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Soto J, Weissglas B, von Plessing-Pierry G, del Solar MP, Peña-Villa C, Flores X, Arancibia M, Campos L. Fetal Hyperthyroidism Secondary to Maternal Basedow-Graves' Disease. AJP Rep 2024; 14:e176-e183. [PMID: 38827649 PMCID: PMC11142847 DOI: 10.1055/a-2317-9431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 04/10/2024] [Indexed: 06/04/2024] Open
Abstract
Fetal hyperthyroidism is a rare prenatal disease and can be life-threatening. The diagnosis is based on ultrasound in mothers with a history of Basedow-Graves' disease and elevation of thyrotropin receptor antibodies (TRAbs) levels. The treatment consists of antithyroid drugs. We present a mother with Basedow-Graves' disease, treated with radioactive iodine 16 years ago. She had an unplanned pregnancy at the age of 29 years, and an elevation of TRAbs (21 U/L) was found at the sixth week of pregnancy. At 22 weeks of gestation, fetal ultrasound displayed tachycardia, goiter, exophthalmos, and suspicion of craniosynostosis, hence methimazole was started. Concomitantly, suppressed maternal thyroid-stimulating hormone (TSH) was found. Her daughter was born at 33 + 6 weeks showing clinical and laboratory findings of hyperthyroidism. Consequently, treatment with methimazole was prescribed. Normal thyroid function was documented in the mother after giving birth. Clear explanation has not been found for the alteration of maternal TSH during pregnancy.
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Affiliation(s)
- Julio Soto
- Department of Pediatrics, School of Medicine, Universidad de Concepcion, Concepcion, Chile
- Division of Pediatric Endocrinology, Pediatrics Service, Hospital Las Higueras, Talcahuano, Chile
| | - Bunio Weissglas
- Department of Internal Medicine, School of Medicine, Universidad de Concepcion, Concepcion, Chile
| | | | - Maria Paz del Solar
- Department of Clinical and Preclinical Sciences, School of Medicine, Universidad Catolica de la Santisima Concepcion, Concepcion, Chile
| | - Carolina Peña-Villa
- Department of Internal Medicine, School of Medicine, Universidad de Concepcion, Concepcion, Chile
- Division of Endocrinology, Internal Medicine Service, Hospital Las Higueras, Talcahuano, Chile
| | - Ximena Flores
- Division of Obstetric and Gynecologic Ultrasound, Obstetrics and Gynecology Service, Hospital Las Higueras, Talcahuano, Chile
- Department of Obstetrics and Ginecology, School of Medicine, Universidad de Concepcion, Concepcion, Chile
| | - Monica Arancibia
- Division of Pediatric Endocrinology, Pediatrics Service, Hospital Las Higueras, Talcahuano, Chile
| | - Laura Campos
- Division of Pediatric Endocrinology, Pediatrics Service, Hospital Las Higueras, Talcahuano, Chile
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Madike R, Cugati S, Qin Q, Chen C. Pregnancy and the eye: What do we need to watch out for? A review. Clin Exp Ophthalmol 2024; 52:234-247. [PMID: 38214050 DOI: 10.1111/ceo.14346] [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: 09/26/2023] [Revised: 11/29/2023] [Accepted: 12/01/2023] [Indexed: 01/13/2024]
Abstract
Pregnancy causes changes in all body systems, including the eye. The eye can undergo physiological and pathological changes in pregnancy. Some changes exacerbate pre-existing eye conditions while other conditions manifest for the first-time during pregnancy. Early recognition and management are essential to prevent sight threatening complications. In addition, some obstetric complications can be associated with ophthalmic signs. Prompt recognition of these eye findings may be life saving for both the mother and the foetus. The aim of this article is to present potential ocular complications in pregnancy and outline the appropriate management to preserve sight and maintain maternal and foetal safety. The safety of the use of common ophthalmological medications will also be discussed.
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Affiliation(s)
- Reema Madike
- School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Sudha Cugati
- School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
- Department of Ophthalmology, Modbury Hospital, South Australia Institute of Ophthalmology, Adelaide, South Australia, Australia
| | - Queena Qin
- Department of Ophthalmology, Modbury Hospital, South Australia Institute of Ophthalmology, Adelaide, South Australia, Australia
| | - Celia Chen
- Department of Ophthalmology, Flinders Medical Centre and Flinders University, Adelaide, South Australia, Australia
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3
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Chaker L, Cooper DS, Walsh JP, Peeters RP. Hyperthyroidism. Lancet 2024; 403:768-780. [PMID: 38278171 DOI: 10.1016/s0140-6736(23)02016-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/07/2023] [Accepted: 09/16/2023] [Indexed: 01/28/2024]
Abstract
Thyrotoxicosis causes a variety of symptoms and adverse health outcomes. Hyperthyroidism refers to increased thyroid hormone synthesis and secretion, most commonly from Graves' disease or toxic nodular goitre, whereas thyroiditis (typically autoimmune, viral, or drug induced) causes thyrotoxicosis without hyperthyroidism. The diagnosis is based on suppressed serum concentrations of thyroid-stimulating hormone (TSH), accompanied by free thyroxine and total or free tri-iodothyronine concentrations, which are raised (overt hyperthyroidism) or within range (subclinical hyperthyroidism). The underlying cause is determined by clinical assessment, detection of TSH-receptor antibodies and, if necessary, radionuclide thyroid scintigraphy. Treatment options for hyperthyroidism include antithyroid drugs, radioactive iodine, and thyroidectomy, whereas thyroiditis is managed symptomatically or with glucocorticoid therapy. In Graves' disease, first-line treatment is a 12-18-month course of antithyroid drugs, whereas for goitre, radioactive iodine or surgery are preferred for toxic nodules or goitres. Evidence also supports long-term treatment with antithyroid drugs as an option for patients with Graves' disease and toxic nodular goitre.
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Affiliation(s)
- Layal Chaker
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands; Department of Epidemiology, Erasmus University Medical Center, Rotterdam, Netherlands; Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - David S Cooper
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John P Walsh
- Department of Endocrinology & Diabetes, Sir Charles Gairdner Hospital, Nedlands, WA, Australia; Medical School, University of Western Australia, Crawley, WA, Australia
| | - Robin P Peeters
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands.
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Cai L, Wang P, Xue C, Chen J, Zhang Y. Clinical Characteristics and Risk Factors Associated With Adverse Pregnancy Outcomes in Patients With Gestational Hypothyroidism: A Case-Control Study. Endocr Pract 2024; 30:101-106. [PMID: 37913924 DOI: 10.1016/j.eprac.2023.10.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/18/2023] [Accepted: 10/27/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE To synthesize evidence, summarize the clinical features of patients diagnosed with gestational hypothyroidism (GH), and analyze the risk factors associated with adverse pregnancy outcomes. METHODS From February 2021 to March 2023, a case-control study was conducted on 298 hospitalized patients with GH and 312 pregnant women without GH who underwent physical examinations. The 312 pregnant women without GH were randomly selected during the same time period. They were allocated into the study and control groups for further comparison of clinical characteristics and pregnancy outcomes. RESULTS The parameters, including age, gestational diabetes, gestational hypertension, gravidity, parity, spontaneous abortion, history of gestation, thyroid-stimulating hormone, free triiodothyronine, thyroid peroxidase antibody (TPO-Ab), and free thyroxine were significantly different between the 2 groups (P <.05). Moreover, significant differences were found between the 2 groups in terms of preterm delivery, preeclampsia, premature rupture of membranes, placental abruption, and postpartum hemorrhage (P <.05). The multivariate logistic regression analysis revealed that the influencing factors of pregnancy outcome in patients with GH were age (≥30 years), gestational diabetes, gestational hypertension, gravidity (≥3 times), spontaneous abortion, parity, history of gestation (multiparity), and TPO-Ab (positive). CONCLUSION Our study revealed that the clinical features of patients with GH were age, gestational diabetes, gestational hypertension, gravidity, parity, spontaneous abortion, history of gestation, thyroid-stimulating hormone, free triiodothyronine, TPO-Ab, and free thyroxine.
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Affiliation(s)
- Lenan Cai
- Department of Hemodialysis, Dingzhou People's Hospital, Dingzhou, China
| | - Pan Wang
- Department of Radiotherapy, Dingzhou People's Hospital, Dingzhou, China.
| | - Caili Xue
- Department of Nursing, Dingzhou People's Hospital, Dingzhou, China
| | - Jie Chen
- Department of Nursing, Dingzhou People's Hospital, Dingzhou, China
| | - Yu Zhang
- Department of Pediatrics, Dingzhou People's Hospital, Dingzhou, China
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Cima LN, Tarna M, Martin CS, Sirbu AE, Soare I, Panaitescu AM, Gica N, Barbu CG, Fica S. Preconceptional Counseling in Women with Hyperthyroidism. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:234. [PMID: 38399522 PMCID: PMC10890308 DOI: 10.3390/medicina60020234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/14/2024] [Accepted: 01/24/2024] [Indexed: 02/25/2024]
Abstract
Preconception evaluation of couples wishing to conceive is an important step toward a healthy pregnancy and it is especially important in people with a chronic condition or at genetic risk. The most common endocrine disorders in women at reproductive age are those involving the thyroid gland and it is well recognized that hyperthyroidism (HT), over-function of the thyroid gland, is associated with risks of maternal, fetal, and neonatal complications. The aim of this paper is to review the latest evidence regarding the components of preconception counseling in women with HT that contemplate a pregnancy. We also want to raise awareness among healthcare professionals about the importance of periconceptional counseling in improving pregnancy outcomes and avoid maternal and fetal complications related to thyroid dysfunction. In women with Graves' disease seeking pregnancy, it is essential to discuss all the treatment options along with the associated risks and benefits. Extensive prospective studies are still needed to understand the implications of current recommended strategies for the management of HT in preconception and during pregnancy.
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Affiliation(s)
- Luminita Nicoleta Cima
- Department of Endocrinology and Diabetes, Nutrition and Metabolic Diseases, "Elias" Emergency University Hospital, 011461 Bucharest, Romania
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Mihaela Tarna
- Department of Endocrinology and Diabetes, Nutrition and Metabolic Diseases, "Elias" Emergency University Hospital, 011461 Bucharest, Romania
| | - Carmen Sorina Martin
- Department of Endocrinology and Diabetes, Nutrition and Metabolic Diseases, "Elias" Emergency University Hospital, 011461 Bucharest, Romania
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Anca Elena Sirbu
- Department of Endocrinology and Diabetes, Nutrition and Metabolic Diseases, "Elias" Emergency University Hospital, 011461 Bucharest, Romania
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Iulia Soare
- Department of Endocrinology and Diabetes, Nutrition and Metabolic Diseases, "Elias" Emergency University Hospital, 011461 Bucharest, Romania
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Anca Maria Panaitescu
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- "Filantropia" Clinical Hospital, 011171 Bucharest, Romania
| | - Nicolae Gica
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- "Filantropia" Clinical Hospital, 011171 Bucharest, Romania
| | - Carmen Gabriela Barbu
- Department of Endocrinology and Diabetes, Nutrition and Metabolic Diseases, "Elias" Emergency University Hospital, 011461 Bucharest, Romania
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Simona Fica
- Department of Endocrinology and Diabetes, Nutrition and Metabolic Diseases, "Elias" Emergency University Hospital, 011461 Bucharest, Romania
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
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Vadini V, Vasistha P, Shalit A, Maraka S. Thyroid storm in pregnancy: a review. Thyroid Res 2024; 17:2. [PMID: 38229163 DOI: 10.1186/s13044-024-00190-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 01/02/2024] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Thyroid storm is a state of circulating thyroid hormone excess leading to multiorgan dysfunction and systemic decompensation. It typically occurs in the setting of poorly controlled hyperthyroidism and a precipitating illness or event. Management of thyroid storm in pregnancy poses unique diagnostic and therapeutic challenges. MAIN BODY Thyroid storm is a clinical diagnosis characterized by hyperpyrexia, tachyarrhythmias, congestive heart failure, gastrointestinal and neuropsychiatric disturbances. However, diagnostic scoring systems have not been validated in pregnancy. Treatment involves specialist consultation, supportive care, and pharmacological options such as anti-thyroid medications, beta blockers, iodine solutions, glucocorticoids, and cholestyramine. These must be adapted and modified in pregnancy to prevent fetal and maternal complications. CONCLUSION There is a critical need to recognize thyroid storm during pregnancy and initiate proper medical interventions promptly.
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Affiliation(s)
- Vidhu Vadini
- Department of Internal Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA
| | - Prabhav Vasistha
- Department of Internal Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA
| | - Almog Shalit
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, School of Medicine, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyridoula Maraka
- Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA.
- Section of Endocrinology, Central Arkansas Veterans Healthcare System, 4300 W. 7Th St, Little Rock, AR, 72205, USA.
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Bogović Crnčić T, Girotto N, Ilić Tomaš M, Krištofić I, Klobučar S, Batičić L, Ćurko-Cofek B, Sotošek V. Innate Immunity in Autoimmune Thyroid Disease during Pregnancy. Int J Mol Sci 2023; 24:15442. [PMID: 37895126 PMCID: PMC10607674 DOI: 10.3390/ijms242015442] [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: 09/28/2023] [Revised: 10/17/2023] [Accepted: 10/20/2023] [Indexed: 10/29/2023] Open
Abstract
Autoimmune thyroid disease (AITD) is the most common organ-specific autoimmune disorder clinically presented as Hashimoto thyroiditis (HT) and Graves' disease (GD). The pathogenesis of AITD is caused by an inappropriate immune response related to genetic, non-genetic, and environmental factors. Pregnancy is one of the factors that have a great influence on the function of the thyroid gland because of the increased metabolic demand and the effects of hormones related to pregnancy. During pregnancy, an adaptation of the maternal immune system occurs, especially of the innate immune system engaged in maintaining adaptive immunity in the tolerant state, preventing the rejection of the fetus. Pregnancy-related hormonal changes (estrogen, progesterone, hCG) may modulate the activity of innate immune cells, potentially worsening the course of AITD during pregnancy. This especially applies to NK cells, which are associated with exacerbation of HD and GD. On the other hand, previous thyroid disorders can affect fertility and cause adverse outcomes of pregnancy, such as placental abruption, spontaneous abortion, and premature delivery. Additionally, it can cause fetal growth retardation and may contribute to impaired neuropsychological development of the fetus. Therefore, maintaining the thyroid equilibrium in women of reproductive age and in pregnant women is of the highest importance.
