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Karavani G, Daoud-Sabag L, Chay C, Gillis D, Strich D. Is TSH a Reliable Indicator of Thyroid Hormone Status in Pregnancy? Horm Metab Res 2022; 54:435-441. [PMID: 35835143 DOI: 10.1055/a-1872-0246] [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: 11/04/2022]
Abstract
Thyroid screening is recommended during pregnancy with serum thyrotropin (TSH) as the primary test. However, since human chorionic gonadotropin, the serum hallmark of pregnancy, has TSH-like effects, the adequacy of TSH as a screening tool in this constellation requires further study. This study aimed to evaluate the relationship between TSH and thyroid hormones during pregnancy in order to determine if TSH is an adequate screening tool. This was a retrospective study utilizing the Clalit Health Service, Jerusalem district database between 2006-2017 in which we analyzed TSH, FT4 and FT3 measurements from 32430 pregnancies resulting in live birth. We grouped FT4 and FT3 levels by trimester and by the following TSH levels: (1) below 0.1/0.2/0.3 mIU/l, (2) 0.1-2.5/0.2-3.0/0.3-3.0 mIU/l, (3) 2.6-4.0/3.1-4.0 mIU/l, (4) 4.1-10.0 mIU/l and (5) above 10.0 mIU/l. In the first trimester, the most important for fetal brain development, FT3 was below normal, defined as below the 2.5th percentile for the population, in only 15.3% of tests with TSH over 10 mIU/l. FT4 was below normal in only 12.8% of such tests. Similar findings were noted for the second and third trimesters. As expected, there were far less abnormal tests when lower TSH cutoff levels were tested. In conclusion, TSH levels beyond the range accepted as normal do not, in most cases, reflect abnormal thyroid hormone levels during pregnancy. TSH is not a good screen for overt hypothyroidism in pregnancy. This may be due, at least in the first trimester, to thyrotropic effects of HCG.
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Affiliation(s)
- Gilad Karavani
- Department of Obstetrics and Gynecology, Hadassah Ein-Kerem Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Infertility and IVF Unit, Hadassah Ein-Kerem Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Lina Daoud-Sabag
- Department of Obstetrics and Gynecology, Hadassah Ein-Kerem Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Cherut Chay
- Department of Family Medicine, Technion Israel Institute of Technology Ruth and Bruce Rappaport Faculty of Medicine, Tel Aviv, Israel
| | - David Gillis
- Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - David Strich
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Pediatrics, Shaare Zedek Medical Center, Jerusalem, Israel
- Pediatric Specialties, Shaare Zedek Medical Center, Jerusalem, Israel
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2
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Ilias I, Milionis C, Koukkou E. Further understanding of thyroid function in pregnant women. Expert Rev Endocrinol Metab 2022; 17:365-374. [PMID: 35831988 DOI: 10.1080/17446651.2022.2099372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 07/05/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Normal thyroid status throughout pregnancy is important for both maternal and fetal health. Despite the bulk of contemporary research honing on thyroid function in gestation and the relevant disorders, there are still gaps in our current knowledge about the etiology and treatment of thyroid diseases in pregnant women. AREAS COVERED This article analyzes the adaptation of the thyroid gland to gestational physiological changes and attempts to explain the effect of several factors on thyroid function in pregnancy. It also stresses proper utilization and interpretation of thyroid tests during pregnancy and underlines the significance of proper screening and treatment of pregnant women aiming at favorable health outcomes. EXPERT OPINION Appropriate strategies for diagnosing and treating thyroid disease in pregnancy are important. Laboratory thyroid testing plays a leading role, but test results should be interpreted with caution. Given the possible serious maternal and fetal/neonatal complications of thyroid disease in pregnancy, we recommend universal screening with TSH measurements of all pregnant women. Additional assessment with determination of the levels of free thyroid hormones and thyroid antibodies may be necessary under certain conditions. The economic burden of such interventions should be considered.
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Affiliation(s)
- Ioannis Ilias
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, Athens, Greece
| | - Charalampos Milionis
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, Athens, Greece
| | - Eftychia Koukkou
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, Athens, Greece
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Turkal R, Turan CA, Elbasan O, Aytan S, Çakmak B, Gözaydınoğlu B, Takır DC, Ünlü O, Bahramzada G, Tekin AF, Çevlik T, Büyükbayrak EE, Şirikçi Ö, Gözü H, Haklar G. Accurate interpretation of thyroid dysfunction during pregnancy: should we continue to use published guidelines instead of population-based gestation-specific reference intervals for the thyroid-stimulating hormone (TSH)? BMC Pregnancy Childbirth 2022; 22:271. [PMID: 35361138 PMCID: PMC8973886 DOI: 10.1186/s12884-022-04608-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 03/22/2022] [Indexed: 11/17/2022] Open
Abstract
Background Considering the changes in thyroid physiology associated with pregnancy and poor outcomes related to abnormal maternal thyroid function, international guidelines recommend using population-based trimester-specific reference intervals (RIs) for thyroid testing. If these RIs are not available in the laboratory, implementing recommended fixed cut-off values globally is still controversial. To address this issue, we aimed to establish appropriate RI of thyroid-stimulating hormone (TSH) in pregnant Turkish women for our laboratory and compare the prevalence of thyroid dysfunction based on the established and recommended criteria. Methods Of 2638 pregnant women, 1777 women followed in the obstetric outpatient were enrolled in the reference interval study after applying exclusion criteria related to medical and prenatal history. A retrospective study was conducted by collecting data from July 2016 to March 2019. Serum TSH was measured by UniCel DxI 800 Immunoassay System (Beckman Coulter Inc., Brea, CA, USA). The study design relied on two approaches in order to classify pregnant women: trimester-specific and subgroup-specific; the latter involved dividing each trimester into two subgroups: T1a, T1b, T2a, T2b, T3a, T3b. The lower and upper limits of the RIs were derived by the parametric method after normalizing the data distribution using the modified Box-Cox power transformation method. Results The lowest TSH value was detected at 8-12 weeks in early pregnancy, and the median value of TSH in the T1b subgroup was significantly lower than the T1a subgroup (P < 0.05). TSH levels showed a gradual trend of increase along with the pregnancy and increased significantly in the T2a, T2b, and T3b subgroups compared to the preceding subgroups (P < 0.05). Compared to the diagnostic criteria recommended by American Thyroid Association (ATA), the prevalence of thyroid dysfunction was significantly different from the established trimester- and subgroup-specific RIs throughout the pregnancy (P < 0.001). Conclusions We conclude that establishing gestation- and laboratory-specific RIs, especially for TSH, is essential for diagnosing thyroid disorders in pregnancy, and the recommended universal cut-off values, which may contribute to the risk of a misdiagnosis or a missed diagnosis, should be taken with caution in the clinical setting. However, regarding the fluctuation of thyroid function tests throughout pregnancy, trimester-specific RIs are insufficient, and implementing split phases is required.
