Thursday, January 12, 2017

American Thyroid Association releases new guidelines on thyroid disease in pregnancy.

Courtesy: Thyroid foundation 
Thyroid disease in pregnancy is very common and is the second most common endocrine disorder of women during reproductive age. Pregnancy leads to an increase in size of thyroid gland from 10-40% depending on iodine content of the area. Iodine requirement also increases by 50% with almost 50% increase in production of thyroxine (T4) and triiodothyronine (T3).

American Thyroid Association (ATA) first published its guidelines in 2011 but, significant scientific and clinical advances since then led ATA to revise the guidelines.

These 162 pages of evidence based guidelines were first published online on January 06, 2017 in Thyroid. [1]The 97 recommendations presented deals with nutrient requirements, screening, diagnosing, testing, complications and management of   thyroid disorder in pregnancy and post-partum period. It also includes neonatal morbidity due to maternal thyroid disease and future research in the field.

The full text of the guidelines can be accessed here.

Some of the salient recommendations are summarized here.

Screening for Thyroid disorder in pregnancy.

  • All pregnant patient should be verbally and clinically screened for thyroid disease and use of thyroid medications. If any of the risk factors are identified, then testing for TSH is advisable. 
  • Universal screening for low free thyroxine concentrations in pregnant women is not recommended. 
  • Insufficient evidence  also exists for Universal screening or no screening for TSH level  preconception or in  early pregnancy. 

Hypothyroid in Pregnancy.

  • The reference range for serum TSH changes in pregnancy. Hence, population based trimester-specific reference range for TSH should be defined.
  • The requirement of Levothyroxine only increases by 20-30% during pregnancy and a simple way of achieving it is to administer 2 additional tablets weekly of the patient’s current daily levothyroxine dosage.
  • Subclincal hypothyroidism in pregnancy should be treated according to the reference range for the population and TPO status.
  • Overt hypothyroidism should always be treated during pregnancy with Levothyroxine only, Other thyroid preparations such as triiodothyronine (T3) or desiccated thyroid should not be used in pregnancy.
  • TSH level tested 6 weeks postpartum and the dose adjusted.


Iodine requirements in pregnancy and before conception

  • All pregnant women should have approximately 250 μg iodine daily. 
  • All women who are planning to become pregnant should supplement the diet with daily 150 μg of iodine, optimally 3 months before the conception except women with already existing hyper or hypothyroidism.
  • Excessive iodine supplements and sustained dietary intake above 500 μg daily should be avoided during pregnancy.


Subclinical hypothyroidism.

  • All Euthyroid but TPO or Tg antibody positive pregnant women should have serum TSH concentration performed at time of pregnancy confirmation, and every 4 weeks through mid-pregnancy. These women should not be treated with thyroxine just to prevent RPL or preterm delivery.


Infertility and Thyroid disorders.

  • All infertility patients should have their thyroid function done and only women with overt hypothyroidism should be treated with levothyroxine. 
  • Evidence is insufficient for supplementing levothyroxine to all women with subclinical hypothyroidism to improve fertility.
  • Women with subclinical hypothyroid undergoing IVF or ICSI should be treated with levothyroxine. The goal of treatment is to achieve a TSH concentration TSH <2.5.

Hyperthyroidism in pregnancy.

  • Managing Hyperthyroidism in pregnancy is very complicated issue. Radionuclide scintigraphy or radioiodine uptake determination is contraindicated in pregnancy.
  • Methimazole (MMI) nor propyl thiouracil (PTU) is safe during pregnancy and should be immediately stopped once the pregnancy is confirmed because of its teratogenic potential. If at all required than PTU is preferred over MMI till 16 weeks in the lowest effective dose.
  • The fetus should be closely looked at for Goiter or hypothyroidism during the second half of pregnancy.
  • Thyroidectomy in Graves’ disease in only indicated in specific situation and should follow the recommendations of ACOG to schedule any surgery during pregnancy.

Other recommendations can be found in the full text of the article.





