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Su GY, Yeh CC, Yang SJ, Yang CC, Hwu CM, Wang FF, Huang CJ. Assessment of iodine nutritional status and gestational thyroid function reference ranges during the first trimester of pregnancy in Taiwan. J Chin Med Assoc 2024; 87:590-596. [PMID: 38651854 DOI: 10.1097/jcma.0000000000001099] [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: 04/25/2024] Open
Abstract
BACKGROUND Iodine nutrition is critical for fetal neurodevelopment in the first trimester of pregnancy, a period associated with dramatic changes in thyroid function. The aim of this study was to evaluate iodine nutritional status and thyroid function reference ranges in the first trimester in Taiwan. METHODS Pregnant women aged 20 years and above in the first trimester were recruited in Taipei Veterans General Hospital, Taiwan from March 2019 to July 2022. Each participant provided a spot urine sample for measurement of urinary iodine concentration (UIC) and a blood sample for checkup of thyroid function and thyroid autoantibodies. A simple food frequency questionnaire was also completed. RESULTS A total of 209 women with a mean age of 32.9 ± 4.4 years were enrolled. The median UIC was 160.9 μg/L (interquartile range [IQR]: 105.0-246.2 μg/L), indicating overall iodine sufficiency. The gestational thyroid function reference ranges were: thyroid stimulating hormone (TSH) (median: 0.93 [0.007-2.9] µIU/mL), free T4 (1.3 [0.93-2.2] ng/dL), free T3 (3.0 [2.3-5.0] ng/dL), total T4 (9.9 [6.4-16.9] ng/dL), and total T3 (135 [88-231] ng/dL). If the nonpregnant reference range of serum TSH was used, eight women (4.8%) would be misclassified as having subclinical hyperthyroidism, and two women (1.2%) with subclinical hypothyroidism would be missed. In multivariate analysis, nulliparous (adjusted odds ratio [OR] from model 1-3: 2.02, 2.05, 2.02; 95% CI, 1.08-3.77, 1.10-3.81, 1.11-3.66; p = 0.027, 0.023, 0.022, respectively) and multivitamin nonusers (adjusted OR from model 1-3: 1.86, 1.85, 1.78; 95% CI, 1.04-3.34, 1.03-3.32, 1.004-3.71; p = 0.038, 0.039, 0.049, respectively) had increased odds of having lower UIC levels <150 μg/L. CONCLUSION The iodine nutritional status in the first trimester is adequate in Taiwan; however, certain subgroups such as nulliparous and multivitamin nonusers are still at risk for iodine deficiency. Gestational thyroid function reference ranges are needed for correct diagnosis of thyroid dysfunction in pregnancy.
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Affiliation(s)
- Guan-Yu Su
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chang-Ching Yeh
- Department of Obstetrics & Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Obstetrics and Gynecology, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Nurse-Midwifery and Women Health, College of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan, ROC
| | - Shun-Jie Yang
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chen-Chang Yang
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Public Health, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Environmental & Occupational Health Sciences, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Occupational Medicine and Clinical Toxicology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chii-Min Hwu
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Fan-Fen Wang
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, Taipei City Hospital Yangming Branch, Taipei, Taiwan, ROC
| | - Chun-Jui Huang
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Public Health, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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Jelloul E, Sitoris G, Veltri F, Kleynen P, Rozenberg S, Poppe KG. Gestation-suppressed serum TSH levels during early pregnancy are not associated with altered maternal and neonatal outcomes. Eur Thyroid J 2023; 12:e230112. [PMID: 37855409 PMCID: PMC10620451 DOI: 10.1530/etj-23-0112] [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: 06/07/2023] [Accepted: 10/02/2023] [Indexed: 10/04/2023] Open
Abstract
Objective The aim of the study was to investigate the impact of suppressed serum TSH levels (sTSH) during early pregnancy on maternal and neonatal outcomes. Methods In this single-centre, retrospective cohort study 1081 women were screened at 11.8 ± 2.4 weeks of pregnancy for TSH, free T4 (FT4) and TPOAb. Exclusion criteria were twin- and assisted- reproduction pregnancies, women with TSH levels >3.74 mIU/L, severe hyperthyroidism, treated for thyroid dysfunction before or after screening and gestational blood sampling <6 or >16 weeks of pregnancy. The prevalence of adverse pregnancy outcomes was compared between the study group sTSH (TSH: < 0.06 mIU/L; n = 36) and euthyroid controls (TSH: 0.06-3.74 mIU/L; n = 1045), and the impact of sTSH on pregnancy outcomes verified in logistic regression analyses. Results Median (IQR) serum TSH level in women with sTSH was 0.03 (0.03-0.03) vs 1.25 (0.81-1.82) mIU/L in controls and FT4 levels 18.0 (14.4-20.3) vs 14.2 (12.9-15.4) pmol/L; both P < 0.001. None of the women with sTSH had thyrotropin receptor antibodies. Compared with controls, the prevalence of TPOAb positivity (TAI) was comparable between groups (5.6% vs 6.6%; P = 0.803). The prevalence of maternal and neonatal pregnancy outcomes was comparable between the study and control group. The logistic regression analyses with corrections for TAI, FT4 and demographic parameters confirmed the absence of an association between sTSH, and the following outcomes: iron deficient anaemia (aORs (95% CI)): 1.41 (0.64-2.99); P = 0.385, gestational diabetes: 1.19 (0.44-2.88); P = 0.713, preterm birth: 1.57 (0.23-6.22);P = 0.574 and low Apgar-1' score: 0.71 (0.11-2.67); P = 0.657. Conclusions Suppressed serum TSH levels during the first to early second trimester of pregnancy were not associated with altered maternal or neonatal outcomes.