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Affiliation(s)
- Tatjana Bogović Crnčić
- Department of Nuclear Medicine, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia; (T.B.C.); (M.I.T.)
| | - Neva Girotto
- Department of Nuclear Medicine, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia; (T.B.C.); (M.I.T.)
| | - Maja Ilić Tomaš
- Department of Nuclear Medicine, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia; (T.B.C.); (M.I.T.)
| | - Ines Krištofić
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia;
| | - Sanja Klobučar
- Department of Internal Medicine, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia;
| | - Lara Batičić
- Department of Medical Chemistry, Biochemistry and Clinical Chemistry, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia;
| | - Božena Ćurko-Cofek
- Department of Physiology, Immunology and Pathophysiology, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia;
| | - Vlatka Sotošek
- Department of Anesthesiology, Reanimatology, Emergency and Intensive Care Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia;
- Department of Clinical Medical Sciences II, Faculty of Health Studies, University of Rijeka, Viktora Cara Emina 2, 51000 Rijeka, Croatia
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Minassian C, Allen LA, Okosieme O, Vaidya B, Taylor P. Preconception Management of Hyperthyroidism and Thyroid Status in Subsequent Pregnancy: A Population-Based Cohort Study. J Clin Endocrinol Metab 2023; 108:2886-2897. [PMID: 37200150 PMCID: PMC10584009 DOI: 10.1210/clinem/dgad276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/18/2023] [Accepted: 05/16/2023] [Indexed: 05/20/2023]
Abstract
CONTEXT Optimal thyroid status in pregnancy is essential in reducing the risk of adverse outcomes. The management of hyperthyroidism in women of reproductive age poses unique challenges and it is unclear how preconception treatment strategies impact on thyroid status in subsequent pregnancy. OBJECTIVE We aimed to determine trends in the management of hyperthyroidism before and during pregnancy and to assess the impact of different preconception treatment strategies on maternal thyroid status. METHODS We utilized the Clinical Practice Research Datalink database to evaluate all females aged 15-45 years with a clinical diagnosis of hyperthyroidism and a subsequent pregnancy (January 2000 to December 2017). We compared thyroid status in pregnancy according to preconception treatment, namely, (1) antithyroid drugs up to or beyond pregnancy onset, (2) definitive treatment with thyroidectomy or radioiodine before pregnancy, and (3) no treatment at pregnancy onset. RESULTS Our study cohort comprised 4712 pregnancies. Thyrotropin (TSH) was measured in only 53.1% of pregnancies, of which 28.1% showed suboptimal thyroid status (TSH >4.0 mU/L or TSH <0.1 mU/L plus FT4 >reference range). Pregnancies with prior definitive treatment were more likely to have suboptimal thyroid status compared with pregnancies starting during antithyroid drug treatment (odds ratio 4.72, 95% CI 3.50-6.36). A steady decline in the use of definitive treatment before pregnancy was observed from 2000 to 2017. One-third (32.6%) of first trimester carbimazole-exposed pregnancies were switched to propylthiouracil while 6.0% of propylthiouracil-exposed pregnancies switched to carbimazole. CONCLUSION The management of women with hyperthyroidism who become pregnant is suboptimal, particularly in those with preconception definitive treatment, and needs urgent improvement. Better thyroid monitoring and prenatal counseling are needed to optimize thyroid status, reduce teratogenic drug exposure, and ultimately reduce the risk of adverse pregnancy outcomes.
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Affiliation(s)
- Caroline Minassian
- Faculty of Epidemiology and Population Health, Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Lowri A Allen
- Diabetes Research Group, Cardiff University School of Medicine, Cardiff CF14 4XN, UK
| | - Onyebuchi Okosieme
- Thyroid Research Group, Systems Immunity Research Institute Medicine, Cardiff University School of Medicine, Cardiff CF14 4XN, UK
| | - Bijay Vaidya
- Department of Endocrinology, Royal Devon & Exeter Hospital, University of Exeter Medical School, Exeter EX2 5DW, UK
| | - Peter Taylor
- Thyroid Research Group, Systems Immunity Research Institute Medicine, Cardiff University School of Medicine, Cardiff CF14 4XN, UK
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Kazakou P, Tzanetakos D, Vakrakou AG, Tzartos JS, Evangelopoulos ΜE, Anagnostouli M, Stathopoulos P, Kassi GN, Stefanis L, Kilidireas C, Zapanti E. Thyroid autoimmunity following alemtuzumab treatment in multiple sclerosis patients: a prospective study. Clin Exp Med 2023; 23:2885-2894. [PMID: 36641771 PMCID: PMC10543528 DOI: 10.1007/s10238-022-00981-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/20/2022] [Indexed: 01/16/2023]
Abstract
Autoimmune thyroid disease (AITD) is the most common adverse effect in alemtuzumab (ALZ) treated relapsing-remitting (RR) multiple sclerosis (MS) patients. The objective of this prospective study was to analyze the occurrence, timing of onset, clinical course, and laboratory characteristics of AITD post-ALZ. We evaluated 35 RRMS patients treated with ALZ at a single academic MS center; clinical and laboratory data were collected before ALZ initiation and thereafter quarterly on follow-up with a median of 43.5 months. Seventeen out of 31 patients (54.8%) with no prior history of thyroid dysfunction developed AITD with a mean onset of 19.4 months ± 10.2 (SD) after the first ALZ cycle; Graves' disease (GD) (n = 9); hypothyroidism with positive stimulating thyrotropin receptor antibodies (TRAb) (n = 1); Hashimoto thyroiditis (HT) (n = 6); HT with hypothyroidism (n = 1). Interestingly, seven of nine (77.7%) GD patients showed a fluctuating course. Three out of four patients with preexisting thyroid disease remained stable, whereas one with prior HT and hypothyroidism developed fluctuating GD. All patients with GD commenced antithyroid drugs (ATDs); five continued on "block and replace" treatment; one required radioactive iodine, and one total thyroidectomy. Our analysis showed earlier onset of ALZ-induced AITD in comparison to most other ALZ cohorts; overall, these patients required complex therapeutic approaches of the AITD. We observed a higher rate of fluctuating GD, with earlier onset and lower remission rate than previously reported, which in the majority of patients required prolonged "block and replace" therapy in the minimum dose of each therapeutic agent or more definitive interventions.
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Affiliation(s)
- Paraskevi Kazakou
- Endocrine Unit and Diabetes Centre, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Dimitrios Tzanetakos
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece.
| | - Aigli G Vakrakou
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - John S Tzartos
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Μaria-Eleptheria Evangelopoulos
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Anagnostouli
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Panos Stathopoulos
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgia N Kassi
- Department of Endocrinology, Alexandra Hospital, Athens, Greece
| | - Leonidas Stefanis
- 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Constantinos Kilidireas
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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10
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Wang X, Zhang S, Yu W, Li G, Li J, Ji J, Mi Y, Luo X. Pre-pregnancy body mass index and glycated-hemoglobin with the risk of metabolic diseases in gestational diabetes: a prospective cohort study. Front Endocrinol (Lausanne) 2023; 14:1238873. [PMID: 37842297 PMCID: PMC10569468 DOI: 10.3389/fendo.2023.1238873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/06/2023] [Indexed: 10/17/2023] Open
Abstract
Background Metabolic diseases during pregnancy result in negative consequences for mothers. Pre-pregnancy body mass index (BMI) and late-pregnancy glycated-hemoglobin (HbA1c) are most important factors independently affecting the risk of gestational diabetes mellitus (GDM). However how both affect the combined risk of other metabolic diseases in women with GDM is unclear. The study aims to investigate the influence of pre-pregnancy BMI and pregnancy glycemic levels on other gestational metabolic diseases in women with GDM. Methods Pregnancies with GDM from January 2015 to December 2018 in the Xi'an longitudinal mother-child cohort study (XAMC) were retrospectively enrolled. Those without other metabolic diseases by the time of oral glucose tolerance test (OGTT) detection were finally recruited and divided into four groups by pre-pregnancy BMI (Underweight <18.5kg/m2; Normal weight 18.5-23.9 kg/m2; Overweight 24.0-27.9 kg/m2; Obesity ≥28.0 kg/m2, respectively) or two groups by HbA1c in late pregnancy (normal HbA1c<5.7%; high HbA1c≥5.7%). Multivariate logistic regression analysis was used to identify risk factors. Interaction between pre-pregnancy BMI (reference group 18.5-23.9 kg/m2) and HbA1c (reference group <5.7%) was determined using strata-specific analysis. Results A total of 8928 subjects with GDM were included, 16.2% of which had a composite of metabolic diseases. The pre-pregnancy overweight and obesity, compared with normal BMI, were linked to the elevated risk of the composite of metabolic diseases, particularly pre-eclampsia (both P <0.001) and gestational hypertension (both P <0.001). Meanwhile, patients with high HbA1c had an obvious higher risk of pre-eclampsia (P< 0.001) and gestational hypertension (P= 0.005) compared to those with normal HbA1c. In addition, there were significant interactions between pre-pregnancy BMI and HbA1c (P< 0.001). The OR of pre-pregnancy BMI≥ 28 kg/m2 and HbA1c≥ 5.7% was 4.46 (95% CI: 2.85, 6.99; P< 0.001). The risk of other metabolic diseases, except for pre-eclampsia (P= 0.003), was comparable between the two groups of patients with different HbA1c levels at normal pre-pregnancy BMI group. However, that was remarkably elevated in obese patients (P= 0.004), particularly the risk of gestational hypertension (P= 0.004). Conclusion Pre-pregnancy overweight/obesity and late-pregnancy high HbA1c increased the risk of other gestational metabolic diseases of women with GDM. Monitoring and controlling late-pregnancy HbA1c was effective in reducing metabolic diseases, particularly in those who were overweight/obese before conception.
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Affiliation(s)
- Xinyue Wang
- Department of Nutrition and Food Safety, School of Public Health, Xi’an Jiaotong University, Xi’an, China
| | - Simin Zhang
- Department of Nutrition and Food Safety, School of Public Health, Xi’an Jiaotong University, Xi’an, China
| | - Wenlu Yu
- Department of Nutrition and Food Safety, School of Public Health, Xi’an Jiaotong University, Xi’an, China
| | - Guohua Li
- Department of Nutrition and Food Safety, School of Public Health, Xi’an Jiaotong University, Xi’an, China
| | - Jinglin Li
- Department of Nutrition and Food Safety, School of Public Health, Xi’an Jiaotong University, Xi’an, China
| | - Jing Ji
- Department of Nutrition and Food Safety, School of Public Health, Xi’an Jiaotong University, Xi’an, China
- Department of Obstetrics and Gynecology, Northwest Women’s and Children’s Hospital, Xi’an, China
| | - Yang Mi
- Department of Obstetrics and Gynecology, Northwest Women’s and Children’s Hospital, Xi’an, China
| | - Xiaoqin Luo
- Department of Nutrition and Food Safety, School of Public Health, Xi’an Jiaotong University, Xi’an, China
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11
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Bhagat M, Singh P, Sunkara SM, Abraham MT, Barroso Alverde MJ, Mundla SR, Mizrahi Drijanski A, Jobilal A, Lakkimsetti M, Nair N, Razzaq W, Abdin ZU, Gupta I. Effects of Methimazole vs Propylthiouracil in Newborns: A Comparative Review. Cureus 2023; 15:e41505. [PMID: 37551246 PMCID: PMC10404379 DOI: 10.7759/cureus.41505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 07/06/2023] [Indexed: 08/09/2023] Open
Abstract
Hyperthyroidism is more common in women and the sensitivity of thyroid function changes during pregnancy. Excess levels of thyroid hormones and thioamides have a major impact on maternal and fetal outcomes. Our aim was to perform an extensive literature review and provide relevant details concerning the analytical and clinical aspects of the potential effects of the two main drugs used (methimazole and propylthiouracil) in newborns. A thorough literature review was conducted using PubMed and Google Scholar databases. In total, 10 relevant studies were identified and data from these studies were extracted and then extrapolated into results after analysis. Three out of four studies that used methimazole and carbimazole, one and two, respectively, showed adverse fetal outcomes requiring surgical management for congenital anomalies like aplasia cutis, patent vitellointestinal duct, and gastroschisis. Out of the three studies that used propylthiouracil, one baby underwent surgery for bilateral pyelectasis, vesicovaginal fistula, anal stenosis, and polydactyly. The findings of the aforementioned studies provide enough evidence to imply that the use of methimazole and carbimazole to treat antenatal hyperthyroidism has worse fetal outcomes than the use of propylthiouracil. Also, given the paucity of data in the existing literature regarding propylthiouracil's effects on newborns, further studies in this demographic are needed.
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Affiliation(s)
- Mehak Bhagat
- Internal Medicine, Government Medical College, Amritsar, IND
| | - Purnima Singh
- College of Medicine, Gulf Medical University, Ajman, ARE
| | | | | | | | - Sravya R Mundla
- Medicine, Apollo Institute of Medical Sciences and Research, Hyderabad, IND
| | | | - Anna Jobilal
- Internal Medicine, Sri Ramaswamy Memorial Medical College Hospital and Research Center, Chennai, IND
| | | | - Nandini Nair
- Internal Medicine, Byramjee Jeejeebhoy Government Medical College, Pune, IND
| | - Waleed Razzaq
- Internal Medicine, Services Hospital Lahore, Lahore, PAK
| | - Zain U Abdin
- Medicine, District Head Quarter Hospital, Faisalabad, PAK
| | - Ishita Gupta
- Medicine, Dr. Rajendra Prasad Government Medical College, Tanda, IND
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12
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Torp NMU, Pedersen IB, Carlé A, Karmisholt JS, Ebbehøj E, Grove-Laugesen D, Brix TH, Bonnema SJ, Schrijvers BF, Nygaard B, Sigurd LB, Feldt-Rasmussen U, Klose M, Rasmussen ÅK, Andersen S, Andersen SL. Hyperthyroidism in pregnancy: design and methodology of a Danish multicenter study. Thyroid Res 2023; 16:11. [PMID: 37041614 PMCID: PMC10088206 DOI: 10.1186/s13044-023-00154-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 03/19/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND Graves' disease (GD) is the main cause of hyperthyroidism in women of the fertile age. In pregnant women, the disease should be carefully managed and controlled to prevent maternal and fetal complications. Observational studies provide evidence of the adverse effects of untreated hyperthyroidism in pregnancy and have in more recent years substantiated a risk of teratogenic side effects with the use of antithyroid drugs (ATDs). These findings have challenged the clinical recommendations regarding the choice of treatment when patients become pregnant. To extend observational findings and support future clinical practice, a systematic collection of detailed clinical data in and around pregnancy is needed. METHODS With the aim of collecting clinical and biochemical data, a Danish multicenter study entitled 'Pregnancy Investigations on Thyroid Disease' (PRETHYR) was initiated in 2021. We here describe the design and methodology of the first study part of PRETHYR. This part focuses on maternal hyperthyroidism and recruits female patients in Denmark with a past or present diagnosis of GD, who become pregnant, as well as women who are treated with ATDs in the pregnancy, irrespective of the underlying etiology. The women are included during clinical management from endocrine hospital departments in Denmark, and study participation includes patient questionnaires in pregnancy and postpartum as well as review of medical records from the mother and the child. RESULTS Data collection was initiated on November 1, 2021 and covered all five Danish Regions from March 1, 2022. Consecutive study inclusion will continue, and we here report the first status of inclusion. As of November 1, 2022, a total of 62 women have been included in median pregnancy week 19 (interquartile range (IQR): 10-27) with a median maternal age of 31.4 years (IQR: 28.5-35.1). At inclusion, 26 women (41.9%) reported current use of thyroid medication; ATDs (n = 14), Levothyroxine (n = 12). CONCLUSION This report describes a newly established systematic and nationwide collection of detailed clinical data on pregnant women with hyperthyroidism and their offspring. Considering the course and relatively low prevalence of GD in pregnant women, such nationwide design is essential to establish a sufficiently large cohort.
