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Gao S, Wang X, Zhao R, Cui Y, Su S, Zhang E, Liu J, Xie S, Zhang Y, Yang Y, Huang K, Hu M, Yue W, Liu R, Yin C. Levothyroxine Treatment in Pregnant Women with Thyrotropin Levels Ranging Between 2.5 and 10 mIU/L: A Propensity Score Matched Analysis. Thyroid 2024; 34:912-919. [PMID: 38666684 DOI: 10.1089/thy.2023.0662] [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: 07/17/2024]
Abstract
Objective: To clarify the association between levothyroxine (LT4) treatment and various adverse pregnancy outcomes in pregnant women with thyrotropin (TSH) levels ranging between 2.5 and 10.0 mIU/L in the first trimester, stratified according to thyroid peroxidase antibody (TPOAb) positivity and TSH level. Methods: This retrospective analysis of retrospectively and prospectively collected cohort data included Chinese pregnant women with TSH levels of 2.5-10 mIU/L and normal free thyroxine levels (11.8-18.4 pmol/L) in the first trimester. All participants were followed up until the completion of pregnancy, and information on LT4 treatment, pregnancy complications, and pregnancy outcomes was recorded. A 1:1 nearest-neighbor propensity score matching (PSM) between the LT4-treated and - untreated groups with a caliper distance of 0.02 was performed using a multivariable logistic regression model. Multivariable-adjusted modified Poisson regression was used to estimate the relative risk (RR) and 95% confidence interval (CI) of LT4 treatment for adverse pregnancy outcomes. Subgroup analyses were also performed in four subgroups simultaneously stratified by TPOAb status (negative or positive) and TSH levels (2.5-4.0 mIU/L as high-normal group and 4.0-10.0 mIU/L as SCH group). The study was registered in the Chinese Clinical Trial Registry (ChiCTR2100047394). Results: Among the 4,370 pregnant women in the study, 1,342 received LT4 treatment and 3,028 did not. The 1:1 PSM yielded 668 pairs of individuals and revealed that LT4 treatment was significantly associated with a decreased risk of pregnancy loss (RR = 0.528, 95% CI: 0.344-0.812) and an increased risk of small-for-gestational-age infants (RR = 1.595, 95% CI: 1.023-2.485). Subgroup analyses suggested that the above effects of LT4 treatment were mainly from TPOAb-negative participants. LT4 treatment was associated with an increased risk of preterm birth (RR = 2.214, 95% CI: 1.016-4.825) in TPOAb-positive pregnant women with high-normal TSH levels. Conclusion: LT4 treatment was significantly associated with a lower risk of pregnancy loss and a higher risk of small-for-gestational-age infants in pregnant women with TSH levels of 2.5-10 mIU/L. An increased risk of preterm birth was observed in the LT4-treated group among TPOAb-positive participants with TSH levels of 2.5-4.0 mIU/L.
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Affiliation(s)
- Shen Gao
- Department of Central Laboratory, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Xueran Wang
- Department of Central Laboratory, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Rong Zhao
- Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Yuchen Cui
- Department of Central Laboratory, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Shaofei Su
- Department of Central Laboratory, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Enjie Zhang
- Department of Central Laboratory, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Jianhui Liu
- Department of Central Laboratory, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Shuanghua Xie
- Department of Central Laboratory, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Yue Zhang
- Department of Research Management, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Yuxi Yang
- Department of Central Laboratory, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Kaikun Huang
- Department of Central Laboratory, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Minhui Hu
- Department of Central Laboratory, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Wentao Yue
- Department of Research Management, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Ruixia Liu
- Department of Central Laboratory, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Chenghong Yin
- Department of Central Laboratory, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
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Sankoda A, Suzuki H, Imaizumi M, Yoshihara A, Kobayashi S, Katai M, Hamada K, Hidaka Y, Yoshihara A, Nakamura H, Kubota S, Kakita-Kobayashi M, Iwase A, Sugiyama T, Ota E, Arata N. Effects of Levothyroxine Treatment on Fertility and Pregnancy Outcomes in Subclinical Hypothyroidism: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Thyroid 2024; 34:519-530. [PMID: 38368537 DOI: 10.1089/thy.2023.0546] [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: 02/19/2024]
