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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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Rodrigo Valero AM, Herranz Antolín S, Bienvenido Villalba M, Cisneros Gutiérrez Del Olmo N. [Reference levels of thyroid hormones in pregnant woman from Guadalajara]. Semergen 2024; 50:102172. [PMID: 38160630 DOI: 10.1016/j.semerg.2023.102172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/20/2023] [Accepted: 12/01/2023] [Indexed: 01/03/2024]
Abstract
INTRODUCTION Thyroid dysfunction during gestation impacts on maternal-fetal health and may influence the neurocognitive development of the child. Thyroid physiology changes during pregnancy and requires the establishment of specific reference levels per trimester and for each population and method. The objectives of our study were to analyse thyroid function throughout pregnancy and to establish reference levels for TSH and T4L in each trimester for our population and methodology. MATERIAL AND METHODS Prospective analytical study of 598 pregnant women from March 2018 to October 2020. TSH, T4L, T3L, ATPO and ATG were determined in all of them. A total of 151 pregnant women were excluded due to positive thyroid immunity, previous thyroid disease in treatment with levothyroxine, twin pregnancy, diagnosis of hypothyroidism and hyperthyroidism in the request or absence of some of the parameters studied, with a reference population of 447 pregnant women. RESULTS The reference levels for TSH were 0.07-3.14mIU/L for the first, 0.66-3.21mIU/L for the second and 0.52-2.97mIU/L for the third trimester. Reference levels for T4L were 0.81-1.19ng/dL for the first, 0.71-1.07ng/dL for the second and 0.69-1.06ng/dL for the third trimester. CONCLUSIONS The reference levels for TSH and T4L obtained in this study differ from those used for the general population, which may have led to misclassification errors and unnecessary treatment in pregnant women.
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Affiliation(s)
- A M Rodrigo Valero
- Servicio de Análisis Clínicos, Hospital Universitario de Guadalajara, Guadalajara, España.
| | - S Herranz Antolín
- Servicio de Endocrinología y Nutrición, Hospital Universitario de Guadalajara, Guadalajara, España
| | - M Bienvenido Villalba
- Servicio de Análisis Clínicos, Hospital Universitario de Guadalajara, Guadalajara, España
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Hinderer J, Lüdeke J, Riege L, Bartel A, Kohn B, Müller E, Arlt SP. Thyroid hormones in canine pregnancy and lactation. Theriogenology 2023; 203:43-52. [PMID: 36966584 DOI: 10.1016/j.theriogenology.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/20/2023] [Accepted: 03/06/2023] [Indexed: 03/10/2023]
Abstract
It is believed that thyroid function has a significant effect on fertility and fetal development in mammals. So far, however, only few studies have been published about potential effects of the reproductive cycle stage on thyroid hormone concentrations in dogs. Therefore, over the course of 122 pregnant and non-pregnant cycles in healthy bitches, Thyroid stimulating hormone (TSH), free Thyroxine (fT4), total Thyroxine (tT4) and Progesterone (P4) were measured six times to assess the influence of the cycle stage and pregnancy on hormone concentrations. The aim was to evaluate established reference intervals for the thyroid hormones in a female study population. Of the 122 bitches, 98 became pregnant. Blood samples were collected during estrus, three times in pregnancy, during lactation and after weaning, or at equivalent times during and after estrus in non-pregnant dogs. No differences between pregnant and non-pregnant animals in any of the thyroid hormones were found. Hormone concentrations, however, differed significantly between the six samplings (p < .01). TSH initially declined during pregnancy, then rose again. The mean concentration of all dogs exceeded the overall upper reference limit of 0.70 ng/mL during lactation. Concentrations of tT4 and ft4 increased during the first third of pregnancy and then subsequently declined. The overall reference limits for tT4 were 0.47-3.20 μg/dL, and for fT4 4.86-29.60 pmol/L, but the reference intervals varied between the sampling dates. The observed patterns may reflect that maternal tT4 and fT4 seem to have important effects during early pregnancy, including a pronounced negative feedback effect on TSH. The initial increase and subsequent decline of tT4 and fT4 concentrations during the course of pregnancy is in accordance with findings in humans and may support the development of fetal thyroid function. The observed peak of TSH concentrations during lactation suggests that the demand for thyroid hormones in this phase is largest. Even if the underlying causes and mechanisms of thyroid regulation are not fully understood, the results of this study show relevant changes of hormone concentrations in the course of the sexual cycle and pregnancy. In that regard, cycle stage needs to be considered when assessing thyroid function in bitches.
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Engel SM, Villanger GD, Herring A, Nethery RC, Drover S, Zoeller RT, Meltzer HM, Zeiner P, Knudsen GP, Reichborn-Kjennerud T, Longnecker MP, Aase H. Gestational thyroid hormone concentrations and risk of attention-deficit hyperactivity disorder in the Norwegian Mother, Father and Child Cohort Study. Paediatr Perinat Epidemiol 2023; 37:218-228. [PMID: 36482860 PMCID: PMC10038840 DOI: 10.1111/ppe.12941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 11/04/2022] [Accepted: 11/16/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Maternal thyroid function plays an important role in foetal brain development; however, little consensus exists regarding the relationship between normal variability in thyroid hormones and common neurodevelopmental disorders, such as attention-deficit hyperactivity disorder (ADHD). OBJECTIVE We sought to examine the association between mid-pregnancy maternal thyroid function and risk of clinically diagnosed ADHD in offspring. METHODS We conducted a nested case-control study in the Norwegian Mother, Father and Child Cohort Study. Among children born 2003 or later, we randomly sampled singleton ADHD cases obtained through linkage with the Norwegian Patient Registry (n = 298) and 554 controls. Concentrations of maternal triiodothyronine (T3), thyroxine (T4), T3-Uptake, thyroid-stimulating hormone (TSH) and thyroid peroxidase antibody (TPO-Ab) were measured in maternal plasma, collected at approximately 17 weeks' gestation. Indices of free T4 (FT4i) and free T3 (FT3i) were calculated. We used multivariable adjusted logistic regression to calculate odds ratios and accounted for missing covariate data using multiple imputation. We used restricted cubic splines to assess non-linear trends and provide flexible representations. We examined effect measure modification by dietary iodine and selenium intake. In sensitivity analyses, we excluded women with clinically significant thyroid disorders (n = 73). RESULTS High maternal T3 was associated with increased risk of ADHD (5th vs 1st quintile odds ratio 2.27, 95% confidence interval 1.21, 4.26). For FT4i, both the lowest and highest quintiles were associated with an approximate 1.6-fold increase in risk of ADHD, with similar trends found for T4. The FT4i association was modified by dietary iodine intake such that the highest risk strata were confined to the low intake group. CONCLUSIONS Both high and low concentrations of maternal thyroid hormones, although within population reference ranges, increase the risk of ADHD in offspring. Increased susceptibility may be found among women with low dietary intake of iodine and selenium.
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Affiliation(s)
- Stephanie M. Engel
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | | | - Amy Herring
- Department of Statistical Science, Duke University, Durham, NC USA
| | - Rachel C. Nethery
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA USA
| | - Samantha Drover
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - R. Thomas Zoeller
- Department of Biology, University of Massachusetts at Amherst, Amherst, MA USA
| | | | | | | | - Ted Reichborn-Kjennerud
- Norwegian Institute of Public Health, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo
| | | | - Heidi Aase
- Norwegian Institute of Public Health, Oslo, Norway
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Kent NL, Young SL, Akison LK, Cuffe JSM. Is the link between elevated TSH and gestational diabetes mellitus dependant on diagnostic criteria and thyroid antibody status: a systematic review and meta-analysis. Endocrine 2021; 74:38-49. [PMID: 33991314 DOI: 10.1007/s12020-021-02733-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/16/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE Clinical studies have investigated the prevalence of gestational diabetes mellitus (GDM) in women with subclinical hypothyroidism (SCH). While some studies demonstrate a clear association, others do not. It is possible this may be due to varied diagnostic criteria for SCH and the presence of thyroid antibodies (TA). We conducted a meta-analysis, separating patients diagnosed with SCH using a diagnostic cut-off <4.0 mIU/L from those diagnosed using a cut-off >4.0 mIU/L and determined the association with GDM and factored TA status into our analysis. METHODS A computerised search of five databases including PubMed, Embase, Cochrane Library, Web of Science and CINAHL returned 787 records. Two independent reviewers assessed abstracts and full texts against pre-specified inclusion and exclusion criteria. Ten cohort studies were included in the final analysis. The diagnostic criteria for SCH and incidence of GDM were extracted from each study. Study quality and risk of bias was assessed by two reviewers. RESULTS TSH levels <4.0 mIU/L for SCH diagnosis was not associated with GDM unless patients were TA positive. Studies that used a diagnostic cut-off >4.0 mIU/L saw a significant increase in the odds of GDM, regardless of TA status (OR = 1.60, 95% CI 1.33-1.93). CONCLUSIONS Women with TSH levels >4.0 mIU/L have an increased odds of GDM regardless of TA status but at TSH levels <4.0 mIU/L, GDM is dependent on TA status. The use of TSH levels to identify pregnancies at risk of GDM is a novel concept that warrants exploration.
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Affiliation(s)
- Nykola L Kent
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia.
| | - Sophia L Young
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Lisa K Akison
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - James S M Cuffe
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
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Bohn MK, Adeli K. Physiological and metabolic adaptations in pregnancy: importance of trimester-specific reference intervals to investigate maternal health and complications. Crit Rev Clin Lab Sci 2021; 59:76-92. [PMID: 34587857 DOI: 10.1080/10408363.2021.1978923] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Diagnosis, prognostication, and monitoring of maternal health throughout pregnancy relies on laboratory testing, including but not limited to key markers of thyroid, hepatic, cardiac, hematology, and renal function. Dynamic physiological processes during gestation significantly influence the maternal biochemistry that supports both the mother and fetus. Resultant changes in blood biochemistry alter the expected values of common laboratory tests. However, the importance of pregnancy-specific reference intervals for laboratory test result interpretation and appropriate monitoring of maternal health and complications is underappreciated. Most clinical laboratories continue to use non-pregnant adult reference intervals for laboratory test interpretation in pregnancy. The current review summarizes and critically evaluates the available literature regarding physiological and metabolic adaptations in pregnancy and their influence on common biomarkers of health and disease. The main laboratory parameters discussed include thyroid, hepatic, metabolic, renal, hematology, inflammatory, and cardiac markers. Considering the available data, further studies are urgently needed to establish trimester-specific reference intervals in healthy pregnant women on updated analytical platforms. Without such data, the standard of clinical laboratory service in pregnancy remains compromised and affects the quality of maternal-fetal healthcare.
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Affiliation(s)
- Mary Kathryn Bohn
- CALIPER Program, Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Khosrow Adeli
- CALIPER Program, Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
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Okosieme OE, Agrawal M, Usman D, Evans C. Method-dependent variation in TSH and FT4 reference intervals in pregnancy: A systematic review. Ann Clin Biochem 2021; 58:537-546. [PMID: 34120478 DOI: 10.1177/00045632211026955] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Gestational TSH and FT4 reference intervals may differ according to assay method, but the extent of variation is unclear and has not been systematically evaluated. We conducted a systematic review of published studies on TSH and FT4 reference intervals in pregnancy. Our aim was to quantify method-related differences in gestation reference intervals, across four commonly used assay methods, Abbott, Beckman, Roche and Siemens. METHODS We searched the literature for relevant studies, published between January 2000 and December 2020, in healthy pregnant women without thyroid antibodies or disease. For each study, we extracted trimester-specific reference intervals (2.5-97.5 percentiles) for TSH and FT4 as well as the manufacturer-provided reference interval for the corresponding non-pregnant population. RESULTS TSH reference intervals showed a wide range of study-to-study differences with upper limits ranging from 2.33 to 8.30 mU/L. FT4 lower limits ranged from 4.40 to 13.93 pmol/L, with consistently lower reference intervals observed with the Beckman method. Differences between non-pregnant and first trimester reference intervals were highly variable, and for most studies, the TSH upper limit in the first trimester could not be predicted or extrapolated from non-pregnant values. CONCLUSIONS Our study confirms significant intra- and intermethod disparities in gestational thyroid hormone reference intervals. The relationship between pregnant and non-pregnant values is inconsistent and does not support the existing practice in many laboratories of extrapolating gestation references from non-pregnant values. Laboratories should invest in deriving method-specific gestation reference intervals for their population.
