The clinical spectrum of postpartum thyroid disease

Association of gestational thyroid function and thyroid peroxidase antibody positivity with postpartum depression: a prospective cohort study and systematic literature review with meta-analysis

IMPORTANCE

Postpartum depression (PPD) has a major impact on maternal and offspring well-being, with multiple possible risk factors: Studies on the association of thyroid peroxidase antibody (TPOAb) positivity and thyroid function with PPD provide heterogeneous results.

OBJECTIVE

To study the association of thyroid function and TPOAb positivity with PPD.

DESIGN

We assessed the association of TPOAb and thyroid function with PPD in a population-based prospective cohort study and performed a systematic literature review and meta-analysis.

METHODS

We measured thyroid stimulating hormone (TSH), free thyroxine (FT4), and TPOAb between 9- and 17-week gestation. Postpartum depression was assessed with Edinburgh Postpartum Depression Scale at 2-month postpartum and Brief Symptom Inventory at 2-, 6-, and 36-month postpartum. Additionally, we performed a systematic literature review and meta-analysis assessing this association.

RESULTS

In the present study, there was no association of thyroid function with PPD (TSH: odds ratio [OR] 0.83, 95% CI 0.58-1.19, P = .32; FT4: OR 0.99, 95% CI 0.95-1.05, P = .86) or TPOAb positivity with PPD (OR 0.79, 95% CI 0.47-1.33, P = .37). An impaired thyroidal response to human chorionic gonadotropin (hCG), a surrogate marker for TPOAb positivity, was associated with a lower risk of PPD (P for interaction TSH = 0.04; FT4 = 0.06). Our systematic review and meta-analysis included 3 articles that were combined with the present study. There was no statistically significant association of TPOAb positivity with PPD (OR 1.93, 95% CI 0.91-4.10, P = .08), but the results were heterogeneous (I2 = 79%).

CONCLUSIONS AND RELEVANCE

There was no significant association of TPOAb positivity, TSH, or FT4 with PPD. Our systematic review and meta-analysis revealed high heterogeneity of the current literature. Although TPOAb-positive women should be monitored for postpartum thyroiditis, our findings do not support routinely screening for PPD.

Postpartum depression in maternal thyroidal changes

Evidence in the literature has suggested that there may be an association between thyroid antibodies and depression during pregnancy and in the postpartum period. Thus, this study aims to conduct a systematic review on the prevalence of postpartum depression (PPD) in women with thyroid abnormalities during pregnancy or in the postpartum period. For this review, we used four databases (PubMed, Lilacs, Scielo, and Scopus). Fifteen studies were selected; one study used a case–control design, four used a cross-sectional design and ten utilized prospective cohort designs. All studies were restricted to up to 1 year postpartum, and 46.7% focused on a period between immediate postpartum and 6 months postpartum. Estimates of the prevalence of PPD in pregnant women with thyroid disorders ranged between 8.3% and 36.0%. For follow-up studies, the cumulative incidence of self-reported depression from the primary episode in the first postpartum year was 6.3% in a high-city survey. Although some authors consider the status of positive anti-TPO antibodies to be a possible marker of vulnerability to depression , it is not yet possible to conclude whether thyroid function in the pregnancy-puerperal cycle is involved with the development of PPD.

Health-related quality of life in women with autoimmune thyroid disease during pregnancy and postpartum: systematic review including 321,850 pregnancies

BACKGROUND

Utilities of the general population or expert estimates have been used for all published cost-effectiveness analyses of screening for thyroid disorders in pregnancy.

METHODS

A systematic review CRD42019120897 of studies with patient-reported outcomes (PRO) and laboratory evidence of thyroid function/autoimmunity was conducted using PubMed, Cochrane Central, EconLit, SocIndex, DARE, NHS EEDS, Annual Reviews, and CINAHL. Quality was assessed using Joanna Briggs Institute appraisal tool.

RESULTS

Of 664 abstracts screened, we analyzed 97 full texts. All studies describing the impact of thyroid disease on the generic QoL excluded pregnant and postpartum women. 21 reports of acceptable quality (321,850 pregnancies) determined depression and anxiety with validated tools and/or reported subjective symptoms. During pregnancy, contradictory conclusions were published on the impact of thyroid disease on PRO. Postpartum, antithyroid antibodies coincide with alexithymia and depression, postpartum thyroiditis negatively impacts mood. No conclusion could be drawn on the impact of thyroid hormonal levels.

CONCLUSIONS

The generic QoL in autoimmune thyroid disease during pregnancy has never been described, which represents an obstacle for the construction of economic models. We found contradictory information on the impact of thyroid disease on depression, anxiety, and specific symptoms.

Diseases and complications of the puerperium

BACKGROUND

In terms of maternal morbidity and mortality, the puerperium is just as significant as pregnancy and childbirth. Nearly half of all maternal deaths occur in the time after delivery.

METHODS

This review is based on pertinent articles in English and German from the years 2000- 2020 that were retrieved by a selective search in MEDLINE and EMBASE, as well as on the available guidelines in English and German and on German-language textbooks of obstetrics.

RESULTS

The most common and severe complications are, in the post-placental phase, bleeding and disturbances of uterine involution; in the first seven days after delivery, infection (e.g., endomyometritis, which occurs after 1.6% [0.9; 2.5] of all births) and hypertension-related conditions. Thromboembolism, incontinence and disorders of the pelvic floor, mental disease, and endocrine disturbances can arise at any time during the puerperium. In an Australian study, the incidence of embolism was 0.45 per 1000 births, with 61.3% arising exclusively after delivery.

CONCLUSION

Basic familiarity with the most common and severe diseases in the puerperium is important for non-gynecologists as well, among other things because highly acute, lifethreatening complications can arise that demand urgent intervention.

Thyroid autoimmunity and risk of post-partum depression: a systematic review and meta-analysis of longitudinal studies

PURPOSE

The aim of this study was to systematically investigate whether, and to what extent, the detection of thyroid autoimmunity during pregnancy and in the weeks after childbirth is associated with an increased risk of developing post-partum depression (PPD), a condition associated with possible adverse outcomes for both mother and offspring. We performed a systematic review and meta-analysis of longitudinal studies, assessing the incidence of PPD in women with and without anti-thyroperoxidase antibody (TPOAb) positivity.

METHODS

We searched MEDLINE, EMBASE, Web of Science, Cochrane Library, and CINAHL. Methodological quality of the studies was assessed by the Newcastle-Ottawa Scale. In the presence of even modest between-studies heterogeneity, assessed by Cochrane Q and I² tests, risk ratios (RRs) for PPD were combined using a random effects model. Funnel plot and trim-and-fill analysis were used to assess publication bias.

RESULTS

Five included studies provided information on 449 women with TPOAb-positive and 2483 TPOAb-negative women. Pooled RR indicated a significantly increased risk to develop PPD in TPOAb-positive group (RR 1.49, 95% CI 1.11-2.00; P = 0.008; I² = 47%, P_{for heterogeneity} = 0.11). Consistent with a possible publication bias, the trim-and-fill test detected two putative missing studies in the funnel plot. Nevertheless, the adjustment for publication bias produced a negligible effect on the pooled estimate (adjusted RR 1.41, 95% CI 1.18-1.68, P = 0.0002).

CONCLUSIONS

Thyroid autoimmunity during pregnancy and in the weeks after childbirth is associated with an increased risk of developing PPD. Further well-designed studies are warranted to confirm this association and elucidate underlying pathophysiological mechanisms.

PROSPERO REGISTRATION

CRD42019129643.