Abstract
Background: Subclinical hypothyroidism, defined by elevated thyrotropin (TSH) and normal free thyroxine levels, is associated with adverse pregnancy outcomes, including preterm birth, pre-eclampsia, and small for gestational age. Despite the uncertainty regarding the effectiveness of levothyroxine (LT4) treatment on pregnancy outcomes in subclinical hypothyroidism, LT4 is widely administered with a pre-treatment threshold TSH level of 2.5 mU/L. The aim of this study is to investigate the efficacy of periconceptional LT4 treatment for subclinical hypothyroidism, including TSH levels >2.5 mU/L, and identify the characteristics of subclinical hypothyroidism that can benefit from LT4 treatment. Methods: We conducted a systematic review and meta-analysis of randomized controlled trials from inception to February 2023. We analyzed the pooled effects of LT4 on subclinical hypothyroidism before and during pregnancy. The main outcomes before pregnancy were live birth, pregnancy, and miscarriage. The main outcomes during pregnancy were live birth, miscarriage, and preterm birth. We conducted subgroup analyses to compare the effects of LT4 on subclinical hypothyroidism with TSH levels of 2.5-4.0 and >4.0 mU/L. Results: Of the 888 studies identified, 27 full-text articles were screened for eligibility. Five studies on pre-conception treatment with 768 participants and eight studies on treatment during early pregnancy with 2622 participants were analyzed. One of the two studies on pre-conception treatment in subclinical hypothyroidism with TSH >4.0 mU/L had high risk of bias and the other was composed of 64 participants. Pre-conception LT4 treatment had no significant effect in improving rates of live births and pregnancies, or reducing miscarriages (risk ratio [RR], 95% confidence interval): 1.41 (0.84-2.36), 1.73 (0.88-3.39), and 0.46 (0.11-2.00), respectively. LT4 treatment during pregnancy was not significantly associated with higher rates of live births (RR 1.03, 0.98-1.09) nor decreased miscarriage rates (RR 1.01, 0.66-1.53). The effect of LT4 treatment on preterm birth during pregnancy was significantly different depending on the TSH values (p = 0.04); a positive effect was shown in the subclinical hypothyroidism subgroup with TSH >4.0 mU/L (RR 0.47, 0.20-1.10), while no significant effect was observed in the subgroup with TSH 2.5-4.0 mU/L (RR 1.35, 0.79-2.31). Conclusions: Pre-conceptional LT4 treatment for subclinical hypothyroidism does not improve fertility or decrease the incidence of miscarriages. However, further well-designed studies are needed for pre-conceptional treatment, especially in TSH >4.0 mU/L. LT4 treatment during pregnancy had a positive effect on preterm birth; nevertheless, this was only applicable to subclinical hypothyroidism with TSH >4.0 mU/L.
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Affiliation(s)
- Akiko Sankoda
- Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Hitomi Suzuki
- Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan
| | - Misa Imaizumi
- Department of Clinical Studies, Radiation Effects Research Foundation, Nagasaki, Japan
| | - Ai Yoshihara
- Department of Internal Medicine, Ito Hospital, Tokyo, Japan
| | - Sakiko Kobayashi
- Department of Endocrinology, Metabolism and Nephrology, NHO Tokyo Medical Center, Tokyo, Japan
| | - Miyuki Katai
- Health Services Center, National Graduate Institute for Policy Studies, Tokyo, Japan
| | | | - Yoh Hidaka
- Laboratory for Clinical Investigation, Osaka University Hospital, Osaka, Japan
| | - Aya Yoshihara
- Department of Internal Medicine, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Hannah Nakamura
- Division of Nephrology and Endocrinology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | | | | | - Akira Iwase
- Department of Obstetrics and Gynecology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Takashi Sugiyama
- Department of Obstetrics and Gynecology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Erika Ota
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan
- Tokyo Foundation for Policy Research, Tokyo, Japan
| | - Naoko Arata
- Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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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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Medenica S, Garalejić E, Abazović D, Bukumirić Z, Paschou SA, Arsić B, Vujošević S, Međo B, Žarković M. Pregnancy outcomes and newborn characteristics in women with follicular fluid thyroid autoantibodies undergoing assisted reproduction. J Med Biochem 2023; 42:27-33. [PMID: 36819134 PMCID: PMC9920930 DOI: 10.5937/jomb0-35243] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/20/2022] [Indexed: 11/02/2022] Open