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Affiliation(s)
- Nanna Maria Uldall Torp
- Department of Clinical Biochemistry, Aalborg University Hospital, Hobrovej 18-22, Aalborg, 9000, Denmark.
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Inge Bülow Pedersen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Allan Carlé
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Jesper Scott Karmisholt
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Eva Ebbehøj
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Diana Grove-Laugesen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas Heiberg Brix
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Steen Joop Bonnema
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bieke F Schrijvers
- Department of Endocrinology, Zealand University Hospital Køge, Køge, Denmark
| | - Birte Nygaard
- Department of Endocrinology, Copenhagen University Hospital Herlev-Gentofte, Herlev, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Lena Bjergved Sigurd
- Department of Endocrinology, Copenhagen University Hospital Herlev-Gentofte, Herlev, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Endocrinology and Metabolism, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Marianne Klose
- Department of Endocrinology and Metabolism, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Åse Krogh Rasmussen
- Department of Endocrinology and Metabolism, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Stig Andersen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Deparment of Geriatrics, Aalborg University Hospital, Aalborg, Denmark
| | - Stine Linding Andersen
- Department of Clinical Biochemistry, Aalborg University Hospital, Hobrovej 18-22, Aalborg, 9000, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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13
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Brown EDL, Obeng-Gyasi B, Hall JE, Shekhar S. The Thyroid Hormone Axis and Female Reproduction. Int J Mol Sci 2023; 24:9815. [PMID: 37372963 DOI: 10.3390/ijms24129815] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 05/24/2023] [Accepted: 05/26/2023] [Indexed: 06/29/2023] Open
Abstract
Thyroid function affects multiple sites of the female hypothalamic-pituitary gonadal (HPG) axis. Disruption of thyroid function has been linked to reproductive dysfunction in women and is associated with menstrual irregularity, infertility, poor pregnancy outcomes, and gynecological conditions such as premature ovarian insufficiency and polycystic ovarian syndrome. Thus, the complex molecular interplay between hormones involved in thyroid and reproductive functions is further compounded by the association of certain common autoimmune states with disorders of the thyroid and the HPG axes. Furthermore, in prepartum and intrapartum states, even relatively minor disruptions have been shown to adversely impact maternal and fetal outcomes, with some differences of opinion in the management of these conditions. In this review, we provide readers with a foundational understanding of the physiology and pathophysiology of thyroid hormone interactions with the female HPG axis. We also share clinical insights into the management of thyroid dysfunction in reproductive-aged women.
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Affiliation(s)
- Ethan D L Brown
- Reproductive Physiology and Pathophysiology Group, Clinical Research Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC 27709, USA
| | - Barnabas Obeng-Gyasi
- Department of Education, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Janet E Hall
- Reproductive Physiology and Pathophysiology Group, Clinical Research Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC 27709, USA
| | - Skand Shekhar
- Reproductive Physiology and Pathophysiology Group, Clinical Research Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC 27709, USA
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14
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Saboo K, Gemnani RR, Manuja N, Kumar S, Acharya S. Propylthiouracil-Induced Neonatal Goiter: An Avoidable Problem. Cureus 2023; 15:e40389. [PMID: 37456378 PMCID: PMC10344733 DOI: 10.7759/cureus.40389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
We present a case of neonatal goiter caused by exposure to propylthiouracil (PTU) during pregnancy in this case report. The mother was treated with PTU while pregnant and had a history of Graves' illness. The baby had a neck tumor and was having breathing problems when they were first seen. A big thyroid gland was detected by a neck CT scan. This instance serves as a reminder of the significance of managing maternal thyroid problems appropriately during pregnancy as well as the requirement for careful thyroid function monitoring in newborns exposed to PTU. Given the possible hazards to the growing baby, it also calls into question whether PTU is an effective first-line treatment for maternal Graves' illness during pregnancy. This case report highlights the importance of shared decision-making with patients (by discussing different treatment options and their side effects).
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Affiliation(s)
- Keyur Saboo
- Department of Medicine, Jawaharlal Nehru Medical College, Wardha, IND
| | - Rinkle R Gemnani
- Department of Medicine, Jawaharlal Nehru Medical College, Wardha, IND
| | - Nishtha Manuja
- Department of Internal Medicine, Jawaharlal Nehru Medical College, Wardha, IND
| | - Sunil Kumar
- Department of Medicine, Jawaharlal Nehru Medical College, Wardha, IND
| | - Sourya Acharya
- Department of Medicine, Jawaharlal Nehru Medical College, Wardha, IND
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15
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Mégier C, Dumery G, Luton D. Iodine and Thyroid Maternal and Fetal Metabolism during Pregnancy. Metabolites 2023; 13:metabo13050633. [PMID: 37233673 DOI: 10.3390/metabo13050633] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 04/26/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023] Open
Abstract
Thyroid hormones and iodine are required to increase basal metabolic rate and to regulate protein synthesis, long bone growth and neuronal maturation. They are also essential for protein, fat and carbohydrate metabolism regulation. Imbalances in thyroid and iodine metabolism can negatively affect these vital functions. Pregnant women are at risk of hypo or hyperthyroidism, in relation to or regardless of their medical history, with potential dramatic outcomes. Fetal development highly relies on thyroid and iodine metabolism and can be compromised if they malfunction. As the interface between the fetus and the mother, the placenta plays a crucial role in thyroid and iodine metabolism during pregnancy. This narrative review aims to provide an update on current knowledge of thyroid and iodine metabolism in normal and pathological pregnancies. After a brief description of general thyroid and iodine metabolism, their main modifications during normal pregnancies and the placental molecular actors are described. We then discuss the most frequent pathologies to illustrate the upmost importance of iodine and thyroid for both the mother and the fetus.
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Affiliation(s)
- Charles Mégier
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie-Obstétrique, Hôpital Bicêtre, Université Paris Saclay, 94270 Le Kremlin-Bicetre, France
| | - Grégoire Dumery
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie-Obstétrique, Hôpital Bicêtre, Université Paris Saclay, 94270 Le Kremlin-Bicetre, France
| | - Dominique Luton
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie-Obstétrique, Hôpital Bicêtre, Université Paris Saclay, 94270 Le Kremlin-Bicetre, France
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16
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Wiersinga WM, Poppe KG, Effraimidis G. Hyperthyroidism: aetiology, pathogenesis, diagnosis, management, complications, and prognosis. Lancet Diabetes Endocrinol 2023; 11:282-298. [PMID: 36848916 DOI: 10.1016/s2213-8587(23)00005-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/28/2022] [Accepted: 01/03/2023] [Indexed: 02/26/2023]
Abstract
Hyperthyroidism is a common condition with a global prevalence of 0·2-1·3%. When clinical suspicion of hyperthyroidism arises, it should be confirmed by biochemical tests (eg, low TSH, high free thyroxine [FT4], or high free tri-iodothyonine [FT3]). If hyperthyroidism is confirmed by biochemical tests, a nosological diagnosis should be done to find out which disease is causing the hyperthyroidism. Helpful tools are TSH-receptor antibodies, thyroid peroxidase antibodies, thyroid ultrasonography, and scintigraphy. Hyperthyroidism is mostly caused by Graves' hyperthyroidism (70%) or toxic nodular goitre (16%). Hyperthyroidism can also be caused by subacute granulomatous thyroiditis (3%) and drugs (9%) such as amiodarone, tyrosine kinase inhibitors, and immune checkpoint inhibitors. Disease-specific recommendations are given. Currently, Graves' hyperthyroidism is preferably treated with antithyroid drugs. However, recurrence of hyperthyroidism after a 12-18 month course of antithyroid drugs occurs in approximately 50% of patients. Being younger than 40 years, having FT4 concentrations that are 40 pmol/L or higher, having TSH-binding inhibitory immunoglobulins that are higher than 6 U/L, and having a goitre size that is equivalent to or larger than WHO grade 2 before the start of treatment with antithyroid drugs increase risk of recurrence. Long-term treatment with antithyroid drugs (ie, 5-10 years of treatment) is feasible and associated with fewer recurrences (15%) than short-term treatment (ie, 12-18 months of treatment). Toxic nodular goitre is mostly treated with radioiodine (131I) or thyroidectomy and is rarely treated with radiofrequency ablation. Destructive thyrotoxicosis is usually mild and transient, requiring steroids only in severe cases. Specific attention is given to patients with hyperthyroidism who are pregnant, have COVID-19, or have other complications (eg, atrial fibrillation, thyrotoxic periodic paralysis, and thyroid storm). Hyperthyroidism is associated with increased mortality. Prognosis might be improved by rapid and sustained control of hyperthyroidism. Innovative new treatments are expected for Graves' disease, by targeting B cells or TSH receptors.
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Affiliation(s)
- Wilmar M Wiersinga
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Netherlands
| | - Kris G Poppe
- Endocrine Unit, CHU Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Grigoris Effraimidis
- Department of Endocrinology and Metabolic Diseases, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
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17
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Hamza A, Schlembach D, Schild RL, Groten T, Wölfle J, Battefeld W, Kehl S, Schneider MO. Recommendations of the AGG (Working Group for Obstetrics, Department of Maternal Diseases) on How to Treat Thyroid Function Disorders in Pregnancy. Geburtshilfe Frauenheilkd 2023; 83:504-516. [PMID: 37152543 PMCID: PMC10159725 DOI: 10.1055/a-1967-1653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 10/23/2022] [Indexed: 03/11/2023] Open
Abstract
Abstract
Objective These recommendations from the AGG (Committee for Obstetrics, Department of Maternal Diseases) on how to treat thyroid function disorder during pregnancy aim to improve the diagnosis and management of thyroid anomalies during pregnancy.
Methods Based on the current literature, the task force members have developed the following recommendations and statements. These recommendations were adopted after a consensus by the members of the working group.
Recommendations The following manuscript gives an insight into physiological and pathophysiological thyroid changes during pregnancy, recommendations for clinical and subclinical hypo- and hyperthyroidism, as well as fetal and neonatal diagnostic and management strategies.
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Affiliation(s)
- Amr Hamza
- Klinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin, Universität des Saarlandes, Homburg a. d. Saar, Germany
- Klinik für Geburtshilfe und Pränatalmedizin, Kantonspital Baden, Baden, Switzerland
| | | | - Ralf Lothar Schild
- Klinik für Geburtshilfe und Perinatalmedizin, Diakovere Perinatalzentrum Hannover, Hannover, Germany
| | - Tanja Groten
- Klinik für Geburtsmedizin, Universitätsklinikum Jena, Jena, Germany
| | - Joachim Wölfle
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Erlangen, Erlangen, Germany
| | | | - Sven Kehl
- Frauenklinik, Universitätsklinikum Erlangen, Erlangen, Germany
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18
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Kim HE, Yang J, Park JE, Baek JC, Jo HC. Thyroid storm in a pregnant woman with COVID-19 infection: A case report and review of literatures. World J Clin Cases 2023; 11:888-895. [PMID: 36818620 PMCID: PMC9928696 DOI: 10.12998/wjcc.v11.i4.888] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/24/2022] [Accepted: 01/05/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has been found to be responsible for the recent global pandemic known as coronavirus disease 2019 (COVID-19). SARS-CoV-2 infections not only result in significant respiratory symptoms but also cause several extrapulmonary manifestations, such as thrombotic complications, myocardial dysfunction and arrhythmia, thyroid dysfunction, acute kidney injury, gastrointestinal symptoms, neurological symptoms, ocular symptoms, and dermatological complications. We present the first documented case of thyroid storm in a pregnant woman precipitated by SARS-CoV-2.
CASE SUMMARY A 42-year-old multiparous woman at 35 + 2 wk of gestation visited the emergency room (ER) with altered mentation, seizures, tachycardia, and high fever. The patient showed no remarkable events in the prenatal examination, and the nasopharyngeal COVID-19 polymerase chain reaction (PCR) test was positive two days before the ER visit. The results of laboratory tests, such as liver function test, serum electrolytes, blood glucose, blood urea nitrogen, and creatinine, were all within the normal ranges. However, the thyroid function test showed hyperthyroidism, and the nasopharyngeal COVID-19 PCR test was positive, as expected. No specific findings were observed on the brain computed tomography, and there were no signs of lateralization on neurological examination. Fetal heartbeat and movement were good, and there were no significant uterine contractions. The initial impression was atypical eclampsia. However, the patient's condition worsened, and a cesarean section was performed under general anesthesia; a healthy boy was delivered, and 12 h after delivery, the patient's seizures disappeared and consciousness was restored. The patient was referred to an endocrinologist for hyperthyroidism, and a thyroid storm with Graves' disease was diagnosed. Here, SARS-CoV-2 was believed to be the trigger for the thyroid storm, considering that the patient tested positive for COVID-19 two days before the seizures.
CONCLUSION In pregnant women presenting with seizures or changes in consciousness, the possibility of a thyroid storm should be considered. There are various causes for a thyroid storm, but given the recent pandemic, it is necessary to bear in mind that the thyroid storm may be precipitated by COVID-19.
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Affiliation(s)
- Hyo-Eun Kim
- Department of Obstetrics and Gynecology, Gyeongsang National University Changwon Hospital, Changwon 51472, South Korea
| | - Juseok Yang
- Department of Obstetrics and Gynecology, Gyeongsang National University Changwon Hospital, Changwon 51472, South Korea
| | - Ji-Eun Park
- Department of Obstetrics and Gynecology, Gyeongsang National University Changwon Hospital, Changwon 51472, South Korea
| | - Jong-Chul Baek
- Department of Obstetrics and Gynecology, Gyeongsang National University Changwon Hospital, Changwon 51472, South Korea
| | - Hyen-Chul Jo
- Department of Obstetrics and Gynecology, Gyeongsang National University Changwon Hospital, Changwon 51472, South Korea
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Wang Y, Sun Y, Yang B, Wang Q, Kuang H. The management and metabolic characterization: hyperthyroidism and hypothyroidism. Neuropeptides 2023; 97:102308. [PMID: 36455479 DOI: 10.1016/j.npep.2022.102308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/21/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022]
Abstract
Hyperthyroidism and hypothyroidism are common diseases resulting from thyroid dysfunction, and are simple to diagnose and treat. The traditional treatment for hypothyroidism is thyroid hormone replacement therapy. The traditional treatments for hyperthyroidism include antithyroid drug, iodine radiotherapy, and surgery. Thyroid disease can be fatal in severe cases if untreated. Current statistical reference ranges used for diagnosis based on relevant biochemical parameters have been debated, and insufficient treatment can result in long-term thyroid hormone deficiency, which is associated with increased risk of cardiovascular disease and persistent symptoms. In contrast, overtreatment can result in heart disease and osteoporosis, particularly in older people and pregnant women. Therefore, under- or over-treatment should be avoided and treatment regimens should be monitored closely. A significant proportion of patients who achieve biochemical treatment goals still complain of significant symptoms. Systematic literature review was performed through the Embase (Elsevier), PubMed and Web of Science databases, and studies summarized evidence regarding treatment and management of hypothyroidism and hyperthyroidism, and reviewed clinical practice guidelines. We also reviewed the latest research on the metabolic mechanisms of hyperthyroidism and hypothyroidism, which contributed to understanding of thyroid diseases in the clinic. A reliable algorithm is needed to management, assessment, and treatment patients with hyperthyroidism and hypothyroidism, which can not only improve management efficiency, but also providing a broad application. In addition, the thyroid disorder showed a lipid metabolism tissue specificity in the Ventromedial Hypothalamus, and effect oxidative stress and energy metabolism of whole body. This review summarizes an algorithm for thyroid disease and the latest pathogenesis that would be useful to generalist and subspecialty physicians and others providing care for patients with this condition.