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Affiliation(s)
- Emna Jelloul
- Endocrine Unit Centre Hospitalier Universitaire (CHU) Saint Pierre, Université Libre de Bruxelles (ULB), Rue Haute, Brussels, Belgium
| | - Georgiana Sitoris
- Endocrine Unit Centre Hospitalier Universitaire (CHU) Saint Pierre, Université Libre de Bruxelles (ULB), Rue Haute, Brussels, Belgium
| | - Flora Veltri
- Endocrine Unit Centre Hospitalier Universitaire (CHU) Saint Pierre, Université Libre de Bruxelles (ULB), Rue Haute, Brussels, Belgium
| | - Pierre Kleynen
- Endocrine Unit Centre Hospitalier Universitaire (CHU) Saint Pierre, Université Libre de Bruxelles (ULB), Rue Haute, Brussels, Belgium
| | - Serge Rozenberg
- Departement of Gynecology and Obstetrics, Centre Hospitalier Universitaire Saint Pierre, Université Libre de Bruxelles (ULB), Rue Haute, Brussels, Belgium
| | - Kris G Poppe
- Endocrine Unit Centre Hospitalier Universitaire (CHU) Saint Pierre, Université Libre de Bruxelles (ULB), Rue Haute, Brussels, Belgium
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Fuse Y, Ito Y, Shishiba Y, Irie M. Gestational trimester-specific reference ranges for serum thyrotropin and free thyroxine in Japanese. Endocr J 2022; 69:1447-1455. [PMID: 35811133 DOI: 10.1507/endocrj.ej22-0237] [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: 12/30/2022] Open
Abstract
Thyroid diseases in pregnant and lactating women may result in adverse outcomes for both mothers and infants. A reference range for thyroid function is required in different areas; however, few studies on the gestational change or reference ranges of thyrotropin (TSH) and free thyroxine (FT4) concentrations for Japanese pregnant women have been reported. To establish the gestational trimester-specific reference ranges of serum TSH and FT4 concentrations, our previously published data on 481 pregnant women with the mean age of 30.8 years who provided serum samples as early as gestational week (GW) 6 was compiled by using their percentile values. The overall median urinary iodine concentration (UIC) during pregnancy was 201 μg/L suggesting adequate iodine intake. The prevalence of positive serum thyroid autoantibody (ThAb), i.e., antithyroid peroxidase antibody (TPOAb) and antithyroglobulin antibody (TgAb), was 11.4%. The reference ranges (2.5-97.5th percentile) of serum TSH and FT4 concentration calculated for samples with negative TgAb and TPOAb were 0.04-6.06 mIU/L in the first trimester (T1), 0.31-3.11 mIU/L in the second trimester (T2) and 0.48-3.93 mIU/L in the third trimester (T3) for TSH, and 1.10-1.87 ng/dL (T1), 0.76-1.56 ng/dL (T2) and 0.76-1.14 ng/dL (T3) for FT4. Compared to published data around the world in the 2017 American Thyroid Association (ATA) guideline, both the upper and lower limits of our TSH and FT4 reference ranges in the first trimester were higher than those in other countries. Further research is necessary in larger samples.
