Management Thyroid Disease in Pregnancy: Preconception, and the postpartum complications

Pregnancy has a profound impact on the thyroid gland and thyroid function since the thyroid may encounter changes to hormones and size during pregnancy. The diagnosis and treatment of thyroid disease during pregnancy and the postpartum is complex but knowledge regarding the interaction between the thyroids and pregnancy/the postpartum period is advancing at a rapid pace. For women known to have hypothyroidism, an increase in thyroxine dose by 20–40% when pregnancy is confirmed usually ensures they remain euthyroid. Treatment of subclinical hypothyroidism is recommended if the woman has antithyroid antibodies. Treatment of hyperthyroidism, unless it is related to human chorionic gonadotrophin, involves propylthiouracil in the first trimester. Carbimazole may be used in the second trimester. Thyroid function tests are checked every month and every two weeks following a change in dose. Women with a current or a past history of Graves’ disease who have thyrotropin receptor antibodies require early specialist referral as there is a 1–5% risk of fetal hyperthyroidism. Women with thyroid disorders in pregnancy should be followed up by their GP in the postpartum period. Postpartum thyroiditis may present months after delivery.

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Management of thyroid disease in pregnancy – Room for improvement in the first trimester

Obstetric Medicine ◽

10.1177/1753495x16629773 ◽

2016 ◽

Vol 9 (3) ◽

pp. 126-129 ◽

Cited By ~ 1

Author(s):

Helen Robinson ◽

Philip Robinson ◽

Michael D’Emden ◽

Kassam Mahomed

Keyword(s):

General Practitioner ◽

Thyroid Function ◽

Thyroid Disease ◽

Thyroid Dysfunction ◽

First Trimester ◽

Antenatal Clinic ◽

Thyroid Stimulating Hormone ◽

Thyroid Function Tests ◽

In Pregnancy ◽

Stimulating Hormone

Background First-trimester care of maternal thyroid dysfunction has previously been shown to be poor. This study evaluates early management of thyroid dysfunction in pregnancy in Australia. Methods Patients reviewed by the Obstetric Medicine team for thyroid dysfunction from 1 January 2012 to 30 June 2013 were included. Data were collected on gestation at referral from the patient’s general practitioner to the antenatal clinic, information provided in the referral letter, thyroid function tests and thyroid medications. Results Eighty-five women were included in the study. At the time of general practitioner referral to antenatal services, 19% of women with preexisting thyroid disease had no thyroid function tested. Forty-three percent had an abnormal thyroid-stimulating hormone defined as being outside the laboratory-specific pregnancy reference range if available, or outside the level of 0.1–2.5 mIu/L in the first trimester, 0.2–3.0 mIu/L in the second trimester and 0.3–3.0 mIu/L in the third trimester. Only 21% of women increased their thyroxine dose prior to their first antenatal clinic review. Conclusion This study highlights that a significant proportion of women with known thyroid disease either have untested thyroid function in the first trimester or a thyroid-stimulating hormone outside of levels recommended by guidelines.

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Moderate Iodine Deficiency Is Common in Pregnancy but Does Not Alter Maternal and Neonatal Thyroid Function Tests

Frontiers in Endocrinology ◽

10.3389/fendo.2020.523319 ◽

2020 ◽

Vol 11 ◽

Author(s):

Tal Schiller ◽

Arnon Agmon ◽

Viviana Ostrovsky ◽

Gabi Shefer ◽

Hilla Knobler ◽

...

Keyword(s):