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Affiliation(s)
- Yangyang Wang
- Key Laboratory of Basic and Application Research of Beiyao (Heilongjiang University of Chinese Medicine), Ministry of Education, Harbin, China
| | - YanPing Sun
- Key Laboratory of Basic and Application Research of Beiyao (Heilongjiang University of Chinese Medicine), Ministry of Education, Harbin, China
| | - Bingyou Yang
- Key Laboratory of Basic and Application Research of Beiyao (Heilongjiang University of Chinese Medicine), Ministry of Education, Harbin, China
| | - Qiuhong Wang
- School of Traditional Chinese Medicine, Guangdong Pharmaceutical University, Guangzhou, China.
| | - Haixue Kuang
- Key Laboratory of Basic and Application Research of Beiyao (Heilongjiang University of Chinese Medicine), Ministry of Education, Harbin, China.
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Selim S, Pathan M, Rahman M, Saifuddin M, Qureshi N, Mir A, Afsana F, Haq T, Kamrul-Hasan AM, Ashrafuzzaman S. Bangladesh endocrine society guidelines for the diagnosis and management of thyroid disease during pregnancy and the postpartum. BANGLADESH JOURNAL OF ENDOCRINOLOGY AND METABOLISM 2023. [DOI: 10.4103/bjem.bjem_2_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
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21
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Sonowal T, Sarmah J, Sarma PK, Deka M. Iodine Status, Thyroid Disorder and Feto-Maternal Outcome among the Tribal Pregnant Women of Eastern Himalayas. Indian J Endocrinol Metab 2023; 27:66-72. [PMID: 37215276 PMCID: PMC10198190 DOI: 10.4103/ijem.ijem_367_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 01/25/2023] [Accepted: 02/03/2023] [Indexed: 03/05/2023] Open
Abstract
Introduction Iodine deficiency and thyroid disorder during pregnancy have adverse effects on fetal and neonatal outcomes. Objective To assess iodine status and thyroid functioning during pregnancy and to evaluate the feto-maternal outcome. Methods Urinary iodine content (UIC) is determined by arsenic cerium catalytic spectrophotometry method and thyroid hormone analysis was carried out by chemiluminescence assay. Fetal and neonatal outcomes were obtained from hospital records. Results Among the considered tribal pregnant women 56.75% had insufficient urinary iodine and 24.5% had a thyroid disorder. Thyroid disorder was more common in pregnant women with urinary iodine concentration (UIC) <99 μg/L than UIC >150 μg/L (56.75% vs 41.5%). Pregnant women with UIC<99 μg/L had a higher incidence of anemia (86.36%), gestational diabetes mellitus (GDM) (3.33%), and preeclampsia (5.71%) than UIC >150 μg/L. The fetal outcome with UIC <99 μg/L had a higher incidence of low birth weight (9.09%) and preterm births (1.9%). Stillbirths were distributed equally among different UIC groups. The neonatal outcomes with UIC <99 μg/L between 150-249 μg/L had a higher incidence of respiratory distress (5.23%). Hypothermia was equally distributed among different UIC groups. Subclinical hypothyroid had a high prevalence of anemia (62.96%), preeclampsia (3.7%), and GDM (6.17%) respectively than the euthyroid group. The fetal outcome with low birth weight (LBW) (9.87%), stillbirths (3.7%), and preterm birth (8.64%) was more common in the subclinical hypothyroid than in the euthyroid group. Among the neonatal outcomes respiratory distress (6.17%) and hypothermia (4.93%) were more common in subclinical hypothyroid than euthyroid pregnant women. Conclusion Insufficient maternal iodine and thyroid disorders during pregnancy were associated with adverse pregnancy outcomes.
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Affiliation(s)
- Trisha Sonowal
- Department of Biotechnology, Bodoland University, Kokrajhar, India
| | - Jatin Sarmah
- Department of Biotechnology, Bodoland University, Kokrajhar, India
| | - Paresh K. Sarma
- Department of Medicine, Dhubri Medical College and Hospital, Dhubri, India
| | - Manab Deka
- Department of Statistics, Arya Vidyapeeth College, Guwahati, Assam, India
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22
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Drui D, Briet C, Guerin C, Lugat A, Borson-Chazot F, Grunenwald S. SFE-AFCE-SFMN 2022 Consensus on the management of thyroid nodules : Thyroid nodules and pregnancy. ANNALES D'ENDOCRINOLOGIE 2022; 83:435-439. [PMID: 36270537 DOI: 10.1016/j.ando.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a condition that is a frequent reason for consultation in endocrinology. In more than 90% of cases, patients are euthyroid, with benign non-progressive nodules that do not warrant specific treatment. The clinician's objective is to detect malignant thyroid nodules at risk of recurrence and death, toxic nodules responsible for hyperthyroidism or compressive nodules warranting treatment. The diagnosis and treatment of thyroid nodules requires close collaboration between endocrinologists, nuclear medicine physicians and surgeons, but also involves other specialists. Therefore, this consensus statement was established jointly by 3 societies: the French Society of Endocrinology (SFE), French Association of Endocrine Surgery (AFCE) and French Society of Nuclear Medicine (SFMN); the various working groups included experts from other specialties (pathologists, radiologists, pediatricians, biologists, etc.). The present section deals with the epidemiology and specificities of diagnosis and treatment of thyroid nodules in pregnant women.
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Affiliation(s)
- Delphine Drui
- Nantes Université, CHU Nantes, Service d'Endocrinologie-Diabétologie et Nutrition, Institut du Thorax, 44000 Nantes, France.
| | - Claire Briet
- Service d'Endocrinologie-Diabétologie Nutrition, et Centre de Référence des Maladies Rares de la Thyroïde et des Récepteurs Hormonaux, CHU Angers, Univ Angers, Inserm, CNRS, MITOVASC, 49000 Angers, France
| | - Carole Guerin
- Service de Chirurgie Générale, Endocrinienne et Métabolique, APHM, Aix Marseille Université, Marseille, France
| | - Alexandre Lugat
- Nantes Université, CHU Nantes, Service d'Oncologie Médicale, 44000 Nantes, France
| | - Francoise Borson-Chazot
- Fédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon; inserm U1290, Université Claude Bernard Lyon 1, Lyon, France
| | - Solange Grunenwald
- Service d'Endocrinologie et Maladies Métaboliques, CHU Larrey, Toulouse, France
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23
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Mammen JSR, Cooper DS. TSH Receptor Antibody Testing in Early Pregnancy. J Clin Endocrinol Metab 2022; 107:e4324-e4325. [PMID: 35973059 DOI: 10.1210/clinem/dgac490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Jennifer S R Mammen
- Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
| | - David S Cooper
- Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
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24
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Orsolini F, Gianetti E, Terrenzio C, Montanelli L, Benelli E, Bagattini B, Fiore E, Tonacchera M. Thyroid Function Rather Than Thyroid Antibodies Affects Pregnancy and Perinatal Outcomes: Results of a Prospective Study. J Clin Endocrinol Metab 2022; 107:e4302-e4310. [PMID: 36054923 DOI: 10.1210/clinem/dgac497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Thyroid autoantibody positivity has been associated with an increased rate of obstetrical complications. OBJECTIVE We aimed to evaluate the role of thyroid autoantibodies in adverse pregnancy outcomes. METHODS This prospective study was conducted in the Endocrinology Unit of Pisa Hospital. A total of 975 pregnant women were studied from 2012 to 2021; 572 (59%) were diagnosed with autoimmune thyroid (AT) diseases; 403 (41%) served as controls. Levothyroxine (LT4) treatment was introduced when TSH was > 2.5 mIU/L in the AT group and when TSH was > 4 mIU/L in the controls. Rates of obstetrical complications in each group were measured. RESULTS Although the frequency of miscarriage in the AT group was greater (4.8%) than in the controls (2.9%), no significant differences were detected (P = 0.181). There were no differences between the 2 groups concerning the other pregnancy complications, and no association with the titer of thyroid antibodies was observed. The frequency of congenital malformations was greater in the AT group than in the controls (P = 0.019), but no correlation with major congenital malformations was detected (P = 0.872). Given that thyroid hormone concentrations were strictly controlled in our population, we documented a tendency (not significant) toward an increase in miscarriage and preterm birth among women with TSH > 4 mIU/L. CONCLUSION If thyroid function is adequately controlled, the presence and titer of thyroid autoantibodies does not negatively influence gestation. Although not significant, suboptimal thyroid hormone status seems to affect pregnancy outcomes more than thyroid autoimmunity.
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Affiliation(s)
- Francesca Orsolini
- Department of Clinical and Experimental Medicine, Endocrine Unit, University of Pisa, Pisa 56124, Italy
| | - Elena Gianetti
- Department of Clinical and Experimental Medicine, Endocrine Unit, University of Pisa, Pisa 56124, Italy
| | - Chiara Terrenzio
- Department of Clinical and Experimental Medicine, Endocrine Unit, University of Pisa, Pisa 56124, Italy
| | - Lucia Montanelli
- Department of Clinical and Experimental Medicine, Endocrine Unit, University of Pisa, Pisa 56124, Italy
| | - Elena Benelli
- Department of Clinical and Experimental Medicine, Endocrine Unit, University of Pisa, Pisa 56124, Italy
| | - Brunella Bagattini
- Department of Clinical and Experimental Medicine, Endocrine Unit, University of Pisa, Pisa 56124, Italy
| | - Emilio Fiore
- Department of Clinical and Experimental Medicine, Endocrine Unit, University of Pisa, Pisa 56124, Italy
| | - Massimo Tonacchera
- Department of Clinical and Experimental Medicine, Endocrine Unit, University of Pisa, Pisa 56124, Italy
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25
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Zuñiga LFF, Muñoz YS, Pustovrh MC. Thyroid hormones: Metabolism and transportation in the fetoplacental unit. Mol Reprod Dev 2022; 89:526-539. [PMID: 36208482 DOI: 10.1002/mrd.23647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 09/20/2022] [Accepted: 09/25/2022] [Indexed: 12/25/2022]
Abstract
The thyroid hormones (THs), thyroxine (T4) and triiodothyronine (T3), are of vital importance for fetal development. The concentration of THs in fetal circulation varies throughout gestation and differs from the concentration in the maternal serum, indicating the presence of maternal-fetal thyroid homeostasis regulatory mechanisms in the placenta. The passage of THs from maternal circulation to fetal circulation is modulated by plasma membrane transporters, enzymes, and carrier proteins. Monocarboxylate transporter 8, iodothyronine deiodinases (DIO2 and DIO3), and transthyretin are especially involved in this maternal-fetal thyroid modulation, shown by a greater expression in the placenta. THs also play a role in placental development and as expected, abnormal variations in TH levels are associated with pregnancy complications and can result in damage to the fetus. Although new evidence regarding TH regulation during pregnancy and its effects in the mother, placenta, and fetus has been published, many aspects of these interactions are still poorly understood. The objective of this review is to provide an evidence-based update, drawn from current data, on the metabolism and transport of THs in the placenta and their vital role in the maternal-fetal relationship.
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Affiliation(s)
- Luis Felipe Falla Zuñiga
- Department of Morphology, College of Basic Sciences, Faculty of Health, Universidad del Valle, Cali, Colombia
| | - Yhoiss Smiht Muñoz
- Department of Morphology, College of Basic Sciences, Faculty of Health, Universidad del Valle, Cali, Colombia
| | - Maria Carolina Pustovrh
- Department of Morphology, College of Basic Sciences, Faculty of Health, Universidad del Valle, Cali, Colombia
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26
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Abstract
Thyroid hormones are primarily responsible for regulating the basal metabolic rate but also make important contributions to reproductive function and fetal development. Both hyper- and hypothyroidism in pregnancy have been associated with increased risks of complications that include preeclampsia and low birth weight, among others. Furthermore, thyroid hormone deficiency in the developing fetus results in neurodevelopmental delay. As the fetus is exclusively reliant on maternal thyroid hormone for most of the first trimester and requires continued maternal supply until birth, identifying maternal thyroid dysfunction is critically important. However, evaluating thyroid function in pregnancy is challenging because of the many physiological changes that affect concentrations of thyroid-related analytes. Increasing plasma human chorionic gonadotropin (hCG) concentrations in the second half of the first trimester elicit a corresponding transient decrease in thyroid-stimulating hormone (TSH), and continually increasing estradiol concentrations throughout pregnancy cause substantial increases in thyroxine-binding globulin (TBG) and total thyroxine (T4) relative to the nonpregnant state. Lastly, free T4 concentrations gradually decrease with increasing gestational age. For these reasons, it is essential to interpret thyroid function test results in the context of trimester-specific reference intervals to avoid misclassification of thyroid status. This review summarizes the effects of thyroid dysfunction prior to conception and during pregnancy and describes considerations for the laboratory assessment of thyroid function in pregnant women.
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Affiliation(s)
- K Aaron Geno
- Department of Pathology, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Robert D Nerenz
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
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27
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Panagiotou G, Taylor PN, Rees DA, Okosieme OE. Late offspring effects of antenatal thyroid screening. Br Med Bull 2022; 143:16-29. [PMID: 35868487 DOI: 10.1093/bmb/ldac018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Thyroid dysfunction in pregnancy is associated with adverse offspring outcomes and recent birth-cohort studies suggest that even mild degrees of thyroid dysfunction may be linked with a range of late cognitive and behavioural effects in childhood and adolescence. SOURCES OF DATA This review summarizes recent literature of observational studies and critically appraises randomized controlled trials (RCTs) of antenatal thyroid screening and Levothyroxine intervention. AREAS OF AGREEMENT Overt hypothyroidism and hyperthyroidism carry significant risks for unfavourable offspring outcomes and should be appropriately corrected in pregnancy. AREAS OF CONTROVERSY The significance of subclinical hypothyroidism and hypothyroxinaemia is still unclear. Meta-analyses of birth-cohort studies show associations of maternal subclinical hypothyroidism and hypothyroxinaemia with intellectual deficits, attention deficit hyperactivity disorder (ADHD) and autism spectrum disorders, while hyperthyroidism and high-normal FT4 were linked with ADHD. RCTs have shown no benefits of screening on neurodevelopmental outcomes although Levothyroxine could have been initiated too late in pregnancy in these trials. GROWING POINTS A small number of studies have shown inconsistent associations of maternal thyroid dysfunction with offspring cardiometabolic indices including blood pressure and body weight. Correction of maternal thyroid dysfunction was, however, associated with favourable long-term metabolic profiles in mothers, including lipid profiles, fat mass and body mass index. Antenatal thyroid screening may therefore present opportunities for optimizing a wider range of outcomes than envisaged. AREAS FOR DEVELOPING RESEARCH Future trials with early antenatal thyroid screening and intervention are necessary to clarify the impact of screening on late offspring and maternal effects.