Postpartal depression and thyroid disorders

Introduction: Postpartum depression negatively affects a woman's quality of life and the development of a relationship with her child, which can have far-reaching consequences on the cognitive, behavioral and emotional development of the child. Etiology includes genetic predisposition, sudden hormonal changes, and sociodemographic factors. Case report: A 28-year-old patient, married, mother of a one-month-old boy. She graduated from the High school of economics, unemployed. She appears in the family medicine clinic due to chronic fatigue and bad mood, at the insistence of her husband, who thinks that she needs professional help. She grew up in a harmonious family. He gets along well with his wife, there are no existential problems. It denies previous illnesses. Neat appearance, inconspicuous posture and behavior, psychomotor diskette slowed down, more sparse spontaneous verbalization, slightly compromised volitional instinctual dynamisms, lowered basic mood. In the laboratory findings, hypothyroidism with elevated thyroid peroxidase antibody and antithyreoglobulin antibodies is detected. The thyroid ultrasound verifies the right lobe of 46x14x15mm, the left lobe of 48x13x12mm, inhomogeneous and easily hypoechoic structure. The Edinburgh Postnatal Depression Scale indicates the presence of depression (total score 18). The patient is referred for a consultative examination by a psychiatrist and a nuclear medicine specialist. Psychiatrist indicates the introduction of Sertralin 50 mg tablets (1x1/2 for the first seven days, then 1x1) and Bromasepam tablets 1,5 mg (2x1/2), nuclear specialist Levotiroskin sodium tablets 50 mcg (1x1/2 for 5 days and 1x1 for 2 days). After six months, withdrawal of the symptoms of the disease and exclusion of therapy by a psychiatrist. Conclusion: Autoimmune thyroid disease is a significant and often unrecognized cause of postpartum depression. Early detection and timely therapeutic intervention of these have a significant role in the prevention and successful treatment of postpartum depression.

A systematic review of cortisol, thyroid-stimulating hormone, and prolactin in peripartum women with major depression

Pregnancy and postpartum are periods of high susceptibility to major depression (MD) and other mood disorders. The peripartum period is also a time of considerable changes in the levels of hormones, including cortisol, thyroid-stimulating hormone (TSH), prolactin, gonadotropins, and gonadal steroids. To investigate the relationship between mood and hormonal changes during and after pregnancy, we reviewed published reports of hormonal measures during this time frame, searched via PubMed and Web of Science. Studies were included if women in the antepartum or postpartum periods were clinically diagnosed with MD, and if there were repeated measures of cortisol, TSH, or prolactin. For these three hormones, the numbers of human studies that met these criteria were 15, 7, and 3, respectively. Convergent findings suggest that morning cortisol is reduced in pregnant and postpartum women with MD. Evidence did not support changes in TSH as a marker of MD during the peripartum period, and evidence for changes in prolactin in peripartum MD was equivocal. Aside from reduced morning cortisol in peripartum women with MD, definitive evidence for an association between specific hormonal fluctuations and mood disorders in the peripartum period remains elusive.

Thyroid peroxidase antibodies during early gestation and the subsequent risk of first-onset postpartum depression: A prospective cohort study

BACKGROUND

During the postpartum period, women are at risk for the new onset of both auto-immune thyroid disorders and depression. The presence of thyroid peroxidase antibodies (TPO-ab) during early gestation is predictive for postpartum auto-immune thyroid dysfunction. The aim of this study was to investigate the association between TPO-ab status during early gestation and first-onset postpartum depression.

METHODS

Prospective cohort study (n = 1075) with follow-up during pregnancy up to one year postpartum. Thyroid function and TPO-ab status were measured during early gestation. Depressive symptomatology was assessed during each trimester and at four time points postpartum with the Edinburgh Depression Scale (EDS). Women with antenatal depression were not eligible for inclusion. Self-reported postpartum depression was defined with an EDS cut-off of ≥ 13.

RESULTS

The cumulative incidence of self-reported first-onset depression in the first postpartum year was 6.3%. A positive TPO-ab status was associated with an increased risk for self-reported first-onset depression at four months postpartum (adjusted OR 3.8; 95% CI 1.3-11.6), but not at other postpartum time points. Prevalence rates of self-reported postpartum depression declined after four months postpartum in the TPO-ab positive group, but remained constant in the TPO-ab negative group.

LIMITATIONS

Depression was defined with a self-rating questionnaire (EDS).

CONCLUSIONS

Women with an increased TPO-ab titer during early gestation are at increased risk for self-reported first-onset depression. The longitudinal pattern of self-reported postpartum depression in the TPO-ab positive group was similar to the typical course of postpartum TPO-ab titers changes. This suggests overlap in the etiology of first-onset postpartum depression and auto-immune thyroid dysfunction. Thyroid function should be evaluated in women with first-onset postpartum depression.

An updated literature review on maternal-fetal and reproductive disorders of Toxoplasma gondii infection

BACKGROUND

Toxoplasma gondii infection is one of the most prevalent infectious disease with worldwide distribution. Congenital toxoplasmosis is annually responsible for 1.20 million disability-adjusted life years around the world, but often it is overlooked many countries.

METHODS

We performed an updated review to summarize the current researches on fetal, neonatal and maternal consequences of T. gondii infection and also adverse effects of toxoplasmosis on women reproductive organs.

RESULTS

T. gondii infection could be cause of several abnormalities from hydrocephalus, microcephaly, deafness, abortion and still birth in fetal to psychomotor retardation, intellectual disability, hearing loss, slower postnatal motor development during the first year of life; and chorioretinitis, cryptogenic epilepsy and autism spectrum disorders in newborns. Moreover, this infection is related with neuropsychiatric disorders such as anxiety, schizophrenia spectrum disorders, depression, decreased weight, autoimmune thyroid diseases, self-directed violence, violent suicide attempts in mothers. This literature review emphasized that toxoplasmosis could be an important neglected factor endometritis, ovarian dysfunction, impaired folliculogenesis, ovarian and uterine atrophy, decrease in reproductive organs weight and reproductive performance in women. We reviewed role of the immunological profile such as pro-infiammatory cytokines and hormonal changes as main potential mechanisms related to this infection and development of maternal-fetal and reproductive disorders.

CONCLUSION

T. gondii is associated with several brain related disorders in both mothers and newborns, and also it is cause of several abnormalities in reproductive organs. Early diagnosis and treatment of the infection could be effective to significantly improve the clinical outcome.

2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum

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.

The correlation between Toxoplasma gondii infection and prenatal depression in pregnant women

Previous studies have demonstrated that latent toxoplasmosis is associated with neuropsychiatric disorders. We evaluated the correlation between Toxoplasma gondii infection and prenatal depression. In this case-control study, we enrolled 116 depressed pregnant women and 244 healthy controls. The Edinburgh Postpartum Depression Scale (EPDS) was used to evaluate the depression symptom severity in study participants. All participants were screened for the anti-Toxoplasma IgG by enzyme-linked immunosorbent assay. Seroprevalence of T. gondii did not significantly differ between the depressed pregnant women and healthy controls (OR = 1.4; 95 % CI = 0.9-2.19; P = 0.142). T. gondii IgG titer was significantly higher in depressed women (18.6 ± 10.9 IUs) than those in the control group (13.6 ± 8.1 IUs) (z = -5.36, P < 0.001). The T. gondii-positive depressed women showed a positive correlation of T. gondii IgG titer with the EPDS scores (r = 0.52; P < 0.01). The mean EPDS score was also significantly higher in the T. gondii-positive depressed women (20.7 ± 2.7) compared with the controls (18.36 ± 2.7) (P < 0.001). The results obtained from the current study revealed that T. gondii infection might affect susceptibility to depression and severity of depressive symptoms in pregnant women, particularly in those patients who have high antibody titers. Further study is required to fully elucidate the characteristics and mechanisms of this association.

Thyroid peroxidase autoantibodies and perinatal depression risk: A systematic review

BACKGROUND

While thyroid autoantibodies have been linked to depression in general population samples, it is unclear if the immunological milieu of pregnancy alters this association. As a result, we systematically reviewed the literature to determine if abnormal levels of autoantibodies that target thyroperoxidase (TPO-AB) during the perinatal period are associated with an increased risk of antenatal and postnatal depression.