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Affiliation(s)
- Yozen Fuse
- Research Committee on Iodine Related Health Problems, Foundation for Growth Science, Tokyo 113-0033, Japan
| | - Yoshiya Ito
- Research Committee on Iodine Related Health Problems, Foundation for Growth Science, Tokyo 113-0033, Japan
- Division of Clinical Medicine, Japanese Red Cross Hokkaido College of Nursing, Kitami 090-0011, Japan
| | - Yoshimasa Shishiba
- Research Committee on Iodine Related Health Problems, Foundation for Growth Science, Tokyo 113-0033, Japan
| | - Minoru Irie
- Research Committee on Iodine Related Health Problems, Foundation for Growth Science, Tokyo 113-0033, Japan
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Poppe KG. Are Live-Birth Rates Reduced in Euthyroid Women with Thyroid Autoimmunity Treated with an Assisted Reproductive Technology? The Janus Face of a Meta-Analysis. Thyroid 2022; 32:1005-1006. [PMID: 35819297 DOI: 10.1089/thy.2022.0370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Kris G Poppe
- Endocrine Clinic, CHU Saint Pierre, Brussels, Belgium
- Université Libre de Bruxelles (ULB), Brussels, Belgium
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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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Sitoris G, Veltri F, Ichiche M, Kleynen P, Praet JP, Rozenberg S, Poppe KG. Association between thyroid autoimmunity and gestational diabetes mellitus in euthyroid women. Eur Thyroid J 2022; 11:e210142. [PMID: 35195084 PMCID: PMC8963167 DOI: 10.1530/etj-21-0142] [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: 02/12/2022] [Accepted: 02/22/2022] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE Pregnant women with autoimmune (subclinical) hypothyroidism have an increased risk of developing gestational diabetes mellitus (GDM). However, this association remains controversial in euthyroid women with thyroid autoimmunity (TAI). Therefore, the aim of the study was to determine the association between TAI and GDM in euthyroid women in a logistic regression analysis with adjustments for baseline/demographic parameters. METHODS Cross-sectional study in 1447 euthyroid women who performed their entire clinical/biological workup and oral glucose tolerance test (OGTT) in our center. At median 13 (11-17) weeks of gestation, thyroid-stimulating hormone, free T4, and thyroid peroxidase antibodies (TPOAb) were measured, baseline characteristics were recorded, and an OGTT was performed between 24 and 28 weeks of pregnancy. Exclusion criteria were pre-pregnancy diabetes, assisted pregnancies, and women with (treated) thyroid dysfunction before or after screening. The diagnosis of GDM was based on 2013 World Health Organization criteria, and TAI was defined as TPOAb levels ≥60 kIU/L. RESULTS Two hundred eighty women were diagnosed with GDM (19.4%), 26.1% in women with TAI, and 18.9% in women without TAI (P = 0.096). In the logistic regression analysis, TAI was associated with GDM in women older than 30 years (adjusted odds ratio 1.68 (95% CI, 1.01-2.78); P = 0.048). Maternal age >30 years, pre-pregnancy BMI ≥30 kg/m2, and other than Caucasian background were also associated with GDM; aOR 1.93 (95% CI, 1.46-2.56); P < 0.001, 2.03 (95% CI, 1.46-2.81); P < 0.001 and 1.46 (95% CI, 1.03-2.06); P = 0.034, respectively. CONCLUSIONS In older pregnant women, the presence of TAI in euthyroid women was associated with GDM. In line with the literature data, (higher) age and BMI were strongly associated with GDM. Future investigations should focus on treatments that might prevent the development of GDM in euthyroid women with TAI.
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Affiliation(s)
- Georgiana Sitoris
- Endocrine Unit Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Flora Veltri
- Endocrine Unit Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Malika Ichiche
- Endocrine Unit Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Pierre Kleynen
- Endocrine Unit Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Jean-Philippe Praet
- Department of Internal Medicine, Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Serge Rozenberg
- Department of Gynecology and Obstetrics, Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Kris G Poppe
- Endocrine Unit Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Correspondence should be addressed to K G Poppe:
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Knøsgaard L, Andersen S, Hansen AB, Vestergaard P, Andersen SL. Classification of maternal thyroid function in early pregnancy using repeated blood samples. Eur Thyroid J 2022; 11:e210055. [PMID: 34981754 PMCID: PMC9142809 DOI: 10.1530/etj-21-0055] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 12/21/2021] [Indexed: 11/22/2022] Open
Abstract
Objective The assessment of maternal thyroid function in early pregnancy is debated. It is well-established that pregnancy-specific reference ranges preferably should be used. We speculated if the use of repeated blood samples drawn in early pregnancy would influence the classification of maternal thyroid function. Methods Pregnant women with repeated early pregnancy blood samples were identified in the North Denmark Region Pregnancy Cohort. Each sample was used for the measurement of TSH, free T4 (fT4), thyroid peroxidase antibodies (TPO-Ab), and thyroglobulin antibodies (Tg-Ab) (ADVIA Centaur XPT, Siemens Healthineers). Method- and pregnancy week-specific reference ranges were used for the classification of maternal thyroid function. Results Among 1466 pregnancies included, 89 women had TSH above the upper reference limit in the first sample (median pregnancy week 8) and 44 (49.4%) of these similarly had high TSH in the second sample (median week 10). A total of 47 women had TSH below the lower reference limit in the first sample and 19 (40.4%) of these similarly had low TSH in the second sample. Regarding women classified with isolated changes in fT4 in the first sample, less than 20% were similarly classified as such in the second sample. The percentage agreement between the samples was dependent on the level of TSH in the first sample and the presence of TPO- and Tg-Ab. Conclusion In a large cohort of pregnant women, the classification of maternal thyroid function varied considerably with the use of repeated blood samples. Results emphasize a focus on the severity of thyroid function abnormalities in pregnant women.