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Affiliation(s)
| | - Peter N Taylor
- Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK
| | - D Aled Rees
- Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK
| | - Onyebuchi E Okosieme
- Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK.,Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Gurnos Estate, Merthyr Tydfil, UK
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28
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Hamidi OP, Barbour LA. Endocrine Emergencies During Pregnancy: Diabetic Ketoacidosis and Thyroid Storm. Obstet Gynecol Clin North Am 2022; 49:473-489. [PMID: 36122980 DOI: 10.1016/j.ogc.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
The physiologic changes and common signs and symptoms of pregnancy can make the early recognition of endocrine emergencies more challenging. Diabetic ketoacidosis (DKA) can occur at only modestly elevated glucose levels (euglycemic DKA), often accompanied by starvation ketosis due to substantial fetal-placental glucose demands and is associated with a high stillbirth rate. Thyroid storm is life threatening with a higher rate of heart failure and both require prompt and aggressive treatment to avoid maternal and fetal morbidity and mortality. Treatment of these disorders and the special considerations for recognition and management in the context of pregnancy are reviewed.
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Affiliation(s)
- Odessa P Hamidi
- University of Colorado, School of Medicine, Aurora, CO, USA.
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29
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Hizkiyahu R, Badeghiesh A, Baghlaf H, Dahan MH. Associations between hyperthyroidism and adverse obstetric and neonatal outcomes: A study of a population database including almost 17,000 women with hyperthyroidism. Clin Endocrinol (Oxf) 2022; 97:347-354. [PMID: 35261044 DOI: 10.1111/cen.14713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 02/19/2022] [Accepted: 02/24/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Large population-based studies on maternal hyperthyroidism's effect on antepartum, intrapartum, and neonatal complications are few. Most of these studies were small or did not evaluate a broad scope of possible complications. Therefore, a large population-based cohort study was conducted to study the associations between maternal hyperthyroidism and pregnancy and perinatal complications. DESIGN This is a retrospective population-based cohort study utilizing data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample over 11 years from 2004 to 2014. PATIENTS 16,984 deliveries to women with hyperthyroidism and 9,079,804 deliveries to mothers who did not suffer of hyperthyroidism. METHODS A cohort of all deliveries between 2004 and 2014 inclusively was created. Within this group, all deliveries to women with hyperthyroidism were the study group (n = 16,984) and the remaining deliveries were categorized as nonhyperthyroidism births and comprised the reference group (n = 9,079,804). The main outcome measures were pregnancy and perinatal complications. RESULTS Maternal hyperthyroidism was associated with several pregnancy and perinatal complications, including increased risks of gestational hypertension (adjusted odds ratio [aOR]: 1.236, 95% confidence interval [CI]: 1.045-1.462, p = .013) and preeclampsia (aOR: 1.190, 95% CI: 1.006-1.408, p = .042). These patients are more likely to experience preterm premature rupture of membranes (aOR: 1.322, 95% CI: 1.007-1.735, p = .044), preterm delivery (aOR: 1.287 95% CI: 1.132-1.465, p < .001), placental previa (aOR: 1.527, 95% CI: 1.082-2.155, p = .016), and suffer from venous thromboembolism (aOR: 2.894, 95% CI: 1.293-6.475, p = .010). As for neonatal outcomes, small for gestational age and stillbirth were more likely to occur in the offspring of women with hyperthyroidism (aOR: 1.688, 95% CI: 1.437-1.984, p < .001 and aOR: 1.647, 95% CI: 1.109-2.447, p = .013, respectively). CONCLUSIONS Women with hyperthyroidism are more likely to experience pregnancy, delivery, and neonatal complications. We found an association between hyperthyroidism and hypertensive disorders, preterm delivery, and intrauterine fetal death.
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Affiliation(s)
- Ranit Hizkiyahu
- Department of Obstetrics and Gynecology, Mcgill University, Montreal, Québec, Canada
| | - Ahmad Badeghiesh
- Department of Obstetrics and Gynecology, Western University, London, Ontario, Canada
| | - Haitham Baghlaf
- Department of Obstetrics and Gynecology, University of Tabuk, Tabouk, Saudi Arabia
| | - Michael H Dahan
- Department of Obstetrics and Gynecology, Mcgill University, Montreal, Québec, Canada
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30
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Uldall Torp NM, Bruun NH, Christensen PA, Handberg A, Andersen S, Andersen SL. Thyrotropin Receptor Antibodies in Early Pregnancy. J Clin Endocrinol Metab 2022; 107:e3705-e3713. [PMID: 35737956 DOI: 10.1210/clinem/dgac383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Thyrotropin (TSH) receptor antibodies (TRAb) are important when distinguishing between Graves' and gestational hyperthyroidism, but sparse evidence exists on the recommended cutoff during pregnancy. OBJECTIVE This work aimed to establish a method- and pregnancy-specific cutoff for TRAb, to describe the frequency of TRAb positivity in early pregnancy, and to follow up the women in the years after pregnancy. METHODS This cohort study used the North Denmark Region Pregnancy Cohort and Danish nationwide registers of women in the North Denmark Region who had a blood sample drawn in early pregnancy, 2011 to 2015, that was stored in a biobank for assessment of thyroid function and thyroid autoantibodies. A cutoff value for TRAb was established in a reference cohort (n = 524) and used to identify TRAb-positive and TRAb-negative hyperthyroidism in early pregnancy for evaluation of frequency and follow-up. RESULTS The method- and cohort-specific cutoff for TRAb in early pregnancy was 0.98 IU/L (95% CI, 0.96-0.99 IU/L). Among women with low TSH in early pregnancy and no known thyroid disease (n = 414), 21 women (5.1%) were TRAb positive and 393 (94.9%) were TRAb negative. Follow-up in the years following the pregnancy (median 8.1 years) revealed that 52.4% of women with TRAb-positive hyperthyroidism and 8.4% of the women with TRAb-negative hyperthyroidism were diagnosed with hyperthyroidism. CONCLUSION This is the first study to measure TRAb in a large group of women in early pregnancy and to establish a pregnancy-specific cutoff. Results reveal that TRAb-negative hyperthyroidism is predominant in early pregnancy and rarely associated with later development of hyperthyroidism.
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Affiliation(s)
- Nanna Maria Uldall Torp
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Niels Henrik Bruun
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Peter Astrup Christensen
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Aase Handberg
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Stig Andersen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Geriatric Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Stine Linding Andersen
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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31
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Rotondi M, Bendotti G, Croce L, Molteni M, Carbone A, Magri F, Pearce EN, Chiovato L. A unique presentation of Graves' disease in a pregnant woman with severe hypothyroidism. Gynecol Endocrinol 2022; 38:697-701. [PMID: 35723545 DOI: 10.1080/09513590.2022.2087216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BackgroundGraves' disease occurrence during pregnancy is not a frequent event, showing an incidence of 0.2-0.4% in unselected pregnant women. Depending on their functional properties, TSH-receptor antibodies can induce hypothyroidism or hyperthyroidism. Recognizing the signs of altered thyroid function is essential to prevent possible complications on the fetus.Materials and methodsThe case of a pregnant woman without previous history of thyroid disease presenting with severe overt hypothyroidism during the first trimester is reported. Levothyroxine therapy was started and 6 weeks later overt hyperthyroidism was observed. TRAb were detected at high titers. Levothyroxine was withdrawn and low dose methimazole was started. Serial obstetric ultrasound scans were negative for indirect signs of fetal thyroid dysfunctions and no fetal goiter was visualized throughout pregnancy. Spontaneous delivery occurred without complications at 39 weeks of gestation. In the post-partum, severe overt hypothyroidism recurred, thus methimazole was discontinued and levothyroxine was restarted. TRAb persisted at high levels. The infant experienced a transient thyrotoxicosis, which fully resolved in three months with normalization of thyroid function and negativization of TRAb levels.ResultsThe present case report allows us to overview the challenges related to the management of hypo and hyperthyroidism in patients with high TRAb levels, requiring strict monitoring aimed at early detection of both maternal and fetal consequences.ConclusionsThis case underlines the importance of close follow-up and the need of collaboration in a multidisciplinary team when Graves's disease is diagnosed in a pregnant woman to prevent adverse neonatal outcomes.
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Affiliation(s)
- Mario Rotondi
- Istituti Clinici Scientifici Maugeri IRCCS, Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Pavia, Italy
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Giulia Bendotti
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Laura Croce
- Istituti Clinici Scientifici Maugeri IRCCS, Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Pavia, Italy
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Martina Molteni
- Unit of Internal Medicine, Medical-Oncologic Department, ASST Lodi, Lodi, Italy
| | - Andrea Carbone
- Unit of Internal Medicine, Medical-Oncologic Department, ASST Lodi, Lodi, Italy
| | - Flavia Magri
- Istituti Clinici Scientifici Maugeri IRCCS, Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Pavia, Italy
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Elizabeth N Pearce
- Section of Endocrinology Diabetes, and Nutrition, Boston University School of Medicine, Boston, MA, USA
| | - Luca Chiovato
- Istituti Clinici Scientifici Maugeri IRCCS, Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Pavia, Italy
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
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32
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Maganha CA, Mattar R, Mesa Júnior CO, Marui S, Solha STG, Teixeira PDFDS, Zaconeta ACM, Souza RT. Screening, diagnosis and management of hyperthyroidism in pregnancy. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2022; 44:806-818. [PMID: 36075227 PMCID: PMC9948172 DOI: 10.1055/s-0042-1756521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Affiliation(s)
| | - Rosiane Mattar
- Departamento de Obstetrícia, Escola Paulista de Medicina, São Paulo, SP, Brazil
| | | | - Suemi Marui
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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33
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Hou X, Guan H, Sun S, Shi Y, Li C, Liu A, Li Y, Gao X, Hou Y, Yang Y, Li Y, Shan Z, Teng W. Outcomes of Early-Pregnancy Antithyroid Drug Withdrawal in Graves' Disease: A Preliminary Prospective Follow-Up Study. Thyroid 2022; 32:983-989. [PMID: 35651276 DOI: 10.1089/thy.2022.0088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective: The use of antithyroid drugs (ATDs) carries potential risk for teratogenic effects. For women with well-controlled hyperthyroidism on a low dose of ATDs, drug withdrawal upon pregnancy is recommended by international medical guidelines. Therefore, it is necessary to determine the characteristics of patients suitable for ATD withdrawal, subsequent changes in thyroid function after ATD discontinuation, and its impact on pregnancy and offspring outcomes. Methods: This prospective study recruited 63 pregnant women with well-controlled Graves' hyperthyroidism who had stopped ATDs during early pregnancy. Patients were followed up until the end of pregnancy and data on pregnancy outcomes were collected. Results: Overall, 20 patients (31.7%) had rebound of hyperthyroidism. Patients with either subnormal thyrotropin (TSH) levels (TSH <0.35 mIU/L, odds ratio [OR] = 5.12, confidence interval [CI = 1.29-20.34], p = 0.03) or positive thyrotropin receptor antibody (TRAb) (TRAb >1.75 IU/L, OR = 3.79, [CI = 1.17-12.30], p = 0.02) at the time of ATDs withdrawal presented a higher risk of rebound than those with either normal TSH levels or negative TRAb. Patients with both subnormal TSH and positive TRAb at the time of ATD withdrawal were more likely to experience rebound (83.3%, 5/6) than those with both normal TSH and negative TRAb (13%, 3/23, OR = 33.33, [CI = 2.83-392.60], p = 0.003). The prevalence of adverse pregnancy outcomes was significantly higher in patients who experienced rebound compared with those who did not (55.0% vs. 9.3%, OR = 11.92, [CI = 3.08-46.18], p = 0.0002). Conclusions: Subnormal TSH levels and TRAb positivity at the time of ATD withdrawal in early pregnancy may be associated with rebound of Graves' hyperthyroidism. Rebound of hyperthyroidism during pregnancy may increase the risk of adverse pregnancy outcomes. Larger prospective studies are needed to confirm these findings.
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Affiliation(s)
- Xin Hou
- Department of Endocrinology and Metabolism, Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Diseases, The First Affiliated Hospital of China Medical University, Shenyang, P.R. China
| | - Haixia Guan
- Department of Endocrinology and Metabolism, Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Diseases, The First Affiliated Hospital of China Medical University, Shenyang, P.R. China
- Department of Endocrinology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, P.R. China
| | - Shuang Sun
- Department of Endocrinology and Metabolism, Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Diseases, The First Affiliated Hospital of China Medical University, Shenyang, P.R. China
| | - Yang Shi
- Department of Endocrinology and Metabolism, Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Diseases, The First Affiliated Hospital of China Medical University, Shenyang, P.R. China
| | - Chenyan Li
- Department of Endocrinology and Metabolism, Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Diseases, The First Affiliated Hospital of China Medical University, Shenyang, P.R. China
| | - Aihua Liu
- Department of Endocrinology and Metabolism, Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Diseases, The First Affiliated Hospital of China Medical University, Shenyang, P.R. China
- Department of Endocrinology and Metabolism, Peking University Third Hospital, Beijing, P.R. China
| | - Yongze Li
- Department of Endocrinology and Metabolism, Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Diseases, The First Affiliated Hospital of China Medical University, Shenyang, P.R. China
| | - Xiaotong Gao
- Department of Endocrinology and Metabolism, Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Diseases, The First Affiliated Hospital of China Medical University, Shenyang, P.R. China
| | - Yuanyuan Hou
- Department of Endocrinology and Metabolism, Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Diseases, The First Affiliated Hospital of China Medical University, Shenyang, P.R. China
| | - Yang Yang
- Department of Endocrinology and Metabolism, Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Diseases, The First Affiliated Hospital of China Medical University, Shenyang, P.R. China
| | - Yushu Li
- Department of Endocrinology and Metabolism, Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Diseases, The First Affiliated Hospital of China Medical University, Shenyang, P.R. China
| | - Zhongyan Shan
- Department of Endocrinology and Metabolism, Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Diseases, The First Affiliated Hospital of China Medical University, Shenyang, P.R. China
| | - Weiping Teng
- Department of Endocrinology and Metabolism, Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Diseases, The First Affiliated Hospital of China Medical University, Shenyang, P.R. China
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Turunen S, Vääräsmäki M, Marttila R, Leinonen MK, Gissler M, Männistö T, Suvanto E. Indications for intensive care unit treatment among neonates born to mothers with thyroid disease: A population-based cohort study. Acta Obstet Gynecol Scand 2022; 101:1093-1101. [PMID: 35778835 PMCID: PMC9812201 DOI: 10.1111/aogs.14413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 05/20/2022] [Accepted: 06/06/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Thyroid diseases in pregnancy are relatively common and are associated with adverse pregnancy and perinatal outcomes, increasing a neonate's risk of admission to the neonatal intensive care unit (NICU). The aim of this study was to evaluate the indications for increased risk of NICU admission among the neonates of hypothyroid and hyperthyroid mothers. MATERIAL AND METHODS The study data consisted of all singleton deliveries (n = 734 773) between 2004 and 2016 in Finland collected from the Finnish Medical Birth Register. The odds of NICU admission (with 95% confidence intervals) were compared between the neonates of hypothyroid or hyperthyroid mothers and of mothers without any thyroid diseases by specified neonatal characteristics and morbidities using logistic regression analysis. The studied neonatal characteristics were preterm birth (<37+0 gestational weeks), low birthweight (<2500 g), the rate of small- and large-for-gestational age infants, and eight disease-specific neonatal outcomes: asphyxia, respiratory distress syndrome, meconium aspiration syndrome, pneumothorax, cardiovascular problems, infections, jaundice and hypoglycemia. RESULTS The most common indications for NICU care were principally the same in the neonates of the mothers with and without thyroid disease: respiratory distress syndrome, infections, preterm birth, low birthweight and neonatal hypoglycemia. The preterm neonates, neonates with low birthweight, and large-for-gestational-age infants had increased odds of NICU admission if their mother had hypothyroidism. Also neonates with cardiovascular problems, jaundice or hypoglycemia associated with maternal diabetes had increased odds of NICU admissions if their mother had hypothyroidism. Further, the preterm neonates, large-for-gestational-age infants, and term infants with jaundice had increased odds of NICU admission if their mother had hyperthyroidism. CONCLUSIONS The most common indications for NICU care were similar for the neonates of the mothers with and without thyroid disease. However, the neonates of the mothers with thyroid diseases were more likely to need NICU care. The neonates of the mothers with thyroid diseases had higher odds of NICU treatment in cases of preterm birth, large for gestational age, and hypoglycemia.
