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Guo N, Xue M, Liang Z. Advances in the differential diagnosis of transient hyperthyroidism in pregnancy and Graves' disease. Arch Gynecol Obstet 2023; 308:403-411. [PMID: 36112207 DOI: 10.1007/s00404-022-06774-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 08/28/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The occurrence of thyrotoxicosis during pregnancy is mainly attributed to gestational transient thyrotoxicosis (GTT) and Graves' disease (GD). It is important to distinguish between GTT and Graves' disease because the two diseases are treated very differently. However, a gold standard for the differential diagnosis of the two diseases is currently lacking, and the most common method of differentiation is based on past medical history and clinical presentation combined with thyroid-related antibodies. METHODS A literature search of the electronic databases PubMed, Embase, Medline, Google Scholar, Cochrane Library, China Knowledge Infrastructure, Wanfang Database, Chinese Scientific Journals Full Text Database and China Biomedical CD-ROM was performed. The search period ranged from journal inception until 2022. We used the following search terms in "All fields": {["thyroid" (common field) OR "thyroid" (subject line)] OR "hyperthyroidism" (common field)} AND {["pregnancy" (title) OR "pregnancy" (title)] AND "one over" (common field)} OR {["pregnancy" (common field) OR "pregnancy" (common field) OR "pregnancy" (subject line)] AND "Graves'" (common field)}. RESULTS In recent years, some clinical studies at home and abroad have proposed other meaningful differential indicators, such as thyroid stimulating hormone, chorionic gonadotropin, thyroid hormone levels and thyroid ultrasound. CONCLUSION The differential diagnostic significance of each of these indicators is summarised here with the goal of providing a better reference for the differential diagnosis of hyperthyroidism during pregnancy in clinical practice.
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Affiliation(s)
- Nian Guo
- Department of Endocrinology and Metabolism, The Second Clinical Medical College, Jinan University (Shenzhen People's Hospital), Shenzhen, Guangdong, China
| | - Meng Xue
- Department of Endocrinology and Metabolism, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Zhen Liang
- Department of Endocrinology and Metabolism, The Second Clinical Medical College, Jinan University (Shenzhen People's Hospital), Shenzhen, Guangdong, China.
- Department of Geriatrics, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China.
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Sankoda A, Arata N, Sato S, Umehara N, Morisaki N, Ito Y, Sago H, Yano Y, Horikawa R. Association of Isolated Hypothyroxinemia and Subclinical Hypothyroidism With Birthweight: A Cohort Study in Japan. J Endocr Soc 2023; 7:bvad045. [PMID: 37122589 PMCID: PMC10139438 DOI: 10.1210/jendso/bvad045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Indexed: 05/02/2023] Open
Abstract
Context Isolated hypothyroxinemia (low maternal free thyroxine [FT4] in the absence of thyroid-stimulating hormone [TSH] elevation) and subclinical hypothyroidism (high TSH in the absence of FT4 elevation) during early pregnancy are common. However, there are limited data regarding pregnancy outcomes, particularly their association with birthweight. Objective We assessed the association between isolated hypothyroxinemia and subclinical hypothyroidism during the first trimester and birthweight. Methods Analyses were conducted using a database of pregnant women (n = 1105; median age, 35 years) who delivered at the National Center for Child Health and Development, a tertiary hospital in Tokyo. The primary outcomes included the rates of small for gestational age (SGA), large for gestational age (LGA), and low birth weight. Results Of the 1105 pregnant women, 981 were classified into the euthyroidism group, 25 into the isolated hypothyroxinemia group, and 26 into the subclinical hypothyroidism group during the first trimester. The prevalence of SGA was significantly higher in isolated hypothyroxinemia and subclinical hypothyroidism groups than the euthyroidism group (28.0% and 19.2%, respectively, vs 5.7%; P < .01). The odds ratio with 95% CI for SGA was 12.51 (4.41-35.53) for isolated hypothyroxinemia and 4.44 (1.57-12.56) for subclinical hypothyroidism in a multivariable adjustment model. Isolated hypothyroxinemia and subclinical hypothyroidism were not significantly associated with LGA and low birth weight. Conclusion Pregnant women with isolated hypothyroxinemia and subclinical hypothyroidism in the first trimester have an increased likelihood of SGA. Screening and careful perinatal checkups for isolated hypothyroxinemia and subclinical hypothyroidism may help identify pregnant women at high risk for SGA.