Abstract
Background Higher levels of thyroid autoantibodies in follicular fluid (FF) of thyroid autoimmunity (TAI) positive women are strongly correlated with serum levels and may have effect on the post-implantation embryo development. Literature highlights that levothyroxine (LT4) treatment may attenuate the risk of adverse pregnancy outcomes. The aim of the study was to estimate the pregnancy and newborn outcomes in women with FF thyroid autoantibodies undergoing assisted reproductive technology (ART). Methods The study population included 24 women with confirmed clinical pregnancy, 8 TAI positive and 16 TAI negative women. LT4 supplementation was applied in 20.8% patients, TAI positive. Results Pregnancy outcomes were: twin pregnancy rate 41.7%, early miscarriage rate 8.3%, late miscarriage rate 4.2%, preterm birth rate 16.7%, term birth rate 70.8%, live birth rate 96.0%. There was significant difference in serum and in FF TgAbs (p< 0.001)between the groups according to TAI, while serum fT3 was lower in the group with TAI (p = 0.047). Serum P4 was higher in LT4 treated group (p = 0.005), with TAI, and newborns in this group had higher birth weight (p = 0.001) and height (p = 0.008). Maternal complications occurred in 23.8% of patients. No congenital malformations in newborns were noted. Conclusions Thyroid autoantibodies present in FF may have an effect on the post-implantation embryo development, but have no effect on further course of pregnancy. The special benefit of LT4 treatment for successful ART outcome was demonstrated for newborn anthropometric parameters.
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Affiliation(s)
- Sanja Medenica
- University of Montenegro, School of Medicine, Clinical Center of Montenegro, Internal Medicine Clinic, Department of Endocrinology, Podgorica, Montenegro
| | - Eliana Garalejić
- Clinic for Gynecology and Obstetrics "Narodni front", In Vitro Fertilisation Department, Belgrade
| | - Džihan Abazović
- Emergency Medicine Center of Montenegro, Podgorica, Montenegro
| | - Zoran Bukumirić
- University of Belgrade, Institute for Medical Statistics and Informatics, Faculty of Medicine, Belgrade
| | - Stavroula A. Paschou
- National and Kapodistrian University of Athens, School of Medicine, Alexandra Hospital, Endocrine Unit and Diabetes Centre, Department of Clinical Therapeutics, Athens, Greece
| | - Biljana Arsić
- Clinic for Gynecology and Obstetrics "Narodni front", In Vitro Fertilisation Department, Belgrade
| | - Snežana Vujošević
- University of Montenegro, School of Medicine, Clinical Center of Montenegro, Internal Medicine Clinic, Department of Endocrinology, Podgorica, Montenegro
| | - Biljana Međo
- University of Belgrade, School of Medicine, Belgrade
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Rahmati M, Nazarpour S, Minooee S, Behboudi-Gandevani S, Azizi F, Tehrani FR. A Bayesian model to estimate the cutoff value of TSH for management of preterm birth. PLoS One 2023; 18:e0283503. [PMID: 36989309 PMCID: PMC10058148 DOI: 10.1371/journal.pone.0283503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/06/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Determining a thyroid hormone cutoff value in pregnancy is challenging issue and several approaches have been introduced to optimize a utility function. We aimed to estimate the cutoff value of TSH using Bayesian method for prediction of preterm-birth. METHODS This study was a secondary-analysis of the population-based data collected prospectively within the framework of the Tehran Thyroid and Pregnancy Study. A total of 1,538 pregnant women attending prenatal clinics. RESULTS Using Bayesian method resulted a TSH-cutoff of (3.97mIU/L,95%CI:3.95-4.00) for distinguishing pregnant women at risk of preterm-birth. The cutoff was associated with acceptable positive predictive and negative predictive values (0.84,95% CI:0.80-0.88) and 0.92 (95%CI: 0.91-0.94), respectively). In women who were negative for thyroid peroxides antibody (TPOAb) with sufficient urinary iodine concentration (UIC), the TSH cutoff of 3.92 mIU/L(95%CI:3.70-4) had the highest predictive value; whereas in TPOAb positive women with insufficient UIC, the cutoff of 4.0 mIU/L(95%:CI 3.94-4) could better predict preterm birth. Cutoffs estimated in this study are close to the revised TSH value of 4.0mIU/L which is currently recommended by the American Thyroid Association. CONCLUSION Regardless of TPOAb status or iodine insufficiency, risk of preterm labor is increased in pregnant women with TSH value of > 3.92 mIU/L; these women may benefit from Levothyroxine (LT4) therapy for preventing preterm birth.