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Affiliation(s)
- Suvi Turunen
- Department of Obstetrics and Gynecology, PEDEGO Research Unit, Medical Research Center OuluUniversity of Oulu and University Hospital of OuluOuluFinland
| | - Marja Vääräsmäki
- Department of Obstetrics and Gynecology, PEDEGO Research Unit, Medical Research Center OuluUniversity of Oulu and University Hospital of OuluOuluFinland
| | | | - Maarit K. Leinonen
- Finnish Institute for Health and WelfareDepartment of Knowledge BrokersHelsinkiFinland
| | - Mika Gissler
- Finnish Institute for Health and WelfareDepartment of Knowledge BrokersHelsinkiFinland,Department of Molecular Medicine and SurgeryKarolinska InstituteStockholmSweden
| | - Tuija Männistö
- Northern Finland Laboratory Center NordlabOuluFinland,Department of Neurobiology, Care Sciences and SocietyKarolinska InstituteStockholmSweden
| | - Eila Suvanto
- Department of Obstetrics and Gynecology, PEDEGO Research Unit, Medical Research Center OuluUniversity of Oulu and University Hospital of OuluOuluFinland
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Ilias I, Milionis C, Koukkou E. Further understanding of thyroid function in pregnant women. Expert Rev Endocrinol Metab 2022; 17:365-374. [PMID: 35831988 DOI: 10.1080/17446651.2022.2099372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 07/05/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Normal thyroid status throughout pregnancy is important for both maternal and fetal health. Despite the bulk of contemporary research honing on thyroid function in gestation and the relevant disorders, there are still gaps in our current knowledge about the etiology and treatment of thyroid diseases in pregnant women. AREAS COVERED This article analyzes the adaptation of the thyroid gland to gestational physiological changes and attempts to explain the effect of several factors on thyroid function in pregnancy. It also stresses proper utilization and interpretation of thyroid tests during pregnancy and underlines the significance of proper screening and treatment of pregnant women aiming at favorable health outcomes. EXPERT OPINION Appropriate strategies for diagnosing and treating thyroid disease in pregnancy are important. Laboratory thyroid testing plays a leading role, but test results should be interpreted with caution. Given the possible serious maternal and fetal/neonatal complications of thyroid disease in pregnancy, we recommend universal screening with TSH measurements of all pregnant women. Additional assessment with determination of the levels of free thyroid hormones and thyroid antibodies may be necessary under certain conditions. The economic burden of such interventions should be considered.
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Affiliation(s)
- Ioannis Ilias
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, Athens, Greece
| | - Charalampos Milionis
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, Athens, Greece
| | - Eftychia Koukkou
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, Athens, Greece
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Del Campo Cano I, Alarza Cano R, Encinas Padilla B, Lacámara Ornaechea N, Royuela Vicente A, Marín Gabriel MÁ. A prospective study among neonates born to mothers with active or past Graves disease. Gynecol Endocrinol 2022; 38:495-498. [PMID: 35548945 DOI: 10.1080/09513590.2022.2073347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE The aim of this prospective study was to describe demographic and clinical characteristics of neonates born to mothers with active or past Graves disease and to assess compliance since implementation of a new protocol in our center. METHODS We prospectively followed up neonates born to mothers with active or past Graves disease in a tertiary hospital in Spain between August 2019 and September 2021 according to our protocol. We reviewed maternal and neonatal history of these neonates, and we followed up newborns at risk of neonatal hyperthyroidism. RESULTS Among 5808 births, 33 neonates were born to mothers with active or past Graves disease (0.57%). Six mothers (18.2%) had positive levels of thyroid-stimulating hormone receptor antibodies during pregnancy and five mothers (15.1%) between weeks 20 and 24 of pregnancy. Two of them had received definitive therapy for Graves disease before pregnancy. Two neonates (7.1%) were at high risk of neonatal hyperthyroidism and were followed-up until two months, without hyperthyroidism signs or abnormal thyroid hormone levels. Compliance of protocol during pregnancy was 84.9% and 75.8% at birth. CONCLUSIONS Prevalence of Graves disease among pregnant women was 0.57%, with no cases of neonatal hyperthyroidism. Compliance of protocol was adequate during pregnancy (84.9%) and acceptable at birth (75.8%).
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Affiliation(s)
- Iván Del Campo Cano
- Department of Pediatrics, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Raquel Alarza Cano
- Department of Obstetric and Gynecology, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Begoña Encinas Padilla
- Department of Obstetric and Gynecology, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | | | - Ana Royuela Vicente
- Biostatistics Unit; Puerta de Hierro Biomedical Research Institute (IDIPHISA); CIBERESP, Madrid, Spain
| | - Miguel Ángel Marín Gabriel
- Department of Pediatrics, Section of Neonatology, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
- Pediatric Deparment Associate Professor, Autónoma University, Madrid, Spain
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Dhillon-Smith RK, Boelaert K. Preconception Counseling and Care for Pregnant Women with Thyroid Disease. Endocrinol Metab Clin North Am 2022; 51:417-436. [PMID: 35662450 DOI: 10.1016/j.ecl.2021.12.005] [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] [Indexed: 11/29/2022]
Abstract
Thyroid disease is associated with adverse maternal and fetal outcomes. Appropriate reference ranges should be used for the interpretation of test results, although universal screening for thyroid dysfunction is not warranted. Overt thyroid dysfunction requires careful consideration of medication adjustments and close monitoring. Mild thyroid hypofunction has been linked to adverse pregnancy outcomes including preterm delivery, and poor neurocognition in the offspring. This review summarizes the most recent evidence on the counseling and management of women with thyroid disease before and during pregnancy and highlights the areas of controversy in need of further research.
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Affiliation(s)
- Rima K Dhillon-Smith
- Institute of Metabolism and Systems Research, Tommy's National Centre for Miscarriage Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Kristien Boelaert
- Institute of Applied Health Research, Room 232 Murray Learning Centre, University of Birmingham, Birmingham, B15 2FG, UK.
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Timing of Graves' Hyperthyroidism Management in Pregnant Women: Impact on the Infant Thyroid Volume. Nutrients 2022; 14:nu14091972. [PMID: 35565939 PMCID: PMC9102435 DOI: 10.3390/nu14091972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/02/2022] [Accepted: 05/05/2022] [Indexed: 11/16/2022] Open
Abstract
The thyroid of the fetus of a mother with Graves’ disease (GD) is affected by the transplacental passage of both antithyroid drugs (ATDs) and thyroid-stimulating hormone receptor antibodies (TRAb). Thyroid hormone imbalances are harmful for the developing brain. This study aimed to evaluate the impact of the duration of antithyroid drug treatment in hyperthyroid pregnant women with GD on infants’ thyroid volume. Twenty-nine neonates born to mothers with GD were divided into two groups depending on the duration of ATDs treatment. The ultrasound thyroid volumes of the infants were measured within the first week of life. Thyroid-stimulating hormone, thyroxine, and TRAb values were recorded. There was no difference between groups in the thyroid hormones’ values. The median thyroid volume for the entire group of neonates with mothers with GD, for the groups of neonates of mothers with long- and short-treated GD, and for the control group were 1.539, 1.816, 1.347 and 1.014 mL, respectively. There were statistically significant differences in the thyroid volume between the GD group and the control group, as well as between the groups of neonates of mothers with long- and short-treated GD (p < 0.05). Studies have shown that the longer the duration of ATDs administration to mothers, the greater the thyroid volume of the neonate.
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Stoltefaut M, Fröschle GM, Haddad M, Perez A, Blohm ME, Deindl P, Singer D, Ebenebe CU. Thyroid function, thyroid antibodies and early postnatal development in neonates of mothers with thyroid disorders. Early Hum Dev 2022; 167:105561. [PMID: 35245827 DOI: 10.1016/j.earlhumdev.2022.105561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/16/2022] [Accepted: 02/22/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Thyroid dysfunction during pregnancy is relatively common and can cause obstetric complications and significantly influence fetal development. AIMS We aimed to evaluate postnatal clinical and laboratory characteristics in the first days of life in infants born to mothers with a thyroid disorder. STUDY DESIGN AND SUBJECTS We conducted a retrospective single-center study with neonates born between January 2010 and May 2020. Early laboratory parameters and clinical findings in neonates of mothers with different maternal thyroid disorders were analysed. RESULTS We included 314 newborns of mothers with Hashimoto's thyroiditis, 171 with non-Hashimoto's hypothyroidism, 42 with Graves' disease, 12 with non-Graves' hyperthyroidism, and 190 neonates born to mothers without thyroid dysfunction. No demographic, clinical, and laboratory differences were observed between neonates from mothers with a thyroid disorder and healthy mothers. FT3 and fT4 correlated positively with gestational age (p < 0.001; p < 0.001) and negatively with maximum postnatal weight loss (p = 0.043; p < 0.001). High fT3 values were associated with lower maximum bilirubin levels (p = 0.020). CONCLUSION Despite an increased morbidity risk due to the transplacental exposure to maternal antibodies, most neonates born to mothers with thyroid disorders show normal postnatal development and thyroid function tests during the first days of life.
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Affiliation(s)
- Meike Stoltefaut
- Division of Neonatology and Pediatric Intensive Care, University Children's Hospital, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Glenn Malin Fröschle
- Division of Neonatology and Pediatric Intensive Care, University Children's Hospital, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Munif Haddad
- Department of Clinical Chemistry, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany
| | - Anna Perez
- Division of Neonatology and Pediatric Intensive Care, University Children's Hospital, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Martin Ernst Blohm
- Division of Neonatology and Pediatric Intensive Care, University Children's Hospital, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Philipp Deindl
- Division of Neonatology and Pediatric Intensive Care, University Children's Hospital, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Dominique Singer
- Division of Neonatology and Pediatric Intensive Care, University Children's Hospital, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Chinedu Ulrich Ebenebe
- Division of Neonatology and Pediatric Intensive Care, University Children's Hospital, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
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40
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Toloza FJK, Derakhshan A, Männistö T, Bliddal S, Popova PV, Carty DM, Chen L, Taylor P, Mosso L, Oken E, Suvanto E, Itoh S, Kishi R, Bassols J, Auvinen J, López-Bermejo A, Brown SJ, Boucai L, Hisada A, Yoshinaga J, Shilova E, Grineva EN, Vrijkotte TGM, Sunyer J, Jiménez-Zabala A, Riaño-Galan I, Lopez-Espinosa MJ, Prokop LJ, Singh Ospina N, Brito JP, Rodriguez-Gutierrez R, Alexander EK, Chaker L, Pearce EN, Peeters RP, Feldt-Rasmussen U, Guxens M, Chatzi L, Delles C, Roeters van Lennep JE, Pop VJM, Lu X, Walsh JP, Nelson SM, Korevaar TIM, Maraka S. Association between maternal thyroid function and risk of gestational hypertension and pre-eclampsia: a systematic review and individual-participant data meta-analysis. Lancet Diabetes Endocrinol 2022; 10:243-252. [PMID: 35255260 PMCID: PMC10314731 DOI: 10.1016/s2213-8587(22)00007-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/24/2021] [Accepted: 01/04/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Adequate maternal thyroid function is important for an uncomplicated pregnancy. Although multiple observational studies have evaluated the association between thyroid dysfunction and hypertensive disorders of pregnancy, the methods and definitions of abnormalities in thyroid function tests were heterogeneous, and the results were conflicting. We aimed to examine the association between abnormalities in thyroid function tests and risk of gestational hypertension and pre-eclampsia. METHODS In this systematic review and meta-analysis of individual-participant data, we searched MEDLINE (Ovid), Embase, Scopus, and the Cochrane Database of Systematic Reviews from date of inception to Dec 27, 2019, for prospective cohort studies with data on maternal concentrations of thyroid-stimulating hormone (TSH), free thyroxine (FT4), thyroid peroxidase (TPO) antibodies, individually or in combination, as well as on gestational hypertension, pre-eclampsia, or both. We issued open invitations to study authors to participate in the Consortium on Thyroid and Pregnancy and to share the individual-participant data. We excluded participants who had pre-existing thyroid disease or multifetal pregnancy, or were taking medications that affect thyroid function. The primary outcomes were documented gestational hypertension and pre-eclampsia. Individual-participant data were analysed using logistic mixed-effects regression models adjusting for maternal age, BMI, smoking, parity, ethnicity, and gestational age at blood sampling. The study protocol was registered with PROSPERO, CRD42019128585. FINDINGS We identified 1539 published studies, of which 33 cohorts met the inclusion criteria and 19 cohorts were included after the authors agreed to participate. Our study population comprised 46 528 pregnant women, of whom 39 826 (85·6%) women had sufficient data (TSH and FT4 concentrations and TPO antibody status) to be classified according to their thyroid function status. Of these women, 1275 (3·2%) had subclinical hypothyroidism, 933 (2·3%) had isolated hypothyroxinaemia, 619 (1·6%) had subclinical hyperthyroidism, and 337 (0·8%) had overt hyperthyroidism. Compared with euthyroidism, subclinical hypothyroidism was associated with a higher risk of pre-eclampsia (2·1% vs 3·6%; OR 1·53 [95% CI 1·09-2·15]). Subclinical hyperthyroidism, isolated hypothyroxinaemia, or TPO antibody positivity were not associated with gestational hypertension or pre-eclampsia. In continuous analyses, both a higher and a lower TSH concentration were associated with a higher risk of pre-eclampsia (p=0·0001). FT4 concentrations were not associated with the outcomes measured. INTERPRETATION Compared with euthyroidism, subclinical hypothyroidism during pregnancy was associated with a higher risk of pre-eclampsia. There was a U-shaped association of TSH with pre-eclampsia. These results quantify the risks of gestational hypertension or pre-eclampsia in women with thyroid function test abnormalities, adding to the total body of evidence on the risk of adverse maternal and fetal outcomes of thyroid dysfunction during pregnancy. These findings have potential implications for defining the optimal treatment target in women treated with levothyroxine during pregnancy, which needs to be assessed in future interventional studies. FUNDING Arkansas Biosciences Institute and Netherlands Organization for Scientific Research.