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Affiliation(s)
- Rana Turkal
- Biochemistry Laboratory, Marmara University Pendik Education and Research Hospital, Istanbul, Turkey.
| | - Cem Armağan Turan
- Department of Internal Medicine, School of Medicine, Marmara University, Istanbul, Turkey
| | - Onur Elbasan
- Subdepartment of Endocrinology, Department of Internal Medicine, School of Medicine, Marmara University, Istanbul, Turkey
| | - Serenay Aytan
- Medical Student, School of Medicine, Marmara University, Istanbul, Turkey
| | - Burcu Çakmak
- Medical Student, School of Medicine, Marmara University, Istanbul, Turkey
| | - Büşra Gözaydınoğlu
- Medical Student, School of Medicine, Marmara University, Istanbul, Turkey
| | - Duygu Ceyda Takır
- Medical Student, School of Medicine, Marmara University, Istanbul, Turkey
| | - Ozan Ünlü
- Department of Biochemistry, School of Medicine, Marmara University, Istanbul, Turkey
| | - Günel Bahramzada
- Department of Biochemistry, School of Medicine, Marmara University, Istanbul, Turkey
| | - Ahmet Faruk Tekin
- Department of Biochemistry, School of Medicine, Marmara University, Istanbul, Turkey
| | - Tülay Çevlik
- Biochemistry Laboratory, Marmara University Pendik Education and Research Hospital, Istanbul, Turkey
| | - Esra Esim Büyükbayrak
- Department of Gynecology and Obstetrics, School of Medicine, Marmara University, Istanbul, Turkey
| | - Önder Şirikçi
- Department of Biochemistry, School of Medicine, Marmara University, Istanbul, Turkey
| | - Hülya Gözü
- Subdepartment of Endocrinology, Department of Internal Medicine, School of Medicine, Marmara University, Istanbul, Turkey
| | - Goncagül Haklar
- Department of Biochemistry, School of Medicine, Marmara University, Istanbul, Turkey
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Vasikaran S, Loh TP. Interpretative commenting in clinical chemistry with worked examples for thyroid function test reports. Pract Lab Med 2021; 26:e00243. [PMID: 34286057 PMCID: PMC8280506 DOI: 10.1016/j.plabm.2021.e00243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/24/2021] [Accepted: 07/08/2021] [Indexed: 11/18/2022] Open
Abstract
Correct interpretation of pathology results is a requirement for accurate diagnosis and appropriate patient management. Clinical Pathologists and Scientists are increasingly focusing on providing quality interpretative comments on their reports and these comments are appreciated by clinicians who receive them. Interpretative comments may improve patient outcomes by helping reduce errors in application of the results in patient management. Thyroid function test (TFT) results are one of the areas in clinical chemistry where interpretative commenting is practised by clinical laboratories. We have provided a series of TFT reports together with possible interpretative comments and a brief explanation of the comments. It is felt that this would be of help in setting up an interpretative service for TFTs and also assist in training and continuing education in their provision.
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Affiliation(s)
- Samuel Vasikaran
- Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Murdoch, WA, 6150, Australia
| | - Tze Ping Loh
- Department of Laboratory Medicine, National University Hospital, Singapore
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Yuen LY, Chan MHM, Sahota DS, Lit LCW, Ho CS, Ma RCW, Tam WH. Development of Gestational Age-Specific Thyroid Function Test Reference Intervals in Four Analytic Platforms Through Multilevel Modeling. Thyroid 2020; 30:598-608. [PMID: 31910112 DOI: 10.1089/thy.2019.0323] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: A population-based reference interval (RI) of thyroid hormones in pregnancy using a standardized methodology is crucial for clinicians to make accurate diagnoses and important for the comparison of test results obtained from different analytic platforms. Methods: We enrolled 600 healthy Chinese women to obtain longitudinal serum samples across gestation, after exclusion of subjects with antibodies to thyroid peroxidase, thyroglobulin or thyrotropin receptor. Gestational age-specific RIs were constructed by using polynomial regression equations with MLwiN. Results: Free thyroxine (fT4) levels rose to a peak at the 7th-8th gestational weeks and then declined gradually till 28th week, while thyrotropin (TSH) level decreased from early pregnancy to a nadir at the 9th week. The data support the recent notion by the American Thyroid Association to raise the TSH upper RI to 4.0 mIU/L. We also demonstrate that thyroid hormone reference ranges are not affected in a mildly iodine-deficient population and by including women with the presence of antibodies against thyroid peroxidase and thyroglobulin who are otherwise healthy. Conclusions: The study highlights a methodology in constructing gestational age-specific thyroid function test RIs on different analytic platforms to provide a better interpretation and comparison of results obtained across different platforms.
