SLIDE 9 The Subtleties of Thyroid Disease Management for the Non-Endocrinologist
9
Controversy Screening
- American Thyroid Association, American College of Obstetricians and Gynecologists, and
The Endocrine Society all recommend targeted rather than universal screening
- BUT may miss 1/3 pregnancy with hypothyroidism
Abalovich M, et al. J Clin Endocrinol Metab. 2007;92(8 Suppl);S1-S47.
Screening for Thyroid Disease Suggested indicators for targeted thyroid case finding in pregnancy, where the incidence
- f clinical hypothyroid disease is high and benefit of therapy is clear, women with:
- A history of hyperthyroid or hypothyroid disease,
postpartum thyroiditis, or thyroid lobectomy
- Type 1 diabetes
- A family history of thyroid disease
- Other autoimmune disorders
- A goiter
- Infertility should have screening with TSH as part of
their infertility work-up
- Thyroid antibodies (when known)
- Prior therapeutic head or neck irradiation
- Symptoms or clinical signs suggestive of thyroid under
function
- A prior history of preterm delivery
The following conditions screening may be considered since the incidence might be high enough but no known benefit of treatment has yet been determined:
- Women in whom the last delivery was preterm
- Women with recurrent pregnancy loss
Lab Findings
- Lab should provide pregnancy and trimester specific ranges of all thyroid tests
- If not provided, then for TSH use
1. First trimester 0.1 to 2.5 2. Second trimester 0.2 to 3.0 3. Third trimester 0.3 to 3.0
- TBG is higher so total T4 is higher as total T4 reflects the increased protein binding
in pregnancy
- FT4 however is more likely to be normal but can be technically difficult to
accurately measure
Ain KB, et al. J Clin Endocrinol Metab. 1987;65:689-696. Ballabio M, et al. J Clin Endocrinol Metab. 1991;73:824-831. Glinoer D. Endocr Rev. 1997;18:404-433. Lee RH, et al. Am J Obstet Gynecol. 2009;200:260.e1-e6. Soldin OP, et al. Thyroid. 2004;14:1084-1090.
Controversy
Managem ent Consult an Experienced Endocrinologist
- Hyperthyroidism
- hCG-mediated hyperthyroidism is usually transient and does not
require treatment
- PTU is 1st choice and ATA recommends treatment saying benefits > risks,
but is category 4
- Surgery if PTU is contraindicated
- Hypothyroidism
- New guidelines suggest rapid dose escalation in pregnancy to avoid
prolonged fetal exposure to underactive thyroid levels
PTU, propylthiouracil
Controversy
Managem ent Consult an Experienced Endocrinologist
- Subclinical Hypothyroidism
- Lower pregnancy risk than with overt disease
- RX with LT4 may improve baby’s neuro development
- The Thyroid Dysfunction during Pregnancy and Postpartum Guideline Task Force
recommends treatment
- Elevated antithyroid peroxidase antibody (TPO antibodies) in euthyroid pregnant
patients
- Increased risk of fetal loss, perinatal mortality, and large-for-gestational-age
- High risk to become hypothyroid, so need monitoring
- LT4 may lower miscarriage rates
- ATA does not recommend for or against treatment
Managem ent
Consult an Experienced Endocrinologist
Hypothyroidism Treatment Recommendations
- 1.1.1. Both maternal and fetal hypothyroidism are known to have serious adverse effects on the fetus. Therefore maternal hypothyroidism
should be avoided.
- 1.1.2. If hypothyroidism has been diagnosed before pregnancy, we recommend adjustment of the preconception thyroxine dose to reach a
TSH level not higher than 2.5 μU/mL prior to pregnancy.
- 1.1.3. The T4 dose usually needs to be incremented by 4-6 wk gestation and may require a 30%-50% increase in dosage.
- 1.1.4. If overt hypothyroidism is diagnosed during pregnancy, thyroid function tests (TFTs) should be normalized as rapidly as possible.
Thyroxine dosage should be titrated to rapidly reach and thereafter maintain serum TSH concentrations of less than 2.5 μU/mL in the first trimester (or 3 μU/mL in the second and third trimester) or to trimester-specific normal TSH ranges. Thyroid function tests should be remeasured within 30-40 days.
- 1.1.5. Women with thyroid autoimmunity who are euthyroid in the early stages of pregnancy are at risk of developing hypothyroidism and
should be monitored for TSH elevation above the normal range.
- 1.1.6. Subclinical hypothyroidism (serum TSH concentration above the upper limit of the reference range with a normal free T4) has been
shown to be associated with an adverse outcome for both the mother and offspring. T4 treatment has been shown to improve obstetrical
- utcome but has not been proved to modify long-term neurological development in the offspring. However, given that the potential benefits
- utweigh the potential risks, the panel recommends T4 replacement in women with subclinical hypothyroidism.
- Women in the childbearing age should have an average iodine intake of 150 μg per day. During pregnancy and breastfeeding, women
should increase their daily iodine intake to 250 μg on average.
Abalovich M, et al. J Clin Endocrinol Metab. 2007;92(8 Suppl);S1-S47.
Best Practices Pearls
- Have a low threshold to test for thyroid disease
- Treatment of both subclinical and overt disease should
be individualized and monitored
- Manage issues around variable therapeutic
equivalence of levothyroxine products
- Appropriately counsel, screen, and monitor thyroid
function in pregnancy to improve outcomes