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Affiliation(s)
- Akiko Sankoda
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo 157-0074, Japan
| | - Naoko Arata
- Correspondence: Naoko Arata, MD, PhD, Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 10-1 Okura 2-chome, Setagaya, Tokyo, 157-8535, Japan.
| | - Shiori Sato
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo 157-0074, Japan
| | - Nagayoshi Umehara
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo 157-0074, Japan
| | - Naho Morisaki
- Department of Social Medicine, National Research Institute for Child Health and Development, Tokyo 157-0074, Japan
| | - Yushi Ito
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo 157-0074, Japan
| | - Haruhiko Sago
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo 157-0074, Japan
| | - Yuichiro Yano
- Noncommunicable Disease Epidemiology Research Center, Shiga University of Medical Science, Otsu 520-2192, Japan
| | - Reiko Horikawa
- Division of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo 157-0074, Japan
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Zhuo L, Wang Z, Yang Y, Liu Z, Wang S, Song Y. Obstetric and offspring outcomes in isolated maternal hypothyroxinaemia: a systematic review and meta-analysis. J Endocrinol Invest 2022; 46:1087-1101. [PMID: 36422828 DOI: 10.1007/s40618-022-01967-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 11/12/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To examine the association between isolated maternal hypothyroxinaemia (IMH) and adverse obstetric outcomes and offspring outcomes and also investigate the effects of levothyroxine therapy on IMH for the above outcomes. METHODS We systematically searched PubMed, EMBASE, and Cochrane Library, and the reference lists of key reviews were hand searched on June 9, 2021. Two authors independently screened titles/abstracts. Full articles were further assessed if the information suggested that the study met the inclusion/exclusion criteria, and two researchers performed data extraction and risk-of-bias assessment using standardized tables. Summary relative risks or the mean difference between maternal effects and offspring outcomes were calculated by a random-effects model. RESULTS We identified 38 eligible articles (35 cohort studies and two randomized controlled trials [RCT]). Meta-analysis showed that maternal IMH was associated with increased gestational diabetes mellitus, preterm premature rupture of membranes, preterm birth, fetal distress, and macrosomia outcomes in IMH compared to euthyroid women, and the relative risks were 1.42 (1.03-1.96), 1.50 (1.05-2.14), 1.33 (1.15-1.55), 1.75 (1.16-2.65) and 1.62 (1.35-1.94), respectively. IMH was not associated with placenta previa, gestational hypertension, pre-eclampsia, intrauterine growth restriction, and offspring outcomes like birth weight, low birth weight infants, fetal macrosomia, neonatal intensive care, neonatal death, or fetal head circumference. In addition, we did not find an association between IMH and adverse offspring cognitive defects. Due to insufficient data for meta-analysis, it failed to pool the evidence of levothyroxine's therapeutic effect on IMH and their offspring. CONCLUSIONS AND RELEVANCE IMH in pregnancy may relate to a few maternal and offspring outcomes. Moreover, there is currently no sufficient evidence that levothyroxine treatment during pregnancy reduces adverse maternal outcomes and disability in offspring. Further investigation to explore the beneficial effects of levothyroxine therapy is warranted.
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Affiliation(s)
- L Zhuo
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, People's Republic of China
| | - Z Wang
- Department of Endocrinology, Shandong Provincial Hospital affiliated to Shandong First Medical University, Jinan, Shandong, People's Republic of China
- Shandong Institute of Endocrine and Metabolic Diseases, Jinan, Shandong, People's Republic of China
| | - Y Yang
- Department of Endocrinology, Shandong Provincial Hospital affiliated to Shandong First Medical University, Jinan, Shandong, People's Republic of China
- Shandong Institute of Endocrine and Metabolic Diseases, Jinan, Shandong, People's Republic of China
| | - Z Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, People's Republic of China
| | - S Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, People's Republic of China.
| | - Y Song
- Department of Endocrinology, Shandong Provincial Hospital affiliated to Shandong First Medical University, Jinan, Shandong, People's Republic of China.
- Shandong Institute of Endocrine and Metabolic Diseases, Jinan, Shandong, People's Republic of China.