METHODS

MEDLINE, EMBASE, PsycINFO, and CINAHL databases were searched through February 2016. Primary studies that examined TPO-AB titers during pregnancy or the postpartum period, and antenatal or postnatal depression were eligible. The quality of each study was assessed using the Newcastle-Ottawa Scale.

RESULTS

Among the eleven articles selected for synthesis, three of these examined associations between TPO-AB and depression both during pregnancy and in the postpartum period. Three of five studies reported statistically significant associations between elevated TPO-AB titers (TPO-AB+) and concurrent depression at 12-25 weeks gestation. Four of five studies found significant associations between TPO-AB+ status at 12-25 weeks gestation and depression in the postpartum period. Two of four studies found links between postpartum TPO-AB and depression concurrently in the puerperium.

LIMITATIONS

Lack of adjustment for confounding variables limits causal inference and conclusions about the predictive power of TPO-AB.

CONCLUSIONS

Studies suggest that TPO-AB+ in early to mid-pregnancy is associated with concurrent depression and may be predictive of depression in the postpartum period. Future studies with improved methodology are required to better understand the full pathophysiological implications and predictive utility of TPO-AB in perinatal depression.

Evaluation of risk-factor-based screening for thyroid peroxidase antibody positivity in pregnancy

OBJECTIVE

To determine whether risk-factor-based screening for thyroid dysfunction in pregnancy performs well for detecting thyroid peroxidase antibodies (TPOAb), a marker for autoimmune thyroid disease.

STUDY DESIGN

We prospectively evaluated pregnant women for thyroid dysfunction using The Endocrine Society's eleven screening questions. Serum was analysed for TPOAb.

RESULT

We enrolled 546 women. TPOAb positivity was higher in women with a personal (odds ratio (OR) = 8·0; 95% confidence interval (CI) = 1·7-37·4; P = 0·02) or family history of thyroid disease (OR = 2·7; 95% CI = 1·3-5·7; P = 0·02). There was no association between the number of positive responses and TPOAb positivity (P = 0·41). Risk-factor-based screening missed 18 women (33%) with TPOAb.

CONCLUSION

One-third of women with TPOAb were missed by the case-finding method. A personal or family history of thyroid disease was most strongly associated with TPOAb positivity.

Bipolar disorder and antithyroid antibodies: review and case series

Mood disorders and circulating thyroid antibodies are very prevalent in the population and their concomitant occurrence may be due to chance. However, thyroid antibodies have been repeatedly hypothesized to play a role in specific forms of mood disorders. Potentially related forms include treatment-refractory cases, severe or atypical depression, and depression at specific phases of a woman’s life (early gestation, postpartum depression, perimenopausal). With regard to bipolar disorder, studies of specific subgroups (rapid cycling, mixed, or depressive bipolar) have reported associations with thyroid antibodies. Offspring of bipolar subjects were found more vulnerable to develop thyroid antibodies independently from the vulnerability to develop psychiatric disorders. A twin study suggested thyroid antibodies among possible endophenotypes for bipolar disorder. Severe encephalopathies have been reported in association with Hashimoto’s thyroiditis. Cases with pure psychiatric presentation are being reported, the antithyroid antibodies being probably markers of some other autoimmune disorders affecting the brain. Vasculitis resulting in abnormalities in cortical perfusion is one of the possible mechanisms.

Changes suggestive of post-partum thyroiditis in women with established hypothyroidism: incidence and predictors

OBJECTIVE

Post-partum thyroiditis (PPT) is a common phenomenon in the general population. To date there have been few studies examining the incidence of PPT in women with hypothyroidism antedating pregnancy. This study aimed to assess the incidence and potential predictors of PPT in women with treated hypothyroidism antedating pregnancy.

DESIGN

Retrospective cohort study.

PATIENTS AND METHODS

We compiled a cohort of 97 women with previous hypothyroidism antedating pregnancy seen in the Endocrinology in Pregnancy clinic from 1999 to 2011, collecting data on thyroid function, antibodies and levothyroxine doses post-partum. The incidence of PPT and its predictors were analysed.

RESULTS

A total of 66 (68%) women had fluctuations in thyroid function consistent with PPT. Of these, 22 (33%) had a hyperthyroid phase alone, 22 (33%) had a hypothyroid phase alone and 22 (33%) had both a hyper and hypo phase. The majority of women had their dose of thyroid medication adjusted during the PPT episode. Women who were on a full dose of thyroxine post-partum were significantly less likely to have a hypothyroid phase. In multivariable analysis, the only predictor of PPT was the presence of thyroid antibodies, with 83% of antibody positive women having PPT compared to 44% of antibody negative women (P = 0·0001).

CONCLUSIONS

In our cohort, 2/3 of women had fluctuations in thyroid function consistent with PPT and most required adjustment of their thyroid dose. Women with hypothyroidism antedating pregnancy are at high risk for PPT and should be closely monitored during the first year post-partum.

Symptoms and signs associated with postpartum thyroiditis

Background. Postpartum thyroiditis (PPT) is a common triphasic autoimmune disease in women with thyroid peroxidase (TPO) autoantibodies. This study evaluated women's thyroid disease symptoms, physical findings, stress levels, and thyroid stimulating hormone (TSH) levels across six postpartum months in three groups, TPO negative, TPO positive, and PPT positive women. Methods. Women were recruited in midpregnancy (n = 631) and TPO status was determined which then was used to form the three postpartum groups. The three groups were compared on TSH levels, thyroid symptoms, weight, blood pressure, heart rate, a thyroid exam, and stress scores. Results. Fifty-six percent of the TPO positive women developed PPT. Hypothyroid group (F (2, 742) = 5.8, P = .003) and hyperthyroid group (F (2, 747) = 6.6, P = .001) subscale scores differed by group. Several symptoms and stress scores were highest in the PPT group. Conclusions. The normal postpartum is associated with many symptoms that mimic thyroid disease symptoms, but severity is greater in women with either TPO or PPT positivity. While the most severe symptoms were generally seen in PPT positive women, even TPO positive women seem to have higher risk for these signs and symptoms.

Thyroid disorders during pregnancy

Thyroid disorders are common in pregnancy and in nonpregnant women of childbearing age, but can be missed because of nonspecific symptoms and normal changes in thyroid gland physiology during pregnancy. The prevalence of overt hyperthyroidism complicating pregnancy has been reported to range between 0.4% and 1.7%, and an estimated 2% to 3% of women are hypothyroid during pregnancy. Abnormalities in maternal thyroid function are associated with complications during pregnancy, and may affect maternal and fetal outcomes. Thus it is important to identify thyroid disorders before pregnancy or early in pregnancy so that appropriate treatment can be initiated.

Selenium supplementation for Hashimoto's thyroiditis

BACKGROUND

Hashimoto's thyroiditis is a common auto-immune disorder. The most common presenting symptoms may include anxiety, negative mood, depression, dry skin, cold intolerance, puffy eyes, muscle cramps and fatigue, deep voice, constipation, slow thinking and poor memory. Clinical manifestations of the disease are defined primarily by low levels of thyroid hormones; therefore it is treated by hormone replacement therapy, which usually consists of levothyroxine (LT4). Selenium might reduce antibody levels and result in a decreased dosage of LT4 and may provide other beneficial effects (e.g. on mood and health-related quality of life).

OBJECTIVES

To assess the effects of selenium supplementation on Hashimoto's thyroiditis.

SEARCH METHODS

We searched the following databases up to 2 October 2012: CENTRAL in The Cochrane Library (2012, Issue 10), MEDLINE, EMBASE, and Web of Science; we also screened reference lists of included studies and searched several online trial registries for ongoing trials (5 November 2012).