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Affiliation(s)
- Onyebuchi E Okosieme
- Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK.,Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK
| | - Medha Agrawal
- Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK.,Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK
| | - Danyal Usman
- Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK.,Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK
| | - Carol Evans
- Department of Medical Biochemistry & Immunology, University Hospital of Wales, Cardiff, UK
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Valores de referencia de hormonas tiroideas en la población de gestantes en Lugo. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2020. [DOI: 10.1016/j.gine.2020.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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9
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Abstract
Thyroid hormones are crucial for normal pregnancy and fetal development. Large physiological changes occur during pregnancy, posing challenges for the correct interpretation of thyroid function tests. TSH concentrations are the principal first test to rule out thyroid disease taking into account trimester-specific reference ranges. Free T4 (FT4) measurements by immuno-assays may be subject to interference by endogenous and exogenous factors. The relevance of measuring free T3 (FT3) during pregnancy is unclear. Thyroid autoimmunity is well-reflected by the presence of antibodies against TPO. TPO-antibody positivity is associated with an increased risk of adverse pregnancy outcomes.
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Affiliation(s)
- W Edward Visser
- Erasmus MC, Department of Internal Medicine, Academic Center for Thyroid Diseases, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands.
| | - Robin P Peeters
- Erasmus MC, Department of Internal Medicine, Academic Center for Thyroid Diseases, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands
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Murillo-Llorente MT, Fajardo-Montañana C, Pérez-Bermejo M. Reference Values of Thyroid Hormones During the First Trimester of Pregnancy in Valencian Community (Spain) and Their Relationship with Iodine Intake. Nutrients 2020; 12:E1433. [PMID: 32429163 PMCID: PMC7284616 DOI: 10.3390/nu12051433] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/07/2020] [Accepted: 05/12/2020] [Indexed: 12/30/2022] Open
Abstract
Thyroid hormones require special monitoring during the first trimester of gestation. Local reference values should be applied if available, especially in iodine-deficient areas, as generalized iodine supplementation is controversial. The aim of the present study was to establish thyroid stimulating hormone (TSH) and free thyroxine (FT4) reference values in the first trimester of gestation in the Valencian community (Spain) and relate them to iodine intake. A total of 261 healthy pregnant women participated in the study. The calculated reference values were 0.128-4.455 mIU/L for TSH and 0.9-1.592 ng/dL for FT4. The upper TSH reference value for pregnant women in the first trimester in our environment was similar to the latest American Thyroid Association (ATA) recommendation (4 mIU/L). The mean TSH value was significantly lower in smokers, and there were no significant differences when analyzing the influence of iodine supplementation, although the low duration of supplement intake needs to be taken into consideration. Ioduria levels (median 57 µg/L) confirmed iodine deficiency. We found statistically significant differences in ioduria levels among patients who consumed iodized salt and iodine supplements and those who did not. It is essential to focus on recommending adequate consumption of iodized salt and iodine supplements prior to gestation and at least during the first trimester to avoid possible maternal thyroid dysfunction and perinatal complications.
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Affiliation(s)
- María Teresa Murillo-Llorente
- SONEV Research Group. School of Medicine and Health Sciences. Catholic University of Valencia San Vicente Mártir. C/Quevedo nº 2, 46001 Valencia, Spain;
| | - Carmen Fajardo-Montañana
- School of Medicine and Health Sciences. Catholic University of Valencia San Vicente Mártir. C/Quevedo nº 2, 46001 Valencia, Spain;
- Department of Endocrinology. Hospital Universitario de La Ribera. Carretera de Corbera, Km1. Alzira, 46600 Valencia, Spain
| | - Marcelino Pérez-Bermejo
- SONEV Research Group. School of Medicine and Health Sciences. Catholic University of Valencia San Vicente Mártir. C/Quevedo nº 2, 46001 Valencia, Spain;
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Bulur O, Atak Z, Ertugrul DT, Beyan E, Gunakan E, Karakaya S, Sahin K, Dal K. Trimester-specific reference intervals of thyroid function tests in Turkish pregnants. Gynecol Endocrinol 2020; 36:413-416. [PMID: 31532263 DOI: 10.1080/09513590.2019.1666817] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Physiological changes in hormone levels occur in thyroid gland during pregnancy. Screening of the thyroid hormone levels and determining trimester-specific reference intervals in pregnancy are important. Guidelines recommend the use of trimester-specific reference ranges for each country. The aim of this study is to determine trimester-specific thyroid function reference intervals for pregnancy in Turkish population. In total, 5000 patients were screened out of which 1258 patients have all of fT3, fT4 and TSH levels measured, were included in the study. Patients were grouped as follows: 482 women were in first trimester, 361 women were in second trimester, and 415 women were in third trimester. All analyses were performed by means of chemiluminescence methods (Liaison®; DiaSorin S.p.A., Saluggia, Italy). The TSH reference intervals were 0.005-3.65, 0.01-3.63, and 0.2-3.46 mIU/L at the first, the second, and the third trimesters of pregnancy, respectively. The fT4 reference intervals were 0.72-1.79, 0.71-1.26, and 0.65-1.12 ng/dL at the first, the second, and the third trimesters, respectively. The fT3 reference intervals were 2.45-4.03, 2.37-3.85, and 2.31-3.77 ng/dL at the first, the second, and the third trimesters, respectively. It is crucial to determine population- and gestational-specific reference intervals for trustworthy treatment of pregnants.
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Affiliation(s)
- Oktay Bulur
- Department of Internal Medicine, Ankara Kecioren Egitim ve Arastirma Hastanesi, Ankara, Turkey
| | - Zeliha Atak
- Department of Obstetrics and Gynecology, Ankara Kecioren Egitim ve Arastirma Hastanesi, Ankara, Turkey
| | - Derun Taner Ertugrul
- Department of Internal Medicine, Ankara Kecioren Egitim ve Arastirma Hastanesi, Ankara, Turkey
| | - Esin Beyan
- Department of Internal Medicine, Ankara Kecioren Egitim ve Arastirma Hastanesi, Ankara, Turkey
| | - Emre Gunakan
- Department of Obstetrics and Gynecology, Ankara Kecioren Egitim ve Arastirma Hastanesi, Ankara, Turkey
| | - Serdar Karakaya
- Department of Internal Medicine, Ankara Kecioren Egitim ve Arastirma Hastanesi, Ankara, Turkey
| | - Kubilay Sahin
- Department of Internal Medicine, Ankara Kecioren Egitim ve Arastirma Hastanesi, Ankara, Turkey
| | - Kursat Dal
- Department of Internal Medicine, Ankara Kecioren Egitim ve Arastirma Hastanesi, Ankara, Turkey
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Pramanik S, Mukhopadhyay P, Bhattacharjee K, Bhattacharjee R, Mukherjee B, Mondal SA, Bandhopadhay S, Biswas S, Chowdhury S, Ghosh S. Trimester-Specific Reference Intervals for Thyroid Function Parameters in Indian Pregnant Women during Final Phase of Transition to Iodine Sufficiency. Indian J Endocrinol Metab 2020; 24:160-164. [PMID: 32699783 PMCID: PMC7333744 DOI: 10.4103/ijem.ijem_561_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/12/2019] [Accepted: 12/16/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Interpretation of thyroid function tests during pregnancy depends on gestational age, method, and population-specific reference intervals. Therefore, there is a worldwide trend to establish trimester-specific levels for different populations. The aim of this study was to establish a trimester-specific reference range for thyroid function parameters during pregnancy in Indian women. MATERIALS AND METHODS Thyroid function tests (TSH, FT4, TT4, TT3) of 80, 76, and 73 women at 1st, 2nd, and 3rd trimester, respectively, and 168 nonpregnant women were analyzed after exclusion of low UIC(<150 μg/L) and anti-TPO positivity(>35 IU/ml). Urinary iodine excretion (UIC) was assessed in all. The 2.5th and 97.5th percentile values were used to determine the reference ranges for thyrotropin (TSH), free thyroxine (FT4), total thyroxine (TT4), and total triiodothyronine (TT3) for each trimester of pregnancy. RESULTS The reference range for TSH for first trimester was 0.19-4.34 μIU/ml, for second trimester 0.46-4.57 μIU/ml, and for third trimester 0.61-4.62 μIU/ml. The reference range during three trimesters for FT4 (ng/dl) was 0.88-1.32, 0.89-1.60, and 0.87-1.54, for total T4 (μg/dl) was 5.9-12.9, 7.4-15.2, and 7.9-14.9. In nonpregnant women, FT4 was 0.83-1.34, total T4 was 5.3-11.8, and TSH was 0.79-4.29. The mean UIC in nonpregnant women was 176 ± 15.7 μg/L suggesting iodine-sufficiency in the cohort. CONCLUSION The trimester-specific TSH range in pregnant women in this study is not significantly different from nonpregnant reference range in the final phase of transition to iodine sufficiency in India.
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Affiliation(s)
- Subhadip Pramanik
- Department of Endocrinology and Metabolism, I.P.G.M.E & R, Kolkata, West Bengal, India
| | - Pradip Mukhopadhyay
- Department of Endocrinology and Metabolism, I.P.G.M.E & R, Kolkata, West Bengal, India
| | | | - Rana Bhattacharjee
- Department of Endocrinology and Metabolism, I.P.G.M.E & R, Kolkata, West Bengal, India
| | - Bidisha Mukherjee
- Department of Endocrinology and Metabolism, I.P.G.M.E & R, Kolkata, West Bengal, India
| | - Samim Ali Mondal
- Department of Endocrinology and Metabolism, I.P.G.M.E & R, Kolkata, West Bengal, India
| | - Sandip Bandhopadhay
- Department of Biochemistry, KPC Medical College, Jadavpur, Kolkata, West Bengal, India
| | - Subhas Biswas
- Department of Gynaecology and Obstetrics, I.P.G.M.E and R, Kolkata, West Bengal, India
| | - Subhankar Chowdhury
- Department of Endocrinology and Metabolism, I.P.G.M.E & R, Kolkata, West Bengal, India
| | - Sujoy Ghosh
- Department of Endocrinology and Metabolism, I.P.G.M.E & R, Kolkata, West Bengal, India
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Thyroid function reference ranges during pregnancy in a large Chinese population and comparison with current guidelines. Chin Med J (Engl) 2019; 132:505-511. [PMID: 30807350 PMCID: PMC6415992 DOI: 10.1097/cm9.0000000000000051] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: A correct thyroid function reference range is important for the accurate diagnosis of thyroid disease during pregnancy. However, there is no consensus on whether thyroid function reference ranges in Chinese population should follow the America Thyroid Association (ATA) guidelines. This study aimed to establish a thyroid function reference range more suited to the Chinese population by evaluating the current thyroid function reference range in pregnant Chinese women and comparing it to the ATA guidelines. Methods: A total of 52,027 pregnant women were enrolled from January 2013 to December 2016. Thyroid stimulating hormone (TSH), free thyroxine (FT4), and thyroid peroxidase antibody (TPOAb) levels were tested during the first and third trimesters of pregnancy. Reference ranges of TSH and FT4 were established from the 2.5th and 97.5th percentiles of the TPOAb-negative population of women. The Mann-Whitney U test was used to compare thyroid hormones between the TPOAb-positive and TPOAb-negative groups. Results: We obtained that the TSH reference ranges were 0.03 to 3.52 mU/L and 0.39 to 3.67 mU/L, and the FT4 reference ranges were 11.7 to 19.7 pmol/L and 9.1 to 14.4 pmol/L, in the first and third trimester, respectively. If we used the 2011 ATA criteria about 7.0% and 4.0% pregnant women would be over diagnosed in first and third trimester, respectively, compared with local population thyroid hormone reference. When we compared our local criteria with the new 2017 ATA criteria, about 1.2% and 0.8% pregnant women would have a missed diagnosis in first and third trimester, respectively. Conclusions: Based on our data, which is in line with the current ATA guidelines, a population-based thyroid function reference range would be the first choice for diagnosis of thyroid disease during pregnancy in China. In case such population-based thyroid function reference ranges are unavailable in the east of China, our reference ranges can be adopted, if the same assay is used. Trial Registration: www.chictr.org.cn (No. ChiCTR1800014394).