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Abstract
Hypothyroidism is the common clinical condition of thyroid hormone deficiency and, if left untreated, can lead to serious adverse health effects on multiple organ systems, with the cardiovascular system as the most robustly studied target. Overt primary hypothyroidism is defined as elevated thyroid-stimulating hormone (TSH) concentration in combination with free thyroxine (fT4) concentration below the reference range. Subclinical hypothyroidism, commonly considered an early sign of thyroid failure, is defined by elevated TSH concentrations but fT4 concentrations within the reference range. Hypothyroidism is classified as primary, central or peripheral based on pathology in the thyroid, the pituitary or hypothalamus, or peripheral tissue, respectively. Acquired primary hypothyroidism is the most prevalent form and can be caused by severe iodine deficiency but is more frequently caused by chronic autoimmune thyroiditis in iodine-replete areas. The onset of hypothyroidism is insidious in most cases and symptoms may present relatively late in the disease process. There is a large variation in clinical presentation and the presence of hypothyroid symptoms, especially in pregnancy and in children. Levothyroxine (LT4) is the mainstay of treatment and is one of the most commonly prescribed drugs worldwide. After normalization of TSH and fT4 concentrations, a considerable proportion of patients treated with LT4 continue to have persistent complaints, compromising quality of life. Further research is needed regarding the appropriateness of currently applied reference ranges and treatment thresholds, particularly in pregnancy, and the potential benefit of LT4/liothyronine combination therapy for thyroid-related symptom relief, patient satisfaction and long-term adverse effects.
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Pearce EN. Management of Hypothyroidism and Hypothyroxinemia in Pregnancy. Endocr Pract 2022; 28:711-718. [PMID: 35569735 DOI: 10.1016/j.eprac.2022.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/04/2022] [Accepted: 05/06/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To review the diagnosis and management of hypothyroidism in pregnancy, preconception, and the postpartum period. METHODS Literature review of English-language papers published between 1982 and 2022, focusing on the most recent literature. RESULTS During pregnancy, thyroid function laboratory tests need to be interpreted with regard to gestational age. Overt hypothyroidism, regardless of the TSH level, should always be promptly treated when it is diagnosed preconception or during pregnancy or lactation. Most women with preexisting treated hypothyroidism will require an increase in levothyroxine dosing to maintain euthyroidism during gestation. levothyroxine-treated pregnant patients need close monitoring with serum thyroid stimulating hormone (TSH) to avoid or- or under treatment. There is no consensus about whether to initiate levothyroxine in women with mild forms of gestational thyroid hypofunction. However, in light of current evidence it is reasonable to treat subclinically hypothyroid women with levothyroxine, particularly if the TSH is >10 mIU/L or the thyroperoxidase antibody is positive. Women who are not treated need to be followed to ensure that treatment is initiated promptly if thyroid failure progresses. Additional studies are needed to better understand the effects of the initiation of levothyroxine in early gestation in subclinically hypothyroid and hypothyroxinemic women and to determine optimal strategies for thyroid function screening in preconception and pregnancy. CONCLUSION The diagnosis and management of hypothyroidism in the peripregnancy period present specific challenges. In making management decisions, it is essential to weigh the risks and benefits of treatments not just for the mother but also for the fetus.
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Affiliation(s)
- Elizabeth N Pearce
- Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, 720 Harrison Ave, Suite 8100, Boston, MA, 02118.
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Potential Risk Factors for Isolated Hypothyroxinemia in Women of Childbearing Age-Results from Retrospective Analysis. J Clin Med 2021; 10:jcm10225384. [PMID: 34830664 PMCID: PMC8617839 DOI: 10.3390/jcm10225384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/12/2021] [Accepted: 11/17/2021] [Indexed: 11/17/2022] Open
Abstract
Isolated hypothyroxinemia (IH) unfavorably affects reproduction. This study aimed to evaluate retrospectively if any routinely measured clinical/laboratory parameters are associated with IH among women of childbearing age hospitalized in the endocrine department. A group of 466 female non-pregnant inpatients (age range 13-57 years) was considered. IH (decreased free thyroxine (FT4) with normal TSH) was found in 8/466 patients (1.72%). Vitamin D deficiency (<30 ng/mL) was found in all patients with IH, whereas severe Vitamin D deficiency (<20 ng/mL) was found in 5/6. Vitamin D concentration was lower in IH females. FT4 concentration was lower in patients with severe vitamin D deficiency and correlated positively with vitamin D concentration. Insulin resistance index (IRI) was increased (>1.25) in 5/6 patients with IH. IRI was higher in IH patients and it was the only independent linear factor for IH in the univariate regression. FT4 concentration was lower in patients with increased IRI and correlated negatively with IRI. FT4 concentration correlated negatively with body mass index (BMI) and LDL cholesterol or triglycerides, and positively with HDL cholesterol or HDLC/cholesterol ratio. Vitamin D deficiency, insulin resistance and increased BMI (as potential causative factors), and abnormal lipid profile (as a possible consequence), are associated with IH in women of childbearing age. Eliminating risk factors for hypothyroxinemia may improve reproductive health.