SELECTION CRITERIA

Randomised controlled clinical trials that assessed the effects of selenium supplementation for adults diagnosed with Hashimoto's thyroiditis.

DATA COLLECTION AND ANALYSIS

Study selection, data extraction, assessment of risk of bias, and analyses were carried out by two independent review authors. We assessed the quality of the evidence of included studies using GRADE. We were unable to conduct a meta-analysis because clinical heterogeneity between interventions that were investigated is substantial.

MAIN RESULTS

Four studies at unclear to high risk of bias comprising 463 participants were included. The mean study duration was 7.5 months (range 3 to 18 months). One of our primary outcomes－'change from baseline in health related quality of life'－and two of our secondary outcomes－'change from baseline in LT4 replacement dosage at end of the study' and 'economic costs'－were not assessed in any of the studies. One study at high risk of bias showed statistically significant improvement in subjective well-being with sodium selenite 200 μg plus titrated LT4 compared with placebo plus titrated LT4 (relative risk (RR) 4.67, 95% confidence interval (CI) 1.61 to 13.50; P = 0.004; 36 participants; number needed to treat (NNT) = 2 (95% CI 2 to 3)).Selenomethionine 200 μg reduced the serum levels of anti-thyroid peroxidase antibodies compared with placebo in two studies (mean difference (MD) -917 U/mL, 95% CI -1056 to -778; P < 0.001; 85 participants) and (MD -345 IU/mL, 95% CI -359 to -331; P < 0.001; 169 participants). Pooling of the studies was not feasible due to marked clinical heterogeneity (I(2) = 99%). In a further comparison within the first study where selenomethionine was combined with LT4 the reduction in TPO antibodies was even more noticeable (MD -1508 U/mL, 95% CI -1671 to -1345; P < 0.001; 86 participants). In a third study, where LT4 was added to both intervention arms, a reduction in serum levels of anti-thyroid peroxidase antibodies favoured the selenomethionine arm as well (MD -235 IU/mL, 95% CI -374 to -95; P = 0.001; 88 participants). Although the changes from baseline were statistically significant in these three studies, their clinical relevance is unclear. Serum antibodies were not statistically significantly affected in the study comparing sodium selenite 200 μg plus titrated LT4 with placebo plus titrated LT4 (MD -25, 95% CI -181 to 131; P = 0.75; 36 participants).Adverse events were reported in two studies (1 of 85 and 1 of 88 participants, respectively). Selenium supplementation did not appear to have a statistically significant impact on the incidence of adverse events (RR 2.93, 95% CI 0.12 to 70.00; and RR 2.63, 95% CI 0.11 to 62.95).

AUTHORS' CONCLUSIONS

Results of these four studies show that evidence to support or refute the efficacy of selenium supplementation in people with Hashimoto's thyroiditis is incomplete. The current level of evidence for the efficacy of selenium supplementation in the management of people with Hashimoto's thyroiditis is based on four randomised controlled trials assessed at unclear to high risk of bias; this does not at present allow confident decision making about the use of selenium supplementation for Hashimoto's thyroiditis. This review highlights the need for randomised placebo-controlled trials to evaluate the effects of selenium in people with Hashimoto's thyroiditis and can ultimately provide reliable evidence to help inform clinical decision making.

Thyroid autoantibodies in pregnancy: their role, regulation and clinical relevance

Autoantibodies to thyroglobulin and thyroid peroxidase are common in the euthyroid population and are considered secondary responses and indicative of thyroid inflammation. By contrast, autoantibodies to the TSH receptor are unique to patients with Graves' disease and to some patients with Hashimoto's thyroiditis. Both types of thyroid antibodies are useful clinical markers of autoimmune thyroid disease and are profoundly influenced by the immune suppression of pregnancy and the resulting loss of such suppression in the postpartum period. Here, we review these three types of thyroid antibodies and their antigens and how they relate to pregnancy itself, obstetric and neonatal outcomes, and the postpartum.

Positive thyroid peroxidase antibody titer is associated with dysphoric moods during pregnancy and postpartum

OBJECTIVE

To examine general dysphoric moods prospectively in women who tested positive for thyroid peroxidase autoantibodies (TPO) during pregnancy and postpartum.

DESIGN

Longitudinal, correlational, two-group, observational study.

SETTING

Perinatal clinics.

PARTICIPANTS

Six-hundred thirty-one (631) pregnant women.

METHODS

Participants were screened for TPO antibodies, and 63 were TPO euthyroid positive. All were asked to continue into a 6-month postpartum follow-up and 47 agreed. A comparison group of TPO negative women (n = 72) was randomly selected for follow-up. Women were visited monthly for 6 months and a blood sample was obtained to measure thyroid stimulating hormone (TSH), a targeted physical exam was conducted, and a thyroid symptom checklist (Perceived Stress Scale) and the Profile of Mood States (POMS) checklist were completed.

RESULTS

Pregnant TPO-positive women had significantly higher depressive symptoms and were more likely to score higher than 20 on the POMS depression (POMS-D) scale than TPO-negative women. The TPO-positive women had significantly higher depression, anger, and total mood disturbance scores postpartum than TPO-negative women, regardless of development of postpartum thyroiditis (n = 25).

CONCLUSIONS

Our results suggest that the presence of TPO autoantibodies alone in euthyroid pregnant and postpartum women increases the possibility of negative dysphoric moods, especially depressive symptoms that cannot be explained by stress or demographic factors.

Thyroid disorders during pregnancy

Thyroid disorders are common in women during pregnancy. If left untreated, both hypothyroidism and hyperthyroidism are associated with adverse effects on pregnancy and fetal outcomes. It is important to correctly identify these disorders and treat them appropriately to prevent pregnancy-related complications. Levothyroxine is the indicated treatment for hypothyroidism, and thionamides are the treatment of choice for hyperthyroidism; thyroidectomy may be indicated in select cases. When thyroid cancer is diagnosed during pregnancy, a decision must be made regarding performing thyroidectomy during the pregnancy or postponing surgical resection until the postpartum period. Radioactive iodine is absolutely contraindicated during pregnancy and lactation.

Prenatal depression and anxiety in Toxoplasma gondii-positive women

OBJECTIVE

This study analyzed a relationship between prenatal mood states and serologic evidence of immune response to Toxoplasma gondii. A secondary aim was to determine whether thyroid peroxidase autoantibody status was related to T gondii status.

STUDY DESIGN

Pregnant women (n = 414) were measured at 16-25 weeks' gestation with demographic and mood questionnaires and a blood draw. All plasma samples were analyzed for thyroid peroxidase and T gondii immunoglobulin G, tryptophan, kynurenine, and neopterin. T gondii serotypes were also measured in the women who were T gondii positive. Cytokines were available on a subset (n = 142).

RESULTS

Women with serologic evidence of exposure to T gondii (n = 44) showed positive correlations between immunoglobulin G levels and the Profile of Mood States depression and anxiety subscales. Plasma tumor necrosis factor-α was higher in women who were positive for T gondii. Serotypes were type I (27%), type II (31%), and unclassified (42%, which shows intermediate levels of reactivity). The depression and anxiety scores were highest in type I, but this was not significant. The Profile of Mood States vigor score was lowest in type II, compared with the type I or unclassified groups.

CONCLUSION

Higher T gondii immunoglobulin G titers in infected women were related to anxiety and depression during pregnancy. Subclinical reactivation of T gondii or immune responses to T gondii may worsen mood in pregnant women.

High rate of persistent hypothyroidism in a large-scale prospective study of postpartum thyroiditis in southern Italy

CONTEXT

The incidence of postpartum thyroiditis (PPT) varies widely in the literature. Limited data exist concerning the hormonal status of women with PPT at the end of the first postpartum year.

