左甲状腺素治疗妊娠期甲状腺功能减退症的剂量分析

Dose analysis of left thyroxine in the treatment of hypothyroidism during pregnancy

目的对左甲状腺素治疗妊娠期甲状腺功能减退症（简称甲减）的剂量进行分析。方法选取260例妊娠合并甲状腺功能减退症孕妇，所有孕妇均采用左甲状腺素进行治疗，根据妊娠前是否合并甲减病史分为A、B两组：A组为妊娠前合并甲减者，共111例，B组妊娠期合并甲减者（妊娠前未合并甲减），共149例。根据孕妇外周血清促甲状腺激素水平调整左甲状腺素服用剂量（L-T4用量），分别观察各组治疗期间药物剂量的调整，并检测治疗前和治疗后不同孕周时促甲状腺激素（TSH）水平。并根据甲状腺病因分为甲状腺炎后甲减、131I治疗后甲减、甲状腺术后甲减，分析不同病因左甲状腺素服用剂量。结果A组孕3～9个月的L—T4用量均显著高于入组时（t=7．848、11．853、14．730、16．608、22．282、22．630、23．238，均P〈0．01），B组孕3～9个月的L—T4用量均显著高于人组时（t=4．046、8．388、12．976、17．348、21．890、27．611、28．998，均P〈0．01），但同一妊娠月份B组的L-T4用量显著性低于A组（t=26．041、33．481、33．077、32．628、32．117、31．322、30．656、29．065、50．272，均P〈0．01）。A组分娩后1个月L—T4用量（82．34±10．12）μg／d，与入组时的（81．34±10．1）μg/d差异无统计学意义（t=0．736，P〉0．05），B组分娩后1个月L—T4用量（28．55±7．13）μg/d，显著性低于入组时的（50．34-1-9．01）μg/d（t=23．149，P〈0．01）。A、B两组均在孕3个月时TSH水平达到治疗达标范围，两组孕3—9个月同一妊娠月份的TSH水平差异无统计学意义（t：0．874、0．913、0．968、1．047、0．219、1．202、1．273、1．187，均P〉0．05）。甲状腺炎后甲减、131I治疗后甲减、甲状腺术后甲减孕妇随着孕周的增加，L—T4用量均呈增加的趋势，131I治疗后甲减孕妇孕3～9个月的L—T4用量均显著高于同一妊娠月份的甲状腺炎后甲减孕妇（t=24．491、27．900、29．949、29．666、31．384、29．774、30．195，均P〈0．01）；甲状腺术后甲减孕妇孕3—9个月的L-T4用量均显著高于同一妊娠月份的甲状腺炎后甲减孕妇（t=25．007、27．887、29．830、31．568、30．248、31．969、28．033，均P〈0．01）。结论甲减患者妊娠期间L—T4用量随着孕周的增加而增加，且同一妊娠月份妊娠前甲减患者的L—T4用量高于妊娠期合并甲减者，甲状腺手术后和131I治疗后甲状腺功能减退患者L—T4治疗剂量较高。

Objective To analyze the dose of left thyroxine in the treatment of hypothyroidism during pregnancy. Methods 260 cases of pregnant women with hypothyroidism were selected and given left thyroxine treatment. According to pre pregnancy with or without hypothyroidism, they were divided into two groups：group A with hypothyroidism before pregnancy （lllcases）, and group B without hypothyroidism before pregnancy （149 cases）. According to the maternal serum TSH level, adjustment of levothyroxine dose （ L - T4 dosage） were observed during the treatment period, and the thyroid stimulating hormone （TSH） levels were detected in different gestational weeks before and after treatment. According to the thyroid etiology all patients were divided into hypothyroidism after 131I therapy, hypothyroidism after thyroiditis, thyroid postoperative hypothyroidism, in order to analyze the different causes of levothyroxine dose. Results The dosages of L - T4 of group A in 3 - 9 months were significantly higher than those in the beginning （ t = 7. 848,11. 853,14. 730,16. 608,22. 282,22. 630,23. 238, all P 〈 0.01 ）, as well as those of group B （ t = 4. 046,8. 388,12. 976,17. 348,21. 890,27.611,28. 998, all P 〈 0.01 ）. But the dosages of L - T4 of group A in 3 - 9 months were significantly higher than those in group B （ t = 26. 041,33.481,33. 077,32. 628, 32. 117,31. 322,30. 656,29. 065,50.272, all P 〈 0.01 ）. In group A 1 month after delivery, the dosages of L - T4 was （82.34 ± 10. 12）p.g/d, which had no significant difference compared with （81.34 ± 10.1 ）μg/d in the beginning （ t = 0.736, P 〉 0.05 ）, and in group B 1 month after delivery, the dosages of L - T4 was （ 28.55 ± 7.13 ） μg/d, which was significantly lower than （50.34 ± 9.01 ） μg/d in the beginning （t = 23. 149, P 〈 0.01 ）. In A and B two groups, TSH reached the levels of the standard treatment scope at the third month, and there were no significant differences in terms of TSH levels between the two groups in 3 - 9 months （ t = 0. 874,0. 913,0. 968,1. 047,0. 219,1. 202,1. 273, 1. 187, all P 〉 0.05 ）. Pregnant women with hypothyroidism,including thyroiditis hypothyroidism,hypothyroidism after 131I treatment, and thyroid postoperative hypothyroidism were increasing along with gestational age increasing, as well as the amount of L - T4. The dosages of L - T4 in 3 - 9 months after 1311 treatment were significantly higher than those in the same month of pregnancy thyroiditis hypothyroidism after pregnant（ t = 24. 491,27. 900,29. 949,29. 666, 31. 384,29. 774,30.195, all P 〈 0.01 ）. After thyroid surgery hypothyroidism pregnant in 3 -9 months, the amount of L- T4 was significantly higher than that in the same month of pregnancy thyroiditis hypothyroidism after pregnant women （ t = 25. 007,27. 887,29. 830,31. 568,30.248,31. 969,28. 033, all P 〈 0.01 ）. Conclusion In patients with hypothyroidism during pregnancy, the amount of L - T4 increases with the gestational age. And the same month of pregnancy with hypothyroidism before pregnancy, the dosage of L - T4 is higher than pregnancy complicated with hypothyroidism,while after thyroid surgery and 131I therapy in patients with hypothyroidism has higher doses of L -T4 treatment.