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Affiliation(s)
- Louise Knøsgaard
- 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 Geriatrics, Aalborg University Hospital, Aalborg, Denmark
| | - Annebirthe Bo Hansen
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
| | - Peter Vestergaard
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Jutland, 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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Sitoris G, Veltri F, Kleynen P, Ichiche M, Rozenberg S, Poppe KG. Does foetal gender influence maternal thyroid parameters in pregnancy? Eur Thyroid J 2022; 11:e210001. [PMID: 34981747 PMCID: PMC9142799 DOI: 10.1530/etj-21-0001] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 06/30/2021] [Indexed: 11/21/2022] Open
Abstract
Objective It is unknown if foetal gender influences maternal thyroid function during pregnancy. We therefore investigated the prevalence of thyroid disorders and determined first-trimester TSH reference ranges according to gender. Methods A cross-sectional study involving 1663 women with an ongoing pregnancy was conducted. Twin and assisted pregnancies and l-thyroxine or antithyroid treatment before pregnancy were exclusion criteria. Serum TSH, free T4 (FT4) and thyroid peroxidase antibodies (TPOAb) were measured at median (interquartile range; IQR) 13 (11-17) weeks of gestation. Subclinical hypothyroidism (SCH) was present when serum TSH levels were >3.74 mIU/L with normal FT4 levels (10.29-18.02 pmol/L), and thyroid autoimmunity (TAI) was present when TPOAb were ≥60 kIU/L. Results Eight hundred and forty-seven women were pregnant with a female foetus (FF) and 816 with a male foetus (MF). In women without TAI and during the gestational age period between 9 and 13 weeks (with presumed high-serum hCG levels), median (IQR range) serum TSH in the FF group was lower than that in the MF group: 1.13 (0.72-1.74) vs 1.24 (0.71-1.98) mIU/L; P = 0.021. First-trimester gender-specific TSH reference range was 0.03-3.53 mIU/L in the FF group and 0.03-3.89 mIU/L in the MF group. The prevalence of SCH and TAI was comparable between the FF and MF group: 4.4% vs 5.4%; P = 0.345 and 4.9% vs 7.5%; P = 0.079, respectively. Conclusions Women pregnant with an MF have slightly but significantly higher TSH levels and a higher upper limit of the first-trimester TSH reference range, compared with pregnancies with a FF. We hypothesise that this difference may be related to higher hCG levels in women pregnant with a FF, although we were unable to measure hCG in this study. Further studies are required to investigate if this difference has any clinical relevance.