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Affiliation(s)
- Lai Yuk Yuen
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, New Territories, Hong Kong
| | - Michael Ho Ming Chan
- Department of Chemical Pathology, The Chinese University of Hong Kong, New Territories, Hong Kong
| | - Daljit Singh Sahota
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, New Territories, Hong Kong
| | - Lydia Choi Wan Lit
- Department of Chemical Pathology, The Chinese University of Hong Kong, New Territories, Hong Kong
| | - Chung Shun Ho
- Department of Chemical Pathology, The Chinese University of Hong Kong, New Territories, Hong Kong
| | - Ronald Ching Wan Ma
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, New Territories, Hong Kong
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, New Territories, Hong Kong
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, New Territories, Hong Kong
| | - Wing Hung Tam
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, New Territories, Hong Kong
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Monitoring of Thyroid Malfunction and Therapies in Pregnancy and the Postpartum Period: A Systematic Updated Critical Review of the Literature. Ther Drug Monit 2020; 42:222-228. [DOI: 10.1097/ftd.0000000000000691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Zhang Y, Sun W, Zhu S, Huang Y, Huang Y, Gao Y, Zhang J, Yang H, Guo X. The Impact of Thyroid Function and TPOAb in the First Trimester on Pregnancy Outcomes: A Retrospective Study in Peking. J Clin Endocrinol Metab 2020; 105:5611194. [PMID: 31677603 DOI: 10.1210/clinem/dgz167] [Citation(s) in RCA: 11] [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] [Received: 06/09/2019] [Accepted: 10/31/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT The impact of mild TSH elevation (2.5-4.08 mIU/L) on pregnancy outcomes is unclear. The treatment strategy for mild TSH elevation is dependent on thyroid peroxidase antibody (TPOAb) status according to the guidelines. OBJECTIVE To assess the effects of mild thyroid dysfunction combined with TPOAb status in the first trimester on pregnancy outcomes and the impact of levothyroxine (L-T4) treatment on pregnancy outcomes. DESIGN The study retrospectively evaluated 3562 pregnant women. A total of 3296 untreated women were divided into 4 subgroups: group A: 4.08 < TSH <10 mIU/L, TPOAb+/-; group B: 2.5 < TSH ≤ 4.08 mIU/L, TPOAb+; group C: 2.5 < TSH ≤ 4.08 mIU/L, TPOAb-; and group D: 0.23 ≤ TSH ≤ 2.5 mIU/L, TPOAb+/-. The other 266 women with L-T4 treatment were divided into TSH 4.08 to 10 mIU/L and 2.5 to 4.08 mIU/L subgroups. SETTING The study was conducted at Peking University First Hospital in China. PATIENTS A total of 3562 pregnant women were evaluated. MAIN OUTCOME MEASURES The incidence of pregnancy outcomes in the untreated subgroups (groups A-D) and treated subgroups were measured. RESULTS Miscarriage and maternal composite outcome risks were 3.53 (1.85-6.75) and 2.19 (1.26-3.81) times greater in group A; 1.58 (1.17-2.13) and 1.27 (1.04-1.54) times greater in group C than in group D. L-T4 improved the miscarriage risk in the TSH 4.08 to 10 and 2.5 to 4.08 mIU/L groups but doubled the risk of gestational diabetes mellitus in the TSH 2.5 to 4.08 mIU/L treated group compared with the untreated group. CONCLUSIONS TSH 2.5 to 4.08 mIU/L combined with TPOAb- during early pregnancy was associated with miscarriages and maternal composite outcomes. The advantages and disadvantages of L-T4 administration in TSH 2.5 to 4.08 mIU/L pregnant women remain uncertain.
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Affiliation(s)
- Yang Zhang
- Department of Endocrinology, Peking University First Hospital, Beijing, China
| | - Weijie Sun
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Sainan Zhu
- Department of Biostatistics, Peking University First Hospital, Beijing, China
| | - Youyuan Huang
- Department of Endocrinology, Peking University First Hospital, Beijing, China
| | - Yu Huang
- National Engineering Research Center of Software Engineering, Peking University, Beijing, China
| | - Ying Gao
- Department of Endocrinology, Peking University First Hospital, Beijing, China
| | - Junqing Zhang
- Department of Endocrinology, Peking University First Hospital, Beijing, China
| | - Huixia Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Xiaohui Guo
- Department of Endocrinology, Peking University First Hospital, Beijing, China
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Hamblin PS, Sheehan PM, Allan C, Houlihan CA, Lu ZX, Forehan SP, Topliss DJ, Gilfillan C, Krishnamurthy B, Renouf D, Sztal‐Mazer S, Varadarajan S. Subclinical hypothyroidism during pregnancy: the Melbourne public hospitals consensus. Intern Med J 2019; 49:994-1000. [DOI: 10.1111/imj.14210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 12/06/2018] [Accepted: 12/12/2018] [Indexed: 02/03/2023]
Affiliation(s)
- Peter S. Hamblin
- Department of Endocrinology and DiabetesWestern Health, Sunshine Hospital Melbourne Victoria Australia
- Department of Medicine – Western PrecinctThe University of Melbourne Melbourne Victoria Australia
| | - Penelope M. Sheehan
- Pregnancy Research CentreRoyal Women's Hospital Melbourne Victoria Australia
- Department of Obstetrics and GynaecologyRoyal Women’s Hospital, University of Melbourne Melbourne Victoria Australia
| | - Carolyn Allan
- Endocrine Services in PregnancyMonash Health Melbourne Victoria Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research Melbourne Victoria Australia
| | - Christine A. Houlihan
- Diabetes and Endocrine Clinic, Mercy Hospital for Women Melbourne Victoria Australia
- Department of Endocrinology and Diabetes, Austin Health Melbourne Victoria Australia
| | - Zhong X. Lu
- Department of Chemical PathologyMelbourne Pathology Melbourne Victoria Australia
- Department of Medicine, andMonash University Melbourne Victoria Australia
| | - Simon P. Forehan
- Department of Diabetes and EndocrinologyRoyal Melbourne Hospital Melbourne Victoria Australia
| | - Duncan J. Topliss
- Department of Endocrinology and DiabetesThe Alfred Melbourne Victoria Australia
- Department of Medicine, Central Clinical SchoolMonash University, The Alfred Melbourne Victoria Australia
| | - Christopher Gilfillan
- Department of Endocrinology and DiabetesEastern Health Melbourne Victoria Australia
- Department of Medicine, Eastern Clinical SchoolMonash University Melbourne Victoria Australia
| | - Bala Krishnamurthy
- Department of EndocrinologyWerribee Mercy Hospital Melbourne Victoria Australia
- St Vincent’s Institute of Medical ResearchSt Vincent’s Hospital Melbourne Victoria Australia
| | - Debra Renouf
- Department of Endocrinology and DiabetesPeninsula Health Melbourne Victoria Australia
- Peninsula Clinical SchoolMonash University Melbourne Victoria Australia
| | - Shoshana Sztal‐Mazer
- Department of Endocrinology and DiabetesThe Alfred Melbourne Victoria Australia
- Department of Medicine, Central Clinical SchoolMonash University, The Alfred Melbourne Victoria Australia
| | - Suresh Varadarajan
- Department of Endocrinology and DiabetesNorthern Health Melbourne Victoria Australia
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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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10
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Pekcan MK, Ozgu-Erdinc AS, Yilmaz N. Impact of subclinical hypothyroidism and thyroid autoimmunity on clinical pregnancy rate after intrauterine insemination in euthyroid women. JBRA Assist Reprod 2019; 23:137-142. [PMID: 30951274 PMCID: PMC6501743 DOI: 10.5935/1518-0557.20190027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective: This study aimed to evaluate the association between subclinical
hypothyroidism and thyroid autoantibodies with clinical pregnancy rate after
intrauterine insemination (IUI) in euthyroid women. Methods: In this prospective cohort study, we recruited 497 women who underwent IUI
treatment. We assessed thyroid function tests, thyroid antibodies and
clinical pregnancy rates of the patients. Results: The patients were divided into two groups according to TSH values: normal
group, n=387, and subclinical hypothyroidism group 2, n=110. The clinical
pregnancy rate was 15.2% in the Control Group and 17.3% in the study group
(p=0.656). In the Study Group, 35% of the patients had
anti-TPO positivity (p=0.531) and 42.1% of the patients had
anti-TG positivity (p=0.285). There was no statistically
significant difference in clinical pregnancy rates between the groups in
terms of antithyroid antibody positivity (p=0.54;
p=0.559, respectively). Conclusion: Anti-TPO antibodies and subclinical hypothyroidism had no impact on clinical
pregnancy rates in the women submitted to IUI.