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Affiliation(s)
- Maryam Rahmati
- Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sima Nazarpour
- Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Midwifery, Varamin-Pishva Branch, Islamic Azad University, Tehran, Iran
| | - Sonia Minooee
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | | | - Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fahimeh Ramezani Tehrani
- Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Peng CCH, Maraka S, Pearce EN. Under and overtreatment with thyroid hormone replacement during pregnancy. Curr Opin Endocrinol Diabetes Obes 2022; 29:474-482. [PMID: 35855544 DOI: 10.1097/med.0000000000000755] [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] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Among pregnant women on thyroid hormone replacement therapy undertreatment is common, while overtreatment is rare. Both deficient and excessive maternal thyroid hormone have been related to adverse maternofetal and long-term offspring outcomes, although studies' results are inconsistent. This review aims to discuss recent evidence regarding the effects of under- and overtreatment with thyroid hormone replacement during pregnancy and how current practices could be improved. RECENT FINDINGS Whether or not thyroid hormone therapy needs to be initiated for maternal subclinical hypothyroidism remains unclear, but recent meta-analyses have confirmed associations between adverse maternal, neonatal, and offspring outcomes in both overt and subclinical hypothyroidism. Subclinical hyperthyroidism in pregnancy is related to fewer adverse outcomes. Current adherence to levothyroxine during pregnancy and medication counseling by healthcare providers are suboptimal. SUMMARY Undertreatment of maternal hypothyroidism may increase risks for adverse maternofetal and offspring effects more than overtreatment does. If thyroid hormone replacement therapy is indicated and initiated in pregnancy, frequent thyroid function monitoring is required to avoid under- or overtreatment. Effective communication between clinicians and patients is imperative to increase medication adherence.
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Affiliation(s)
- Carol Chiung-Hui Peng
- Section of Endocrinology, Diabetes, Nutrition & Weight Management, Boston University School of Medicine, Boston, Massachusetts
| | - Spyridoula Maraka
- Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences
- Section of Endocrinology, Central Arkansas Veterans Health System, Little Rock, Arkansas, USA
| | - Elizabeth N Pearce
- Section of Endocrinology, Diabetes, Nutrition & Weight Management, Boston University School of Medicine, Boston, Massachusetts
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Capozzi A, Scambia G, Lello S. Subclinical hypothyroidism in women's health: from pre- to post-menopause. Gynecol Endocrinol 2022; 38:357-367. [PMID: 35238251 DOI: 10.1080/09513590.2022.2046728] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 02/07/2022] [Accepted: 02/22/2022] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE Subclinical hypothyroidism (SCH) is a quite frequent condition among women, affecting 3-12% of the general population. Its consequences on women's health in reproductive age, pregnancy and menopause have been extensively investigated but data about the effective impact of treatment with levothyroxine (LT4) remain conflicting. METHODS This is a narrative review and analysis of the most relevant data until June 2021. RESULTS SCH may affect reproduction. Evidence suggests that women with SCH undergoing assisted reproductive technique (ART) may benefit from LT4 therapy whereas there are no conclusive data regarding women attempting natural conception. SCH may be associated with several negative pregnancy outcomes, that is to say recurrent pregnancy loss (RPL), preterm delivery, preeclampsia and neurocognitive disturbances of offspring. However, the protective role of LT4 treatment has been established in selected cases, for instance in thyroid peroxidase antibody (TPOAb) -positive women with TSH greater than the pregnancy specific reference range and/or in TPOAb-negative women with TSH >10.0 mIU/L. In menopause, SCH can worsen the negative cardio-metabolic effects of hormonal loss and/or aging, by exacerbating dyslipidaemia and hypertension. Nevertheless, robust data about the benefits of LT4 therapy are still lacking and treatment should be encouraged with caution. CONCLUSIONS SCH represents a challenging condition during pre- and post- menopause. An aware knowledge of its possible principal consequences could help all clinicians who are involved in women's health to manage more properly it, preventing its sequelae.