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Affiliation(s)
- Georgiana Sitoris
- Endocrine Unit Centre Hospitalier Universitaire (CHU) Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Flora Veltri
- Endocrine Unit Centre Hospitalier Universitaire (CHU) Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Pierre Kleynen
- Endocrine Unit Centre Hospitalier Universitaire (CHU) Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Malika Ichiche
- Endocrine Unit Centre Hospitalier Universitaire (CHU) Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Serge Rozenberg
- Department of Gynecology and Obstetrics, Centre Hospitalier Universitaire (CHU) Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Kris G Poppe
- Endocrine Unit Centre Hospitalier Universitaire (CHU) Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
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Sletner L, Jenum AK, Qvigstad E, Hammerstad SS. Thyroid Function During Pregnancy in A Multiethnic Population in Norway. J Endocr Soc 2021; 5:bvab078. [PMID: 34159284 PMCID: PMC8212686 DOI: 10.1210/jendso/bvab078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Indexed: 12/31/2022] Open
Abstract
Context Ethnic differences in thyroid function during pregnancy have been reported. However, it is unclear if this is equally valid across ethnic groups within multiethnic populations. Objective We aimed to assess ethnic differences in thyrotropin (TSH) and free thyroxine (FT4), and the prevalence of thyroid dysfunction and thyroid autoimmunity during pregnancy. Methods In a population-based cohort of 785 pregnant women in Oslo, Norway, TSH, FT4, and thyroid peroxidase antibodies (TPO Abs) were measured twice: at gestational week (GW) 15 and 28, and urine iodine concentration at GW 15. Associations were assessed using multivariate linear regression. Results We found ethnic differences in TSH levels at both time points, but not for fT4. South Asians had 0.42 mU/L (95% CI, 0.20-0.64) higher TSH than Europeans in GW 15. This difference persisted after adjusting for covariates (including TPO Ab positivity and iodine status), and increased further as pregnancy progressed. In contrast, East Asians had the lowest TSH. No new cases of overt hypothyroidism were detected in early pregnancy, but subclinical hypothyroidism was found in 6.6% among all, highest in South Asians (14.2%). Hyperthyroidism early in pregnancy was observed in 3.7% (almost all subclinical), highest in East Asians (11.9%). The prevalence of TPO Ab positivity was 4%, highest in South Asians (8%). Conclusion In a multiethnic population of presumably healthy women, we found ethnic variations in TSH but not FT4 levels throughout pregnancy. South Asians had higher TSH and more subclinical hypothyroidism, not explained by their higher prevalence of TPO Ab positivity. Larger studies are needed to define ethnic- and trimester-specific reference ranges in pregnancy.
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Affiliation(s)
- Line Sletner
- Department of Pediatric and Adolescents Medicine, Akershus University Hospital, PB 1000, 1478 Lørenskog, Norway.,Institute of Clinical Medicine, Campus Ahus, University of Oslo, Norway
| | - Anne Karen Jenum
- General Practice Research Unit (AFE), Department of General Practice, Institute of Health and Society, Faculty of Medicine, University of Oslo, PB 1130 Blindern, 0318, Oslo, Norway
| | - Elisabeth Qvigstad
- Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Aker, PB 4950, 0424 Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Norway
| | - Sara Salehi Hammerstad
- Department of Pediatric, Oslo University Hospital, Ullevål, PB 4950, 0424, Oslo, Norway.,Specialist Center Pilestredet Park, Pilestredet Park 12.A 0176 Oslo, Norway
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Andersen SL, Andersen S, Liew Z, Vestergaard P, Lundbye-Christensen S, Sørensen TIA, Olsen J. Maternal thyroid disease and adiposity in mother and child. Clin Endocrinol (Oxf) 2021; 94:484-493. [PMID: 32794201 DOI: 10.1111/cen.14314] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Thyroid hormones are crucial developmental factors, and thyroid disease in pregnant women is a concern. Overweight and obesity are also important health concerns, and we hypothesized that in utero exposure to maternal thyroid disease could programme the foetus to development of adiposity. DESIGN Cohort and case-cohort studies. PARTICIPANTS Pregnant women from the Danish National Birth Cohort and their 7-year-old children. MEASUREMENTS Maternal thyroid disease (hyperthyroidism and hypothyroidism) was assessed from registrations of diagnoses and treatment (n = 71 706) or from the measurement of thyroid-stimulating hormone (TSH) in a stored blood sample from the early pregnancy (n = 7624). Maternal prepregnancy body mass index (BMI) and child BMI at 7 years of age were used to define overweight and obesity, and associations were evaluated using regression models adjusting for potential confounders. RESULTS No association was found between maternal thyroid disease in pregnancy and child overweight (hyperthyroidism: adjusted risk ratio (aRR): 1.02 (95% confidence interval (CI): 0.58-1.82); hypothyroidism: 1.31 (0.86-1.97)) or obesity (hyperthyroidism: 0.96 (0.53-1.75); hypothyroidism: 1.25 (0.76-2.05)). On the other hand, pregnant women with hypothyroidism in early pregnancy had a higher risk of being overweight (aRR: 1.20 (95% CI: 1.03; 1.41)) and obese (1.45 (1.07; 1.96)), whereas women with hyperthyroidism had a lower risk of being overweight (0.79 (0.64; 0.98)). CONCLUSIONS Results provide no evidence that maternal thyroid disease in pregnancy programmes adiposity in the child, but corroborate an association between maternal thyroid disease and adiposity in the mother.