OBJECTIVE

Our aim was to conduct a large prospective study of the incidence and clinical course of PPT.

DESIGN

A total of 4394 women were screened for thyroid function and thyroid autoantibodies at 6 and 12 months postpartum. Women were classified as being at high or low risk of having thyroid disease before any thyroid testing.

SETTING

The study was conducted at two ambulatory clinics in southern Italy, an area of mild iodine deficiency.

PATIENTS

A total of 4394 pregnant women were studied.

INTERVENTION

There was no intervention.

MAIN OUTCOME MEASURES

We measured incidence, clinical presentation, and course of postpartum thyroiditis.

RESULTS

The incidence of postpartum thyroiditis was 3.9% (169 of 4384). Women classified as being at high risk for thyroid disease had a higher incidence of PPT than women classified as low risk (11.1 vs. 1.9%; odds ratio, 6.69; 95% confidence interval, 4.63, 9.68). Eighty-two percent of the 169 women with PPT had a hypothyroid phase during the first postpartum year. At the end of the first postpartum year, 54% of the 169 women had persistent hypothyroidism.

CONCLUSIONS

One of every 25 women in southern Italy developed PPT. Women at high risk for thyroid disease have an increased rate of PPT. The high rate of permanent hypothyroidism at 1 yr should result in a reevaluation of the widely held belief that most women with PPT are euthyroid at the end of the first postpartum year.

Thyroid dysfunction in pregnancy: optimizing fetal and maternal outcomes

Recent decades have seen a growing awareness of the threat posed by thyroid dysfunction in pregnancy on maternal, fetal and neonatal well-being. Uncontrolled hypothyroidism and hyperthyroidism are associated with adverse obstetrics and fetal outcomes and also affect neurointellectual development in the offspring. Excellent outcomes are, however, achievable with appropriate management. An understanding of the changes in thyroid hormone economy in pregnancy is crucial to the evaluation of thyroid status in pregnant patients with thyroid dysfunction. Furthermore, a balance must be maintained between the control of maternal disease and the requirements of the developing fetus. Careful monitoring of patients in a multidisciplinary care setting, and appropriate adjustments of treatment, is essential throughout pregnancy and the puerperium. In this special report we summarize best practice in the management of thyroid dysfunction in pregnancy.

Repeated episodes of respiratory distress in an obese parturient after cesarean delivery

A 25-yr-old obese parturient with mild asthma underwent an uneventful spinal anesthetic for primary cesarean delivery. Within 4 h after delivery, the patient twice developed acute shortness of breath, inspiratory stridor, and hypoxemia that required intubation. A battery of blood tests revealed no evidence of an allergic reaction. She had a normal echocardiogram and chest computed tomography, but her neck computed tomography showed an enlarged left thyroid lobe asymmetrically compressing the endotracheal tube cuff. We hypothesized that, after delivery, decreased maternal vascular capacitance increased central venous pressure such that venous engorgement of an undiagnosed goiter may have caused symptomatic tracheal compression.

Medical management of thyroid dysfunction in pregnancy and the postpartum

BACKGROUND

Uncontrolled thyroid dysfunction in pregnancy is associated with adverse fetal and maternal outcomes.

OBJECTIVES

To review relevant literature and developments in the medical management of thyroid dysfunction in pregnancy.

RESULTS

Hyperthyroidism in pregnancy requires careful control of maternal disease whilst avoiding fetal hypothyroidism. Propylthiouracil is the preferred antithyroid drug in pregnancy although thiamazole can be used where propylthiouracil is unavailable. Synthetic levothyroxine is the treatment of choice in hypothyroidism. Patients with pre-existing hypothyroidism will generally require an increase in thyroxine dose in pregnancy. Most patients with postpartum thyroiditis will require treatment during the hypothyroid phase. Long-term follow-up of patients with this syndrome is essential owing to the risk of permanent hypothyroidism.

CONCLUSION

Excellent maternal and fetal outcomes can be achieved with appropriate management of thyroid dysfunction in pregnancy.

Value of Combined Clinical Information and Thyroid Peroxidase Antibodies in Pregnancy for the Prediction of Postpartum Thyroid Dysfunction

PROBLEM

To investigate the utility of thyroid peroxidase antibodies (TPOAb) in early pregnancy combined with clinical information for prediction of postpartum thyroid dysfunction (PPTD) within 1 year postpartum.

METHOD OF STUDY

We studied 98 pregnant women by determining their TPOAb levels in early pregnancy, as well as their serum thyrotropin and free thyroid (fT4) levels at 6 and 12 months postpartum. Furthermore, they answered a questionnaire and physical examination was performed by only one examiner.

RESULTS

Of the 98 women, 10 were positive TPOAb in early pregnancy. The overall risk of PPTD within 1 year of follow-up was 10.2% (95% CI 4.1-16.3). Risk of PPTD was significantly higher among women with a family history of thyroid disease, TPOAb positive and presenting goiter in early pregnancy. The sensitivity, specificity and positive predictive value of TPOAb in PPTD prediction were 60.0%, 95.5% and 60%. Restricting screening to women with a family history of thyroid disease or presenting goiter increases the positive predictive value from 60% to 82.4%.

CONCLUSION

Our results suggest that TPOAb could be used as a screening test for PPTD prediction at least among women who present a high risk of developing PPTD.

Screening for thyroid disease in pregnancy

Although gestational hyperthyroidism is uncommon (0.2%), hypothyroidism (autoimmune disease or suboptimal iodine intake) occurs in 2.5% of women and is predictive of reduced neonatal and child neuropsychological development and maternal obstetric complications. Postpartum thyroid dysfunction (PPTD) occurs in 5-9% of women and is associated with antithyroid peroxidase antibodies (antiTPOAb) in 10% of women in early pregnancy. Therefore, screening for thyroid dysfunction in pregnancy should be considered. T4 and thyroid stimulating hormone measurements could be used to screen for hypothyroidism, which would require levothyroxine intervention treatment. T4 supply is crucial to fetal nervous system maturation; currently, the recommended daily iodine intake is 200 microg, and this is not always achieved, even in the UK. At present, a randomised prospective trial is ongoing to provide the evidence base for this screening strategy. Meanwhile, it is reasonable to (a) optimise iodine nutrition during pregnancy; (b) ascertain women with known thyroid disease; (c) identify women at increased risk of thyroid disease-for example, those with other autoimmune diseases. PPTD can be predicted by measurement of antiTPOAb in early gestation.

Sequential studies on thyroid antibodies during pregnancy

Thyroid antibodies were measured sequentially in 25 pregnant women from a Sri Lankan population. A high prevalence of antithyroid antibodies, particularly antithyroglobulin antibodies (TgAb) had previously been demonstrated in female schoolchildren drawn from this population. In the present study TgAb were detected in 36.8% of nonpregnant controls while thyroid peroxidase antibody (TPOAb) positivity was present in 26.3%. The prevalence of both antibodies in the pregnancy study group showed a progressive decline compared to nonpregnant controls throughout gestation becoming undetectable in the third trimester. The results are consistent with an immunosuppressive effect of pregnancy in a population in whom high thyroid autoantibody titers may have resulted from a recent salt iodization program.

