Subclinical hypothyroidism during pregnancy: the Melbourne public hospitals consensus

Australasian Recurrent Pregnancy Loss Clinical Management Guideline 2024 Part I

Guidelines for the investigation and management of recurrent pregnancy loss (RPL) have been developed in Europe, USA and UK, but there is currently no Australasian guideline. The Australasian Certificate of Reproductive Endocrinology and Infertility Consensus Expert Panel on Trial Evidence group has prepared a two-part guideline to provide guidance on the management of RPL. In Part I chromosomal, anatomical, and endocrine factors are outlined along with relevant recommendations for clinical management, levels of evidence and grades of consensus. In Part II thrombophilia, autoimmune factors, infective, inflammatory, and endometrial causes, environmental and lifestyle factors, male factor and unexplained causes will be outlined.

Use of thyroid hormones in hypothyroid and euthyroid patients: A survey of members of the Endocrine Society of Australia

OBJECTIVE

Hypothyroidism is a common endocrine condition usually managed with levothyroxine (LT4). However, controversy remains around the use of liothyronine (LT3). We aimed to investigate the practices of Australian endocrinologists when managing patients with hypothyroidism, their use of LT3 + LT4 combination therapy and use of thyroid hormones in euthyroid patients.

DESIGN AND PARTICIPANTS

Members of the Endocrine Society of Australia (ESA) were invited to participate in an online questionnaire.

MEASUREMENTS

We analysed questionnaires that had complete demographic data.

RESULTS

Eighty-seven questionnaires fulfilled the criteria. LT4 was used as first line treatment for hypothyroidism by all respondents. Only 45% reported that their patients were dispensed the brand of LT4 that they recommend. LT3 (alone or in combination) was prescribed by 44% in their clinical practice. Although 49% of respondents would consider LT3 + LT4 in patients with normal TSH who had ongoing symptoms of hypothyroidism, the inability of LT4 to restore normal physiology was ranked the least likely explanation for persistent symptoms and only 32% would consider it for themselves if they were diagnosed with hypothyroidism. The majority (55%), in accordance with evidence, would not prescribe thyroid hormone to euthyroid individuals but 39% would consider use in euthyroid female infertility with high levels of thyroid antibodies and 11% in euthyroid patients with a simple goitre growing over time. LT4 use in pregnancy was variable among members.

CONCLUSIONS

Australian endocrinologists mostly follow international guidelines when prescribing thyroid hormone therapy and many prescribe combination LT3 and LT4 therapy, particularly for patients who remain symptomatic on LT4 monotherapy. Prescribing practices are largely similar to other countries who have completed similar questionnaires.

Effect of Bisphenol A-Mediated RBP-4 on Pregnancy Outcomes in Nonobese Pregnant Female with Subclinical Hypothyroidism

Hypothyroidism is a systemic hypometabolic syndrome caused by the thyroxine resistance or a reduction in its extent. It is an endocrinopathy secondary to gestational diabetes and occurs usually without significant symptoms. This study explored the effect of bisphenol A (BPA)-mediated retinol-binding protein 4 (RBP-4) on pregnancy outcomes in a nonobese pregnant female with subclinical hypothyroidism. Three hundred nonobese pregnant females who had that established pregnancy files and had regular obstetric examinations from January 2021 to March 2022 were enrolled and classified with 100 cases in each group as early pregnancy (6–12 weeks of gestation), second-trimester (13–24 weeks of gestation), and third-trimester groups (25–36 weeks of gestation). Thirty pregnant women with subclinical hypothyroidism were selected as subjects, and another thirty pregnant women with normal thyroid function were selected as the normal control group. Thyroid function (thyroid-stimulating hormone (TSH), free triiodothyronine (FT₃), free T₄ (FT₄), and thyroid peroxidase antibody (TPO-Ab)) was measured by immunoelectrochemiluminescence. The level of BPA in urine was determined by solid-phase extraction high-performance liquid chromatography-tandem mass spectrometry. Serum RBP4 levels were determined by enzyme-linked immunosorbent assay. The level of TSH in the third-trimester group was higher than that in the first- and second-trimester groups, while the levels of FT₃, FT₄, and TPO-Ab were lower than those in the other two groups (P < 0.05). TSH in the second-trimester group was higher than that in the first-trimester group, while FT₃, FT₄, and TPO-Ab levels were lower than those in the first-trimester group (P < 0.05). The levels of BPA and RBP4 in gestational diabetes mellitus and hypertension were higher than those in the nongestational period, and the levels of BPA and RBP4 in gestational intrahepatic cholestasis and anemia were higher than those in the nongestational period, and the levels of BPA and RBP4 in preterm delivery were higher than those in nongestational period (P < 0.05). Also, the level of urinary BPA in the hypothyroidism group was higher than that in the normal control group (P < 0.05) and the level of serum RBP4 in the hypothyroidism group was higher than that in the normal control group (P < 0.05). According to multivariate logistic regression analysis, age ≥30 years and the ascending BPA and RBP4 were risk factors for subclinical hypothyroidism during pregnancy in the nonobese female. BPA and RBP-4 are closely related to the pregnancy outcome of nonobese subclinical hypothyroidism in the pregnant female. The degree of BPA and RBP-4 in adverse pregnancy outcomes is increased, which is the risk factor for nonobese subclinical hypothyroidism.

