水激素水平确诊胎儿甲状腺功能减退。在评估了包括甲状腺肿体积、羊水指数、羊水过多和气管受压等相关危险因素以及宫内干预标准后，我们确定激素治疗是必要的。每7 - 10天注射一次左甲状腺素，并通过超声变化和羊水激素采样监测其疗效。
甲状腺肿体积减小，恢复了正常的颈部屈曲，减轻了对气管的压迫，预防了羊水过多，羊水激素水平恢复正常。婴儿出生时甲状腺功能正常，但在4日龄时被诊断为甲状腺功能减退，并开始使用左旋甲状腺素治疗。
胎儿超声检查的进展使得对甲状腺功能减退胎儿不断增大的甲状腺肿进行明智的治疗成为可能，这可能有助于促进认知发育。我们根据近期文献和我们自己的观察结果讨论了羊水激素采样的价值、宫内干预的目标和风险。