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Affiliation(s)
- Meryem Kuru Pekcan
- University of Health Sciences, Ankara Dr. Zekai Tahir Burak Health Practice Research Center, Ankara, Turkey
| | - A Seval Ozgu-Erdinc
- University of Health Sciences, Ankara Dr. Zekai Tahir Burak Health Practice Research Center, Ankara, Turkey
| | - Nafiye Yilmaz
- University of Health Sciences, Ankara Dr. Zekai Tahir Burak Health Practice Research Center, Ankara, Turkey
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Kianpour M, Aminorroaya A, Amini M, Feizi A, Janghorbani M, Shokri S, Yamini SA, Farghadani M, Hekmatnia A, Gharib H. Reference Intervals for Thyroid Hormones During the First Trimester of Gestation: A Report from an Area with a Sufficient Iodine Level. Horm Metab Res 2019; 51:165-171. [PMID: 30861562 DOI: 10.1055/a-0855-7128] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The physiological changes during pregnancy modulate the endocrine system. Therefore, both the American and the European thyroid associations recommend the use of local trimester-specific reference intervals. The purpose of this study was to establish the first trimester reference intervals for thyroid function tests in the central area of Iran. We examined 436 pregnant women in their first trimester of pregnancy, and 444 non-pregnant women in a cross sectional study. Serum levels of thyroid stimulating hormone (TSH), free thyroxin (FT4), free triiodothyronine (FT3), thyroid peroxidase antibody, urinary iodine concentration (UIC), and thyroid volume were measured for all subjects. The first trimester-specific reference intervals (2.5th-97.5th percentile) were determined for 185 pregnant women and 256 non-pregnant women with negative TPOAb, adequate iodine level (UIC≥150 μg/l in pregnant and UIC≥100 μg/l in non-pregnant women), and normal thyroid examination. We calculated multiples of the median (MoM) for TFTs to normalize the obtained data. The first trimester-specific reference intervals of serum TSH, FT4, and FT3 for pregnant women were 0.20-4.60 mIU/l, 9.0-18.02 pmol/l, and 3.40-5.64 pmol/l, respectively, while the corresponding figures for non-pregnant women were 0.59-5.60 mIU/l, 9.52-19.30 pmol/l, and 3.70-5.55 pmol/l, respectively. The first and 99th percentile MoM of TSH in pregnant women in their first-trimester was 0.06-4.62. The local normal reference ranges for the first trimester of pregnancy in central region of Iran were different from the ranges suggested by the ATA.
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Affiliation(s)
- Maryam Kianpour
- Isfahan Endocrine and Metabolism Research Center, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ashraf Aminorroaya
- Isfahan Endocrine and Metabolism Research Center, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Massoud Amini
- Isfahan Endocrine and Metabolism Research Center, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Awat Feizi
- Isfahan Endocrine and Metabolism Research Center, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Biostatistics & Epidemiology, School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohsen Janghorbani
- Isfahan Endocrine and Metabolism Research Center, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Biostatistics & Epidemiology, School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saeideh Shokri
- Department of Radiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Maryam Farghadani
- Department of Radiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Hekmatnia
- Department of Radiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hossien Gharib
- Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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12
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Teasdale S, Morton A. Changes in biochemical tests in pregnancy and their clinical significance. Obstet Med 2018; 11:160-170. [PMID: 30574177 PMCID: PMC6295771 DOI: 10.1177/1753495x18766170] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 02/22/2018] [Indexed: 12/11/2022] Open
Abstract
Interpretation of laboratory investigations relies on reference intervals. Physiological changes in pregnancy may result in significant changes in normal values for many biochemical assays, and as such results may be misinterpreted as abnormal or mask a pathological state. The aims of this review are as follows: 1. To review the major physiological changes in biochemical tests in normal pregnancy. 2. To outline where these physiological changes are important in interpreting laboratory investigations in pregnancy. 3. To document the most common causes of abnormalities in biochemical tests in pregnancy, as well as important pregnancy-specific causes.
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Affiliation(s)
- Stephanie Teasdale
- Queensland Diabetes and Endocrine Centre, Mater Misericordiae Hospital, Brisbane, Australia
| | - Adam Morton
- Queensland Diabetes and Endocrine Centre, Mater Misericordiae Hospital, Brisbane, Australia
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Zhao T, Chen BM, Zhao XM, Shan ZY. Meta-analysis of ART outcomes in women with different preconception TSH levels. Reprod Biol Endocrinol 2018; 16:111. [PMID: 30396353 PMCID: PMC6219175 DOI: 10.1186/s12958-018-0424-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 10/14/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To assess whether elevated thyroid-stimulating hormone (TSH) levels before conception can predict poor outcomes of assisted reproductive technology (ART). METHODS Prior to July 2018, we searched the PubMed, EMBASE, COCHRANE, Google Scholar, and CNKI databases for studies. Retrospective or prospective reports that compared ART results in patients with subclinical hypothyroidism (SCH) with normal thyroid function were selected. Two reviewers separately reviewed each potential article for qualification, analyzed the quality of the studies according to the Newcastle-Ottawa scale, and extracted the data. The PRISMA guidelines were adopted. RESULTS We selected a total of 18 publications that included 14,846 participants for this meta-analysis. When the TSH cut-off value for SCH was set at 2.5 mIU/L, no significant differences were observed in ART-related outcomes between SCH patients and normal women. The evaluated outcomes included the live birth rate (LBR) (OR: 0.93; 95% CI (0.77,1.12), P = 0.43), clinical pregnancy rate (CPR) (OR:1.02; 95% CI (0.90,1.17); P = 0.74), pregnancy rate (PR) (OR: 1.00; 95% CI (0.89,1.12); P = 0.99), and miscarriage rate (MR) (OR:1.24; 95% CI (0.85, 1.80); P = 0.26). Furthermore, when a higher TSH level was used as the cut-off value to diagnose SCH (i.e., 3.5-5 mIU/L), a significant difference was found in the MR (OR: 1.91; 95% CI (1.09, 3.35); P = 0.02) between the two groups of ART-treated women. However, when a broader cut-off value was used to define SCH, no significant differences were observed in the LBR (OR: 0.72; 95% CI (0.47,1.11); P = 0.14), CPR (OR: 0.82; 95% CI (0.66,1.00); P = 0.052), or PR (OR: 1.07; 95% CI (0.72,1.60); P = 0.74) between the two groups of ART-treated women. CONCLUSION No difference was observed in ART outcomes when a TSH cut-off value of 2.5 mIU/L was used. However, when a broader TSH cut-off value was used, preconception SCH resulted in a higher miscarriage rate than in normal women.