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Affiliation(s)
- Stine Linding Andersen
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Biochemistry, Viborg Regional Hospital, Viborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Stig Andersen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Geriatrics, Aalborg University Hospital, Aalborg, Denmark
| | - Zeyan Liew
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA
- Yale Center for Perinatal, Pediatric, and Environmental Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - Peter Vestergaard
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Lundbye-Christensen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Unit of Clinical Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Thorkild I A Sørensen
- Section of Epidemiology, Department of Public Health, Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jørn Olsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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11
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Berlin M, Barchel D, Brik A, Kohn E, Livne A, Keidar R, Tovbin J, Betser M, Moskovich M, Mandel D, Lubetzky R, Ovental A, Factor-Litvak P, Britzi M, Ziv-Baran T, Koren R, Klieger C, Berkovitch M, Matok I, Marom R. Maternal and Newborn Thyroid Hormone, and the Association With Polychlorinated Biphenyls (PCBs) Burden: The EHF (Environmental Health Fund) Birth Cohort. Front Pediatr 2021; 9:705395. [PMID: 34589452 PMCID: PMC8473683 DOI: 10.3389/fped.2021.705395] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 08/20/2021] [Indexed: 12/22/2022] Open
Abstract
Background: Polychlorinated biphenyls (PCBs) are ubiquitous environmental contaminants found in human tissues. PCBs can be transferred through the placenta and may disrupt the maternal thyroid homeostasis, and affect fetal thyroid hormone production. Several studies have shown that intrauterine exposure to PCBs might be associated with abnormal levels of thyroid hormones in mothers and their offspring. Objectives: To examine the associations between environmental exposure to PCBs and thyroid hormone levels in mothers and newborns. Methods: The EHF-Assaf-Harofeh-Ichilov cohort includes 263 mothers-newborns dyads. A total of 157 mother-newborn dyads had both PCBs and thyroid function measures. Regression models were used to estimate associations between maternal PCB exposure and maternal and newborn thyroid function, controlling for possible confounders. Results: Four PCBs congeners were analyzed: PCBs 118, 138, 153, and 180. ∑PCBs median (IQR) level was 14.65 (2.83-68.14) ng/g lipids. The median maternal thyroid-stimulating hormone (TSH) level was 2.66 (0.70-8.23) μIU/ml, the median maternal free thyroxine (FT4) level was 12.44 (11.27-13.53) μg/dL, the median maternal thyroid peroxidase antibodies (TPO Ab) level was 9.6 (7.36-12.51) IU/mL. Newborns' median total thyroxine (T4) level was 14.8 (7.6-24.9) μg/dL. No association was found between exposure to different congeners or to ∑PCBs and maternal TSH, FT4, thyroglobulin autoantibodies (Tg Ab), TPO Ab and newborn total T4 levels. In multivariable analysis a 1% change in ∑PCBs level was significantly associated with a 0.57% change in maternal TSH levels in women with body mass index (BMI) < 19. The same association was observed for each of the studied PCB congeners. Maternal TPO Ab levels statistically significantly increased by 0.53 and 0.46% for 1% increase in PCB 118 and 153 congeners, respectively. In women with BMI > 25, the association between the PCBs levels and maternal TSH levels was in the opposite direction. No association was found in women with normal BMI (19-24.9). Conclusions: Background exposure to environmentally relevant concentrations of some PCBs can alter thyroid hormone homeostasis in pregnant women and might be associated with abnormal TSH levels and TPO-Ab in women with low BMI. However, these findings require further investigation.