Pregnant Women ◽

Thyroid Function ◽

Iodine Deficiency ◽

Urinary Iodine ◽

Iodine Content ◽

First Trimester ◽

Thyroid Function Tests ◽

Neonatal Thyroid Function ◽

Iodine Deficiency In Pregnancy ◽

In Pregnancy

IntroductionAn Israeli national survey found that 85% of pregnant women had urinary iodine content (UIC) levels below the adequacy range (<150 µg/L). Widespread desalinated water usage and no national fortification plan are possible causes. Studies assessing relationships between iodine status and maternal and neonatal thyroid function provided varying results. Our aims were to determine whether iodine deficiency was associated with altered maternal or neonatal thyroid function and the factors leading to iodine deficiency.MethodsA cross-sectional study including 100 healthy women without prior thyroid disease, in their first trimester of a singleton pregnancy were recruited from an HMO clinic in central Israel. The women were followed from their first trimester. All women completed a 24-h dietary recall and life habits questionnaires. We tested for UIC, maternal and neonatal thyroid function, maternal autoantibodies, and neonatal outcomes.ResultsMedian UIC in our cohort was 49 µg/L [25%–75% interquartile range (IQR) 16-91.5 µg/L], with 84% below adequacy range. No correlation was found between iodine deficiency and maternal or neonatal thyroid function which remained within normal ranges. Antibody status did not differ, but thyroglobulin levels were significantly higher in iodine insufficient subjects. UIC was higher in women consuming an iodine containing supplement. There was no association between UIC and dietary iodine content or water source.ConclusionsModerate iodine deficiency is common in our healthy pregnant women population. Our data imply that moderate iodine deficiency in pregnancy seem sufficient to maintain normal maternal and neonatal thyroid function.

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Postpartum Thyroid Abnormalities and Systemic Lupus Erythematosus: Is There a Link?

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.1938 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A948-A949

Author(s):

Jordan Albrecht ◽

Moeed Ahmed ◽

Sudha Nandala ◽

Saad Farooqi ◽

Robert J Anderson

Keyword(s):

Systemic Lupus Erythematosus ◽

Thyroid Function ◽

Lupus Erythematosus ◽

Thyroid Disease ◽

Postpartum Period ◽

Thyroid Function Tests ◽

Systemic Lupus ◽

Free T4 ◽

Postpartum Thyroiditis ◽

Function Tests

Abstract Introduction: Postpartum Thyroiditis (PPT) is an autoimmune disorder characterized by destruction of the thyroid gland within the first year after delivery. Systemic Lupus Erythematosus (SLE), another autoimmune disease, has been associated with a spectrum of thyroid disorders. While the prevalence of thyroid diseases in patients with SLE is increased, the association between SLE and PPT is not well known. The infrequency of encountering SLE and PPT makes abnormal thyroid tests in the postpartum period a diagnostic challenge. Clinical Case: A 27-year-old G1P1001 who was five months postpartum and not breast feeding was referred to Endocrinology clinic for evaluation of abnormal thyroid function tests. Past medical history was significant for SLE with renal and pericardial involvement. SLE was well controlled, treated with hydroxychloroquine. Family history was significant for hypothyroidism in her mother. She was asymptomatic and appeared clinically euthyroid. Vitals were stable and physical exam was negative for goiter, nodule or orbitopathy. Lab results at two months postpartum showed an elevated TSH of 3.87 UIU/mL (Normal 0.40-3.8 UIU/mL) and at four months postpartum TSH was low at 0.012 UIU/mL. Repeat labs at five months postpartum continued to show a low TSH at 0.007 UIU/mL with mildly elevated Free T4 at 1.7 ng/dL (Normal 0.6-1.6 ng/dL) and elevated Free T3 of 6.0 pg/mL (Normal 2.1-3.8 pg/mL). Anti-thyroid peroxidase antibodies (TPO), thyroid stimulating antibodies (TSI) and TSH receptor antibodies (TRAb) were negative. Thyroid Ultrasound with Doppler was within normal limits. Radioactive Iodine Uptake and Scan, obtained at 6 months postpartum, showed high normal uptake (17% and 32% at 4 hours and 24 hours respectively), suggestive of recovery phase of PPT. The most recent TSH was elevated at 8.5 UIU/mL and Free T4 was low at 0.7 ng/dL. Disease course was consistent with PPT. Conclusion: The Th1 (T-helper) lymphocyte immune predominance in autoimmune thyroid disease and SLE is the immune-pathogenetic base of the association between both diseases. Postpartum thyroiditis is a variant of chronic autoimmune thyroiditis. Serum anti-TPO antibodies vary during pregnancy and tend to increase early and may decline later. Immunologic tolerance increases during pregnancy, fades in the postpartum period and makes interpretation of thyroid function tests and disease process challenging. Pregnant and postpartum patients who have SLE have increased prevalence of thyroid disease. Causes are multifactorial with a higher prevalence of hypothyroidism and thyroid autoantibodies. Hyperthyroidism is much less likely. One comparable study found 6 of 43 (14%) women with SLE developed PPT and only one of these patients had positive thyroid antibodies. These reports and our patient illustrate the variability of thyroid function tests in patients with SLE.