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Affiliation(s)
- T Zhao
- Department of Endocrinology and Metabolism, Institute of Endocrinology, First Affiliated Hospital, China Medical University, Shenyang, Liaoning, China
| | - B M Chen
- The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - X M Zhao
- Chengde Medical University, Chengde, Hebei, China
| | - Z Y Shan
- Department of Endocrinology and Metabolism, Institute of Endocrinology, First Affiliated Hospital, China Medical University, Shenyang, Liaoning, China.
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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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Tuncay G, Karaer A, İnci Coşkun E, Baloğlu D, Tecellioğlu AN. The impact of thyroid-stimulating hormone levels in euthyroid women on intrauterine insemination outcome. BMC WOMENS HEALTH 2018; 18:51. [PMID: 29558997 PMCID: PMC5859715 DOI: 10.1186/s12905-018-0541-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 03/09/2018] [Indexed: 01/08/2023]
Abstract
Background The aim of this study was to examine the effect of thyroid-stimulating hormone (TSH) levels on intrauterine insemination (IUI) outcomes among euthyroid women. Methods A retrospective cohort study was conducted. A total of 302 women who started their first IUI cycle in our fertility center were included in this study. The patients were categorized into two groups based on their preconception TSH values: 0.38–2.49 mIU/Land 2.50–4.99 mIU/L. The clinical pregnancy rate was the main outcome parameter. As secondary parameters, we evaluated the differences in spontaneous abortion rate, live-birth delivery rate, and perinatal outcomes according to the preconception TSH threshold (< 2.5 and < 5.00 mIU/L). Results There was no significant difference between the two groups with respect to clinical pregnancy, miscarriage, and live-birth rates with an odds ratio of 1.67 (95% CI: 0.79–3.53), 1.08 (95% CI: 0.09–13.1), and 1.79 (95% CI: 0.77–4.2), respectively. In addition, there were no significant differences in perinatal outcomes (gestation at delivery, birth weight, and neonatal intensive care unit–administration rate) between the two groups. Conclusions Our findings indicate that among euthyroid patients, preconception TSH values in the high-normal range (between 2.5 and 4.9 mIU/L) do not have a negative effect on IUI outcomes. Trial registration This study is retrospectively registered by Ethical Review Board at Inonu University in 19th December 2017; Ethics approval no is 2017–27-20.
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Affiliation(s)
- Gorkem Tuncay
- Division of Reproductive Endocrinology and Infertility, Departments of Obstetrics and Gynecology, School of Medicine, Inonu University, 44315, Malatya, Turkey.
| | - Abdullah Karaer
- Division of Reproductive Endocrinology and Infertility, Departments of Obstetrics and Gynecology, School of Medicine, Inonu University, 44315, Malatya, Turkey
| | - Ebru İnci Coşkun
- Departments of Obstetrics and Gynecology, School of Medicine, Inonu University, Malatya, Turkey
| | - Demet Baloğlu
- Departments of Obstetrics and Gynecology, School of Medicine, Inonu University, Malatya, Turkey
| | - Ayşe Nihan Tecellioğlu
- Division of Reproductive Endocrinology and Infertility, Departments of Obstetrics and Gynecology, School of Medicine, Inonu University, 44315, Malatya, Turkey
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Šálek T, Dhaifalah I, Langova D, Havalová J. Maternal thyroid-stimulating hormone reference ranges for first trimester screening from 11 to 14 weeks of gestation. J Clin Lab Anal 2018; 32:e22405. [PMID: 29396862 DOI: 10.1002/jcla.22405] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 01/19/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND To establish maternal thyroid-stimulating hormone (TSH) reference ranges for first trimester screening from 11 + 0 to 13 + 6 weeks of gestation. METHODS A total of 10 592 singleton and 201 twin consecutive Caucasian pregnant women who underwent simultaneously prenatal first trimester Down's syndrome screening and thyroid function screening from January 2010 to November 2017 were included in the study. Women with positive antithyroid peroxidase antibody (TPOAb) and positive personal history of thyroid disease were previously excluded. TSH was measured by immunochemiluminescent assay on ci 16200 Abbott Architect analyzer. Nonparametric percentile method (also known as CLSI C28.A3) was used for the determination of reference ranges. RESULTS We established reference ranges of TSH for the period of gestation from 11 + 0 to 13 + 6 weeks of pregnancy as 0.16-3.43 mU/L for singleton Caucasian pregnancies and 0.02-2.95 mU/L for twin Caucasian pregnancies. The median (IQR) of TSH for singleton pregnancies was higher than that for twin pregnancies (1.25 mU/L (0.83-1.81) vs 0.84 (0.37-1.47), respectively; P < .0001). CONCLUSIONS Each first trimester screening center should be aware of which type of immunoassay their laboratory uses. TSH reference ranges in women during the first trimester of pregnancy are lower than those for general population. Twin pregnancies have lower TSH than singleton pregnancies.