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Affiliation(s)
- Anna Capozzi
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Scambia
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Stefano Lello
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Yuan N, Sun J, Zhao X, Du J, Nan M, Zhang Q, Zhang X. Untreated thyroid autoantibody-negative SCH increases the risk of spontaneous abortions. Endocr Connect 2022; 11:e210600. [PMID: 35258484 PMCID: PMC9066569 DOI: 10.1530/ec-21-0600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/08/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Numerous studies have found that subclinical hypothyroidism (SCH) may increase adverse pregnancy outcomes; however, the benefit of levothyroxine (LT4) treatment remains controversial. The 2017 guidelines of the American Thyroid Association weakly recommended LT4 therapy for serum antithyroid peroxidase antibody (TPOAb)-negative women with thyroid-stimulating hormone (TSH) concentrations greater than the pregnancy-specific reference range and below 10.0 mU/L. Therefore, the primary goal of this study was to investigate the correlation between thyroid autoantibody-negative SCH with or without LT4 treatment and adverse pregnancy outcomes. METHODS We prospectively enrolled 1868 consecutive pregnant women. Finally, 1344 women were involved in the study according to the inclusion and exclusion criteria. Assays for TSH, free thyroxine (FT4), TPOAb, anti-thyroglobulin antibody, and laboratory indicators were performed. The participants were divided into the euthyroid (ET) group (n = 1250) and the SCH group(n = 94). The SCH group was further divided into LT4 group (n = 40) and non-LT4 group(n = 54). The laboratory indicators and pregnancy outcomes were evaluated during follow-ups. RESULTS Maternal age, BMI, parity, and the history of spontaneous abortion did not differ significantly between the ET group and the different SCH groups. There were no significant differences in lipid profile and homocysteine levels between ET and SCH group in the first and third trimester of pregnancy. After adjusting the confounding factors, the non-LT4 group was a risk factor for spontaneous abortion (odds ratio: 3.141, 95% CI: 1.060-9.302). Survival analysis showed that the time of abortion was different between the ET group and SCH group (log-rank P= 0.042). The spontaneous abortion in SCH, especially in non-LT4, group mainly occurred in the first trimester of pregnancy. CONCLUSIONS Thyroid autoantibody negative-SCH seems to be associated with increased risk of spontaneous abortions during the first trimester of pregnancy. LT4 therapy in this patient population might be beneficial to reduce adverse pregnancy outcomes.
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Affiliation(s)
- Ning Yuan
- Department of Endocrinology, Peking University International Hospital, Beijing, China
| | - Jianbin Sun
- Department of Endocrinology, Peking University International Hospital, Beijing, China
| | - Xin Zhao
- Department of Endocrinology, Peking University International Hospital, Beijing, China
| | - Jing Du
- Department of Endocrinology, Peking University International Hospital, Beijing, China
| | - Min Nan
- Department of Endocrinology, Peking University International Hospital, Beijing, China
| | - Qiaoling Zhang
- Department of Endocrinology, Peking University International Hospital, Beijing, China
| | - Xiaomei Zhang
- Department of Endocrinology, Peking University International Hospital, Beijing, China
- Correspondence should be addressed to X Zhang:
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Bein M, Yu OHY, Grandi SM, Frati FYE, Kandil I, Filion KB. Levothyroxine and the risk of adverse pregnancy outcomes in women with subclinical hypothyroidism: a systematic review and meta-analysis. BMC Endocr Disord 2021; 21:34. [PMID: 33639909 PMCID: PMC7912520 DOI: 10.1186/s12902-021-00699-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 02/11/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Levothyroxine replacement therapy may decrease the risk of adverse pregnancy outcomes among women with subclinical hypothyroidism (SCH). The aim of this study is to conduct a systematic review and meta-analysis to examine the risk of adverse pregnancy, perinatal, and early childhood outcomes among women with SCH treated with levothyroxine. METHODS A systematic literature search was conducted using Ovid-Medline, Ovid-EMBASE, Pubmed (non-Medline), Ebsco-CINAHL Plus with full text and Cochrane Library databases. Randomized controlled studies (RCTs) and observational studies examining the association between treatment of SCH during pregnancy and our outcomes of interest were included. Studies that compared levothyroxine treatment versus no treatment were eligible for inclusion. Data from included studies were extracted and quality assessment was performed by two independent reviewers. RESULTS Seven RCTs and six observational studies met our inclusion criteria. A total of 7342 individuals were included in these studies. RCTs demonstrated several sources of bias, with lack of blinding of the participants or research personnel; only one study was fully blinded. In the observational studies, there was moderate to serious risk of bias due to lack of adjustment for certain confounding variables, participant selection, and selective reporting of results. Pooled analyses showed decreased risk of pregnancy loss (RR: 0.79; 95% CI: 0.67 to 0.93) and neonatal death (RR: 0.35; 95% CI: 0.17 to 0.72) associated with levothyroxine treatment during pregnancy among women with SCH. There were no associations between levothyroxine treatment and outcomes during labour and delivery, or cognitive status in children at 3 or 5 years of age. CONCLUSION Treatment of SCH with levothyroxine during pregnancy is associated with decreased risks of pregnancy loss and neonatal death. Given the paucity of available data and heterogeneity of included studies, additional studies are needed to address the benefits of levothyroxine use among pregnant women with SCH.