[1] http://online.liebertpub.com/doi/pdfplus/10.1089/thy.2016.0457

19 comments:

  1. Excellent piece of informations. So long we were treating with low doses of L-Tx in sub clinical hypothyroid cases who are attempting for pregnancy. We think we should stop such medications.Once again thank U & your team members for enlightening us with new academic recommendations and guidelines by reputed well recognized academic bodies.Prof.(Dr.) S K Pal, Kolkata, India.E Mail:(new) drsrimantapal@gmail.com

    ReplyDelete
    Replies
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  2. Thanks for these nice recent information. Itis rather difficult esp. Wz the hyperthy.
    Q:how to treat hyperthyroidism after16 weeks

    ReplyDelete
    Replies
    1. Thanks Dr. Hashim mohamed . Most of the women with mild hyperthyroidism receiving antithyroid medication becomes euthyroid in first 16 weeks.They should be monitored closely for symptoms of Thyrotoxicosis.If ATD therapy is required after 16 weeks gestation, it remains unclear whether PTU
      should be continued or therapy changed to MMI. As both medications are associated with
      potential adverse effects and shifting potentially may lead to a period of less-tight control, no
      recommendation regarding switching antithyroid drug medication can be made at this time.

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    Replies
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  9. i visited different hospital but they gave me list of expensive drugs to treat the symptoms and never cured me. A closed friend of mine introduce me to a Herbal Doctor who cured her. I was scared to contact him because of what i experienced from fake doctors. she encouraged me and gave me his whatsapp contact,and i contacted him and i asked him series of questions, i also ask him to show me the results of those he have cured with his herbal drugs,and he gave me all the information i needed that gave me hope. He send a Herbal medicine to me that i took and it seriously worked for me. am now Hepatitis negative. God bless you for being a sincere and great man. Am so excited and am free from herpes virus. you can reach him via email;dralikaherbalhome@gmail.com or whats-app/call on +2348116570358.

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  10. This comment has been removed by the author.

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  11. God bless Dr.CHUKWU MADU for his wonderful work in my life, my name is Helen from USA, I was diagnosed of HERPES since 2016 and it has affected my life i was
    taking my medications, I wasn't satisfied i needed to get the HERPES out of my system, I searched about some possible cure for HERPES i saw a comment about Dr CHUKWU MADU HERBALHOME how he cured HERPES with his herbal medicine, I contacted him and he guided me. I asked for solutions, he started the remedy for my health, he sent me the medicine through UPS delivery company. I took the medicine as prescribed by him and 11 days later i tested negative for HERPES, Dr.CHUKWU MADU truly you are great,It's Good for herpes patient to please read my testimony becuase People think herpes is really a minor skin irritation,herpes has a long term effects on health and The stigma attached to this virus by ignorant people is ridiculous. do you need his help also? Why don't you contact him through his email (dr.chukwumaduherbalhome@gmail.com) or call him on +234703
    0936239, DOCTOR CHUKWU MADU CAN AS WELL CURE THE FOLLOWING DISEASE:- 1. HIV/AIDS 2. HERPES 3. CANCER 4. ALS 5. Hepatitis B AND C 6. Diabetes 7. Athrux, 8. hydrophobia 9.hpv 10 pregnancy spell and bring back your ex back 11 scabies 12. STD. 13.Kidney stone?

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  12. I am so happy, i never believe i will be this happy again in life, I was working as an air-hoster ( cabby crew ) for 3years but early this year, i loose my job because of this deadly disease called Herpes virus (HSV), I never felt sick or have any symptom, till all workers were ask to bring their doctors report, that was how i got tested and i found out that am HSV positive that make me loose my job, because it was consider as an STD and is incurable disease, i was so depress was thinking of committing suicide, till i explain to a friend of mine, who always said to me a problem share is a problem solved, that was how she directed me to Dr Isibor, that was how i contacted him and get the medication from this doctor and i got cured for real, I just went back to my work and they also carry out the test to be real sure and i was negative. Please contact this doctor if you are herpes positive  diseases his email is: drisiborspellhome@gmail.com 
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