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Affiliation(s)
- Tomáš Šálek
- Department of Clinical Biochemistry and Pharmacology, Tomas Bata Hospital in Zlín, Zlín, Czech Republic.,Medical Faculty, University of Ostrava in Ostrava, Ostrava, Czech Republic
| | - Ishraq Dhaifalah
- Department of Obstetrics and Gynecology, Tomas Bata Hospital in Zlín, Zlín, Czech Republic.,FETMED (Fetmed Fetal medicine center and genetics), Olomouc, Ostrava, Czech Republic
| | - Dagmar Langova
- Internal Medicine Clinic, Tomas Bata Hospital in Zlín, Zlín, Czech Republic
| | - Jana Havalová
- Department of Obstetrics and Gynecology, Tomas Bata Hospital in Zlín, Zlín, Czech Republic
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Kannan S, Mahadevan S, Sigamani A. A Systematic Review on Normative Values of Trimester-specific Thyroid Function Tests in Indian Women. Indian J Endocrinol Metab 2018; 22:7-12. [PMID: 29535929 PMCID: PMC5838915 DOI: 10.4103/ijem.ijem_211_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Small cross-sectional studies are published on the trimester-specific normal ranges of thyrotropin and thyroxine levels in Indian women from various parts of the country. OBJECTIVE We sought to review the published literature on thyroid function tests in normal pregnant Indian women to see if the pooled data from various studies can define normative data and hypothyroidism in pregnancy. METHODS We retrieved 56 studies from online databases with detailed search using multiple search terms. Unanimously eight studies were finalized. RESULTS Data of 2703 pregnant women (age 16-45 years; 966 were in the first trimester, 1072 in their second trimester, and 1037 women in their third trimester) were analyzed. All eight studies included singleton pregnancies from the northern and eastern part of India with seven studies being cross-sectional in nature. The exclusion criteria in all studies included those with historical/clinical evidence of thyroid dysfunction, those with family history of thyroid dysfunction, infertility and those with history of recurrent miscarriages (usually >3). Ultrasound evidence of thyroid disease, urinary iodine assessment, and thyroid antibodies were included as additional exclusion criteria in two, three, and four studies, respectively. None of the studies included the outcome of pregnancy as part of follow-up. As part of the pooled data analysis, the 5th-95th centile values of normal TSH extended from 0.09 to 6.65 IU/mL in the first trimester, 0.39-6.61 IU/mL in the second trimester, and 0.70-5.18 IU/mL in the third trimester. The FT4 levels (5th-95th centile values) extended from 8.24 to 25.74 pmol/L in the first trimester, 6.82-26.0 pmol/L, and 5.18-25.61 pmol/L in the third trimester. CONCLUSIONS With due limitations imposed by the quality of the available studies, the current review suggests that upper normal limit of TSH values can extend up to 5-6 IU/mL in pregnancy.
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Affiliation(s)
- Subramanian Kannan
- Department of Endocrinology, Mazumdar Shaw Medical Center, Narayana Health, Bengaluru, Karnataka, India
| | - Shriraam Mahadevan
- Department of Endocrinology, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India
| | - Alben Sigamani
- Department of Clinical Research, Mazumdar Shaw Medical Center, Narayana Health, Bengaluru, Karnataka, India
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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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20
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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: 1282] [Impact Index Per Article: 183.1] [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: 83] [Impact Index Per Article: 11.9] [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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Maciel LMZ. Are TSH normal reference ranges adequate for pregnant women? ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2016; 60:303-6. [PMID: 27533612 PMCID: PMC10118714 DOI: 10.1590/2359-3997000000182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 06/20/2016] [Indexed: 11/22/2022]
Affiliation(s)
- Léa Maria Zanini Maciel
- Divisão de Endocrinologia e Metabologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
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Prenatal Exposures to Multiple Thyroid Hormone Disruptors: Effects on Glucose and Lipid Metabolism. J Thyroid Res 2016; 2016:8765049. [PMID: 26989557 PMCID: PMC4773558 DOI: 10.1155/2016/8765049] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 01/08/2016] [Accepted: 01/12/2016] [Indexed: 01/28/2023] Open
Abstract
Background. Thyroid hormones (THs) are essential for normal human fetal development and play a major role in the regulation of glucose and lipid metabolism. Delivery of TH to target tissues is dependent on processes including TH synthesis, transport, and metabolism. Thyroid hormone endocrine disruptors (TH-EDCs) are chemical substances that interfere with these processes, potentially leading to adverse pregnancy outcomes. Objectives. This review focuses on the effects of prenatal exposures to combinations of TH-EDCs on fetal and neonatal glucose and lipid metabolism and also discusses the various mechanisms by which TH-EDCs interfere with other hormonal pathways. Methods. We conducted a comprehensive narrative review on the effects of TH-EDCs with particular emphasis on exposure during pregnancy. Discussion. TH imbalance has been linked to many metabolic processes and the effects of TH imbalance are particularly pronounced in early fetal development due to fetal dependence on maternal TH for proper growth and development. The pervasive presence of EDCs in the environment results in ubiquitous exposure to either single or mixtures of EDCs with deleterious effects on metabolism. Conclusions. Further evaluation of combined effects of TH-EDCs on fetal metabolic endpoints could improve advice provided to expectant mothers.
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Karmon AE, Cardozo ER, Souter I, Gold J, Petrozza JC, Styer AK. Donor TSH level is associated with clinical pregnancy among oocyte donation cycles. J Assist Reprod Genet 2016; 33:489-94. [PMID: 26847132 DOI: 10.1007/s10815-016-0668-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 01/24/2016] [Indexed: 12/19/2022] Open
Abstract
PURPOSE The purpose of the study is to evaluate the association between donor TSH level (independent of recipient TSH level) and recipient pregnancy outcome among fresh donor oocyte IVF cycles. METHODS This is a retrospective cohort study investigating 232 consecutive fresh donor-recipient cycles (200 total oocyte donors) at an academic medical center. Main outcome measures include clinical pregnancy and live birth. RESULTS Cycles were categorized into two groups based on donor TSH level (< 2.5 and ≥ 2.5 mIU/L). After controlling for multiple donor and recipient characteristics, the probability of clinical pregnancy was significantly lower among donors with TSH levels ≥2.5 mIU/L compared to those with TSH values <2.5 mIU/L (43.1 %, 95 % CI 28.5-58.9, versus 66.7 %, 95 % CI 58.6-73.9, respectively, p = 0.01). The difference in live birth rates between the two groups did not achieve statistical significance (43.1 %, 95 % CI 28.8-58.6, versus 58.0 %, 95 % CI 50.0-65.6, respectively, p = 0.09). CONCLUSIONS Donor TSH level, independent of recipient TSH level, is associated with recipient clinical pregnancy. These findings suggest that thyroid function may impact the likelihood of pregnancy at the level of the oocyte.