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Progestogens for treatment and prevention of pregnancy disorders

Hormone Molecular Biology and Clinical Investigation ◽

10.1515/hmbci.2010.069 ◽

2010 ◽

Vol 3 (3) ◽

Author(s):

Adolf E. Schindler

Keyword(s):

Premature Birth ◽

Previous History ◽

First Trimester ◽

Study Groups ◽

Treatment And Prevention ◽

Maternal Immune System ◽

Hydroxyprogesterone Caproate ◽

History Of ◽

Threatened Abortion ◽

In Pregnancy

AbstractProgesterone appears to be the dominant hormone not only establishing a proper secretory endometrial development but also adequate decidualization to establish pregnancy and sustain pregnancy development. Progesterone is the natural immunoregulator to control the maternal immune system and not to reject the allogeneic fetus. There are two sources of progesterone: corpus luteum first and placenta later. Three progestogens can be used in pregnancy: (i) progesterone (per os, intravaginal and intramuscular), (ii) dydrogesterone (per os), and (iii) 17α-hydroxyprogesterone caproate (intramuscular). There are three indications, for which these progestogens can be clinically used either for treatment or prevention: (i) first trimester threatened and recurrent (habitual) abortion, (ii) premature labor/premature birth, and (iii) pre-eclampsia (hypertension in pregnancy). The available data are limited and only partially randomized. In threatened abortion the use of progesterone, dydrogesterone and 17α-hydroxyprogesterone caproate leads to a significant improved outcome, when at the time of threatened abortion a viable fetus has been ascertained by ultrasound. For prevention of recurrent abortion there are also some data indicating a significant effect compared with women without progestogen treatment. Prevention of preterm birth by progestogens (progesterone vaginally, orally and 17α-hydroxyprogesterone caproate intramuscularly) was significantly effective. The main study groups include pregnant women with a previous history of premature birth. However, also in women with shortened cervix use of progesterone seems to be helpful. The studies done so far in women with risk factors for pre-eclampsia or established pre-eclampsia were based on parenteral progesterone application. However, new studies are urgently needed.

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The Characteristics of Children with Abnormalities Detected in Thyroid Function Tests, and Distribution of Diagnoses

Journal of Dr Behcet Uz Children s Hospital ◽

10.5222/buchd.2020.57704 ◽

2020 ◽

Author(s):

Elif Çelik ◽

Ayşe Anık

Keyword(s):

Thyroid Function ◽

Thyroid Disease ◽

Correct Diagnosis ◽

Thyroid Function Test ◽

Hashimoto Thyroiditis ◽

Thyroid Stimulating Hormone ◽

Thyroid Function Tests ◽

Test Results ◽

Function Tests ◽

Function Test

INTRODUCTION: Thyroid function tests are among the most frequently implemented laboratory tests in primary, and secondary healthcare institutions. The aim of the present study was to investigate the demographic and clinical characteristics and final diagnosis of children referred by primary and secondary healthcare institutions with the suspicion of an abnormality in thyroid function test and/or with the initial diagnosis of specific thyroid disease. METHODS: A total of two hundred eighty-nine pediatric patients, aged between 4 and 18 years admitted to the outpatient clinics of Behçet Uz Children’s Health and Diseases Hospital between January 2018 and January 2020, were included in the study. The patient data were obtained retrospectively from the hospital records. RESULTS: A total of 66% of the patients who were included in the study were female with a median age of 12 years (8.7-14.4), while 64% of them were pubertal; and 78% of the cases were referred by secondary healthcare institutions. The most common reason for referral was isolated elevation of thyroid stimulating hormone (TSH). A total of 56% of the patients were asymptomatic at the time of admission, and thyroid function test results of 75% of them were within normal limits. When evaluated according to their final diagnoses, the children were normal/healthy (64%), diagnosed with Hashimoto thyroiditis (30%), nodular thyroid disease (3%), Graves disease (2%) and isolated increase of TSH was related to obesity in 5 patients (1%). DISCUSSION AND CONCLUSION: It is essential to evaluate children with abnormal thyroid function test results with detailed history and physical examination. Besides, the thyroid function tests should be performed with reliable and sensitive methods in standardized laboratories to reach the correct diagnosis in these children.