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Affiliation(s)
- Sun Y. Lee
- Section of Endocrinology, Diabetes, and Weight Management, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, U.S.A
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Sun Y, Zheng W, Zhang L, Zhao H, Li X, Zhang C, Ma W, Tian D, Yu KH, Xiao S, Jin L, Hua J. Quantifying the Impacts of Pre- and Post-Conception TSH Levels on Birth Outcomes: An Examination of Different Machine Learning Models. Front Endocrinol (Lausanne) 2021; 12:755364. [PMID: 34777251 PMCID: PMC8586450 DOI: 10.3389/fendo.2021.755364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 10/12/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND While previous studies identified risk factors for diverse pregnancy outcomes, traditional statistical methods had limited ability to quantify their impacts on birth outcomes precisely. We aimed to use a novel approach that applied different machine learning models to not only predict birth outcomes but systematically quantify the impacts of pre- and post-conception serum thyroid-stimulating hormone (TSH) levels and other predictive characteristics on birth outcomes. METHODS We used data from women who gave birth in Shanghai First Maternal and Infant Hospital from 2014 to 2015. We included 14,110 women with the measurement of preconception TSH in the first analysis and 3,428 out of 14,110 women with both pre- and post-conception TSH measurement in the second analysis. Synthetic Minority Over-sampling Technique (SMOTE) was applied to adjust the imbalance of outcomes. We randomly split (7:3) the data into a training set and a test set in both analyses. We compared Area Under Curve (AUC) for dichotomous outcomes and macro F1 score for categorical outcomes among four machine learning models, including logistic model, random forest model, XGBoost model, and multilayer neural network models to assess model performance. The model with the highest AUC or macro F1 score was used to quantify the importance of predictive features for adverse birth outcomes with the loss function algorithm. RESULTS The XGBoost model provided prominent advantages in terms of improved performance and prediction of polytomous variables. Predictive models with abnormal preconception TSH or not-well-controlled TSH, a novel indicator with pre- and post-conception TSH levels combined, provided the similar robust prediction for birth outcomes. The highest AUC of 98.7% happened in XGBoost model for predicting low Apgar score with not-well-controlled TSH adjusted. By loss function algorithm, we found that not-well-controlled TSH ranked 4th, 6th, and 7th among 14 features, respectively, in predicting birthweight, induction, and preterm birth, and 3rd among 19 features in predicting low Apgar score. CONCLUSIONS Our four machine learning models offered valid predictions of birth outcomes in women during pre- and post-conception. The predictive features panel suggested the combined TSH indicator (not-well-controlled TSH) could be a potentially competitive biomarker to predict adverse birth outcomes.
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Affiliation(s)
- Yuantong Sun
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Weiwei Zheng
- Key Laboratory of the Public Health Safety, Ministry of Education, Department of Environmental Health, School of Public Health, Fudan University, Shanghai, China
| | - Ling Zhang
- Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huijuan Zhao
- Key Laboratory of the Public Health Safety, Ministry of Education, Department of Environmental Health, School of Public Health, Fudan University, Shanghai, China
| | - Xun Li
- Key Laboratory of the Public Health Safety, Ministry of Education, Department of Environmental Health, School of Public Health, Fudan University, Shanghai, China
| | - Chao Zhang
- Key Laboratory of the Public Health Safety, Ministry of Education, Department of Environmental Health, School of Public Health, Fudan University, Shanghai, China
| | - Wuren Ma
- Key Laboratory of the Public Health Safety, Ministry of Education, Department of Environmental Health, School of Public Health, Fudan University, Shanghai, China
| | - Dajun Tian
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, St. Louis, MO, United States
| | - Kun-Hsing Yu
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, United States
| | - Shuo Xiao
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy, Environmental and Occupational Health Sciences Institute, Rutgers University, Piscataway, NJ, United States
| | - Liping Jin
- Department of Maternity and Children’s Health Care Department, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Liping Jin, ; Jing Hua,
| | - Jing Hua
- Department of Maternity and Children’s Health Care Department, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Liping Jin, ; Jing Hua,
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