Thyroid disorders associated with pregnancy: etiology, diagnosis, and management

Pregnancy has an effect on thyroid economy with significant changes in iodine metabolism, serum thyroid binding proteins, and the development of maternal goiter especially in iodine-deficient areas. Pregnancy is also accompanied by immunologic changes, mainly characterized by a shift from a T helper-1 (Th1) lymphocyte to a Th2 lymphocyte state. Thyroid peroxidase antibodies are present in 10% of women at 14 weeks' gestation, and are associated with (i) an increased pregnancy failure (i.e. abortion), (ii) an increased incidence of gestational thyroid dysfunction, and (iii) a predisposition to postpartum thyroiditis. Thyroid function should be measured in women with severe hyperemesis gravidarum but not in every patient with nausea and vomiting during pregnancy. Graves hyperthyroidism during pregnancy is best managed with propylthiouracil administered throughout gestation. Thyroid-stimulating hormone-receptor antibody measurements at 36 weeks' gestation are predictive of transient neonatal hyperthyroidism, and should be checked even in previously treated patients receiving thyroxine. Postpartum exacerbation of hyperthyroidism is common, and should be evaluated in women with Graves disease not on treatment. Radioiodine therapy in pregnancy is absolutely contraindicated. Hypothyroidism (including subclinical hypothyroidism) occurs in about 2.5% of pregnancies, and may lead to obstetric and neonatal complications as well as being a cause of infertility. During the last few decades, evidence has been presented to underpin the critical importance of adequate fetal thyroid hormone levels in order to ensure normal central and peripheral nervous system maturation. In iodine-deficient and iodine-sufficient areas, low maternal circulating thyroxine levels have been associated with a significant decrement in child IQ and development. These data suggest the advisability of further evaluation for a screening program early in pregnancy to identify women with hypothyroxinemia, and the initiation of prompt treatment for its correction. Hypothyroidism in pregnancy is treated with a larger dose of thyroxine than in the nonpregnant state. Postpartum thyroid dysfunction (PPTD) occurs in 50% of women found to have thyroid peroxidase antibodies in early pregnancy. The hypothyroid phase of PPTD is symptomatic and requires thyroxine therapy. A high incidence (25-30%) of permanent hypothyroidism has been noted in these women. Women having transient PPTD with hypothyroidism should be monitored frequently, as there is a 50% chance of these patients developing hypothyroidism during the next 7 years.

Thyroid peroxidase autoantibodies in euthyroid subjects

Thyroid peroxidase (TPO) is a key enzyme in the formation of thyroid hormones and a major autoantigen in autoimmune thyroid diseases. Titers of TPO antibodies also correlate with the degree of lymphocytic infiltration in euthyroid subjects, and they are frequently present in euthyroid subjects (prevalence 12-26%). Even within the normal range for thyrotropin (TSH), TPO antibody titers correlate with TSH levels, suggesting that their presence heralds impending thyroid failure. Assays for serum TPO antibodies have become much more sensitive, and very low titers can be found in virtually all subjects. However, titers above an assay-dependent cut-off are a clear risk factor for hypothyroidism; in the Whickham survey the annual risk of developing hypothyroidism in TPO-positive women with normal thyrotropin levels was 2.1%. Measuring TPO antibodies in euthyroid subjects can be used to identify subjects with increased risk for hypothyroidism: e.g. as triage to measure thyrotropin. This could be done in women who wish to become pregnant and those with an increased risk per se who are pregnant (to predict first trimester hypothyroidism, and postpartum thyroid dysfunction), patients with other autoimmune diseases, subjects on amiodarone, lithium, or interferon-alpha, and in relatives of patients with autoimmune thyroid diseases.

Thyroid function inside and outside of pregnancy: what do we know and what don't we know?

A workshop entitled, "The Impact of Maternal Thyroid Diseases on the Developing Fetus: Implications for Diagnosis, Treatment, and Screening," was held in Atlanta, Georgia, January 12-13, 2004. This paper reports on the session that examined the prevalence of thyroid dysfunction in reproductive-age women and the factors associated with abnormal function. For this session the following papers were presented: "Thyroidal Economy in the Pregnant State: An Overview," "The Prevalence of Thyroid Dysfunction in Reproductive-Age Women- United States," and "Risk Factors for Thyroid Disease: Autoimmunity and Other Conditions." These presentations were formally discussed by invited respondents and by others in attendance. Salient points from this session about which there was agreement include the following: physiologic changes associated with pregnancy require an increased availability of thyroid hormones by 40% to 100% in order to meet the needs of mother and fetus during pregnancy. In the first trimester of gestation the fetus is wholly dependent on thyroxine from the mother for normal neurologic development. For the maternal thyroid gland to meet the demands of pregnancy it must be present, disease-free, and capable of responding with adequate stores of iodine. Thyroid autoimmunity is common and may contribute to miscarriages, as well as to hypothyroidism. With sufficient iodine nutrition, autoimmune thyroid disease (AITD) is the most common cause of hypothyroidism. As of 1994, iodine nutrition in the United States appeared to be adequate, but its continued monitoring is essential.

Age as a predictor of recurrent hypothyroidism in patients with post-partum thyroid dysfunction

The long term effect of post-partum thyroid dysfunction (PPTD) is not well established. This study was conducted to evaluate the outcome of permanent hypothyroidism and factors predictive of thyroid dysfunction in a large cohort of women with PPTD. In 164 women, treated with levothyroxine for moderate and severe post- partum hypothyroidism, the treatment was discontinued and subjects were followed-up for the recurrence of hypothyroidism. Factors such as thyroid function tests, tyroid peroxidase antibodies (TPOAb) titers, multiparity, history of autoimmune disorders, smoking habits, use of oral contraceptives, family history of thyroid disease, goiter size and age at active phase of PPTD were assessed. Seventy-one post-partum women without PPTD were considered as control group. One hundred forty-eight women (90%) returned for follow-up, and 93 subjects (63%) developed hypothyroidism with a median of 2 months after T4 withdrawal. Of factors predicting recurrence of hypothyroidism, only age, and serum TSH and T3 concentrations at the time of occurrence of PPTD entered the model in multiple stepwise regression analysis. Hypothyroidism occurred earlier and more frequently in women aged 30 and over, as compared to younger ones (p < 0.01), hazard ratio 1.69. In 55 euthyroid subjects with history of PPTD, serum TSH was significantly increased as compared to the control group (3.0 +/- 1.6 vs 0.8 +/- 0.5 mU/l, p < 0.001). These data, representing the largest cohort of women with PPTD who have been followed, show that a significant proportion of women with moderate and severe PPTD, in particular those aged 30 yr and over, develop recurrent hypothyroidism. Proper follow-up of all women with PPTD, the older ones in particular, is recommended.

Prospective Study of Post‐partum Thyroid Immune Dysfunctions in Type 1 Diabetic Women and in a Healthy Control Group Living in a Mild Iodine Deficient Area

Second to diabetes mellitus, thyroid diseases are the most common endocrinopathies seen in pregnancy. The incidence of post-partum thyroid dysfunction (PPTD) in women with type 1 diabetes mellitus is three-fold increased. We determined the incidence of thyroid abnormalities in a well-defined group of young subjects with type 1 diabetes and in an age-matched healthy controls during and six months after pregnancy in an area of mild iodine deficiency. Twenty-five out of twenty-eight pregnant women completed the study. Fifteen were affected by type 1 diabetes and ten were controls. Our protocol of study consisted of four evaluations of each subject: in the first, in the second trimester, at delivery and six months after. At each control the patients were submitted to physical examination, thyroid ultrasonography, and determination of fT3, fT4, TSH, Antithyroglobulin antibodies (TgAbs), Antithyroperoxidase antibodies (TPOAbs). The variation of thyroid volume is statistically significant in both the diabetics and in the controls during the different times of observations. Four out of the fifteen diabetic pregnant patients (27%) developed a thyroid disease: two cases of post-partum thyroiditis (PPT) and two cases of euthyroid benign nodular goiter, as confirmed by cytological examination. Two out ten controls (20%) developed positive antibodies (TPO Abs and TgAbs) since the first observation and showed an autoimmune thyroiditis six months after delivery. Both of them showed a familial history of thyroid disease. Our study suggests that in an area of mild iodine deficiency the incidence of thyroid autoimmunity in pregnant women is similar, whether diabetic or not; moreover, thyroid volume is increasing in the diabetics as much as in the non diabetics during pregnancy.