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When thyroid labs do not add up, physicians should ask patients about biotin supplements

BMJ Case Reports ◽

10.1136/bcr-2019-231337 ◽

2020 ◽

Vol 13 (3) ◽

pp. e231337

Author(s):

Michael S Lundin ◽

Ahmad Alratroot ◽

Fawzi Abu Rous ◽

Saleh Aldasouqi

Keyword(s):

Thyroid Function ◽

Dose Adjustment ◽

Radioactive Iodine ◽

Graves Disease ◽

Thyroid Function Tests ◽

Medication List ◽

Function Tests ◽

Extensive Evaluation ◽

History Of ◽

Radioactive Iodine Ablation

A 69-year-old woman with a remote history of Graves’ disease treated with radioactive iodine ablation, who was maintained on a stable dose of levothyroxine for 15 years, presented with abnormal and fluctuating thyroid function tests which were confusing. After extensive evaluation, no diagnosis could be made, and it became difficult to optimise the levothyroxine dose, until we became aware of the recently recognised biotin-induced lab interference. It was then noticed that her medication list included biotin 10 mg two times per day. After holding the biotin and repeating the thyroid function tests, the labs made more sense, and the patient was easily made euthyroid with appropriate dose adjustment. We also investigated our own laboratory, and identified the thyroid labs that are performed with biotin-containing assays and developed strategies to increase the awareness about this lab artefact in our clinics.

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Thyroid disorders in subfertility and early pregnancy

Therapeutic Advances in Endocrinology and Metabolism ◽

10.1177/2042018820945855 ◽

2020 ◽

Vol 11 ◽

pp. 204201882094585

Author(s):

Samantha Anandappa ◽

Mamta Joshi ◽

Lukasz Polanski ◽

Paul V. Carroll

Keyword(s):

Pregnant Women ◽

Thyroid Function ◽

Current Knowledge ◽

Thyroid Autoimmunity ◽

Thyroid Disorders ◽

Thyroid Function Tests ◽

Increased Risk ◽

Hormone Use ◽

Current Knowledge Base ◽

In Pregnancy

Disorders of thyroid function are common in pregnancy and have implications for foetal and maternal health. Thyroid autoimmunity, as evidenced by the presence of elevated levels of anti-thyroid antibodies (anti-TPO and anti-Tg antibodies) is associated with an increased risk of miscarriage, though the mechanism remains poorly understood. There has been considerable focus on the implications and optimal management of pregnant women with thyroid disease, especially those undergoing assisted reproduction. Pregnancy results in significant changes in thyroid physiology and these need to be understood by clinicians involved in the care of pregnant women. Guidelines for the use of thyroxine and target thyroid function tests have been produced by international bodies but it is recognised that these predominantly reflect expert opinion rather than established evidence-based practice. Importantly a number of key clinical trials have been performed to aid understanding, particularly of the consequences of hypothyroidism for mother and baby, and the effectiveness of thyroid hormone use in autoimmune and subclinical hypothyroidism. This review summarises the current knowledge base and guidance for practice relating to thyroid disorders in pregnancy and subfertility.

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Previous induced abortion and ante-natal depression in primiparae: preliminary report of a survey of mental health in pregnancy

Psychological Medicine ◽

10.1017/s0033291700018912 ◽

1978 ◽

Vol 8 (4) ◽

pp. 711-715 ◽

Cited By ~ 39

Author(s):

R. Kumar ◽

Kay Robson

Keyword(s):

Mental Health ◽

Preliminary Report ◽

Previous History ◽

First Trimester ◽

Induced Abortion ◽

Depression And Anxiety ◽

History Of ◽

Expectant Mothers ◽

Clinically Significant ◽

In Pregnancy

SynopsisOne hundred and nineteen primiparae, who were routinely attending ante-natal clinics, were interviewed repeatedly between the 12th and 36th weeks of their pregnancies. The incidence of depression was highest in the first trimester and, overall, about a fifth of the sample was found to be suffering from clinically significant neurotic disturbances. In a proportion of these expectant mothers there was an association between depression and anxiety early in pregnancy and a previous history of induced abortion; this phenomenon may reflect a reactivation of mourning which was previously suppressed.

