# 情境 28歲懷孕8週的葛瑞夫茲病個案孕前已使用methimazole 15 mg daily。產前回診free T4仍升高。護理師預期處方者會做什麼藥物調整?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375115&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

情境 28歲懷孕8週的葛瑞夫茲病個案孕前已使用methimazole 15 mg daily。產前回診free T4仍升高。護理師預期處方者會做什麼藥物調整?

## 選項

1. 第1孕期改為propylthiouracil(PTU)，第2孕期再考慮換回methimazole。 **✔ 正確答案**
2. 加入高劑量碘補充以抑制荷爾蒙合成。
3. 停所有抗甲狀腺藥，僅靠飲食。
4. 整個孕期維持原劑量methimazole。

**正確答案: 1**

## 解析

懷孕中抗甲狀腺藥的選擇取決於各孕期的致畸性。Methimazole可通過胎盤，於第1孕期使用與胚胎病變(aplasia cutis、choanal atresia、esophageal atresia、omphalocele)相關。PTU在第1孕期致畸風險較低故優先，但嚴重肝毒性比率較高。標準作法：(1) 懷孕前或盡早改為PTU；(2) 整個第1孕期維持PTU；(3) 第2孕期開始時換回methimazole以減少其餘孕期的肝毒性暴露；(4) 使用維持free T4在正常上限附近的最低劑量以避免胎兒甲狀腺低下；(5) 放射性碘絕對禁忌、避免高劑量碘補充、甲狀腺切除僅特殊情況；(6) 母體TSH/free T4每4週監測，並考慮周期性胎兒甲狀腺超音波。停藥會造成甲狀腺風暴與流產風險。碘負載短暫抑制荷爾蒙但會脫離Wolff-Chaikoff並惡化疾病。

## 深入解析

第1孕期PTU、第2孕期換回methimazole — 為懷孕葛瑞夫茲病的NCLEX教科書處置邏輯。致畸性視窗決定選擇。

## 重要概念

- **propylthiouracil (PTU)** — 硫脲類，抑制thyroid peroxidase並阻斷末梢T4→T3轉換，懷孕初期優先，肝毒性較高
- **pregnancy thyroid management** — 第1孕期PTU、第2孕期methimazole、最低劑量、free T4近正常上限、禁用放射性碘
- **aplasia cutis** — 頭皮缺損，與methimazole於第1孕期暴露相關的畸形

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