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Affiliation(s)
- Magnus Bein
- Department of Biology, McGill University, Montreal, Quebec, Canada
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Oriana Hoi Yun Yu
- Division of Endocrinology, Department of Medicine, Jewish General Hospital, Montreal, Quebec, Canada
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, H3T 1E2, Canada
| | - Sonia Marzia Grandi
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Francesca Y E Frati
- Department of McGill University Library & Archives, McGill University, Montreal, Quebec, Canada
| | - Ihab Kandil
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Kristian B Filion
- Department of Medicine, McGill University, Montreal, Quebec, Canada.
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, H3T 1E2, Canada.
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada.
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10
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Shilova ES, Borovik NV, Popova PV, Yarmolinskaya MI. [Diagnostic and treatment of subclinical hypothyroidism in pregnant and planning pregnancy patients: modern view of the problem]. ACTA ACUST UNITED AC 2020; 66:65-73. [PMID: 33481369 DOI: 10.14341/probl12687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 10/09/2020] [Accepted: 12/03/2020] [Indexed: 12/27/2022]
Abstract
There is no universal diagnostic and treatment strategy of subclinical hypothyroidism (SHT) in pregnant women and those who are planning pregnancy due to differences in population-specific and trimester-specific thyroid-stimulating hormone (TSH) reference values, influence of thyroid autoimmunity markers on pregnancy outcomes, adherence to fixed universal cutoff concentrations TSH in Russia and multidisciplinary team care with different treatment opinions involving. An absence of universal approach to SHT leads to excess treatment, financial and psychological burden on pregnant women.Up to American Thyroid Association (ATA) Guidelines 2017 and project of Clinical Guidelines of Russian Association of Endocrinologists 2019 a treatment strategy of SHT should be left up to the endocrinologist to choose. In our paper we systematize global scientific and clinical experience of planning and management pregnancies with SHT to help physicians to choose treatment option based on principals of evidence-based medicine.