Complementary medicines and therapies in clinical guidelines on pregnancy care: A systematic review

BACKGROUND

There is a need for evidence-based guidance on complementary medicines and therapies (CMT) use during pregnancy due to high prevalence of use and lack of guidance on the balance of benefit and harms.

AIM

Evaluate the extent to which current clinical practice guidelines relevant to Australian healthcare professionals make clear and unambiguous recommendations about CMT use in pregnancy, and synthesise these recommendations.

METHODS

The search included EMBASE, PubMed, the National Health and Medical Research Council's Clinical Practice Guidelines Portal, and websites of Australian maternity hospitals and professional/not-for-profit organisations for published guidelines on pregnancy care. Data were synthesised narratively. Guidelines were appraised by two independent reviewers using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

FINDINGS

A total of 48 guidelines were found, of which 41% provided recommendations that were not limited to routine vitamin and mineral supplementation. There were wide variations in recommendations, particularly for vitamin D and calcium. There was some consensus on recommending ginger and vitamin B6 for nausea and vomiting, and additional supplementation for women with obesity. Guidelines generally scored poorly in the domains of editorial independence and rigour of development.

DISCUSSION

There is a lack of guidance with regard to appropriate CMT use during pregnancy, which may result in less-than-optimal care. Inconsistency between guidelines may lead to variations in care.

CONCLUSION

Guidelines should include clear and unambiguous guidance on appropriate CMT use during pregnancy, be based on a structured search of the evidence and informed by stakeholder engagement.

The impact of subclinical hypothyroidism on health-related quality of life: a narrative review

A biochemical diagnosis of subclinical hypothyroidism is defined by an elevated serum thyroid-stimulating hormone (TSH) with a normal serum free thyroxine (FT4). This paper discusses SCH in the Australian population, the impact of SCH on health-related quality of life (HRQoL), and the evidence for thyroid hormone therapy as well as exercise therapy to improve HRQoL in SCH. The prevalence of SCH in Australia is approximately 4-5% and is higher in females and the elderly. Current evidence suggests thyroid hormone therapy is not associated with an improvement in HRQoL. However, there does appear to be a subgroup of those with SCH that experience an impairment in HRQoL who may potentially benefit from treatment. Because the majority of research to date has been done in elderly, largely asymptomatic individuals, this may not be representative of the entire SCH population. Additionally, alternative treatments such as exercise therapy have not been well explored in the literature, despite exercise therapy's effects on HRQoL in other populations. Further research is required to clearly define which individuals with SCH are likely to experience an impaired HRQoL, as well as explore the effects of thyroid hormone therapy and exercise therapy in these individuals. This article is protected by copyright. All rights reserved.

Systemic endocrinopathies (thyroid conditions and diabetes): impact on postnatal life of the offspring

Fetal programming may influence childhood and adult life, determining the risk of specific diseases. During earlier stages of pregnancy, the transfer of maternal thyroid hormones to the fetus is vital for adequate neurologic development. The presence of severe maternal thyroid dysfunction, particularly severe iodine deficiency, is devastating, leading to irreversible neurologic sequelae. Moreover, mild maternal thyroid conditions, such as a mild-to-moderate iodine deficiency, may also lead to milder neurologic and behavioral conditions later during the life of the offspring. Maternal dysglycemia due to pregestational or gestational diabetes mellitus is another common situation in which fetal development encounters a hostile environment. Hyperglycemia in utero may trigger metabolic conditions in the offspring, including abnormalities of glucose tolerance and weight excess. Physicians assisting pregnant women have to be aware about these conditions, because they may go unnoticed if not properly screened. Because an early diagnosis and appropriate management may prevent most of the possible negative consequences for the progeny, the prevention, early diagnosis, and proper management of these endocrine conditions should be offered to all women undergoing pregnancy. Here, we comprehensively review the current evidence about the effects of maternal thyroid dysfunction and maternal dysglycemia on the cognitive function and carbohydrate metabolism in the offspring, two prevalent conditions of utmost importance for the child's health and development.