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Affiliation(s)
- Freddy J K Toloza
- Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Department of Medicine, MetroWest Medical Center, Tufts Medical School, Framingham, MA, USA
| | - Arash Derakhshan
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands; Academic Center for Thyroid Diseases, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Tuija Männistö
- Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland; Northern Finland Laboratory Center Nordlab, University of Oulu, Oulu, Finland
| | - Sofie Bliddal
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Polina V Popova
- Department of Endocrinology, Almazov National Medical Research Centre, Saint Petersburg, Russia; Institute of Endocrinology, Almazov National Medical Research Centre, Saint Petersburg, Russia; World-Class Research Center for Personalized Medicine, Almazov National Medical Research Centre, Saint Petersburg, Russia; Department of Internal Diseases and Endocrinology, St Petersburg Pavlov State Medical University, Saint Petersburg, Russia
| | - David M Carty
- Department of Diabetes, Endocrinology and Clinical Pharmacology, Glasgow Royal Infirmary, Glasgow, UK; Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Liangmiao Chen
- Department of Endocrinology and Rui'an Center of the Chinese-American Research Institute for Diabetic Complications, Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Peter Taylor
- Thyroid Research Group, Institute of Molecular and Experimental Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Lorena Mosso
- Department of Endocrinology and Centro Traslacional en Endocrinologia, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Emily Oken
- Division of Chronic Disease Research Across the Lifecourse, Department of Population Medicine, Harvard Medical School, Boston, MA, USA
| | - Eila Suvanto
- Department of Obstetrics and Gynecology, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Sachiko Itoh
- Center for Environmental and Health Sciences, Hokkaido University, Sapporo, Japan
| | - Reiko Kishi
- Center for Environmental and Health Sciences, Hokkaido University, Sapporo, Japan
| | - Judit Bassols
- Maternal-Fetal Metabolic Research Group, Girona Biomedical Research Institute, Dr Josep Trueta Hospital, Girona, Spain
| | - Juha Auvinen
- Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland; Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - Abel López-Bermejo
- Pediatric Endocrinology Research Group, Girona Biomedical Research Institute, Dr Josep Trueta Hospital, Girona, Spain
| | - Suzanne J Brown
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Laura Boucai
- Division of Endocrinology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, Weill Cornell University, New York, NY, USA
| | - Aya Hisada
- Center for Preventive Medical Sciences, Chiba University, Chiba, Japan
| | - Jun Yoshinaga
- Faculty of Life Sciences, Toyo University, Gunma, Japan
| | - Ekaterina Shilova
- Institute of Endocrinology, Almazov National Medical Research Centre, Saint Petersburg, Russia; Department of Gynecology and Endocrinology, DO Ott Research Institute of Obstetrics and Gynecology, Saint Petersburg, Russia
| | - Elena N Grineva
- Department of Endocrinology, Almazov National Medical Research Centre, Saint Petersburg, Russia; Institute of Endocrinology, Almazov National Medical Research Centre, Saint Petersburg, Russia
| | - Tanja G M Vrijkotte
- Department of Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Jordi Sunyer
- ISGlobal, Barcelona, Spain; Pompeu Fabra University, Barcelona, Spain; Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - Ana Jiménez-Zabala
- Spanish Consortium for Research on Epidemiology and Public Health, Instituto de Salud Carlos III, Madrid, Spain; BIODONOSTIA Health Research Institute, San Sebastian, Spain; Public Health Division of Gipuzkoa, Basque Government, San Sebastian, Spain
| | - Isolina Riaño-Galan
- Spanish Consortium for Research on Epidemiology and Public Health, Instituto de Salud Carlos III, Madrid, Spain; AGC Pediatrics, Hospital Universitario Central de Asturias, Oviedo, Spain; IUOPA-Departamento de Medicina-ISPA, Universidad de Oviedo, Oviedo, Spain
| | - Maria-Jose Lopez-Espinosa
- Spanish Consortium for Research on Epidemiology and Public Health, Instituto de Salud Carlos III, Madrid, Spain; Epidemiology and Environmental Health Joint Research Unit, FISABIO-Universitat Jaume I-Universitat de València, Valencia, Spain; Faculty of Nursing and Chiropody, Universitat de València, Valencia, Spain
| | | | - Naykky Singh Ospina
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Juan P Brito
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rene Rodriguez-Gutierrez
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Division of Endocrinology, Department of Internal Medicine, University Hospital Dr Jose E Gonzalez, Autonomous University of Nuevo León, Monterrey, Mexico; Plataforma INVEST Medicina UANL-KER Unit, Universidad Autónoma de Nuevo León, Monterrey, México
| | - Erik K Alexander
- Division of Endocrinology, Hypertension and Diabetes, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Layal Chaker
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands; Academic Center for Thyroid Diseases, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Elizabeth N Pearce
- Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, Boston, MA, USA
| | - Robin P Peeters
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands; Academic Center for Thyroid Diseases, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Ulla Feldt-Rasmussen
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Mònica Guxens
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus University Medical Center, Rotterdam, Netherlands; ISGlobal, Barcelona, Spain; Pompeu Fabra University, Barcelona, Spain; Spanish Consortium for Research on Epidemiology and Public Health, Instituto de Salud Carlos III, Madrid, Spain
| | - Leda Chatzi
- Department of Population and Public Health Sciences, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Christian Delles
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - Victor J M Pop
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, Netherlands
| | - Xuemian Lu
- Department of Endocrinology and Rui'an Center of the Chinese-American Research Institute for Diabetic Complications, Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - John P Walsh
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, WA, Australia; Medical School, University of Western Australia, Crawley, WA, Australia
| | | | - Tim I M Korevaar
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands; Academic Center for Thyroid Diseases, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Spyridoula Maraka
- Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Central Arkansas Veterans Healthcare System, Little Rock, AR, USA.
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Turkal R, Turan CA, Elbasan O, Aytan S, Çakmak B, Gözaydınoğlu B, Takır DC, Ünlü O, Bahramzada G, Tekin AF, Çevlik T, Büyükbayrak EE, Şirikçi Ö, Gözü H, Haklar G. Accurate interpretation of thyroid dysfunction during pregnancy: should we continue to use published guidelines instead of population-based gestation-specific reference intervals for the thyroid-stimulating hormone (TSH)? BMC Pregnancy Childbirth 2022; 22:271. [PMID: 35361138 PMCID: PMC8973886 DOI: 10.1186/s12884-022-04608-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 03/22/2022] [Indexed: 11/17/2022] Open
Abstract
Background Considering the changes in thyroid physiology associated with pregnancy and poor outcomes related to abnormal maternal thyroid function, international guidelines recommend using population-based trimester-specific reference intervals (RIs) for thyroid testing. If these RIs are not available in the laboratory, implementing recommended fixed cut-off values globally is still controversial. To address this issue, we aimed to establish appropriate RI of thyroid-stimulating hormone (TSH) in pregnant Turkish women for our laboratory and compare the prevalence of thyroid dysfunction based on the established and recommended criteria. Methods Of 2638 pregnant women, 1777 women followed in the obstetric outpatient were enrolled in the reference interval study after applying exclusion criteria related to medical and prenatal history. A retrospective study was conducted by collecting data from July 2016 to March 2019. Serum TSH was measured by UniCel DxI 800 Immunoassay System (Beckman Coulter Inc., Brea, CA, USA). The study design relied on two approaches in order to classify pregnant women: trimester-specific and subgroup-specific; the latter involved dividing each trimester into two subgroups: T1a, T1b, T2a, T2b, T3a, T3b. The lower and upper limits of the RIs were derived by the parametric method after normalizing the data distribution using the modified Box-Cox power transformation method. Results The lowest TSH value was detected at 8-12 weeks in early pregnancy, and the median value of TSH in the T1b subgroup was significantly lower than the T1a subgroup (P < 0.05). TSH levels showed a gradual trend of increase along with the pregnancy and increased significantly in the T2a, T2b, and T3b subgroups compared to the preceding subgroups (P < 0.05). Compared to the diagnostic criteria recommended by American Thyroid Association (ATA), the prevalence of thyroid dysfunction was significantly different from the established trimester- and subgroup-specific RIs throughout the pregnancy (P < 0.001). Conclusions We conclude that establishing gestation- and laboratory-specific RIs, especially for TSH, is essential for diagnosing thyroid disorders in pregnancy, and the recommended universal cut-off values, which may contribute to the risk of a misdiagnosis or a missed diagnosis, should be taken with caution in the clinical setting. However, regarding the fluctuation of thyroid function tests throughout pregnancy, trimester-specific RIs are insufficient, and implementing split phases is required.
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Affiliation(s)
- Rana Turkal
- Biochemistry Laboratory, Marmara University Pendik Education and Research Hospital, Istanbul, Turkey.
| | - Cem Armağan Turan
- Department of Internal Medicine, School of Medicine, Marmara University, Istanbul, Turkey
| | - Onur Elbasan
- Subdepartment of Endocrinology, Department of Internal Medicine, School of Medicine, Marmara University, Istanbul, Turkey
| | - Serenay Aytan
- Medical Student, School of Medicine, Marmara University, Istanbul, Turkey
| | - Burcu Çakmak
- Medical Student, School of Medicine, Marmara University, Istanbul, Turkey
| | - Büşra Gözaydınoğlu
- Medical Student, School of Medicine, Marmara University, Istanbul, Turkey
| | - Duygu Ceyda Takır
- Medical Student, School of Medicine, Marmara University, Istanbul, Turkey
| | - Ozan Ünlü
- Department of Biochemistry, School of Medicine, Marmara University, Istanbul, Turkey
| | - Günel Bahramzada
- Department of Biochemistry, School of Medicine, Marmara University, Istanbul, Turkey
| | - Ahmet Faruk Tekin
- Department of Biochemistry, School of Medicine, Marmara University, Istanbul, Turkey
| | - Tülay Çevlik
- Biochemistry Laboratory, Marmara University Pendik Education and Research Hospital, Istanbul, Turkey
| | - Esra Esim Büyükbayrak
- Department of Gynecology and Obstetrics, School of Medicine, Marmara University, Istanbul, Turkey
| | - Önder Şirikçi
- Department of Biochemistry, School of Medicine, Marmara University, Istanbul, Turkey
| | - Hülya Gözü
- Subdepartment of Endocrinology, Department of Internal Medicine, School of Medicine, Marmara University, Istanbul, Turkey
| | - Goncagül Haklar
- Department of Biochemistry, School of Medicine, Marmara University, Istanbul, Turkey
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Efficacy of propylthiouracil in the treatment of pregnancy with hyperthyroidism and its effect on pregnancy outcomes: A meta-analysis. PLoS One 2022; 17:e0265085. [PMID: 35271661 PMCID: PMC8912150 DOI: 10.1371/journal.pone.0265085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 02/22/2022] [Indexed: 11/26/2022] Open
Abstract
Background Hyperthyroidism affects about 0.2%-2.7% of all pregnancies, and is generally treated with propylthiouracil (PTU). However, previous studies about the effects of propylthiouracil on maternal or foetal are contentious. Objective This meta-analysis was carried out to investigate the safety and efficacy of propylthiouracil during pregnancy. Materials and methods PubMed, EBSCO, Embase, Scopus, Web of Science, Cochrane, CNKI, Wanfang and VIP database were searched from inception until August 31, 2021 for all available randomized controlled trials (RCTs) or cohort studies that evaluated the efficacy of propylthiouracil and its effects on pregnancy outcomes. Odds ratio (OR) and 95% confidence interval (CI) were used for binary variables, weighted mean difference (WMD) and 95% confidence interval (CI) were used for continuous variables. RevMan5.4 and Stata 16.0 were used for performing the meta-analysis. Results The researchers examined data from 13 randomized controlled trials and cohort studies involving 18948 infants. Congenital anomalies were not significantly associated with PTU in the pooled results (OR = 1.03, 95%CI: 0.84–1.25, P = 0.80, I2 = 40.3%). There were no statistically significant differences in neonatal hypothyroidism (OR = 0.55, 95%CI: 0.06–4.92, P = 0.593, I2 = 57.0%) or hepatotoxicity (OR = 0.34, 95%CI: 0.08–1.48, P = 0.151, I2 = 0.0%) exposed to PTU compared to the control group. The serum levels of FT3, FT4, TT3, and TT4 were significantly lower in the propylthiouracil group compared to the control group. Conclusion This meta-analysis confirmed the beneficial effects of propylthiouracil treatment, namely the risks of adverse pregnancy outcomes were not increased, and it also proved PTU’s efficacy in the treatment of pregnant women with hyperthyroidism. The findings supported the use of propylthiouracil during pregnancy with hyperthyroidism in order to improve clinical pregnancy outcomes in patients with thyroid dysfunction.
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Lee SY, Pearce EN. Assessment and treatment of thyroid disorders in pregnancy and the postpartum period. Nat Rev Endocrinol 2022; 18:158-171. [PMID: 34983968 PMCID: PMC9020832 DOI: 10.1038/s41574-021-00604-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2021] [Indexed: 12/13/2022]
Abstract
Thyroid disorders are prevalent in pregnant women. Furthermore, thyroid hormone has a critical role in fetal development and thyroid dysfunction can adversely affect obstetric outcomes. Thus, the appropriate management of hyperthyroidism, most commonly caused by Graves disease, and hypothyroidism, which in iodine sufficient regions is most commonly caused by Hashimoto thyroiditis, in pregnancy is important for the health of both pregnant women and their offspring. Gestational transient thyrotoxicosis can also occur during pregnancy and should be differentiated from Graves disease. Effects of thyroid autoimmunity and subclinical hypothyroidism in pregnancy remain controversial. Iodine deficiency is the leading cause of hypothyroidism worldwide. Despite global efforts to eradicate iodine deficiency disorders, pregnant women remain at risk of iodine deficiency due to increased iodine requirements during gestation. The incidence of thyroid cancer is increasing worldwide, including in young adults. As such, the diagnosis of thyroid nodules or thyroid cancer during pregnancy is becoming more frequent. The evaluation and management of thyroid nodules and thyroid cancer in pregnancy pose a particular challenge. Postpartum thyroiditis can occur up to 1 year after delivery and must be differentiated from other forms of thyroid dysfunction, as treatment differs. This Review provides current evidence and recommendations for the evaluation and management of thyroid disorders in pregnancy and in the postpartum period.
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Affiliation(s)
- Sun Y Lee
- Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, Boston, MA, USA
| | - Elizabeth N Pearce
- Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, Boston, MA, USA.