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Ollero MD, Toni M, Pineda JJ, Martínez JP, Espada M, Anda E. Thyroid Function Reference Values in Healthy Iodine-Sufficient Pregnant Women and Influence of Thyroid Nodules on Thyrotropin and Free Thyroxine Values. Thyroid 2019; 29:421-429. [PMID: 30693851 DOI: 10.1089/thy.2018.0324] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Thyroid function assessment in pregnancy requires specific reference intervals stratified by gestational age and according to each laboratory method. Thyroid nodules may influence thyroid function in pregnant women. The aims of this study were to define the reference values of thyrotropin (TSH) and free thyroxine (fT4) in the three pregnancy trimesters in iodine-sufficient pregnant women, and to analyze the influence of thyroid nodules on thyroid function during pregnancy. METHODS This was a prospective, longitudinal study comprising 400 pregnant women with no history of thyroid disease and no medication influencing thyroid function. TSH, fT4, antithyroglobulin, and antithyroid peroxidase antibodies were measured each trimester by chemiluminescent immunoassays. Urinary iodine concentration was measured in the first trimester when a thyroid echography was also performed. Women with multiple gestation pregnancies, positive thyroid autoimmunity, TSH values >5 or <0.1 mIU/L with a simultaneous fT4 level above the general population reference value in the first trimester, or clinically significant thyroid nodules (nodules ≥1 cm and/or multiple nodules) were excluded to establish TSH and fT4 reference values. RESULTS Reference intervals in the first, second, and third trimesters were 0.13-4.16, 0.31-3.73, and 0.58-4.36 mIU/L, respectively, for TSH, and 0.85-1.24, 0.82-1.20, and 0.67-1.06 ng/dL, respectively, for fT4. The total prevalence of thyroid nodules was 28.8% [95% confidence interval (CI) 24.4-33.5%], and 6.0% of the participants showed clinically significant nodules. Pregnant women with thyroid nodules (n = 115) showed consistently lower TSH values during all pregnancy stages (first trimester: median 1.14 mIU/L [interquartile range (IQR) 0.53-1.75 mIU/L] vs. 1.48 mIU/L [IQR 0.94-2.19 mIU/L], p < 0.001; second trimester: 1.22 mIU/L [IQR 0.66-1.77 mIU/L] vs. 1.45 mIU/L [1.04-2.05 mIU/L], p = 0.001; third trimester: 1.74 mIU/L [IQR 1.08-2.36 mIU/L] vs. 1.93 mIU/L [IQR 1.37-2.58 mIU/L], p = 0.041) and higher fT4 values in the first trimester (M ± SD = 1.08 ± 0.14 ng/dL vs. 1.03 ± 0.12, p < 0.001) compared to those without nodules (n = 285). Both pregnant women with clinically significant thyroid nodules and those with nonsignificant ones had lower TSH values than women without nodules. CONCLUSIONS TSH/fT4 reference intervals in pregnant women from the authors' geographical area will thyroid dysfunction in pregnancy to be appropriately diagnosed. The prevalence of thyroid nodules is high in iodine-sufficient pregnant women, and is associated with low TSH values across pregnancy.
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Affiliation(s)
- M Dolores Ollero
- 1 Department of Endocrinology and Nutrition, Complejo Hospitalario de Navarra (CHN); Hospital García Orcoyen; Instituto de Investigación Sanitaria de Navarra (IdisNa), Navarra, Spain
| | - Marta Toni
- 2 Section of Endocrinology, Hospital García Orcoyen; Instituto de Investigación Sanitaria de Navarra (IdisNa), Navarra, Spain
| | - José Javier Pineda
- 1 Department of Endocrinology and Nutrition, Complejo Hospitalario de Navarra (CHN); Hospital García Orcoyen; Instituto de Investigación Sanitaria de Navarra (IdisNa), Navarra, Spain
| | - Juan Pablo Martínez
- 2 Section of Endocrinology, Hospital García Orcoyen; Instituto de Investigación Sanitaria de Navarra (IdisNa), Navarra, Spain
| | - Mercedes Espada
- 3 Clinical Chemistry Unit, Public Health Laboratory of Basque Government, Derio, Spain
| | - Emma Anda
- 1 Department of Endocrinology and Nutrition, Complejo Hospitalario de Navarra (CHN); Hospital García Orcoyen; Instituto de Investigación Sanitaria de Navarra (IdisNa), Navarra, Spain
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Donnay Candil S, Oleaga Alday A, Álvarez-García E. Valores de referencia de TSH en población gestante española. ¿Podemos unificar criterios? ENDOCRINOL DIAB NUTR 2019; 66:124-131. [DOI: 10.1016/j.endinu.2018.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 09/15/2018] [Accepted: 09/25/2018] [Indexed: 10/27/2022]
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Hypothyroidism during pregnancy and its association to perinatal and obstetric morbidity: a review. ACTA ACUST UNITED AC 2019; 65:107-113. [PMID: 29396214 DOI: 10.1016/j.endinu.2017.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 11/07/2017] [Accepted: 11/07/2017] [Indexed: 12/13/2022]
Abstract
There is currently no consensus among the different scientific societies on screening for thyroid dysfunction in the first trimester of pregnancy. Indeed, diagnosis and treatment of subclinical hypothyroidism during pregnancy are controversial, as no cut-off value for thyrotropin (TSH) is universally accepted. TSH measurement may be influenced by different factors throughout pregnancy, but especially during the first trimester. The association between overt hypothyroidism during pregnancy and obstetric and perinatal complications is well established. It is also accepted that thyroid hormones are important for neurodevelopment of the offspring. However, there is no scientific evidence available about the impact of subclinical hypothyroidism and its treatment during the first trimester of pregnancy on children's neurodevelopment. In recent years, studies conducted in the offspring of mothers with subclinical hypothyroidism have reported new biochemical parameters which may eventually serve as biomarkers of offspring neurodevelopment and which are more reproducible and are measured at an earlier time than the conventional clinical tests.
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Support for the upregulation of serum thyrotropin by estrogens coming from the increased requirement of levothyroxine in one gynecomastic patient with excess of thyroxine-binding globulin secondary to exposure to exogenous estrogens. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY CASE REPORTS 2018. [DOI: 10.1016/j.jecr.2018.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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18
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Derakhshan A, Shu H, Broeren MAC, de Poortere RA, Wikström S, Peeters RP, Demeneix B, Bornehag CG, Korevaar TIM. Reference Ranges and Determinants of Thyroid Function During Early Pregnancy: The SELMA Study. J Clin Endocrinol Metab 2018; 103:3548-3556. [PMID: 29982605 DOI: 10.1210/jc.2018-00890] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 06/27/2018] [Indexed: 12/13/2022]
Abstract
CONTEXT Establishing reference ranges as well as identifying and quantifying the determinants of thyroid function during pregnancy is important for proper clinical interpretation and optimizing research efforts. However, such data are sparse, specifically for triiodothyronine measurements, and most studies do not take into account thyroid antibodies or human chorionic gonadotropin. OBJECTIVE To determine reference ranges and to identify/quantify determinants of TSH, free T4 (FT4), free triiodothyronine (FT3), total T4 (TT4), and total triiodothyronine (TT3). DESIGN, SETTING, AND PARTICIPANTS This study included 2314 participants of the Swedish Environmental Longitudinal, Mother and child, Asthma and allergy study, a population-based prospective pregnancy cohort of mother-child pairs. Reference ranges were calculated by 2.5th to 97.5th percentiles after excluding thyroperoxidase antibody (TPOAb)-positive and/or thyroglobulin antibody (TgAb)-positive women. INTERVENTION None. MAIN OUTCOME MEASURES TSH, FT4, FT3, TT4, and TT3 in prenatal serum. RESULTS After exclusion of TPOAb-positive women, reference ranges were as follows: TSH, 0.11 to 3.48 mU/L; FT4, 11.6 to 19.4 pmol/L; FT3, 3.72 to 5.92 pg/mL; TT4, 82.4 to 166.2 pmol/L; and TT3, 1.28 to 2.92 nmol/L. Additional exclusion of TgAb-positive women did not change the reference ranges substantially. Exposure to tobacco smoke, as assessed by questionnaires and serum cotinine, was associated with lower TSH and higher FT3 and TT3. Body mass index (BMI) and gestational age were the main determinants of TSH (only for BMI), FT4, FT3, TT4, and TT3. CONCLUSIONS We show that the exclusion of TgAb-positive women on top of excluding TPOAb-positive women hardly affects clinical reference ranges. We identified various relevant clinical determinants of TSH, FT4, FT3, TT4, and TT3 that could reflect endocrine-disrupting effects and/or effects on thyroid hormone transport or deiodination.
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Affiliation(s)
- Arash Derakhshan
- Academic Center for Thyroid Diseases, Erasmus MC, GE Rotterdam, Netherlands
- Department of Internal Medicine, Erasmus MC, GE Rotterdam, Netherlands
| | - Huan Shu
- Department of Environmental Science and Analytical Chemistry, Stockholm University, Stockholm, Sweden
| | - Maarten A C Broeren
- Laboratory of Clinical Chemistry and Haematology, Máxima Medical Centre, Veldhoven, DB Veldhoven, Netherlands
| | - Ralph A de Poortere
- Laboratory of Clinical Chemistry and Haematology, Máxima Medical Centre, Veldhoven, DB Veldhoven, Netherlands
| | - Sverre Wikström
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Robin P Peeters
- Academic Center for Thyroid Diseases, Erasmus MC, GE Rotterdam, Netherlands
- Department of Internal Medicine, Erasmus MC, GE Rotterdam, Netherlands
| | - Barbara Demeneix
- Laboratoire d'Evolution des Régulations Endocriniennes, Muséum National d'Histoire Naturelle, Paris, France
| | - Carl-Gustaf Bornehag
- Department of Health Sciences, Karlstad University, Karlstad, Sweden
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Tim I M Korevaar
- Academic Center for Thyroid Diseases, Erasmus MC, GE Rotterdam, Netherlands
- Department of Internal Medicine, Erasmus MC, GE Rotterdam, Netherlands
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Kim HJ, Cho YY, Kim SW, Kim TH, Jang HW, Lee SY, Choi SJ, Roh CR, Kim JH, Chung JH, Oh SY. Reference intervals of thyroid hormones during pregnancy in Korea, an iodine-replete area. Korean J Intern Med 2018; 33:552-560. [PMID: 28171716 PMCID: PMC5943647 DOI: 10.3904/kjim.2016.051] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 07/05/2016] [Accepted: 07/19/2016] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS Maternal thyroid dysfunction has been associated with adverse pregnancy outcomes. The purpose of our study was to establish trimester-specific reference intervals for thyroid hormones in pregnant women in Korea, where iodine intake is more than adequate and to examine pregnancy and perinatal outcomes in their offspring. METHODS Among 459 healthy pregnant women who were screened, we enrolled 417 subjects who had negative results for thyroid autoantibodies. Serum thyroid stimulating hormone (TSH) and free thyroxine were measured using an immunoradiometric assay. Urine iodine concentration was measured using inductively coupled plasma-mass spectrometry in 275 women. Reference ranges of thyroid hormones were determined according to the guidelines of the National Academy of Clinical Biochemistry. Pregnancy and perinatal outcomes were compared according to maternal thyroid function. RESULTS The reference ranges of serum TSH were 0.03 to 4.24 mIU/L in the first trimester, 0.13 to 4.84 mIU/L in the second trimester, and 0.30 to 5.57 mIU/L in the third trimester. Pregnancy and perinatal outcomes did not vary in mothers with subtle changes in thyroid function. CONCLUSIONS Trimester-specific thyroid hormone reference intervals in Korean pregnant women differ from those of other countries with different iodine nutrition status and ethnicity. The establishment of population-based, reliable trimester-specific reference intervals is critical for the interpretation of thyroid function in pregnant women to avoid unnecessary tests and treatments.