Thyroid peroxidase antibodies in early pregnancy: utility for prediction of postpartum thyroid dysfunction and implications for screening

Thyroid peroxidase antibodies (TPOAb) in pregnancy are a marker for postpartum (PPTD) and long-term thyroid dysfunction, with variable sensitivity and specificity in PPTD prediction. To test its utility in prediction, we recruited 308 TPOAb-positive (147 developed PPTD (PPTD group) and 161 remained euthyroid [PPTE group]) and 102 TPOAb-negative women (none developed PPTD), in early pregnancy (median, 18; range, 9-19 weeks' gestation). TPOAb levels were higher in the PPTD group (median) (125.2 kIU/L; p < 0.001), and in its hypothyroid (162.4 kIU.; p < 0.0001), hyperthyroid (114.2 kIU/L; p < 0.007), and biphasic (105.1 kIU/L; p < 0.02) variants, compared to the PPTE group (66.7 kIU/L) The incidence of PPTD was significantly higher with TPOAb levels above 58.2 kIU/L (early pregnancy versus postpartum; relative risk, 1.37 [95% confidence interval [CI] 1.17-1.61] versus 0.78 [95% CI 0.5-1.2]) compared to levels below. The integrated postpartum TPOAb response was higher in the PPTD group (median) (159 kIU/L per week) and its variants (hypothyroid; 199 kIU/L per week; biphasic, 180 kIU/L per week; hyperthyroid, 120 kIU/L per week), compared to the PPTE group (86 kIU/L per week p < 0.004). Median early pregnancy TPOAb levels in the PPTD and PPTE groups correlated well with the postpartum antibody response (r = 0.58, p < 0.001). The sensitivity of TPOAb in PPTD prediction was 100% (early pregnancy and postpartum), specificity 62% (early pregnancy) versus 41% (postpartum) and positive predictive value 48% (early pregnancy and postpartum). The timing of TPOAb testing, the sensitive assay used and the absence of PPTD in TPOAb-negative subjects contributed to this high sensitivity. We recommend TPOAb in early pregnancy as a useful predictor of PPTD, particularly in populations where PPTD does not occur in TPOAb-negative women.

Postpartum mood disorders: a review of clinical and epidemiological factors

The postpartum period is a time of risk for mood disturbance in women. Postpartum blues occurs commonly, but is self-limited. Postpartum depression occurs in 13% of postpartum women. However, it is estimated that nearly one-half of all cases go undetected. Postpartum psychosis is rare, affecting 1-2 per 1000 women. Postpartum mood disorders can have far-reaching consequences and have been shown to affect the social and psychological development of children. It is critical that healthcare providers understand these disorders and their risk factors to increase detection and to educate women about the risks and treatments of postpartum mood disorders. This review is intended to provide healthcare providers with a better understanding of the descriptive epidemiology, risk factors, and treatments of postpartum mood disorders. The utility of specific screening instruments is also discussed.

Postpartum thyroiditis is associated with fluctuations in transforming growth factor-beta1 serum levels

Postpartum thyroiditis (PPT) is characterized by a rapid evolution and recovery of euthyroidism. Therefore, it can represent a good model to study early cytokine fluctuations in autoimmune thyroid diseases. TGFbeta1 is an immunosuppressive cytokine, as it inhibits T and B cell proliferation, natural killer cell cytotoxic activity, and the generation of T cell cytotoxicity. The aim of this study was to assess serum concentrations of TGFbeta1 during pregnancy and to study possible serum fluctuations of this cytokine during the different phases of PPT. Thyroid biochemical pattern, antithyroid autoantibodies (ATA), and total and active TGFbeta1 (aTGFbeta1) serum concentrations were evaluated in 63 pregnant women. Thirty-four of them were ATA(+), and 29 were ATA(-). Twenty of the 34 ATA(+) women were followed in the postpartum year. Nine of these 20 women developed PPT; 11 remained euthyroid. All of the PPT women became euthyroid during the follow-up. Our results showed 1) detectable serum levels of aTGFbeta1 in 50% of ATA(+) pregnant women, suggesting that the presence of autoantibodies may characterize a favorable condition for TGFbeta1 activation; and 2) decreased total TGFbeta1 and increased aTGFbeta1 serum levels during the active phase of PPT in ATA(+) women. This seems to suggest that inflammation may be responsible for TGFbeta1 activation and autoantibody increase because of antigen release. Although further studies of women with persistent hypothyroidism after the postpartum year are needed, the possibility that the enhanced activation of TGFbeta1 may contribute to resolution of thyroid inflammation postpartum cannot be excluded.

Epidemiology and prevention of thyroid disease in pregnancy

Pregnancy has variable effects on thyroid hormone concentrations throughout pregnancy as well as being associated with goiter. The latter is largely preventable by ensuring optimal iodine intake of at least 200 microg/d. Immunologic changes in pregnancy include a so-called T(H)2 shift that reverts to T(H)1 status around birth or early in the postpartum period. Hyperthyroidism during gestation, usually caused by Graves' disease, is rare (0.2%) and is best managed medically with propylthiouracil; thyroid-stimulating antibodies should be measured. Prevention of the deleterious effects of Graves' disease includes adequate preconception advice, adequate monitoring during pregnancy, and total avoidance of (131)I therapy during pregnancy. Hypothyroidism during pregnancy has an incidence of 2.5% although there is a 10% incidence of thyroid peroxidase (TPO)-antibody positivity in early gestation. There are convincing epidemiologic data to show that suboptimal thyroid function in pregnancy is associated with impaired neurointellectual development (e.g., 19% with IQ < 85 compared to 5% in one study). Therefore, there is a case for screening for thyroid function in early pregnancy with thyroxine (T(4)) intervention therapy. Maintenance of optimal iodine intake is critical to prevent nonautoimmune gestational maternal hypothyroxinaemia. Postpartum thyroid dysfunction (PPTD) occurs in 5%-9% of women and in up to 50% of TPO-antibody positive women (as ascertained in early pregnancy). Prevention of PPTD at this time could only be achieved by pregestational ablation of the thyroid. Another approach is to at least improve the prediction of postpartum thyroid disease (PPT) because the TPO antibody has a sensitivity of only 50%.

Post-partum thyroiditis in a mediterranean population: a prospective study of a large cohort of thyroid antibody positive women at the time of delivery

Post-partum thyroiditis (PPT) is a common disease with important clinical sequelae. Its clinical features, association with antimicrosomal antibodies (TPOAb) and long-term prognosis are not thoroughly described in Mediterranean populations. The aims of this study were: 1) to describe clinical features of PPT in a Greek population, 2) to associate TPOAb with PPT presence, and 3) to identify long-term prognosis of PPT. 1,594 consecutive post-partum women were studied within 3 days of their delivery. Women with positive TPOAb were followed-up for one yr for clinical and biochemical evidence of PPT. Incidence of positive TPOAb was 5.2% whereas incidence of PPT was 2.4%. PPT was presented as hyperthyroidism alone (18%), hypothyroidism alone (40%) and hyperthyroidism followed by hypothyroidism (42%). A titer of 1:1600, immediately post-partum, could predict PPT with 97% sensitivity and 91% specificity. History of PPT in previous pregnancies was associated with PPT in the current pregnancy. This association did not exist with maternal age, gestation duration, parity, abortions, sex of the newborn, birth-weight or smoking. Long-term hypothyroidism developed in 21% of women. Observation and post-partum thyroid function testing, where PPT is suspected, seems to constitute the best clinical approach. There is need for long-term follow-up in PPT patients.