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Affiliation(s)
- Anatte E Karmon
- Vincent Reproductive Medicine and IVF, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Yawkey 10A 55 Fruit Street, Boston, MA, 02114, USA. .,Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, 02115, USA.
| | - Eden R Cardozo
- Vincent Reproductive Medicine and IVF, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Yawkey 10A 55 Fruit Street, Boston, MA, 02114, USA.,Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, 02115, USA
| | - Irene Souter
- Vincent Reproductive Medicine and IVF, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Yawkey 10A 55 Fruit Street, Boston, MA, 02114, USA.,Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, 02115, USA
| | - Julie Gold
- Vincent Reproductive Medicine and IVF, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Yawkey 10A 55 Fruit Street, Boston, MA, 02114, USA
| | - John C Petrozza
- Vincent Reproductive Medicine and IVF, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Yawkey 10A 55 Fruit Street, Boston, MA, 02114, USA.,Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, 02115, USA
| | - Aaron K Styer
- Vincent Reproductive Medicine and IVF, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Yawkey 10A 55 Fruit Street, Boston, MA, 02114, USA.,Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, 02115, USA
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Kim JI. Thyroid disease in pregnancy. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2016. [DOI: 10.5124/jkma.2016.59.1.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Jong In Kim
- Department of Obstetrics and Gynecology, Dongsan Medical Center, Keimyung University School of Medcine, Daegu, Korea
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Akarsu S, Akbiyik F, Karaismailoglu E, Dikmen ZG. Gestation specific reference intervals for thyroid function tests in pregnancy. ACTA ACUST UNITED AC 2016; 54:1377-83. [DOI: 10.1515/cclm-2015-0569] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 11/30/2015] [Indexed: 12/26/2022]
Abstract
AbstractThyroid function tests are frequently assessed during pregnancy to evaluate thyroid dysfunction or to monitor pre-existing thyroid disease. However, using non-pregnant reference intervals can lead to misclassification. International guidelines recommended that institutions should calculate their own pregnancy-specific reference intervals for free thyroxine (FT4), free triiodothyronine (FT3) and thyroid-stimulating hormone (TSH). The objective of this study is to establish gestation-specific reference intervals (GRIs) for thyroid function tests in pregnant Turkish women and to compare these with the age-matched non-pregnant women.Serum samples were collected from 220 non-pregnant women (age: 18–48), and 2460 pregnant women (age: 18–45) with 945 (39%) in the first trimester, 1120 (45%) in the second trimester, and 395 (16%) in the third trimester. TSH, FT4 and FT3 were measured using the Abbott Architect i2000SR analyzer.GRIs of TSH, FT4 and FT3 for first trimester pregnancies were 0.49–2.33 mIU/L, 10.30–18.11 pmol/L and 3.80–5.81 pmol/L, respectively. GRIs for second trimester pregnancies were 0.51–3.44 mIU/L, 10.30–18.15 pmol/L and 3.69–5.90 pmol/L. GRIs for third trimester pregnancies were 0.58–4.31 mIU/L, 10.30–17.89 pmol/L and 3.67–5.81 pmol/L. GRIs for TSH, FT4 and FT3 were different from non-pregnant normal reference intervals.TSH levels showed an increasing trend from the first trimester to the third trimester, whereas both FT4 and FT3 levels were uniform throughout gestation. GRIs may help in the diagnosis and appropriate management of thyroid dysfunction during pregnancy which will prevent both maternal and fetal complications.
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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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Moon HW, Chung HJ, Park CM, Hur M, Yun YM. Establishment of trimester-specific reference intervals for thyroid hormones in Korean pregnant women. Ann Lab Med 2015; 35:198-204. [PMID: 25729721 PMCID: PMC4330169 DOI: 10.3343/alm.2015.35.2.198] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 09/12/2014] [Accepted: 12/29/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Establishment of trimester- and assay-specific reference intervals for every population is recommended. The aim of this study was to establish a trimester- and assay-specific reference interval for thyroid-stimulating hormone (TSH) and free thyroxine (FT4) in Korean pregnant women. METHODS From April 2012 to December 2012, 531 pregnant women receiving prenatal care and 238 age-matched, non-pregnant women were enrolled in this study. After excluding patients with pregnancy-associated complications or thyroid-specific autoantibody, 465 pregnant and 206 non-pregnant women were included. Non-parametric analysis (2.5-97.5th percentile) was performed to determine the reference interval. Levels of TSH and FT4 were determined by electrochemiluminescence immunoassay (Elecsys thyroid tests, Roche Diagnostics, Germany). RESULTS The TSH reference intervals were 0.01-4.10, 0.01-4.26, and 0.15-4.57 mIU/L for the first, second, and third trimester, respectively. From the first trimester to the third trimester, the median TSH levels showed a significantly increasing trend (P<0.0001). The FT4 reference intervals were 0.83-1.65, 0.71-1.22, and 0.65-1.13 ng/dL for the first, second, and third trimester, respectively, showing a significantly decreasing trend (P<0.0001). CONCLUSIONS Establishing trimester-specific reference intervals in pregnant women is essential for accurate assessment of thyroid function. Our population-specific and method-specific reference intervals will be useful for screening Korean pregnant women for thyroid disease.
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Affiliation(s)
- Hee-Won Moon
- Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Hee-Jung Chung
- Department of Laboratory Medicine, Cheil General Hospital and Women's Healthcare Center, Kwandong University College of Medicine, Seoul, Korea
| | - Chul-Min Park
- Department of Laboratory Medicine, Dongnam Institute of Radiological and Medical Sciences, Busan, Korea
| | - Mina Hur
- Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Yeo-Min Yun
- Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Korea
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Karmon AE, Batsis M, Chavarro JE, Souter I. Preconceptional thyroid-stimulating hormone levels and outcomes of intrauterine insemination among euthyroid infertile women. Fertil Steril 2015; 103:258-63.e1. [DOI: 10.1016/j.fertnstert.2014.09.035] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 09/23/2014] [Accepted: 09/24/2014] [Indexed: 11/16/2022]
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Ong GSY, Hadlow NC, Brown SJ, Lim EM, Walsh JP. Does the thyroid-stimulating hormone measured concurrently with first trimester biochemical screening tests predict adverse pregnancy outcomes occurring after 20 weeks gestation? J Clin Endocrinol Metab 2014; 99:E2668-72. [PMID: 25226292 DOI: 10.1210/jc.2014-1918] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
CONTEXT Maternal hypothyroidism in early pregnancy is associated with adverse outcomes, but not consistently across studies. First trimester screening for chromosomal anomalies is routine in many centers and provides an opportunity to test thyroid function. OBJECTIVE To determine if thyroid function tests performed with first trimester screening predicts adverse pregnancy outcomes. DESIGN, PARTICIPANTS AND SETTING A cohort study of 2411 women in Western Australia with singleton pregnancies attending first trimester screening between 9 and 14 weeks gestation. OUTCOME MEASURES We evaluated the association between TSH, free T4, free T3, thyroid antibodies, free beta human chorionic gonadotrophin (β-hCG) and pregnancy associated plasma protein A (PAPP-A) with a composite of adverse pregnancy events as the primary outcome. Secondary outcomes included placenta previa, placental abruption, pre-eclampsia, pregnancy loss after 20 weeks gestation, threatened preterm labor, preterm birth, small size for gestational age, neonatal death, and birth defects. RESULTS TSH exceeded the 97.5th percentile for the first trimester (2.15 mU/L) in 133 (5.5%) women, including 22 (1%) with TSH above the nonpregnant reference range (4 mU/L) and 5 (0.2%) above 10 mU/L. Adverse outcomes occurred in 327 women (15%). TSH and free T4 did not differ significantly between women with or without adverse pregnancy events. On the multivariate analysis, neither maternal TSH >2.15 mU/L nor TSH as a continuous variable predicted primary or secondary outcomes. CONCLUSION Testing maternal TSH as part of first trimester screening does not predict adverse pregnancy outcomes. This may be because in the community setting, mainly mild abnormalities in thyroid function are detected.