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Affiliation(s)
- Hye Jeong Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Soonchunhyang University Hospital Seoul, Seoul Korea
| | - Yoon Young Cho
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
- Department of Medicine, Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Sun Wook Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Hyuk Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Won Jang
- Department of Medical Education, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo-Youn Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Suk-Joo Choi
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Cheong-Rae Roh
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong-Hwa Kim
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Hoon Chung
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo-young Oh
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Correspondence to Soo-young Oh, M.D. Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea Tel: +82-2-3410-3517 Fax: +82-2-3410-0630 E-mail:
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Rotondi M, Chiovato L, Pacini F, Bartalena L, Vitti P. Management of Subclinical Hypothyroidism in Pregnancy: A Comment from the Italian Society of Endocrinology and the Italian Thyroid Association to the 2017 American Thyroid Association Guidelines-"The Italian Way". Thyroid 2018; 28:551-555. [PMID: 29644934 DOI: 10.1089/thy.2017.0424] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The 2017 American Thyroid Association guidelines for the diagnosis and management of thyroid disease during pregnancy and the postpartum were published six years after the previous ones. They provide comprehensive clinical recommendations for the whole spectrum of thyroid diseases, as well as for optimal iodine intake during pregnancy, postpartum, and lactation. The present position statement mainly regards the recommended flow chart for therapeutic decision making in pregnant women being diagnosed with subclinical hypothyroidism. Here, we comment on the major biochemical and clinical situations and the corresponding therapeutic recommendations. In particular, we welcome the critical revision of the thyrotropin (TSH) reference range in pregnancy, and we agree that there is no need to treat thyroid peroxidase antibody-negative women with a serum TSH ranging from 2.5 μIU/mL to the upper limit of the reference range. This recommendation will hopefully reduce the huge proportion of healthy pregnant women in whom, according to the previous guidelines, levothyroxine therapy had to be initiated. On the other hand, we are concerned with the recommendation to only "consider treatment" in thyroid peroxidase antibody-negative pregnant women with a serum TSH ranging from the upper limit of the reference range to 10.0 μIU/mL. This is because thyroid antibodies may be falsely negative during gestation, and serum negative chronic autoimmune thyroiditis is a well-known clinical entity even outside pregnancy. Based on these and other arguments, we recommend treatment with levothyroxine in pregnant women with TSH levels ranging between the upper limit of the reference range and 10.0 μIU/mL independently from their thyroid antibody status.
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Affiliation(s)
- Mario Rotondi
- 1 Unit of Internal Medicine and Endocrinology, ICS-Maugeri, Laboratory for Endocrine Disruptors and Chair of Endocrinology University of Pavia , Pavia, Italy
| | - Luca Chiovato
- 1 Unit of Internal Medicine and Endocrinology, ICS-Maugeri, Laboratory for Endocrine Disruptors and Chair of Endocrinology University of Pavia , Pavia, Italy
| | - Furio Pacini
- 2 Department of Medical, Surgical, and Neurological Sciences, University of Siena , Siena, Italy
| | - Luigi Bartalena
- 3 Department of Medicine and Surgery, Endocrine Unit, University of Insubria , ASST dei Sette Laghi, Ospedale di Circolo, Varese, Italy
| | - Paolo Vitti
- 4 Department of Clinical and Experimental Medicine, Endocrinology Section, University of Pisa , Pisa, Italy
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Circulating thyrotropin is upregulated by estradiol. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2018; 11:11-17. [PMID: 29725582 PMCID: PMC5928282 DOI: 10.1016/j.jcte.2018.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 01/30/2018] [Accepted: 02/12/2018] [Indexed: 01/26/2023]
Abstract
After encountering two women with serum thyrotropin (TSH) levels greater in periovulatory phase than in other days of the menstrual cycle, we hypothesized that TSH levels could be sensitive to changes in circulating estrogens in women. The objective of this study was to evaluate whether serum TSH increases after an induced acute increase of serum estradiol, and compare serum TSH increase with that of prolactin (PRL) which is a classic estradiol-upregulated pituitary hormone. In this retrospective study, we resorted to stored frozen sera from 55 women who had undergone the GnRH agonist (buserelin)-acute stimulation test of ovarian steroidogenesis. This test, that is preceded by dexamethasone administration to suppress adrenal steroidogenesis, had been performed to show an increased buserelin-stimulated response of 17-hydroxyprogesterone, a response that is frequent in polycystic ovary syndrome. Fifty-five women had enough serum volume at pertinent times (first observation early in the follicular phase and all times of the test) to permit assay of serum estradiol, TSH and PRL. Before dexamethasone administration, estradiol averaged 26.4 ± 15.5 pg/ml (reference range 23–139, follicular phase), TSH 1.78 ± 0.86 mU/L (reference range 0.3–4.2) and PRL 409.4 ± 356 mU/L (reference range 70.8–556) (mean ± SD). Serum estradiol, TSH and PRL averaged 47.2 ± 27 pg/ml, 0.77 ± 0.48 mU/L and 246.4 ± 206.8 mU/L just prior to the buserelin injection, but they peaked at 253.4 ± 113.5 pg/ml (nv 83–495, midcycle), 3.30 ± 1.65 mU/L and 540.3 ± 695.2 mU/L after injection. The responses to buserelin of estradiol, TSH and PRL were of wide magnitude. There was a significant correlation between TSH peak and serum estradiol peak, betweeen AUC0-24 h-TSH and AUC0-24 h-estradiol, or between PRL peak and estradiol peak and AUC0-24 h -PRL and AUC0-24 h-estradiol in only a subgroup of women. Therefore, women with estradiol-dependent increase in serum TSH do exist. Reference bands of serum TSH dependent on the phases of the menstrual cycle should be available.
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Key Words
- 17-OHPg, 17-hydroxyprogesterone
- AUC, area under the curve
- Buserelin
- E2, estradiol
- Estradiol
- FSH, follicle-stimulating hormone
- FT3, free T3
- GnRH, gonadotropin-releasing hormone
- LH, luteinizing hormone
- Menstrual cycle
- PCOS, polycystic ovary syndrome
- PRL, prolactin
- Polycystic ovary syndrome
- Prolactin
- T3, triiodothyronine
- T4, thyroxine
- TRH, TSH-releasing hormone
- TSH, thyrotropin
- Thyrotropin
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Hypothyroidism during pregnancy and its association to perinatal and obstetric morbidity: a review. ENDOCRINOLOGÍA, DIABETES Y NUTRICIÓN (ENGLISH ED.) 2018. [DOI: 10.1016/j.endien.2017.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Nazarpour S, Ramezani Tehrani F, Simbar M, Minooee S, Rahmati M, Mansournia MA, Azizi F. Establishment of trimester-specific reference range for thyroid hormones during pregnancy. Clin Biochem 2018; 53:49-54. [PMID: 29337034 DOI: 10.1016/j.clinbiochem.2018.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 01/10/2018] [Accepted: 01/10/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Physiological gestational changes are associated with alterations in thyroid function which require different biochemical interpretation from that of non-pregnant women and necessitate established pregnancy-specific reference ranges. We aimed to identify the trimester-specific ranges of thyroid markers in a healthy population of pregnant Iranian women. METHODS In this self-sequential study, data were extracted from The Tehran Thyroid and Pregnancy Study; a total of 314 women were tested during the 1st, 2nd and 3rd trimesters for serum levels of thyrotropin (TSH), thyroxine (T4), free thyroxine index (FT4I) and thyroid peroxidase antibody (TPOAb). Trimester-specific reference intervals for TSH, T4 and FT4I and first trimester reference range for TPOAb were estimated. The normal and modulus exponential-normal models were fitted by maximum likelihood using STATA software. The 2.5th and 97.5th percentiles of thyroid parameters were determined and used as reference intervals. RESULTS Mean±SD age of participants was 26.8±5.2years. Estimated reference intervals for TSH, T4 and FT4I in the 1st, 2nd and 3rd trimesters corresponding to the 2.5th and 97.5th percentiles were 0.14-6.14, 0.43-4.64, 0.63-3.9μIU/ml; 78.01-215.19, 93.23-243.87, 89.61-211.37nmol/L; and 1.73-4.53, 1.96-5.64, 1.72-4.30, respectively. Reference interval for TPOAb in the 1st trimester was 1.40-38.02IU/mL. Median of TSH was low in the 1st trimester, and gradually increased until 2nd trimester, followed by a slight decrease onward. A decreasing trend in TSH levels was observed in higher centiles with advancing gestational age. CONCLUSION This study provides trimester-specific reference ranges for some common thyroid markers among healthy Iranian women in an iodine sufficient area, to prevent biochemical misinterpretations during pregnancy.
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Affiliation(s)
- Sima Nazarpour
- Department of Midwifery, Varamin-Pishva Branch, Islamic Azad University, Tehran, Iran; Reproductive Endocrinology 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.
| | - Masoumeh Simbar
- Midwifery and Reproductive Health Research Center, Department of Midwifery and Reproductive Health, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sonia Minooee
- Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Rahmati
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran; Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Mansournia
- 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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López-Tinoco C, Rodríguez-Mengual A, Lara-Barea A, Barcala J, Larrán L, Saez-Benito A, Aguilar-Diosdado M. Impact of positive thyroid autoimmunity on pregnant women with subclinical hypothyroidism. ACTA ACUST UNITED AC 2018; 65:150-155. [PMID: 29317172 DOI: 10.1016/j.endinu.2017.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 11/04/2017] [Accepted: 11/09/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The impact of subclinical hypothyroidism (SH) and thyroid autoimmunity on obstetric and perinatal complications continues to be a matter of interest and highly controversial. AIM To assess the impact of SH and autoimmunity in early pregnancy on the obstetric and perinatal complications in our population. MATERIAL AND METHOD A retrospective cohort study in 435 women with SH (TSH ranging from 3.86 and 10 μIU/mL and normal FT4 values) in the first trimester of pregnancy. Epidemiological and clinical parameters were analyzed and were related to obstetric and perinatal complications based on the presence of autoimmunity (thyroid peroxidase antibodies [TPO] > 34 IU/mL). RESULTS Mean age was 31.3 years (SD 5.2). Seventeen percent of patients had positive TPO antibodies. Presence of positive autoimmunity was associated to a family history of hypothyroidism (P=.04) and a higher chance of miscarriage (P=.009). In the multivariate analysis, positive TPO antibodies were associated to a 10.25-fold higher risk of miscarriage. No statistically significant associations were found with all other obstetric and perinatal complications. CONCLUSIONS In our region, pregnant women with SH and thyroid autoimmunity had a higher risk of miscarriage but not of other obstetric and perinatal complications.