Soluble CD4 concentrations predict relapse of post-partum thyroiditis

Post-partum thyroiditis (PPT) is a common autoimmune thyroid disorder which results in significant morbidity at a critical time of a woman's life. The presence of anti-thyroglobulin (anti-TG) and, more so, anti-thryroperoxidase (anti-TPO) antibodies in the first trimester of pregnancy has been reported to forecast subsequent PPT. Despite their predictive value, these tests lack in specificity. We have sought to find an alternative that is more specific and, ideally, which could be tested immediately proximate to the event. We have taken advantage of the high recurrence rate of PPT in subsequent pregnancies to perform a prospective study of serum soluble CD4 (sCD4) and CD8 (sCD8) levels in 22 pregnant women who had at least one previous episode of PPT. This group was matched with 21 pregnant women of comparable age with no evidence of thyroid disease. Both groups of women were sampled in each of the three trimesters of pregnancy, 1 month, 3 months and 6 months post-partum for sCD4, sCD8, thyroid function parameters and antibodies. Twelve of the 22 women with previous PPT had recurrent disease; they were more likely to be cigarette smokers and to have a family history of autoimmune disorders (p<0.05, for both) than those who did not. Half of these women had high anti-TG or anti-TPO each in the first trimester compared to none among those without recurrent PPT and 2/21 controls. Serum sCD8 levels showed no changes over the observation points among the two PPT patient subsets and were comparable to those of the controls. By contrast, serum sCD4 concentrations showed divergent changes in the group with recurrent PPT in the course of pregnancy and postpartum period compared to those without disease recurrence and controls: sCD4 failed to show the physiological fall in the third trimester of pregnancy [19.0+/-1.7 (+/-SD) U/ml vs 15.6+/-2.3 U/ml in controls, NS]. This trend was continued into the first month post-partum when sCD4 levels were clearly higher than in controls (22.1+/-2.6 U/ml compared to 17.9+/-1.9 U/ml in controls, p<0.001) and well before the episode of PPT. An sCD4 serum level outside the 95% reference range at 1 month post-partum (9/12 in recurrent PPT, 1/21 in controls) yields a relative risk of 6.9 (chi2=14.67, p<0.001) compared to 3.3 for first trimester thyroid antibody positivity (p=0.029). In summary, we describe a reliable test for forecasting PPT that can be obtained immediately proximate to the possible event. If our findings are verified in larger studies, the measurement of serum sCD4 concentration drawn in the first month post-partum may prove an ideal test for population screening for impending PPT.

Case finding and screening strategies for thyroid dysfunction

BACKGROUND

A case can be made for routine testing for thyroid dysfunction (TD) in women aged over 50 years once every 5 years when they present for medical care (case finding). This recommendation is based on: (i) the prevalence of TD, predominantly hypothyroidism, (ii) the insensitivity of standard clinical assessment in detecting even overt TD, (iii) the sensitivity of a single test, serum thyroid stimulating hormone (TSH), in identifying both over- and under-function, (iv) the probable adverse consequences of failure to recognize even mild TD, (v) the safety and effectiveness of treatment, and (vi) presumed lack of adverse effect from the testing program.

METHODS

A normal serum TSH value has a high negative predictive value in ruling out primary TD; if TSH is abnormal, measurement of serum free thyroxine (T(4)) and further clinical assessment are both required to establish the degree of TD.

RESULTS

Case finding identifies more "subclinical" or mild TD (abnormal TSH, normal T(4) and triiodothyronine (T(3))), than overt disease, but a major benefit of widespread testing is the earlier detection and treatment of unsuspected overt disease. There is now evidence that mild TD has adverse consequences and should not merely be regarded as a prognostic indicator, but there is still no consensus whether there is a causal relationship between mild thyroid failure and dyslipidemia.

CONCLUSIONS

A case can be made for treatment of both mild thyrotoxicosis and hypothyroidism, but the therapeutic decision is generally simpler for hypothyroidism.

Postpartum thyroid dysfunction and postpartum depression: are they two linked disorders?

OBJECTIVE

Postpartum has been considered as a period of risk for developing postpartum depression (PD) by some but not all authors, and this PD has been linked with postpartum thyroid dysfunction (PPTD). The major aim of this study was to evaluate the relation between the presence of PPTD and PD.

DESIGN AND PATIENTS

Six hundred and forty-one healthy Caucasian women recruited between their 36th week of pregnancy and fourth day postpartum underwent clinical and laboratory evaluation and were checked again at 1 (n = 605), 3 (n = 552), 6 (n = 574), 9 (n = 431), and 12 (n = 444) months postpartum.

MEASUREMENTS

At baseline and at each clinical evaluation, Beck Depression Inventory (BDI) was administered to screen PD. The definitive diagnoses of PD was performed by a psychiatrist according to the DSM-III-R criteria. At each visit, we determined serum free T4 and TSH concentrations. Thyroperoxidase and thyroglobulin antibodies were determined only in patients with abnormal hormone concentrations. Postpartum thyroiditis (PPT) was considered to be present in women with overt or subclinical transient hyperthyroidism between 1 and 3 months postpartum and/or overt or subclinical hypothyroidism between 3 and 6 months postpartum.

RESULTS

Fifty-six women developed postpartum thyroid dysfunction (PPTD), corresponding to an incidence rate of 11%: 45 with PPT [incidence rate 7.8%; confidence interval (CI) 5.6-10%], eight with Graves' disease (incidence rate 1.5%; CI 0.5-2.5%) and three with nonpalpable toxic thyroid adenoma (incidence rate 0.5%; CI 0-1.5%). Five hundred and eighty of the evaluated women (incidence rate 90.5%; CI 95% 88.2-92.8) presented BDI scores below 21 and therefore the PD diagnoses was excluded. In 50 cases (incidence rate 7.8%; Cl 95% 5.7-9.8), we detected a BDI score over 21 in some evaluations, but the PD diagnosis was not confirmed. Another 11 (incidence rate 1.7%; CI 95% 0.7-2.7) were diagnosed as having PD and required psychiatric treatment. None of the PPTD was diagnosed as having PD. The BDI scores frequency over 21 was similar between healthy women and those with PPTD. Patients with a previous history of depression developed PD more often (P < 0.0001). One hundred and ninety women breast fed their babies for more than 2 months, without observing a higher PD rate or BDI scores over 21 (P = 0.5).

CONCLUSIONS

We found a general PD incidence rate of 1.7% in our group of patients. This figure is not higher in women with hormone abnormalities caused by PPTD. Women with a past history of depression present a higher risk of PD while those who breast fed did not have an increased risk.

Autoimmune thyroid disease in pregnancy and the postpartum period: relationship to spontaneous abortion

The aim of this study was to determine the prevalence of autoimmune thyroid disease and the risk of miscarriage in autoimmune thyroid antibody (ATA)-positive women. Eight hundred seventy-six subjects completed the study, and 12.3% were thyroid antibody-positive (4.5% tested positive for both thyroid peroxidase antibody [TPO-Ab] and thyroglobulin autoantibody [Tg-Ab], 4.79% were TPO-Ab-positive only, and 3.1% were Tg-Ab-positive only). Fifty percent of the ATA-positive women and 14.1% of the ATA-negative group had a history of spontaneous abortion. Forty-eight of the ATA-positive women developed postpartum autoimmune thyroid dysfunction (PATD). Of these, 50% had hypothyroidism alone, 31.3% had transient hyperthyroidism followed by hypothyroidism, and 18.8% had transient thyrotoxicosis alone. Of the 48 PATD subjects, 12.5% developed persistent hypothyroidism. None of the ATA-negative women developed any form of thyroid dysfunction. The thyroid-stimulating hormone (TSH) levels in the ATA-positive group were significantly higher than those in the ATA-negative group, and only the ATA-positive women with a history of abortion had significantly higher TSH and lower free thyroxine (FT4) concentrations than the other subgroups. The results revealed a 5.5% prevalence rate for PATD in the study population. In addition to TPO-Ab, Tg-Ab is a useful marker for autoimmune thyroiditis.