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Affiliation(s)
- Maya Berlin
- Clinical Pharmacology and Toxicology Unit, Shamir Medical Center (Assaf Harofeh), Affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.,Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dana Barchel
- Clinical Pharmacology and Toxicology Unit, Shamir Medical Center (Assaf Harofeh), Affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Anna Brik
- Clinical Pharmacology and Toxicology Unit, Shamir Medical Center (Assaf Harofeh), Affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Elkana Kohn
- Clinical Pharmacology and Toxicology Unit, Shamir Medical Center (Assaf Harofeh), Affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ayelet Livne
- Department of Neonatology, Shamir Medical Center (Assaf Harofeh), Affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Rimona Keidar
- Department of Neonatology, Shamir Medical Center (Assaf Harofeh), Affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Josef Tovbin
- Division of Obstetrics and Gynecology, Shamir Medical Center (Assaf Harofeh), Affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Moshe Betser
- Division of Obstetrics and Gynecology, Shamir Medical Center (Assaf Harofeh), Affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Miki Moskovich
- Division of Obstetrics and Gynecology, Shamir Medical Center (Assaf Harofeh), Affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Dror Mandel
- Departments of Neonatology and Pediatrics, Dana Dwek Children's Hospital, Tel Aviv Medical Center, Affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ronit Lubetzky
- Departments of Neonatology and Pediatrics, Dana Dwek Children's Hospital, Tel Aviv Medical Center, Affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Amit Ovental
- Departments of Neonatology and Pediatrics, Dana Dwek Children's Hospital, Tel Aviv Medical Center, Affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Pam Factor-Litvak
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Malka Britzi
- Residues Lab, Kimron Veterinary Institute, Beit-Dagan, Israel
| | - Tomer Ziv-Baran
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ronit Koren
- Division of Obstetrics and Gynecology, Shamir Medical Center (Assaf Harofeh), Affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.,Department of Internal Medicine A, Shamir Medical Center (Assaf Harofeh), Affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Chagit Klieger
- Feto-Maternal Unit, Lis Hospital, Tel Aviv Medical Center, Affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Matitiahu Berkovitch
- Clinical Pharmacology and Toxicology Unit, Shamir Medical Center (Assaf Harofeh), Affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ilan Matok
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ronella Marom
- Departments of Neonatology and Pediatrics, Dana Dwek Children's Hospital, Tel Aviv Medical Center, Affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
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12
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Knøsgaard L, Andersen S, Hansen AB, Vestergaard P, Andersen SL. Thyroid function abnormalities and thyroid autoantibodies in Danish pregnant women. Clin Endocrinol (Oxf) 2020; 93:329-338. [PMID: 31876038 DOI: 10.1111/cen.14147] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/13/2019] [Accepted: 12/19/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Abnormal thyroid function in pregnant women is a matter of concern. Knowledge on the occurrence of known and unidentified thyroid function abnormalities in a large unselected cohort of pregnant women is warranted as part of the debate on benefits and risks of routine testing. DESIGN Cohort study. PARTICIPANTS A total of 14 323 pregnant women in the North Denmark Region, who had a blood sample drawn as part of the prenatal screening program in early pregnancy (2011-2015). MEASUREMENTS TSH, free thyroxine, thyroid peroxidase and thyroglobulin antibodies were measured in the stored blood samples using an automatic immunoassay (ADVIA Centaur XPT, Siemens Healthineers). Cohort-, method- and week-specific reference ranges were used for classification of maternal thyroid function, and a cut-off of 60 U/mL was used for thyroid autoantibodies. Information in Danish nationwide registers was used to identify diagnosed and treated maternal thyroid disease. RESULTS Overall, 15.2% had thyroid function abnormalities in the early pregnancy and 14.9% were thyroid peroxidase and/or thyroglobulin antibody positive. Among women with known thyroid disease (n = 365), the frequency of abnormal thyroid function was 45.7%, and 62.8% in women (n = 172) who received current treatment in the pregnancy. When maternal thyroid disease was diagnosed in the years following pregnancy (n = 313), 46.7% had abnormal thyroid function and 54.3% were thyroid peroxidase and/or thyroglobulin antibody positive in the early pregnancy. CONCLUSION Thyroid function abnormalities and thyroid autoantibodies were common in Danish pregnant women, particularly in women with known or later diagnosed thyroid disease, which raises concern about inadequately treated and unidentified abnormal thyroid function.
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Affiliation(s)
- Louise Knøsgaard
- 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 Geriatrics, Aalborg University Hospital, Aalborg, Denmark
| | - Annebirthe Bo Hansen
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
| | - Peter Vestergaard
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Jutland, 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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13
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Sitoris G, Veltri F, Kleynen P, Belhomme J, Rozenberg S, Poppe K. Screening for Thyroid Dysfunction in Pregnancy With Targeted High-Risk Case Finding: Can It Be Improved? J Clin Endocrinol Metab 2019; 104:2346-2354. [PMID: 30608533 DOI: 10.1210/jc.2018-02303] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 12/26/2018] [Indexed: 01/28/2023]
Abstract
CONTEXT AND OBJECTIVE Targeted screening is proposed for the detection of thyroid dysfunction in pregnant women rather than universal screening (US). We aimed to determine the detection rate of subclinical hypothyroidism (SCH) and overt hypothyroidism (OH) based on American Thyroid Association guidelines (ATA-GL) and whether it could be improved. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of 1832 pregnant women in a single center. Thyroid function (TSH and free T4) and iron status were determined. The high-risk group (HRG) included women with one or more ATA-GL risk factors and the low-risk group (LRG) included women without. Participants with other risk factors [body mass index (BMI) 30 to 39.9 kg/m2, Caucasian background] were classified as HRG+ and those with iron deficiency as HRG++. RESULTS The HRG included 64% of women and the LRG included 36% (P < 0.001). Of all participants, 4.5% had SCH and 0.5% OH. The detection rate of SCH and OH was comparable between the LRG and HRG (46% vs 54% and 25% vs 75%; P = 0.560 and 0.157, respectively). In the HRG, the detection rate of SCH was lower than that of US (54% vs 100%; P < 0.001), but that of OH was comparable (75%; P = 0.596). The detection rate of SCH in the HRG+ and HRG++ was comparable to that in the US group (81% and 88% vs 100%; P = 0.220 and 0.439, respectively). CONCLUSIONS Targeted high-risk case finding screening was not effective for the detection of SCH but performed better for OH. When obesity in the range BMI 30 to 39.9 kg/m2 and a Caucasian background were included as risk factors, the detection rate of SCH became comparable with that of US.