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Affiliation(s)
- Cristina López-Tinoco
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta del Mar, Departamento de Medicina, Facultad de Medicina, Universidad de Cádiz, Cádiz, España.
| | | | - Almudena Lara-Barea
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta del Mar, Cádiz, España
| | - Julia Barcala
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta del Mar, Cádiz, España
| | - Laura Larrán
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta del Mar, Cádiz, España
| | - Ana Saez-Benito
- Servicio de Análisis Clínico, Hospital Universitario Puerta del Mar, Cádiz, España
| | - Manuel Aguilar-Diosdado
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta del Mar, Departamento de Medicina, Facultad de Medicina, Universidad de Cádiz, Cádiz, España
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Gao X, Li Y, Li J, Liu A, Sun W, Teng W, Shan Z. Gestational TSH and FT4 Reference Intervals in Chinese Women: A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2018; 9:432. [PMID: 30123185 PMCID: PMC6086137 DOI: 10.3389/fendo.2018.00432] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 07/13/2018] [Indexed: 01/11/2023] Open
Abstract
Background: Serum thyroid-stimulating hormone (TSH) and free thyroxine (FT4) change dynamically during pregnancy. Differences in geographic regions, populations, and manufacturer's methodologies can affect the reference intervals for thyroid function tests. The 2017 guidelines of the American Thyroid Association (ATA) recommended 4.0 mU/L as the cut-off point for the upper limit of serum TSH in early pregnancy. A systematic review is called for to establish practical, gestational-specific TSH and FT4 reference intervals for pregnant Chinese women and to explore whether the criteria are suitable for China. Methods: English and Chinese articles published from inception to Aug 2017 were searched in the PubMed, EMBASE, and SCIE English-language databases and the CNKI, WanFang, and CQVIP Chinese databases. The relative descent or ascent rates of serum TSH and FT4 were calculated, after which Comprehensive Meta-Analysis V2.0 software was used to analyze the data. Results: Eleven studies (6 in English and 5 in Chinese), five kits and 11,629 Chinese women from nine cities were considered in this meta-analysis. Compared with the reference ranges provided by manufacturers, serum TSH decreased in the first trimester, with the upper limit declining by 21.7% (5.0-36.6%), to a value close to 4.0 mU/L, and the lower limit declining by 85.7% (73.5-97.1%). It continued decreasing in the second trimester, with the upper limit declining by 24.0% (6.4-40.9%) and the lower limit declining by 40.7% (9.0-85.7%). For FT4, the upper limit fluctuated slightly, and the lower limit increased by 6.8% (1.0-14.6%) in the first trimester. Serum FT4 dropped gradually, with the upper limit declining by 21.8% (2.5-31.8%) and the lower limit declining by 12.7% (2.6-19.6%) in the second trimester. During the third trimester, the upper limit decreased by 25.1% (12.7-35.0%), while the lower limit decreased by 20.9% (14.8-27.3%). Conclusions: Various regions, kits and test methods affect the gestational TSH and FT4 levels. The non-pregnant serum TSH upper limit minus 22% is very close to 4.0 mU/L, which can be used as a sub-optimal approach to represent the cut-off value for pregnant Chinese women in the first trimester.
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Affiliation(s)
- Xiaotong Gao
- Department of Endocrinology and Metabolism, Institute of Endocrinology, Liaoning Provincial Key Laboratory of Endocrine Diseases, The First Affiliated Hospital of China Medical University, China Medical University, Shenyang, China
| | - Yongze Li
- Department of Endocrinology and Metabolism, Institute of Endocrinology, Liaoning Provincial Key Laboratory of Endocrine Diseases, The First Affiliated Hospital of China Medical University, China Medical University, Shenyang, China
| | - Jiashu Li
- Department of Endocrinology and Metabolism, Institute of Endocrinology, Liaoning Provincial Key Laboratory of Endocrine Diseases, The First Affiliated Hospital of China Medical University, China Medical University, Shenyang, China
| | - Aihua Liu
- Department of Endocrinology and Metabolism, Institute of Endocrinology, Liaoning Provincial Key Laboratory of Endocrine Diseases, The First Affiliated Hospital of China Medical University, China Medical University, Shenyang, China
| | - Wei Sun
- Department of Thyroid Surgery, The First Affiliated Hospital of China Medical University, China Medical University, Shenyang, China
| | - Weiping Teng
- Department of Endocrinology and Metabolism, Institute of Endocrinology, Liaoning Provincial Key Laboratory of Endocrine Diseases, The First Affiliated Hospital of China Medical University, China Medical University, Shenyang, China
| | - Zhongyan Shan
- Department of Endocrinology and Metabolism, Institute of Endocrinology, Liaoning Provincial Key Laboratory of Endocrine Diseases, The First Affiliated Hospital of China Medical University, China Medical University, Shenyang, China
- *Correspondence: Zhongyan Shan
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Castillo Lara M, Vilar Sánchez Á, Cañavate Solano C, Soto Pazos E, Iglesias Álvarez M, González Macías C, Ayala Ortega C, Moreno Corral LJ, Fernández Alba JJ. "Hypothyroidism screening during first trimester of pregnancy". BMC Pregnancy Childbirth 2017; 17:438. [PMID: 29273014 PMCID: PMC5741893 DOI: 10.1186/s12884-017-1624-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 12/12/2017] [Indexed: 12/27/2022] Open
Abstract
Background Subclinical hypothyroidism is defined as an elevated thyroid-stimulating hormone level with a normal thyroxin level without signs or symptoms of hypothyroidism. Although it is well accepted that overt hypothyroidism has a deleterious impact on pregnancy, recent studies indicate that subclinical hypothyroidism may affect maternal and fetal health. Studies suggest an association between miscarriage and preterm delivery in euthyroid women positive for anti-peroxidase antibodies and/or anti-thyroglobulin antibodies. A proposal of a new set-point to diagnose SCH was recently published. The aim of this research was to determine the optimal thyroid-stimulating hormone cut-off point to screen for subclinical hypothyroidism in the first trimester of gestation in a population of our clinical area and to determine the diagnostic value of this screening test for detecting anti-thyroid peroxidase antibodies. Methods This cross-sectional study determines the cutoff point for SCH screening and evaluates its usefulness to detect TPO Ab using the Receiver Operating Characteristics (ROC) curve. Prevalence of SCH was calculated using as cut-off 2.5 mIU/L, 4 mIU/L, and our TSH 97.5th percentile. The ability to detect positive anti-thyroglobulin antibodies (TG Ab) and anti-thyroid peroxidase antibodies (TPO Ab) in patients with levels of TSH >97.5th percentile was determined by ROC curves. Results The mean, range and standard deviation of TSH was 2.15 ± 1.34 mIU/L (range 0.03–8.82); FT4 was 1.18 ± 0.13 ng/dL (range 0.94–1.3); TG Ab was 89.87 ± 413.56 IU/mL (range 0.10–4000); and TPO Ab was 21.61 ± 46.27 IU/mL(range 0.10–412.4). The ROC. analysis of the ability of the TSH level to predict the presence of positive TPO Ab found an AUC of 0.563. Conclusion In our population, the TSH cutoff value for gestational SCH screening is 4.7 mIU/L. Using the SEGO recommended 2.5 mIU/L TSH cut-off point, the prevalence of SCH is 37%. Applying the ATA 2017 recommended cutoff point of 4 mIU/L, the prevalence of SCH is 9.6%. Finally, when the cut-off of 4.7 mIU/L (our 97.5th centile) was used, the SCH prevalence is 5%. TSH levels in the first trimester of pregnancy are not useful to detect TPO Ab.
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Affiliation(s)
- María Castillo Lara
- Department of Obstetrics and Gynecology, University Hospital of Puerto Real, Ctra. Nac. IV, km 665. Puerto Real, Cádiz, Spain
| | - Ángel Vilar Sánchez
- Department of Obstetrics and Gynecology, University Hospital of Puerto Real, Ctra. Nac. IV, km 665. Puerto Real, Cádiz, Spain
| | - Consuelo Cañavate Solano
- Department of Clinical Analyses, University Hospital of Puerto Real, Crta Nac. IV, km 655. Puerto Real, Cádiz, Spain
| | - Estefanía Soto Pazos
- Department of Obstetrics and Gynecology, University Hospital of Puerto Real, Ctra. Nac. IV, km 665. Puerto Real, Cádiz, Spain
| | - María Iglesias Álvarez
- Department of Obstetrics and Gynecology, University Hospital of Puerto Real, Ctra. Nac. IV, km 665. Puerto Real, Cádiz, Spain
| | - Carmen González Macías
- Department of Obstetrics and Gynecology, University Hospital of Puerto Real, Ctra. Nac. IV, km 665. Puerto Real, Cádiz, Spain
| | - Carmen Ayala Ortega
- Department of Endocrinology, University Hospital of Puerto Real, Crta Nac. IV, km 655. Puerto Real, Cádiz, Spain
| | | | - Juan Jesús Fernández Alba
- Department of Obstetrics and Gynecology, University Hospital of Puerto Real, Ctra. Nac. IV, km 665. Puerto Real, Cádiz, Spain.
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[Thyrotropin reference ranges during pregnancy in the province of Huelva, Spain]. Semergen 2017; 44:372-379. [PMID: 29162475 DOI: 10.1016/j.semerg.2017.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/26/2017] [Accepted: 08/16/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The correct diagnosis of hypothyroidism during pregnancy requires knowledge of the local trimester-specific thyrotropin (TSH) reference ranges. When these are not available, the guidelines recommend upper limits of 2.5, 3.0, and 3.0μU/ml for the 1st, 2nd, and 3rd trimesters, respectively. The aim is to establish the reference range for our local population. MATERIAL AND METHODS A population-based observational study was performed on healthy pregnant women from 11 healthcare centres in the province of Huelva. Women were recruited consecutively during 2016 through the pregnancy process. Women were excluded who had a history of thyroid or medical disease, a poor obstetric history, multiple pregnancy, thyroid autoimmunity, and extreme TSH values (<0.4μU/ml or>10μU/ml), as well as women treated with levothyroxine for thyroid dysfunction. RESULTS The study included a total of 186 pregnant women, with a mean age of 30.7 years (95% CI: 29.8-31.6) and a body mass index (BMI) of 23.6 (95% CI: 23.2-24.0). Most of them had the first laboratory tests performed before week 11 of pregnancy. Valid subjects for analysis were 145, 105, and 67 pregnant women in the 1st, 2nd, and 3rd trimesters, respectively, after excluding those due to abortion (18.9%), autoimmunity (6.5%), hypo/hyperthyroidism (2.2%), and levothyroxine treatment during the 2nd/3rd trimester (18.6%). The 97.5% TSH percentile for the 1st, 2nd, and 3rd trimester was 4.68, 4.83, and 4.57μU/ml, respectively. Thyroid dysfunction was identified in 80 women (55.2%), 33 of whom received treatment with Levothyroxine (22.7%). With the new criteria, thyroid dysfunction prevalence would be reduced to 6.2%, and the need for treatment to 4.1%. CONCLUSION The reference range for TSH in our population differs from that proposed by the guidelines. Unnecessary treatment was being given to 18.6% of pregnant women.