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Ashkar C, Sztal-Mazer S, Topliss DJ. How to manage Graves' disease in women of childbearing potential. Clin Endocrinol (Oxf) 2022; 98:643-648. [PMID: 35192205 DOI: 10.1111/cen.14705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/20/2022] [Accepted: 02/08/2022] [Indexed: 11/30/2022]
Abstract
The management of Graves' disease (GD) in women of childbearing potential has multiple specific complexities. Many factors are involved, which differ at the various stages from preconception, conception, first trimester, later pregnancy, postpartum and lactation, with both maternal and foetal considerations. The incidence and significance of the risks incurred from antithyroid drugs (ATDs) in pregnancy have been re-evaluated recently and must be balanced against the risks of uncontrolled hyperthyroidism during childbearing years. Contraception is advised until hyperthyroidism is controlled. ATD cessation should be considered in those who are well controlled on low dose therapy before conception and in early pregnancy. Advice on iodine supplementation does not generally differ in those with GD. Radioiodine (RAI) is contraindicated from 6 months preconception until completion of breastfeeding. In all women who have a history of GD, monitoring of TSH receptor antibodies (TRAb) is strongly recommended during pregnancy, and if elevated, foetal monitoring and assessment of thyroid function in the neonate are required. Of note, RAI increases TRAb for up to a year, making this treatment option even less attractive in this patient group. A small amount of ATD is transferred into breast milk but low doses are safe during lactation. Routine periodic thyroid function testing is recommended in remission to detect postpartum GD recurrence. We present our approach to the Clinical Question 'How to manage GD in women of childbearing potential?'
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Affiliation(s)
- Claudia Ashkar
- Department of Endocrinology and Diabetes, Alfred Health, Melbourne, Australia
| | - Shoshana Sztal-Mazer
- Department of Endocrinology and Diabetes, Alfred Health, Melbourne, Australia
- Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
- Adjunct Research Fellow, Women's Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Duncan J Topliss
- Department of Endocrinology and Diabetes, Alfred Health, Melbourne, Australia
- Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
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Abstract
Fetal and neonatal dysfunctions include rare serious disorders involving abnormal thyroid function during the second half of gestation, which may persist throughout life, as for most congenital thyroid disorders, or be transient, resolving in the first few weeks of life, as in autoimmune hyperthyroidism or hypothyroidism and some cases of congenital hypothyroidism (CH) with the thyroid gland in situ. Primary CH is diagnosed by neonatal screening, which has been implemented for 40 years in developed countries and should be introduced worldwide, as early treatment prevents irreversible neurodevelopmental delay. Central CH is a rarer entity occurring mostly in association with multiple pituitary hormone deficiencies. Other rare disorders impair the action of thyroid hormones. Neonatal Graves' disease (GD) results from the passage of thyrotropin receptor antibodies (TRAbs) across the placenta, from mother to fetus. It may affect the fetuses and neonates of mothers with a history of current or past GD, but hyperthyroidism develops only in those with high levels of stimulatory TRAb activity. The presence of antibodies predominantly blocking thyroid-stimulating hormone receptors may result in transient hypothyroidism, possibly followed by neonatal hyperthyroidism, depending on the balance between the antibodies present. Antithyroid drugs taken by the mother cross the placenta, treating potential fetal hyperthyroidism, but they may also cause transient fetal and neonatal hypothyroidism. Early diagnosis and treatment are key to optimizing the child's prognosis. This review focuses on the diagnosis and management of these patients during the fetal and neonatal periods. It includes the description of a case of fetal and neonatal autoimmune hyperthyroidism.
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Affiliation(s)
- Juliane Léger
- Assistance Publique-Hôpitaux de Paris, Robert Debré University Hospital, Pediatric Endocrinology-Diabetology Department, Reference Center for Growth and Development Endocrine Diseases, Paris, France
- Université de Paris; NeuroDiderot, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - Clemence Delcour
- Université de Paris; NeuroDiderot, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
- Assistance Publique-Hôpitaux de Paris, Robert Debré University Hospital, Gynecology and Obstetric Department, Paris, France
| | - Jean-Claude Carel
- Assistance Publique-Hôpitaux de Paris, Robert Debré University Hospital, Pediatric Endocrinology-Diabetology Department, Reference Center for Growth and Development Endocrine Diseases, Paris, France
- Université de Paris; NeuroDiderot, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
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Caron P. MANAGEMENT OF THYROTOXICOSIS AND PREGNANCY: Review of the current literature and an update of the care pathway. ANNALES D'ENDOCRINOLOGIE 2022; 83:226-231. [PMID: 35143751 DOI: 10.1016/j.ando.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 01/12/2022] [Accepted: 01/20/2022] [Indexed: 10/19/2022]
Abstract
Pregnancy can be complicated by hyperthyroidism or thyrotoxicosis. Diagnosis is founded on an increase in free thyroid hormones and low TSH. The most frequent etiologies are Graves' disease, an autoimmune disease linked to stimulatory anti-TSH receptor antibodies, and non-autoimmune gestational hyperthyroidism linked to the TSH-like activity of the chorionic growth hormone (hCG). During pregnancy, thyrotoxicosis can entail maternal, obstetrical and fetal or neonatal complications. Graves' hyperthyroidism may be responsible for fetal and neonatal hyperthyroidism due to placental transfer of stimulatory anti-TSH receptor antibodies. During pregnancy, treatment of thyrotoxicosis must restore normal thyroid function in the mother without affecting fetal thyroid function. The recent reassessment of the prevalence of teratogenic effects in children of women treated with antithyroid drugs in the first weeks of gestation should orient the care pathway before and during pregnancy for women of child-bearing age with hyperthyroidism linked to Graves' disease.
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Affiliation(s)
- Philippe Caron
- Department of Endocrinology and Metabolic diseases, Cardiovascular and Metabolic Unit CHU-Larrey, Toulouse, France.
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Carvalho DP, Dias AF, Sferruzzi-Perri AN, Ortiga-Carvalho TM. Gaps in the knowledge of thyroid hormones and placental biology. Biol Reprod 2022; 106:1033-1048. [DOI: 10.1093/biolre/ioac006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Thyroid hormones (THs) are required for the growth and development of the foetus, stimulating anabolism and oxygen consumption from the early stages of pregnancy to the period of foetal differentiation close to delivery. Maternal changes in the hypothalamic–pituitary thyroid axis are also well known. In contrast, several open questions remain regarding the relationships between the placenta and the maternal and foetal TH systems. The exact mechanism by which the placenta participates in regulating the TH concentration in the foetus and mother and the role of TH in the placenta are still poorly studied. In this review, we aim to summarize the available data in the area and highlight significant gaps in our understanding of the ontogeny and cell-specific localization of TH transporters, TH receptors and TH metabolic enzymes in the placenta in both human and rodent models. Significant deficiencies also exist in knowledge of the contribution of genomic and nongenomic effects of TH on the placenta and finally how the placenta reacts during pregnancy when the mother has thyroid disease. By addressing these key knowledge gaps, improved pregnancy outcomes and management of women with thyroid alterations may be possible.
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Affiliation(s)
- Daniela Pereira Carvalho
- Instituto de Biofísica Carlos Chagas Filho, Laboratório de Endocrinologia Translacional, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ariane Fontes Dias
- Instituto de Biofísica Carlos Chagas Filho, Laboratório de Endocrinologia Translacional, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Amanda Nancy Sferruzzi-Perri
- Centre for Trophoblast Research, Department of Physiology, Development and Neuroscience, University of Cambridge, UK
| | - Tania Maria Ortiga-Carvalho
- Instituto de Biofísica Carlos Chagas Filho, Laboratório de Endocrinologia Translacional, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Abstract
Importance Thyroid disorders represent one of the most frequent complications of pregnancy associated with adverse obstetric, fetal, and neonatal outcomes, especially in case of delayed diagnosis and suboptimal management. Objective The aim of this study was to review and compare the recommendations of the most recently published guidelines on the diagnosis and management of these common conditions. Evidence Acquisition A descriptive review of guidelines from the Endocrine Society, the European Thyroid Association, the Royal Australian and New Zealand College of Obstetricians and Gynecologists, the American Thyroid Association, and the American College of Obstetricians and Gynecologists on thyroid disease in pregnancy was carried out. Results There is an overall consensus regarding the diagnosis of overt and subclinical hypothyroidism and hyperthyroidism in pregnancy using the pregnancy-specific reference ranges and the definition of postpartum thyroiditis. The reviewed guidelines unanimously discourage universal screening for thyroid function abnormalities before and during pregnancy and support targeted screening of high-risk patients by measuring serum thyroid-stimulating hormone levels. Moreover, they all highlight the need of treating overt hypothyroidism and hyperthyroidism, not only during pregnancy, but also before conception, suggesting similar management policies and treatment targets. There is also agreement regarding the management of gestational transient hyperthyroidism with hyperemesis gravidarum, suspected fetal thyrotoxicosis, postpartum thyroiditis, and thyroid malignancy. Scanning or treating with radioactive iodine is contraindicated during pregnancy and breastfeeding. On the other hand, there is controversy on the management of subclinical thyroid disease, thyroid function surveillance protocols, and iodine nutrition recommendations. Of note, the American College of Obstetricians and Gynecologists makes some specific recommendations on the treatment of thyroid storm and thyrotoxic heart failure in pregnant women, whereas the American Thyroid Association makes a special reference to the management of women with thyroid cancer. Conclusions As the disorders of the thyroid gland affect a significant proportion of pregnant women, it is of paramount importance to develop uniform international evidence-based protocols for their accurate diagnosis and optimal management, in order to safely guide clinical practice and eventually improve perinatal outcomes.
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Zimmerman CF, Ilstad-Minnihan AB, Bruggeman BS, Bruggeman BJ, Dayton KJ, Joseph N, Moas DI, Rohrs HJ. Thyroid Storm Caused by Hyperemesis Gravidarum. AACE Clin Case Rep 2022; 8:124-127. [PMID: 35602873 PMCID: PMC9123575 DOI: 10.1016/j.aace.2021.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/01/2021] [Accepted: 12/23/2021] [Indexed: 11/29/2022] Open
Abstract
Background Transient thyrotoxicosis has been documented in the setting of hyperemesis gravidarum (HG) with elevated human chorionic gonadotropin (hCG) levels. Thyroid storm in pregnancy is rarer and typically associated with autoimmune hyperthyroidism. We described thyroid storm in a primigravid 18-year-old patient due to hCG level elevation secondary to HG, which resolved in the second trimester of pregnancy. Case Report Our patient presented with vomiting, hyperthyroidism, and cardiac and renal dysfunction at 16 weeks’ gestation. She was clinically found to have a thyroid storm, with undetectable thyroid-stimulating hormone (TSH) and a free thyroxine level of >6.99 ng/dL. The hCG level was elevated at 246 030 mIU/L (9040-56 451 mIU/L). She was treated with methimazole, saturated solution potassium iodide, and propranolol. Because thyroid autoantibodies were absent, thyroid ultrasound yielded normal results, and thyroid function testing results rapidly improved as the hCG level decreased, the medications were tapered and ultimately discontinued by day 10 of hospitalization. The thyroid function remained normal after discharge. Discussion Because hCG and TSH have identical alfa subunits and similar beta subunits, hCG can bind to the TSH receptor and stimulate thyroxine production. The hCG level peaks at around 8-14 weeks of gestation, correlating with decreased TSH levels in this same time frame. This case emphasizes the relevant physiology and importance of timely and thorough evaluation to determine the appropriate management, prognosis, and follow-up for patients with thyroid storm in the setting of HG. Conclusion Although transient thyrotoxicosis is documented in patients with HG, thyroid storm is rare, and our case illustrates a severe example of these comorbidities.
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Affiliation(s)
- Chelsea F. Zimmerman
- Division of Pediatric Endocrinology, College of Medicine, University of Florida, Gainesville, Florida
- Address correspondence to Dr Chelsea Zimmerman, Endocrinology and Metabolism of East Alabama, 2420 Village Professional Parkway, Opelika, AL 36801.
| | | | - Brittany S. Bruggeman
- Division of Pediatric Endocrinology, College of Medicine, University of Florida, Gainesville, Florida
| | - Bradley J. Bruggeman
- Department of Obstetrics and Gynecology, College of Medicine, University of Florida, Gainesville, Florida
| | - Kristin J. Dayton
- Division of Pediatric Endocrinology, College of Medicine, University of Florida, Gainesville, Florida
| | - Nancy Joseph
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, Florida
| | - Daniel I. Moas
- Division of Pediatric Critical Care, College of Medicine, University of Florida, Gainesville, Florida
| | - Henry J. Rohrs
- Division of Pediatric Endocrinology, College of Medicine, University of Florida, Gainesville, Florida
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Klosinska M, Kaczynska A, Ben-Skowronek I. Congenital Hypothyroidism in Preterm Newborns - The Challenges of Diagnostics and Treatment: A Review. Front Endocrinol (Lausanne) 2022; 13:860862. [PMID: 35370986 PMCID: PMC8972126 DOI: 10.3389/fendo.2022.860862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/23/2022] [Indexed: 12/26/2022] Open
Abstract
Preterm newborns are forced to adapt to harsh extrauterine conditions and endure numerous adversities despite their incomplete growth and maturity. The inadequate thyroid hormones secretion as well as the impaired regulation of hypothalamus-pituitary-thyroid axis may lead to hypothyroxinemia. Two first weeks after birth are pivotal for brain neurons development, synaptogenesis and gliogenesis. The decreased level of thyroxine regardless of cause may lead to delayed mental development. Congenital hypothyroidism (CH) is a disorder highly prevalent in premature neonates and it originates from maternal factors, perinatal and labor complications, genetic abnormalities, thyroid malformations as well as side effects of medications and therapeutic actions. Because of that, the prevention is not fully attainable. CH manifests clinically in a few distinctive forms: primary, permanent or transient, and secondary. Their etiologies and implications bear little resemblance. Therefore, the exact diagnosis and differentiation between the subtypes of CH are crucial in order to plan an effective treatment. Hypothyroxinemia of prematurity indicates dynamic changes in thyroid hormone levels dependent on neonatal postmenstrual age, which directly affects patient's maintenance and wellbeing. The basis of a successful treatment relies on an early and accurate diagnosis. Neonatal screening is a recommended method of detecting CH in preterm newborns. The preferred approach involves testing serum TSH and fT4 concentrations and assessing their levels according to the cut-off values. The possible benefits also include the evaluation of CH subtype. Nevertheless, the reference range of thyroid hormones varies all around the world and impedes the introduction of universal testing recommendations. Unification of the methodology in neonatal screening would be advantageous for prevention and management of CH. Current guidelines recommend levothyroxine treatment of CH in preterm infants only when the diagnose is confirmed. Moreover, they underline the importance of the re-evaluation among preterm born infants due to the frequency of transient forms of hypothyroidism. However, results from multiple clinical trials are mixed and depend on the newborn's gestational age at birth. Some benefits of treatment are seen especially in the preterm infants born <29 weeks' gestation. The discrepancies among trials and guidelines create an urgent need to conduct more large sample size studies that could provide further analyses and consensus. This review summarizes the current state of knowledge on congenital hypothyroidism in preterm infants. We discuss screening and treatment options and demonstrate present challenges and controversies.
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