ropathy and/or corneal breakdown.Hyperthyroidism 34 Women with gd should be instructed to immediately ust be treated with ATD and immediate treatment with confirm pregnancy and contact their physician. high-dose intravenous steroids is imperative with subse. quent orbital decompression if response to steroids is in- 35 Women treated with MMI should be switched to PTU adequate within 2-4 weeks [1151. when planning pregnancy and/or during the first tri- mester of pregnancy.1,00 s d Gr ined.1.0000 CBZ10-30 29 Patients treated with RAI should receive steroid pro- 50-200mg[139,140j.MM(CBZ)emb includ. phylaxis if mild and active GO preexists or there are ing dvsm hic facies.aplasia cutis.choanal or esopha risk factors for RAI-associated GO occurrence or pro- geal atresia,abdominal wall defects,umbilicocele,and ression.1,000☑ ventricular septal defects,affects 2-4%of children who 30In patients with catmentofGo 品 moder ate-t -severe and active GO eeks 6-1 14 The prevalence of b ects I am with 2 ects is aintain tening GO should be treated with ATD.1.00OO 40 mo sed.b 32 Treatment for hyp erthyroidism in patients with inac tive GO can be selected independently of GO.1. cause intrauterine growth restriction.fetal bradycardia nd neonatal hypoglycemia 143].Thyroidectomy may be indicated in the case of allergy/contraindications to ATD and should be performed in the second trimester of Pregnancy and Postpartum ts relapse with Women Planning P The choice of th nds on the patient's robable.ATD ence,disease history,the nce ofhigh TSH-R-Ablevels can be withdrawn and thyroid function monitored every and the timescale for conception [134-138).Pregnancy 2 weeks during the first trimester of pregnancy.If the should be postponed if hyperthyroidism is inadequately pregnant woman remains euthyroid,thyroid function is controlled until euthyroidism is reached and confirmed on monitored every 4 weeks during the second/third trime e s of TSH suppresse ity o e on med n, 1 stoppr PTU.wh 10:3)th ATDpresenc ATD lI146 TT4)value s should be Grst trimester of p v:(4)the advice to switchfrom maintained at the u oper limit of the PTU to MMI after 16 weeks of pregnancy:and (5)not to thyroid function tests [14].During the third trimester use block-replacement therapy.Pregnancy should be de. discontinuation of ATD is often feasible due to the disap- layed for 6 months post-RAI,and contraception is advised pearance of maternal TSH-R-Ab [135,136].In contras in the case ing for the onset o neona icated in the pre igh TS -A serum level prior to conception 14-151)thct-o n late pregnand s a strong all hi 33 Women with GD of reproductive ag e should be of ease should have their TSH-R-Ab serum levels mea- fered preconception counseling and be stably euthy- sured at the first presentation of pre nancy using either a roid before attempting pregnancy.1, sensitive binding or a functional cell-based bioassay,and, 2018 ETA Guideline for the Management 177 医肺润 http://guide.medlive.cn/2018 ETA Guideline for the Management of Graves’ Hyperthyroidism Eur Thyroid J 2018;7:167–186 177 DOI: 10.1159/000490384 ropathy and/or corneal breakdown. Hyperthyroidism must be treated with ATD and immediate treatment with high-dose intravenous steroids is imperative with subse￾quent orbital decompression if response to steroids is in￾adequate within 2–4 weeks [115]. Recommendations 28 In patients with GO, hyperthyroidism should be promptly controlled by ATD, and euthyroidism stably maintained. 1, ∅∅∅∅ 29 Patients treated with RAI should receive steroid pro￾phylaxis if mild and active GO preexists or there are risk factors for RAI-associated GO occurrence or pro￾gression. 1, ∅∅∅∅ 30 In patients with moderate-to-severe and active GO, treatment of GO should be the priority. Euthyroidism should be promptly restored with ATD and stably maintained. 