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Ho CKM, Tan ETH, Ng MJ, Yeo GSH, Chern B, Tee NWS, Kwek KYC, Tan KH. Gestational age-specific reference intervals for serum thyroid hormone levels in a multi-ethnic population. Clin Chem Lab Med 2017; 55:1777-1788. [PMID: 28391251 DOI: 10.1515/cclm-2016-0790] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 03/06/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Thyroid disorders are common during pregnancy. To date, a limited number of studies have reported differences in serum thyroid hormone concentrations between different ethnic groups. We sought to establish gestational age-specific reference intervals for serum levels of thyroid hormones in a multi-ethnic population and investigate whether separate reference intervals should be used for different ethnic groups. METHODS A total of 926 pregnant women from multiple ethnic groups attended four separate study visits spanning the three trimesters. Venous blood samples were taken at 9 to 14 weeks, 18 to 22 weeks, 28 to 32 weeks, and 34 to 39 weeks of gestation. Serum concentrations of thyroid-stimulating hormone (TSH), free thyroxine (T4), free triiodothyronine (T3), total T4, total T3, thyroid peroxidase antibody and thyroglobulin antibody were measured using Abbott Architect immunoassays. A total of 562 women with singleton pregnancies were found to be negative for both thyroid autoantibodies at all four study visits and thus included in the reference sample group for the establishment of reference intervals (2.5th to 97.5th percentiles). RESULTS Reference intervals for serum thyroid hormones at 9-14 weeks of gestation derived from the combined group of pregnant women are as follows: TSH, 0.01-2.39 mIU/L; free T4, 11.4-19.5 pmol/L; free T3, 4.23-6.69 pmol/L; total T4, 77.8-182.4 nmol/L; total T3, 1.39-2.97 nmol/L. No differences in the five thyroid parameters' reference intervals are detectable among the ethnic groups except that at study visit 3 (28-32 weeks of gestation), the upper reference limit of total T3 in Malays (3.20 nmol/L; 90% CI, 2.99-3.76 nmol/L) is slightly higher than that in Chinese (2.86 nmol/L; 90% CI, 2.70-2.98 nmol/L). CONCLUSIONS The findings from this study on a multi-ethnic cohort highlight the importance of establishing locally derived and gestational age-specific reference intervals for the five thyroid hormone parameters.
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Liu J, Yu X, Xia M, Cai H, Cheng G, Wu L, Li Q, Zhang Y, Sheng M, Liu Y, Qin X. Development of gestation-specific reference intervals for thyroid hormones in normal pregnant Northeast Chinese women: What is the rational division of gestation stages for establishing reference intervals for pregnancy women? Clin Biochem 2017; 50:309-317. [DOI: 10.1016/j.clinbiochem.2016.11.036] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 11/24/2016] [Accepted: 11/29/2016] [Indexed: 11/16/2022]
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Joosen AMCP, van der Linden IJM, de Jong-Aarts N, Hermus MAA, Ermens AAM, de Groot MJM. TSH and fT4 during pregnancy: an observational study and a review of the literature. Clin Chem Lab Med 2017; 54:1239-46. [PMID: 26641966 DOI: 10.1515/cclm-2015-0629] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 10/23/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Trimester-specific reference intervals for TSH are recommended to assess thyroid function during pregnancy due to changes in thyroid physiology. Laboratories should verify reference intervals for their population and assay used. No consistent upper reference limit (URL) for TSH during pregnancy is reported in literature. We investigated the use of non-pregnant reference intervals for TSH, recommended during pregnancy by current Dutch guidelines, by deriving trimester-specific reference intervals in disease-free Dutch pregnant women as these are not available. METHODS Apparently healthy low risk pregnant women were recruited via midwifery practices. Exclusion criteria included current or past history of thyroid or other endocrine disease, multiple pregnancy, use of medication known to influence thyroid function and current pregnancy as a result of hormonal stimulation. Women who were TPO-antibody positive, miscarried, developed hyperemesis gravidarum, hypertension, pre-eclampsia, HELLP, diabetes or other disease, delivered prematurely or had a small for gestational age neonate were excluded. Blood samples were collected at 9-13 weeks (n=99), 27-29 weeks (n=96) and 36-39 weeks (n=96) of gestation and at 4-13 weeks post-partum (n=95). Sixty women had complete data during pregnancy and post-partum. All analyses were performed on a Roche Cobas e601 analyser. RESULTS AND CONCLUSIONS In contrast to current Dutch guidelines, the 97.5th percentiles of TSH in the first (3.39 mIU/L) and second trimesters (3.38 mIU/L) are well under the non-pregnant URL of 4.0 mIU/L. The higher TSH in the third trimester (97.5th percentile 3.85 mIU/L) is close to the current non-pregnant URL of 4.0 mIU/L. Absolute intra-individual TSH is relatively stable during pregnancy and post-partum as individuals tracked within the tertile assigned in trimester 1. Even small deviations within the population reference interval may indicate subtle thyroid dysfunction.
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Alexander EK, Pearce EN, Brent GA, Brown RS, Chen H, Dosiou C, Grobman WA, Laurberg P, Lazarus JH, Mandel SJ, Peeters RP, Sullivan S. 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum. Thyroid 2017; 27:315-389. [PMID: 28056690 DOI: 10.1089/thy.2016.0457] [Citation(s) in RCA: 1346] [Impact Index Per Article: 192.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Thyroid disease in pregnancy is a common clinical problem. Since the guidelines for the management of these disorders by the American Thyroid Association (ATA) were first published in 2011, significant clinical and scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid disease in women during pregnancy, preconception, and the postpartum period. METHODS The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles were eligible for inclusion. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations. The guideline task force had complete editorial independence from the ATA. Competing interests of guideline task force members were regularly updated, managed, and communicated to the ATA and task force members. RESULTS The revised guidelines for the management of thyroid disease in pregnancy include recommendations regarding the interpretation of thyroid function tests in pregnancy, iodine nutrition, thyroid autoantibodies and pregnancy complications, thyroid considerations in infertile women, hypothyroidism in pregnancy, thyrotoxicosis in pregnancy, thyroid nodules and cancer in pregnant women, fetal and neonatal considerations, thyroid disease and lactation, screening for thyroid dysfunction in pregnancy, and directions for future research. CONCLUSIONS We have developed evidence-based recommendations to inform clinical decision-making in the management of thyroid disease in pregnant and postpartum women. While all care must be individualized, such recommendations provide, in our opinion, optimal care paradigms for patients with these disorders.
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Affiliation(s)
- Erik K Alexander
- 1 Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Elizabeth N Pearce
- 2 Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine , Boston, Massachusetts
| | - Gregory A Brent
- 3 Department of Medicine, VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA , Los Angeles, California
| | - Rosalind S Brown
- 4 Division of Endocrinology, Boston Children's Hospital , Harvard Medical School, Boston, Massachusetts
| | - Herbert Chen
- 5 Department of Surgery, University of Alabama at Birmingham , Birmingham, Alabama
| | - Chrysoula Dosiou
- 6 Division of Endocrinology, Stanford University School of Medicine , Stanford, California
| | - William A Grobman
- 7 Department of Obstetrics and Gynecology, Northwestern University , Chicago, Illinois
| | - Peter Laurberg
- 8 Departments of Endocrinology & Clinical Medicine, Aalborg University Hospital , Aalborg, Denmark
| | - John H Lazarus
- 9 Institute of Molecular Medicine, Cardiff University , Cardiff, United Kingdom
| | - Susan J Mandel
- 10 Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Robin P Peeters
- 11 Department of Internal Medicine and Rotterdam Thyroid Center, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Scott Sullivan
- 12 Department of Obstetrics and Gynecology, Medical University of South Carolina , Charleston, South Carolina
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Springer D, Jiskra J, Limanova Z, Zima T, Potlukova E. Thyroid in pregnancy: From physiology to screening. Crit Rev Clin Lab Sci 2017; 54:102-116. [PMID: 28102101 DOI: 10.1080/10408363.2016.1269309] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Thyroid hormones are crucial for the growth and maturation of many target tissues, especially the brain and skeleton. During critical periods in the first trimester of pregnancy, maternal thyroxine is essential for fetal development as it supplies thyroid hormone-dependent tissues. The ontogeny of mature thyroid function involves organogenesis, and maturation of the hypothalamus, pituitary and the thyroid gland; and it is almost complete by the 12th-14th gestational week. In case of maternal hypothyroidism, substitution with levothyroxine must be started in early pregnancy. After the 14th gestational week, fetal brain development may already be irreversibly affected by lack of thyroid hormones. The prevalence of manifest hypothyroidism in pregnancy is about 0.3-0.5%. The prevalence of subclinical hypothyroidism varies between 4 and 17%, strongly depending on the definition of the upper TSH cutoff limit. Hyperthyroidism occurs in 0.1-1% of all pregnancies. Positivity for antibodies against thyroid peroxidase (TPOAb) is common in women of childbearing age with an incidence rate of 5.1-12.4%. TPOAb-positivity may be regarded as a manifestation of a general autoimmune state which may alter the fertilization and implantation processes or cause early missed abortions. Women positive for TPOAb are at a significant risk of developing hypothyroidism during pregnancy and postpartum. Laboratory diagnosis of thyroid dysfunction during pregnancy is based upon serum TSH concentration. TSH in pregnancy is physiologically lower than the non-pregnant population. Results of multiple international studies point toward creation of trimester-specific reference intervals for TSH in pregnancy. Screening for hypothyroidism in pregnancy is controversial and its implementation varies from country to country. Currently, the case-finding approach of screening high-risk women is preferred in most countries to universal screening. However, numerous studies have shown that one-third to one-half of women with thyroid disorders escape the case-finding approach. Moreover, the universal screening has been shown to be more cost-effective. Screening for thyroid disorders in pregnancy should include assessment of both TSH and TPOAb, regardless of the screening approach. This review summarizes the current knowledge on physiology of thyroid hormones in pregnancy, causes of maternal thyroid dysfunction and its effects on pregnancy course and fetal development. We discuss the question of case-finding versus universal screening strategies and we display an overview of the analytical methods and their reference intervals in the assessment of thyroid function and thyroid autoimmunity in pregnancy. Finally, we present our results supporting the implementation of universal screening.
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Affiliation(s)
- Drahomira Springer
- a Institute of Medical Biochemistry and Laboratory Medicine, 1st Faculty of Medicine, Charles University and General University Hospital , Prague , Czech Republic
| | - Jan Jiskra
- b 3rd Department of Medicine - Clinical Department of Endocrinology and Metabolism , 1st Faculty of Medicine, Charles University and General University Hospital , Prague , Czech Republic , and
| | - Zdenka Limanova
- b 3rd Department of Medicine - Clinical Department of Endocrinology and Metabolism , 1st Faculty of Medicine, Charles University and General University Hospital , Prague , Czech Republic , and
| | - Tomas Zima
- a Institute of Medical Biochemistry and Laboratory Medicine, 1st Faculty of Medicine, Charles University and General University Hospital , Prague , Czech Republic
| | - Eliska Potlukova
- c Division of Internal Medicine , University Hospital Basel , Basel , Switzerland
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Mosso L, Martínez A, Rojas MP, Latorre G, Margozzini P, Lyng T, Carvajal J, Campusano C, Arteaga E, Boucai L. Early pregnancy thyroid hormone reference ranges in Chilean women: the influence of body mass index. Clin Endocrinol (Oxf) 2016; 85:942-948. [PMID: 27260560 PMCID: PMC5572466 DOI: 10.1111/cen.13127] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 05/19/2016] [Accepted: 06/01/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Thyroid dysfunction and obesity during pregnancy have been associated with negative neonatal and obstetric outcomes. Thyroid hormone reference ranges have not been established for the pregnant Hispanic population. This study defines thyroid hormone reference ranges during early pregnancy in Chilean women and evaluates associations of body mass index (BMI) with thyroid function. DESIGN, PATIENTS, MEASUREMENTS This is a prospective observational study of 720 healthy Chilean women attending their first prenatal consultation at an outpatient clinic. Thyroid function [TSH, Free T4, Total T4 and antithyroid peroxidase antibodies (TPOAb)] and BMI were assessed at 8·8 ± 2·4 weeks of gestational age. RESULTS Median, 2·5th percentile (p2·5), and 97·5th percentile (p97·5) TSH values were higher, while median, p2·5, and p97·5 free T4 values were lower in obese patients compared with normal weight patients. Obesity was associated with a median TSH 16% higher (P = 0·035) and a median free T4 6·5% lower (P < 0·01) than values from patients with normal weight. BMI had a small, but statistically significant effect on TSH (P = 0·04) and free T4 (P < 0·01) when adjusted by maternal age, TPO antibodies, parity, sex of the newborn, gestational age and smoking. In all TPOAb (-) patients, median (p2·5-p.97·5) TSH was 1·96 mIU/l (0·11-5·96 mIU/l) and median (p2·5-p.97·5) free T4 was 14·54 pmol/l (11·1 - 19·02 pmol/l). Applying these reference limits, we found a prevalence of overt and subclinical hypothyroidism of 0·9% and 3·05% respectively. CONCLUSIONS TSH distributes at higher values and free T4 at lower values in obese pregnant women compared to normal weight pregnant women. Thyroid hormone reference ranges derived from Chilean patients with negative TPOAb are different from the fixed internationally proposed reference ranges and may be used in the Hispanic population.