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Affiliation(s)
- Georgiana Sitoris
- Endocrine Unit, Centre Hospitalier Universitaire Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Flora Veltri
- Endocrine Unit, Centre Hospitalier Universitaire Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Pierre Kleynen
- Endocrine Unit, Centre Hospitalier Universitaire Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Julie Belhomme
- Department of Gynecology and Obstetrics, Centre Hospitalier Universitaire Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Serge Rozenberg
- Department of Gynecology and Obstetrics, Centre Hospitalier Universitaire Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Kris Poppe
- Endocrine Unit, Centre Hospitalier Universitaire Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
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14
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Andersen SL, Andersen S, Carlé A, Christensen PA, Handberg A, Karmisholt J, Knøsgaard L, Kristensen SR, Bülow Pedersen I, Vestergaard P. Pregnancy Week-Specific Reference Ranges for Thyrotropin and Free Thyroxine in the North Denmark Region Pregnancy Cohort. Thyroid 2019; 29:430-438. [PMID: 30734656 DOI: 10.1089/thy.2018.0628] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Physiological changes in maternal thyroid function during pregnancy necessitate the use of pregnancy-specific reference ranges. Dynamic changes in thyrotropin (TSH) within the first trimester of pregnancy have been reported, but more evidence is needed to substantiate the findings. The objective of this study was to estimate pregnancy week-specific reference ranges for maternal TSH and free thyroxine (fT4) in early pregnancy. METHODS The study consecutively recruited serum residues from blood samples collected as part of the prenatal screening in the North Denmark Region, 2011-2015. TSH, fT4, thyroid peroxidase antibodies (TPOAb), and thyroglobulin antibodies (TgAb) were measured using an ADVIA Centaur XPT immunoassay. The reference cohort included 10,337 pregnant women who had no thyroid disease or other autoimmune diseases and were TPOAb- and TgAb negative. The main outcome measures were lower and upper reference limits (2.5th and 97.5th percentiles) for TSH and fT4 stratified by week of pregnancy. RESULTS Blood samples were drawn in pregnancy weeks 4-20 (median week 10), and 92% of the pregnancies ended with a live birth. TSH varied considerably in the first trimester of pregnancy, and the levels were highest in early pregnancy (weeks 4-6: 0.6-3.7 mIU/L) followed by a gradual decline to lower levels in weeks 9-11 (0.1-2.8 mIU/L) and 12-14 (0.03-2.8 mIU/L). Maternal fT4 showed less variation (weeks 4-6: 12-20 pmol/L; weeks 9-11: 13-21 pmol/L; weeks 12-14: 13-20 pmol/L). CONCLUSIONS The results corroborate dynamic week-specific changes in maternal TSH in early pregnancy. The use of uniform lower and upper reference limits for TSH in early pregnancy may be too simple.
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Affiliation(s)
- Stine Linding Andersen
- 1 Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
- 2 Department of Clinical Biochemistry, and Aalborg University Hospital, Aalborg, Denmark
| | - Stig Andersen
- 3 Department of Geriatrics, Aalborg University Hospital, Aalborg, Denmark
- 4 Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Allan Carlé
- 1 Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Aase Handberg
- 2 Department of Clinical Biochemistry, and Aalborg University Hospital, Aalborg, Denmark
- 4 Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jesper Karmisholt
- 1 Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Louise Knøsgaard
- 2 Department of Clinical Biochemistry, and Aalborg University Hospital, Aalborg, Denmark
- 4 Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Søren Risom Kristensen
- 2 Department of Clinical Biochemistry, and Aalborg University Hospital, Aalborg, Denmark
- 4 Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Inge Bülow Pedersen
- 1 Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Peter Vestergaard
- 1 Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
- 4 Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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