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Assessment of Thyroid Function in Early Pregnancy

Bangladesh Journal of Nuclear Medicine ◽

10.3329/bjnm.v19i2.35864 ◽

2018 ◽

Vol 19 (2) ◽

pp. 98

Author(s):

Mohammad Saifur Rahman ◽

Sadia Sultana ◽

Ayesha Nazneen

Keyword(s):

Pregnant Women ◽

Thyroid Function ◽

Early Pregnancy ◽

Correct Diagnosis ◽

First Trimester ◽

Military Hospital ◽

Thyroid Disorders ◽

Thyroid Disorder ◽

Cross Sectional ◽

In Pregnancy

Objectives: Thyroid disorders are commonly observed in pregnancy. Thyroid hormones play an important role in embryogenesis and fetal development. The fetus is completely dependent on the mother for thyroid hormone in first trimester. About 10% of all pregnant women can be affected by thyroid disorders during pregnancy. Thyroid function abnormalities in pregnancy are a challenge for the concerned physicians. The objective of this study was to assess the maternal thyroid function in first trimester of pregnancy.Patients and Methods: A descriptive cross sectional study was carried out at the Combined Military Hospital (CMH), Dhaka over a period of one year from January 2013 to December 2013 to see the serum FT3, FT4, TSH, thyroid antibodies level and common thyroid disorders in pregnancy. A total of 138 pregnant women in their first trimester (up to 12 weeks) of pregnancy with an age range of 18-35 years were enrolled in this study. Pregnant women with known thyroid disorder and on treatment and pregnancy more than three months were excluded. Measurement of serum FT3, FT4, TSH, Anti TPO-Ab and Anti TG-Ab were done in each patient at the time of enrolment. Ultrasonography of each patient was done for confirmation of pregnancy and correlation of gestational age.Results: Among 138 pregnant women, subclinical hypothyroidism was detected in 10 (7.2%) patients and subclinical hyperthyroidism was detected in 3 (2.2%) patients. Mean difference of the investigation findings were not statistically significant among primi and multi gravida. TPO-Ab and TG-Ab difference were statistically significant between two age groups.Conclusion: Subclinical thyroid disorders are fairly high among pregnant women. Correct diagnosis in early pregnancy and prompt treatment will bring an excellent prognosis for both mother and offspring.Bangladesh J. Nuclear Med. 19(2): 98-102, July 2016

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Gestation specific reference intervals for thyroid function tests in pregnancy

Clinical Chemistry and Laboratory Medicine (CCLM) ◽

10.1515/cclm-2015-0569 ◽

2016 ◽

Vol 54 (8) ◽

Cited By ~ 6

Author(s):

Süleyman Akarsu ◽

Filiz Akbiyik ◽

Eda Karaismailoglu ◽

Zeliha Gunnur Dikmen

Keyword(s):

Pregnant Women ◽

Thyroid Function ◽

First Trimester ◽

Reference Intervals ◽

Specific Reference ◽

Thyroid Function Tests ◽

Second Trimester ◽

Third Trimester ◽

The Third ◽

Function Tests

AbstractThyroid function tests are frequently assessed during pregnancy to evaluate thyroid dysfunction or to monitor pre-existing thyroid disease. However, using non-pregnant reference intervals can lead to misclassification. International guidelines recommended that institutions should calculate their own pregnancy-specific reference intervals for free thyroxine (FT4), free triiodothyronine (FT3) and thyroid-stimulating hormone (TSH). The objective of this study is to establish gestation-specific reference intervals (GRIs) for thyroid function tests in pregnant Turkish women and to compare these with the age-matched non-pregnant women.Serum samples were collected from 220 non-pregnant women (age: 18–48), and 2460 pregnant women (age: 18–45) with 945 (39%) in the first trimester, 1120 (45%) in the second trimester, and 395 (16%) in the third trimester. TSH, FT4 and FT3 were measured using the Abbott Architect i2000SR analyzer.GRIs of TSH, FT4 and FT3 for first trimester pregnancies were 0.49–2.33 mIU/L, 10.30–18.11 pmol/L and 3.80–5.81 pmol/L, respectively. GRIs for second trimester pregnancies were 0.51–3.44 mIU/L, 10.30–18.15 pmol/L and 3.69–5.90 pmol/L. GRIs for third trimester pregnancies were 0.58–4.31 mIU/L, 10.30–17.89 pmol/L and 3.67–5.81 pmol/L. GRIs for TSH, FT4 and FT3 were different from non-pregnant normal reference intervals.TSH levels showed an increasing trend from the first trimester to the third trimester, whereas both FT4 and FT3 levels were uniform throughout gestation. GRIs may help in the diagnosis and appropriate management of thyroid dysfunction during pregnancy which will prevent both maternal and fetal complications.

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