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Affiliation(s)
- E S Shilova
- Research Institute of Obstetrics, Gynecology, and Reproductology named after D.O. Ott; Almazov National Medical Research Center
| | - N V Borovik
- Research Institute of Obstetrics, Gynecology, and Reproductology named after D.O. Ott
| | - P V Popova
- Almazov National Medical Research Center
| | - M I Yarmolinskaya
- Research Institute of Obstetrics, Gynecology, and Reproductology named after D.O. Ott; North-Western State Medical University named after I.I. Mechnikov
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11
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Dong AC, Stephenson MD, Stagnaro-Green AS. The Need for Dynamic Clinical Guidelines: A Systematic Review of New Research Published After Release of the 2017 ATA Guidelines on Thyroid Disease During Pregnancy and the Postpartum. Front Endocrinol (Lausanne) 2020; 11:193. [PMID: 32318026 PMCID: PMC7154179 DOI: 10.3389/fendo.2020.00193] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/18/2020] [Indexed: 12/19/2022] Open
Abstract
Background: The American Thyroid Association Guidelines on Thyroid Disease During Pregnancy and the Postpartum (ATA Guidelines) were published in 2017, with an update not expected for another 5 years. Since release of the 2017 ATA Guidelines, greater than 500 articles have been published in the field. Furthermore, there are presently 14 prospective, interventional trials in progress registered at Clinicaltrials.gov Static guidelines updated every 5-7 years fail to provide timely evidence-based guidance to practicing clinicians. Consequently, guideline development should move toward the creation of dynamic documents. The present article reviews the literature published since the 2017 ATA Guidelines, both to benefit clinicians in practice and to make the case for Dynamic ATA Guidelines. Methods: Using the search terms "thyroid" and "pregnancy," a systematic review of literature published in Pubmed from 3/1/2017 to 12/31/2018 was conducted. The titles and/or abstracts of all articles were reviewed. All articles were classified by subject headings used in the 2017 ATA Guidelines. English-text articles classified under "hypothyroidism" or "thyroid autoimmunity" were examined in full-text. Using the questions and recommendations put forth by the previous ATA Guidelines, relevant articles were selected for discussion in this review. Results: At the time of the search, 659 unique articles on "thyroid and pregnancy" were identified, including 66 original studies on hypothyroidism and 26 on thyroid autoimmunity. Of these, 26 studies on hypothyroidism and 18 studies on thyroid autoimmunity were selected for inclusion in this review based on specific questions in the 2017 ATA Guidelines. Based on these 44 articles, we propose two specific changes to the 2017 ATA Guidelines. Conclusion: Based on new research, we recommend the 2017 ATA Guidelines be updated to recommend against treating thyroid antibody-negative women diagnosed with subclinical hypothyroidism in the second trimester or later; to reflect new, moderate-quality evidence supporting the treatment of thyroid peroxidase antibody-negative women with elevated thyroid stimulating hormone levels in the first trimester or earlier; and to recommend against treatment of euthyroid, thyroid peroxidase antibody-positive women undergoing assisted reproductive technology. Transitioning to a Dynamic ATA Guidelines would allow for these and future recommendations to be implemented in real time.
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Affiliation(s)
- Allan C. Dong
- Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Chicago, Chicago, IL, United States
- Department of Obstetrics and Gynecology, Advocate Lutheran General Hospital, Park Ridge, IL, United States
| | - Mary D. Stephenson
- Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Chicago, Chicago, IL, United States
| | - Alex Stewart Stagnaro-Green
- Department of Medicine, Obstetrics & Gynecology and Medical Education, University of Illinois College of Medicine at Rockford, Rockford, IL, United States
- *Correspondence: Alex Stewart Stagnaro-Green
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12
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Frank AS, Lupattelli A, Matteson DS, Meltzer HM, Nordeng H. Thyroid hormone replacement therapy patterns in pregnant women and perinatal outcomes in the offspring. Pharmacoepidemiol Drug Saf 2019. [DOI: 10.1002/pds.4927] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Anna S. Frank
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy University of Oslo Oslo Norway
| | - Angela Lupattelli
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy University of Oslo Oslo Norway
| | - David S. Matteson
- Department of Statistical Science Cornell University Ithaca NY USA
- Department of Biological Statistics and Computational Biology Cornell University Ithaca NY USA
| | - Helle Margrete Meltzer
- Division of Infectious Diseases and Environmental Health Norwegian Institute of Public Health Oslo Norway
| | - Hedvig Nordeng
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy University of Oslo Oslo Norway
- Department of Child Health and Development Norwegian Institute of Public Health Oslo Norway
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13
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Nazarpour S, Ramezani Tehrani F, Amiri M, Bidhendi Yarandi R, Azizi F. Levothyroxine treatment and pregnancy outcomes in women with subclinical hypothyroidism: a systematic review and meta-analysis. Arch Gynecol Obstet 2019; 300:805-819. [PMID: 31399840 DOI: 10.1007/s00404-019-05245-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 07/10/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE To evaluate the benefits of LT4 treatment on pregnancy outcomes in SCH women. STUDY DESIGN PubMed [including Medline], Web of Science, Wiley, Google Scholar, Science direct and Scopus were searched for identifying and retrieving all English articles published up to May 2018 on the effects of levothyroxine treatment on pregnancy outcomes in pregnant women with SCH compared to untreated or healthy controls. In this systematic review and meta-analysis, both fixed and random effect models were applied to estimate the pooled effect size. Heterogeneity and publication bias were evaluated using the I-squared (I2) and Begg's statistics, respectively. We also explored heterogeneity sources using meta-regression models and sensitivity analysis. RESULTS Data of 13 cohort studies and randomized controlled trials with a total of 11,503 participants were analyzed. This meta-analysis showed that pregnant women with SCH treated with levothyroxine had lower chances of pregnancy loss (OR 0.78, 95% CI 0.66-0.94; I2 = 0%) and higher chances for live birth rates (OR 2.72, 95% CI 1.44-5.11; I2 = 25%) than the placebo group. Compared to euthyroid women, SCH patients treated with levothyroxine had higher odds ratio for preterm labor (OR 1.82, 95% CI 1.14-2.91; I2 = 0%). CONCLUSIONS Results of this study showed that the effects of treatment with levothyroxine in SCH pregnant women are not the same for all pregnancy outcomes. Levothyroxine treatment in these patients can reduce pregnancy loss. Considering the limited number of studies available, further studies are warranted to document more precise data on other consequences.