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Affiliation(s)
- Lorena Mosso
- Departments of Endocrinology, Faculty of Medicine. Pontificia Universidad Catolica de Chile
| | - Alejandra Martínez
- Departments of Endocrinology, Faculty of Medicine. Pontificia Universidad Catolica de Chile
| | - María Paulina Rojas
- Family Medicine, Faculty of Medicine. Pontificia Universidad Catolica de Chile
| | - Gonzalo Latorre
- Public Health, Faculty of Medicine. Pontificia Universidad Catolica de Chile
| | - Paula Margozzini
- Public Health, Faculty of Medicine. Pontificia Universidad Catolica de Chile
| | - Trinidad Lyng
- Departments of Endocrinology, Faculty of Medicine. Pontificia Universidad Catolica de Chile
| | - Jorge Carvajal
- Obstetrics and Gynecology, Faculty of Medicine. Pontificia Universidad Catolica de Chile
| | - Claudia Campusano
- Departments of Endocrinology, Faculty of Medicine. Pontificia Universidad Catolica de Chile
| | - Eugenio Arteaga
- Departments of Endocrinology, Faculty of Medicine. Pontificia Universidad Catolica de Chile
| | - Laura Boucai
- Department of Medicine, Division of Endocrinology, Memorial Sloan-Kettering Cancer Center, Weill Cornell University
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Khan I, Okosieme OE, Lazarus JH. Current challenges in the pharmacological management of thyroid dysfunction in pregnancy. Expert Rev Clin Pharmacol 2016; 10:97-109. [PMID: 27781488 DOI: 10.1080/17512433.2017.1253471] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Thyroid dysfunction is common in pregnancy and has adverse fetal and maternal health consequences. A number of challenges in the management of gestational thyroid dysfunction remain unresolved including uncertainties in optimal thresholds for correction of hypothyroidism and strategies for pharmacological management of hyperthyroidism. Areas covered: We addressed key challenges and areas of uncertainty in the management of thyroid dysfunction in pregnancy. Expert commentary: Gestational thyroid hormone reference intervals vary according to population ethnicity, iodine nutrition, and assay method and each population should derive trimester specific reference intervals for use in pregnancy. Subclinical hypothyroidism and isolated hypothyroxinaemia are common in pregnancy but there is no consensus on the benefits of correcting these conditions. Although observational studies show potential benefits of levothyroxine on child neurocognitive function these benefits are have not been supported by two controlled trials. Carbimazole should be avoided in the first trimester of pregnancy due to risk of congenital anomalies but recent studies would suggest that this risk is present to a lesser magnitude with propylthiouracil. Current international guidelines recommend the use of propylthiouracil in the first trimester and switching to carbimazole for the remainder of pregnancy but the benefits and practicalities of this approach is unproven.
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Affiliation(s)
- I Khan
- a Thyroid Research Group, Institute of Molecular and Experimental Medicine, School of Medicine , Cardiff University , Cardiff , CF14 4XN , UK
| | - O E Okosieme
- a Thyroid Research Group, Institute of Molecular and Experimental Medicine, School of Medicine , Cardiff University , Cardiff , CF14 4XN , UK.,b Endocrine and Diabetes Department , Prince Charles Hospital, Cwm Taf University Health Board , Merthyr Tydfil , UK
| | - J H Lazarus
- a Thyroid Research Group, Institute of Molecular and Experimental Medicine, School of Medicine , Cardiff University , Cardiff , CF14 4XN , UK
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Elhaj ET, Adam I, Ahmed MA, Lutfi MF. Trimester-specific thyroid hormone reference ranges in Sudanese women. BMC PHYSIOLOGY 2016; 16:5. [PMID: 27795209 PMCID: PMC5087113 DOI: 10.1186/s12899-016-0025-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 10/13/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND Trimester-specific reference ranges for T3, T4, and TSH need to be established in different communities. Neither Sudan nor other African countries have established trimester-specific reference ranges for TSH, free T3 (FT3), and free T4 (FT4) in healthy pregnant women. This study aimed to establish trimester-specific reference ranges for TSH, FT3, and FT4 in healthy pregnant Sudanese women. RESULTS We performed a longitudinal study, which included 63 women with singleton pregnancies who were followed since early pregnancy until the third trimester. The study was performed in Saad Abu-Alela Hospital, Khartoum, Sudan, during January to October 2014. An equal number of age- and parity-matched non-pregnant women were enrolled as a control group. Basic clinical and obstetrics data were gathered using questionnaires. TSH, FT3, and FT4 levels were measured. Median (5th-95th centile) values of TSH, FT3, and FT4 were 1.164 IU/ml (0.079-2.177 IU/ml), 4.639 nmol/l (3.843-6.562 nmol/l), and 16.86 pmol/l (13.02-31.48 pmol/l) in the first trimester. Median values of TSH, FT3, and FT4 were 1.364 IU/ml (0.540-2.521 IU/ml), 4.347 nmol/l (3.425-5.447 nmol/l), and 13.51 pmol/l (11.04-31.07 pmol/l) in the second trimester. These values were 1.445 IU/ml (0.588-2.460 IU/ml), 4.132 nmol/l (3.176-5.164 nmol/l), and 12.87 pmol/l (9.807-23.78 pmol/l) in the third trimester, respectively. TSH levels increased throughout the trimesters. FT3 and FT4 levels were significantly higher in the first trimester compared with the second and third trimesters. TSH, FT3, and FT4 levels were significantly lower in pregnant women compared with non-pregnant women (P < 0.001). CONCLUSIONS The present study is the first to establish trimester-specific reference ranges of TSH, FT3, and FT4 in Sudanese women with normal pregnancies. Our results suggest that pregnancy is likely to suppress TSH, T3, and T4 levels in healthy women.
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Affiliation(s)
- Enaam T Elhaj
- Faculty of Applied Medical Science, Gezira University, Wad Madani, Sudan
| | - Ishag Adam
- Faculty of Medicine, University of Khartoum, Khartoum, Sudan
| | - Mohamed A Ahmed
- Faculty of Medicine, University of Khartoum, Khartoum, Sudan
| | - Mohamed F Lutfi
- Faculty of Medicine and Health Sciences, Alneelain University, Khartoum, Sudan.
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Negro R, Stagnaro-Green A. Clinical aspects of hyperthyroidism, hypothyroidism, and thyroid screening in pregnancy. Endocr Pract 2016; 20:597-607. [PMID: 24449669 DOI: 10.4158/ep13350.ra] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To evaluate the peer-reviewed literature on hypothyroidism, hyperthyroidism, and thyroid autoimmunity in pregnancy. METHODS We review published studies on thyroid autoimmunity and dysfunction in pregnancy, the impact of thyroid disease on pregnancy, and discuss implications for screening. RESULTS Overt hyperthyroidism and hypothyroidism are responsible for adverse obstetric and neonatal events. Several studies of association suggest that either subclinical hypothyroidism or thyroid autoimmunity increase the risk of complications. One randomized controlled trial showed that pregnant women with subclinical hypothyroidism benefit from treatment in terms of obstetric and neonatal complications, whereas another study demonstrated no benefit in the intelligence quotient of babies born to women with subclinical hypothyroidism. Thyroid autoimmunity has been associated with increased rate of pregnancy loss, recurrent miscarriage, and preterm delivery. CONCLUSION Current guidelines agree that overt hyperthyroidism and hypothyroidism need to be promptly treated and that as potential benefits outweigh potential harm, subclinical hypothyroidism also requires substitutive treatment. The chance that women with thyroid autoimmunity may benefit from levothyroxine treatment to improve obstetric outcome is intriguing, but adequately powered randomized controlled trials are needed. The issue of universal thyroid screening at the beginning of pregnancy is still a matter of debate, and aggressive case-finding is supported.
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Affiliation(s)
- Roberto Negro
- Division of Endocrinology, "V. Fazzi" Hospital, Lecce, Italy
| | - Alex Stagnaro-Green
- Rockford Regional Dean, College of Medicine, University of Illinois, Rockford, Illinois
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Almomin AMS, Mansour AA, Sharief M. Trimester-Specific Reference Intervals of Thyroid Function Testing in Pregnant Women from Basrah, Iraq Using Electrochemiluminescent Immunoassay. Diseases 2016; 4:diseases4020020. [PMID: 28933400 PMCID: PMC5456279 DOI: 10.3390/diseases4020020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 04/18/2016] [Accepted: 04/18/2016] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Abbas Ali Mansour
- Diabetes, Endocrine and Metabolism Division, Department of Medicine, Basrah College of Medicine, Basrah 61013, Iraq.
| | - Maysoon Sharief
- Department of Gynecology and Obstetrics, Basrah College of Medicine, Basrah 61013, Iraq.
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39
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McNeil AR, Stanford PE. Reporting Thyroid Function Tests in Pregnancy. Clin Biochem Rev 2015; 36:109-126. [PMID: 26900190 PMCID: PMC4758281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
While there is agreement that overt maternal hypothyroidism (serum thyroid stimulating hormone (TSH) >10 mIU/L) should be treated immediately, the evidence is mixed regarding the harm associated with subclinical hypothyroidism and the benefits of thyroxine replacement. The diagnosis of subclinical hypothyroidism rests on the recognition of an increased serum concentration of TSH which may be affected by many factors including gestational age, analytical method, the antibody status of the mother, ethnicity, iodine nutrition and even the time of day when the blood is collected. The 97.5(th) percentile of TSH at the end of the first trimester is commonly used as the upper boundary of normal in early pregnancy with a default value of 2.5 mIU/L specified in a number of recent clinical guidelines. There have now been numerous papers showing that a more realistic figure is between 3.0 and 4.0 mIU/L depending on the analytical method that is used. There are suggestions that ethnicity may also have a significant effect on TSH and FT4 reference limits in pregnancy.
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Affiliation(s)
- Alan R McNeil
- Biochemistry Department, Dorevitch Pathology, 18 Banksia Street, Heidelberg, Vic. 3084
| | - Phoebe E Stanford
- Department of Clinical Chemistry, Level 4, Campus centre, Prince of Wales Hospital, Barker Street, Randwick, NSW 2031, Australia
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Kim HS, Kim BJ, Oh S, Lee DY, Hwang KR, Jeon HW, Lee SM. Gestational Age-specific Cut-off Values Are Needed for Diagnosis of Subclinical Hypothyroidism in Early Pregnancy. J Korean Med Sci 2015; 30:1308-12. [PMID: 26339172 PMCID: PMC4553679 DOI: 10.3346/jkms.2015.30.9.1308] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 06/01/2015] [Indexed: 11/21/2022] Open
Abstract
During the first trimester of pregnancy, thyroid-stimulating hormone (TSH) >2.5 mIU/L has been suggested as the universal criterion for subclinical hypothyroidism. However, TSH levels change continuously during pregnancy, even in the first trimester. Therefore the use of a fixed cut-off value for TSH may result in a different diagnosis rate of subclinical hypothyroidism according to gestational age. The objective of this study was to obtain the normal reference range of TSH during the first trimester in Korean gravida and to determine the diagnosis rate of subclinical hypothyroidism using the fixed cut-off value (TSH >2.5 mIU/L). The study population consisted of pregnant women who were measured for TSH during the first trimester of pregnancy (n=492) and nonpregnant women (n=984). Median concentration of TSH in pregnant women was lower than in non-pregnant women. There was a continuous decrease of median TSH concentration during the first trimester of pregnancy (median TSH concentration: 1.82 mIU/L for 3+0 to 6+6 weeks; 1.53 mIU/L for 7+0 to 7+6 weeks; and 1.05 mIU/L for 8+0 to 13+6 weeks). Using the fixed cut-off value of TSH >2.5 mIU/L, the diagnosis rate of subclinical hypothyroidism decreased significantly according to the gestational age (GA) at TSH (25% in 3+0 to 6+6 weeks, 13% in 7+0 to 7+6 weeks, and 9% for 8+0 to 13+6 weeks, P<0.001), whereas the diagnosis rate was 5% in all GA with the use of a GA-specific cut-off value (P=0.995). Therefore, GA-specific criteria might be more appropriate for the diagnosis of subclinical hypothyroidism.