1, ∅∅∅∅ 31 Patients with sight-threatening GO should be treated with ATD. 1, ∅∅○○ 32 Treatment for hyperthyroidism in patients with inac￾tive GO can be selected independently of GO. 1, ∅∅○○ Pregnancy and Postpartum Women Planning Pregnancy The choice of therapy depends on the patient’s prefer￾ence, disease history, the presence of high TSH-R-Ab levels, and the timescale for conception [134–138]. Pregnancy should be postponed if hyperthyroidism is inadequately controlled until euthyroidism is reached and confirmed on two occasions over 2 months on a stable therapeutic regi￾men. Patients should be informed about: (1) the increased risk of ATD-associated birth defects; (2) the possibility of stopping ATD during gestational weeks 6–10; (3) the pref￾erence for PTU, when ATD are necessary before/during the first trimester of pregnancy; (4) the advice to switch from PTU to MMI after 16 weeks of pregnancy; and (5) not to use block-replacement therapy. Pregnancy should be de￾layed for 6 months post-RAI, and contraception is advised during that period. Thyroidectomy is indicated in the case of contraindications/rejection of ATD/RAI. After surgery, euthyroidism should be confirmed prior to conception. Recommendations 33 Women with GD of reproductive age should be of￾fered preconception counseling and be stably euthy￾roid before attempting pregnancy. 1, ∅∅○○ 34 Women with GD should be instructed to immediately confirm pregnancy and contact their physician. 1, ∅∅∅∅ 35 Women treated with MMI should be switched to PTU when planning pregnancy and/or during the first tri￾mester of pregnancy. 1, ∅∅∅∅ Pregnant Women and GD The initial ATD daily dose depends on the severity of hyperthyroidism: MMI 5–15 mg, CBZ 10–30 mg, PTU 50–200 mg [139, 140]. MMI (CBZ) embryopathy, includ￾ing dysmorphic facies, aplasia cutis, choanal or esopha￾geal atresia, abdominal wall defects, umbilicocele, and ventricular septal defects, affects 2–4% of children who have been exposed to MMI, especially during gestational weeks 6–10 [137, 141]. The prevalence of birth defects is the same with PTU, but the spectrum of defects is less se￾vere, primarily consisting of face and neck cysts and uri￾nary tract abnormalities in males [142]. Propranolol 10– 40 mg, 3–4 times daily may be used; however, long-term treatment should be avoided since beta-blockers may cause intrauterine growth restriction, fetal bradycardia, and neonatal hypoglycemia [143]. Thyroidectomy may be indicated in the case of allergy/contraindications to ATD and should be performed in the second trimester of pregnancy [136, 144]. Only 5% of TSH-R-Ab-negative patients relapse with￾in 8 weeks after ATD withdrawal [145]. Therefore, when pregnancy is determined and remission is probable, ATD can be withdrawn and thyroid function monitored every 2 weeks during the first trimester of pregnancy. If the pregnant woman remains euthyroid, thyroid function is monitored every 4 weeks during the second/third trimes￾ter. A treatment period of less than 6 months, a high dai￾ly ATD dose, high levels of TSH-R-Ab, low/suppressed serum TSH levels while on medication, and the presence of GO increased the recurrence risk after ATD withdraw￾al [146, 147]. Maternal FT4 (or TT4) values should be maintained at the upper limit of the pregnancy-specific thyroid function tests [148]. During the third trimester, discontinuation of ATD is often feasible due to the disap￾pearance of maternal TSH-R-Ab [135, 136]. In contrast, monitoring for the onset of neonatal dysthyroidism is in￾dicated in the presence of high TSH-R-Ab serum levels (>3 times the cut-off) in the mother in late pregnancy [149–151]. In line with this and as a strong recommenda￾tion, all patients with a history of autoimmune thyroid disease should have their TSH-R-Ab serum levels mea￾sured at the first presentation of pregnancy using either a sensitive binding or a functional cell-based bioassay, and, http://guide.medlive.cn/