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Affiliation(s)
- Sima Nazarpour
- Department of Midwifery, Islamic Azad University, Varamin-Pishva Branch, Tehran, Iran.,Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24 Parvaneh, Yaman Street, Velenjak, P.O. Box: 19395-4763, Tehran, 1985717413, Iran
| | - Fahimeh Ramezani Tehrani
- Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24 Parvaneh, Yaman Street, Velenjak, P.O. Box: 19395-4763, Tehran, 1985717413, Iran.
| | - Mina Amiri
- Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24 Parvaneh, Yaman Street, Velenjak, P.O. Box: 19395-4763, Tehran, 1985717413, Iran
| | - Razieh Bidhendi Yarandi
- Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24 Parvaneh, Yaman Street, Velenjak, P.O. Box: 19395-4763, Tehran, 1985717413, Iran.,Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Kianpour M, Aminorroaya A, Amini M, Feizi A, Aminorroaya Yamini S, Janghorbani M. Thyroid-stimulating hormone (TSH) serum levels and risk of spontaneous abortion: A prospective population-based cohort study. Clin Endocrinol (Oxf) 2019; 91:163-169. [PMID: 30927551 DOI: 10.1111/cen.13979] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 03/23/2019] [Accepted: 03/24/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Thyroid dysfunction, a common complication of pregnancy, is associated with adverse obstetric and neonatal consequences. This study aimed to determine the effect of TSH levels on early pregnancy outcome in a prospective population-based cohort study. DESIGN AND METHODS The serum TSH, free thyroxine, free triiodothyronine, thyroid peroxidase antibody levels and urinary iodine concentration of 418 pregnant women in their first trimester of pregnancy were measured. According to the American Thyroid Association (ATA) and the local reference ranges for TSH, women were divided into two groups of 0.1-2.5, >2.5 mIU/L and 0.2-4.6, >4.6 mIU/L. The risk of spontaneous abortion (SA) was calculated for each group. RESULTS Spontaneous abortion was detected in 7.2% (n = 30) of total 418 pregnancies. Women with TSH levels > 2.5 mIU/L had an increased risk of SA, compared to women with TSH levels of 0.1-2.5 mIU/L (relative risk [RR] 3.719, 95% confidence interval [CI]:1.713-8.074). The risk of SA was increased in women with TSH levels > 4.6 mIU/L (RR 5.939, 95% CI: 1.711-20.620). The rate of SA was increased by 78% for every unit increase in standard deviation of TSH concentration (RR 1.35, 95% CI: 1.09-1.70). The rate of miscarriages in the treated group by levothyroxine was 9.8% (n = 6) compared to 28.6% (n = 8) in the untreated group (P = 0.024). CONCLUSIONS Our finding suggests that the upper limit for the TSH normal range should be redefined to <2.5 mIU/L during the first trimester of gestation. The local upper limit was 4.6 mIU/L, consistent with 4.0 mIU/L cut-off value recommended by the ATA.
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Affiliation(s)
- Maryam Kianpour
- Isfahan Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ashraf Aminorroaya
- Isfahan Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Massoud Amini
- Isfahan Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Awat Feizi
- Isfahan Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Biostatistics & Epidemiology, School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Mohsen Janghorbani
- Isfahan Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Biostatistics & Epidemiology, School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran
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