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Affiliation(s)
- Hye Sung Kim
- Department of Obstetrics and Gynecology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Byoung Jae Kim
- Department of Obstetrics and Gynecology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Sohee Oh
- Department of Biostatistics, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Da Young Lee
- Department of Obstetrics and Gynecology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Kyu Ri Hwang
- Department of Obstetrics and Gynecology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Hye Won Jeon
- Department of Obstetrics and Gynecology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Seung Mi Lee
- Department of Obstetrics and Gynecology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
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Valores de referencia y cribado universal de la función tiroidea en el primer trimestre de la población de mujeres gestantes del área de Toledo. ACTA ACUST UNITED AC 2015; 62:358-60. [DOI: 10.1016/j.endonu.2015.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 03/25/2015] [Accepted: 04/14/2015] [Indexed: 11/19/2022]
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Medici M, Korevaar TIM, Visser WE, Visser TJ, Peeters RP. Thyroid Function in Pregnancy: What Is Normal? Clin Chem 2015; 61:704-13. [DOI: 10.1373/clinchem.2014.236646] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 03/03/2015] [Indexed: 01/29/2023]
Abstract
Abstract
BACKGROUND
Gestational thyroid dysfunction is common and associated with maternal and child morbidity and mortality. During pregnancy, profound changes in thyroid physiology occur, resulting in different thyroid-stimulating hormone (TSH) and free thyroxine (FT4) reference intervals compared to the nonpregnant state. Therefore, international guidelines recommend calculating trimester- and assay-specific reference intervals per center. If these reference intervals are unavailable, TSH reference intervals of 0.1–2.5 mU/L for the first trimester and 0.2–3.0 mU/L for the second trimester are recommended. In daily practice, most institutions do not calculate institution-specific reference intervals but rely on these fixed reference intervals for the diagnosis and treatment of thyroid disorders during pregnancy. However, the calculated reference intervals for several additional pregnancy cohorts have been published in the last few years and show substantial variation.
CONTENT
We provide a detailed overview of the available studies on thyroid function reference intervals during pregnancy, different factors that contribute to these reference intervals, and the maternal and child complications associated with only minor variations in thyroid function.
SUMMARY
There are large differences in thyroid function reference intervals between different populations of pregnant women. These differences can be explained by variations in assays as well as population-specific factors, such as ethnicity and body mass index. The importance of using correct reference intervals is underlined by the fact that even small subclinical variations in thyroid function have been associated with detrimental pregnancy outcomes, including low birth weight and pregnancy loss. It is therefore crucial that institutions do not rely on fixed universal cutoff concentrations, but calculate their own pregnancy-specific reference intervals.
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Affiliation(s)
- Marco Medici
- Department of Internal Medicine
- Rotterdam Thyroid Center, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Tim I M Korevaar
- Department of Internal Medicine
- Rotterdam Thyroid Center, Erasmus Medical Center, Rotterdam, the Netherlands
| | - W Edward Visser
- Department of Internal Medicine
- Rotterdam Thyroid Center, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Theo J Visser
- Department of Internal Medicine
- Rotterdam Thyroid Center, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Robin P Peeters
- Department of Internal Medicine
- Rotterdam Thyroid Center, Erasmus Medical Center, Rotterdam, the Netherlands
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Santiago Fernández P, González-Romero S, Martín Hernández T, Navarro González E, Velasco López I, Millón Ramírez MC. [Thyroid dysfunction in pregnancy. Consensus document. Andalusian Society of Endocrinology and Nutrition (SAEN)]. Semergen 2015; 41:315-23. [PMID: 25700854 DOI: 10.1016/j.semerg.2014.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 12/23/2014] [Accepted: 12/25/2014] [Indexed: 12/28/2022]
Abstract
A position statement on the diagnosis and treatment of thyroid dysfunction in pregnancy has been agreed on behalf of The Sociedad Andaluza de Endocrinología y Nutrición (SAEN), based on a review of the literature to date and all good clinical practice guidelines. The document is set out in different sections as regards the diagnosis and treatment of, overt and subclinical hypo- and hyperthyroidism, isolated hypothyroxinaemia and postpartum thyroiditis. It also justifies the implementation of universal screening for thyroid dysfunction in pregnancy, and provides practitioners who care for these patients with tool for rational decision making.
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Affiliation(s)
- P Santiago Fernández
- Servicio de Endocrinología y Nutrición, Complejo Hospitalario de Jaén, Jaén, España.
| | - S González-Romero
- Servicio de Endocrinología y Nutrición, Hospital Regional de Málaga, Instituto de Investigaciones Biomédicas de Málaga (IBIMA), CIBER de Diabetes y Enfermedades Metabólicas, Málaga, España
| | - T Martín Hernández
- Servicio de Endocrinología y Nutrición, Hospital Virgen Macarena, Sevilla, España
| | - E Navarro González
- Servicio de Endocrinología y Nutrición, Hospital Virgen del Rocío, Sevilla, España
| | - I Velasco López
- Servicio de Ginecología y Obstetricia, Hospital de Riotinto, Huelva, España
| | - M C Millón Ramírez
- Unidad de Gestión Clínica (UGC) Axarquía-Norte, Área de Gestión Sanitaria (AGS) Este de Málaga-Axarquia, Málaga, España
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44
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Labadzhyan A, Brent GA, Hershman JM, Leung AM. Thyrotoxicosis of Pregnancy. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2014; 1:140-144. [PMID: 25243108 PMCID: PMC4166486 DOI: 10.1016/j.jcte.2014.07.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Thyrotoxicosis presenting during pregnancy is a common clinical problem and can be challenging to differentiate between physiologic patterns of thyroid dysfunction during gestation and intrinsic hyperthyroidism. This review provides a summary of the differential diagnosis, clinical presentation, diagnostic options, potential adverse effects of maternal thyrotoxicosis to the fetus, and treatment recommendations for thyrotoxicosis arising in pregnancy.
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Affiliation(s)
- Artak Labadzhyan
- Division of Endocrinology, Cedars-Sinai Medical Center and VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Gregory A Brent
- Division of Endocrinology, David Geffen School of Medicine, University of California Los Angeles
| | - Jerome M Hershman
- Division of Endocrinology, David Geffen School of Medicine, University of California Los Angeles
| | - Angela M Leung
- Division of Endocrinology, David Geffen School of Medicine, University of California Los Angeles
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Díez JJ, Iglesias P, Donnay S. [Thyroid dysfunction during pregnancy]. Med Clin (Barc) 2014; 145:344-9. [PMID: 25433782 DOI: 10.1016/j.medcli.2014.08.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 08/19/2014] [Indexed: 11/25/2022]
Abstract
Recent clinical practice guidelines on thyroid dysfunction and pregnancy have changed health care provided to pregnant women, although their recommendations are under constant revision. Trimester- and area-specific reference ranges for serum thyroid-stimulating hormone are required for proper diagnosis of hypothyroidism and hyperthyroidism. There is no doubt on the need of therapy for overt hypothyroidism, while therapy for subclinical hypothyroidism is controversial. Further research is needed to settle adverse effects of isolated hypothyroxinemia and thyroid autoimmunity. Differentiation between hyperthyroidism due to Graves' disease and the usually self-limited gestational transient thyrotoxicosis is critical. It is also important to recognize risk factors for postpartum thyroiditis. Supplementation with iodine is recommended to maintain adequate iodine nutrition during pregnancy and avoid serious consequences in offspring. Controversy remains about universal screening for thyroid disease during pregnancy or case-finding in high-risk women. Opinions of some scientific societies and recent cost-benefit studies favour universal screening. Randomized controlled studies currently under development should reduce the uncertainties that still remain in this area.
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Affiliation(s)
- Juan J Díez
- Servicio de Endocrinología, Hospital Universitario Ramón y Cajal, Madrid, España; Universidad de Alcalá de Henares, Alcalá de Henares, Madrid, España.
| | - Pedro Iglesias
- Servicio de Endocrinología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Sergio Donnay
- Unidad de Endocrinología y Nutrición, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
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Díaz-Soto G, Largo E, Álvarez-Colomo C, Martínez-Pino I, de Luis D. Valores de referencia y cribado universal de la disfunción tiroidea en la mujer gestante. ACTA ACUST UNITED AC 2014; 61:336-8. [DOI: 10.1016/j.endonu.2014.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 03/01/2014] [Accepted: 03/06/2014] [Indexed: 11/24/2022]
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47
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Cai J, Zhao X, Lei T, Meng Q, Zhou H, Zhang M. Urinary thyroid hormone parameters test for evaluating the thyroid function during pregnancy. Syst Biol Reprod Med 2014; 60:171-6. [DOI: 10.3109/19396368.2014.900138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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48
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Galofré JC, Riesco-Eizaguirre G, Álvarez-Escolá C. Guía clínica para el manejo del nódulo tiroideo y cáncer de tiroides durante el embarazo. ACTA ACUST UNITED AC 2014; 61:130-8. [DOI: 10.1016/j.endonu.2013.08.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 08/05/2013] [Accepted: 08/08/2013] [Indexed: 12/30/2022]
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49
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Thyroid function and thyroid autoimmunity in apparently healthy pregnant and non-pregnant Mexican women. Clin Chem Lab Med 2014; 52:1305-11. [DOI: 10.1515/cclm-2014-0350] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 04/01/2014] [Indexed: 11/15/2022]
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50
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Vila L, Velasco I, González S, Morales F, Sánchez E, Torrejón S, Soldevila B, Stagnaro-Green A, Puig-Domingo M. Controversies in endocrinology: On the need for universal thyroid screening in pregnant women. Eur J Endocrinol 2014; 170:R17-30. [PMID: 24128429 DOI: 10.1530/eje-13-0561] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
There is a well-known controversy among scientific societies regarding the recommendation to screen for thyroid dysfunction (TD) during pregnancy. Although several studies have shown an association between maternal subclinical hypothyroidism and/or hypothyroxinemia with obstetric problems and/or neurocognitive impairment in the offspring, there is only limited evidence on the possible positive effects of thyroxine (T4) treatment in such cases. Despite the scarcity of this evidence, there is a widespread agreement among clinicians on the need for treatment of clinical hypothyroidism during pregnancy and the risks that could arise due to therapeutic abstention. As maternal TD is a quite prevalent condition, easily diagnosed and for which an effective and safe treatment is available, some scientific societies have proposed to assess thyroid function during the first trimester of pregnancy and ideally before week 10 of gestational age. Given the physiologic changes of thyroid function during pregnancy, hormone assessment should be performed using trimester-specific reference values ideally based on locally generated data as geographic variations have been detected. Screening of TD should be based on an initial determination of TSH performed early during the first trimester and only if abnormal should it be followed by either a free or total T4 measurement. Furthermore, adequate iodine supplementation during pregnancy is critical and if feasible it should be initiated before the woman attempts to conceive.
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Affiliation(s)
- Lluís Vila
- Department of Endocrinology and Nutrition, Hospital de Sant Joan Despí Moisès Broggi, Barcelona, Spain
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