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Affiliation(s)
- Gregory S Y Ong
- Department of Endocrinology and Diabetes (G.S.Y.O., S.J.B., E.M.L., J.P.W.) and Department of General Medicine (G.S.Y.O.), Sir Charles Gairdner Hospital, Nedlands 6009 Australia; Department of Clinical Biochemistry (N.C.H., E.M.L.), PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Nedlands 6009 Australia; and School of Medicine and Pharmacology (J.P.W.), The University of Western Australia, Crawley 6009 Australia
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Ahmed IZ, Eid YM, El Orabi H, Ibrahim HR. Comparison of universal and targeted screening for thyroid dysfunction in pregnant Egyptian women. Eur J Endocrinol 2014; 171:285-91. [PMID: 24842727 DOI: 10.1530/eje-14-0100] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To compare universal vs targeted screening for thyroid dysfunction and to estimate the prevalence of hypothyroidism in pregnant Egyptian women. SUBJECTS AND METHODS A total of 168 of pregnant women who attended the outpatient obstetric clinic at Ain Shams University Hospital (Cairo, Egypt) for antenatal care between September 2011 and December 2011 were enrolled. Based on the detailed data collection and results of laboratory testing, they were subdivided into the high- and low-risk group for thyroid disease according to the most recent Endocrine Society clinical practice guidelines, as well as into groups by trimester for application of American Thyroid Association guidelines. The group values were subjected to statistical analysis for estimating the prevalence of clinical and subclinical hypothyroidism and for identifying significant differences. RESULTS Of the 168 patients, 104 were classified into the low-risk group and 64 into the high-risk group. Using the trimesteric and normal population cutoff values for thyroid functions, the prevalence of hypothyroidism was found to be 56% (n=94) and 44.6% (n=75) respectively. No statistically significant differences were found between the high- and low-risk group regarding prevalence of either clinical or subclinical hypothyroidism, and no significant differences were found regarding the prevalence of hypothyroidism in the first, second, or third trimester. CONCLUSION Use of the most recent Endocrine Society clinical practice guidelines led to missed detection of clinical or subclinical hypothyroidism in 34.5% of pregnant women. Universal screening of pregnant women for thyroid dysfunction should thus be adopted throughout Egypt.
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Affiliation(s)
- Iman Z Ahmed
- Endocrinology and Metabolism UnitInternal Medicine DepartmentAin Shams University Hospital, Abbassia square, Ramsis street, Cairo 11591, EgyptMatarya Teaching HospitalCairo, Egypt
| | - Yara M Eid
- Endocrinology and Metabolism UnitInternal Medicine DepartmentAin Shams University Hospital, Abbassia square, Ramsis street, Cairo 11591, EgyptMatarya Teaching HospitalCairo, Egypt
| | - Hussein El Orabi
- Endocrinology and Metabolism UnitInternal Medicine DepartmentAin Shams University Hospital, Abbassia square, Ramsis street, Cairo 11591, EgyptMatarya Teaching HospitalCairo, Egypt
| | - Hani Refat Ibrahim
- Endocrinology and Metabolism UnitInternal Medicine DepartmentAin Shams University Hospital, Abbassia square, Ramsis street, Cairo 11591, EgyptMatarya Teaching HospitalCairo, Egypt
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Siest G, Henny J, Gräsbeck R, Wilding P, Petitclerc C, Queraltó JM, Hyltoft Petersen P. The theory of reference values: an unfinished symphony. Clin Chem Lab Med 2014. [PMID: 23183761 DOI: 10.1515/cclm-2012-0682] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The history of the theory of reference values can be written as an unfinished symphony. The first movement, allegro con fuoco, played from 1960 to 1980: a mix of themes devoted to the study of biological variability (intra-, inter-individual, short- and long-term), preanalytical conditions, standardization of analytical methods, quality control, statistical tools for deriving reference limits, all of them complex variations developed on a central melody: the new concept of reference values that would replace the notion of normality whose definition was unclear. Additional contributions (multivariate reference values, use of reference limits from broad sets of patient data, drug interferences) conclude the movement on the variability of laboratory tests. The second movement, adagio, from 1980 to 2000, slowly develops and implements initial works. International and national recommendations were published by the IFCC-LM (International Federation of Clinical Chemistry and Laboratory Medicine) and scientific societies [French (SFBC), Spanish (SEQC), Scandinavian societies…]. Reference values are now topics of many textbooks and of several congresses, workshops, and round tables that are organized all over the world. Nowadays, reference values are part of current practice in all clinical laboratories, but not without difficulties, particularly for some laboratories to produce their own reference values and the unsuitability of the concept with respect to new technologies such as HPLC, GCMS, and PCR assays. Clinicians through consensus groups and practice guidelines have introduced their own tools, the decision limits, likelihood ratios and Reference Change Value (RCV), creating confusion among laboratorians and clinicians in substituting reference values and decision limits in laboratory reports. The rapid development of personalized medicine will eventually call for the use of individual reference values. The beginning of the second millennium is played allegro ma non-troppo from 2000 to 2012: the theory of reference values is back into fashion. The need to revise the concept is emerging. The manufacturers make a friendly pressure to facilitate the integration of Reference Intervals (RIs) in their technical documentation. Laboratorians are anxiously awaiting the solutions for what to do. The IFCC-LM creates Reference Intervals and Decision Limits Committee (C-RIDL) in 2005. Simultaneously, a joint working group IFCC-CLSI is created on the same topic. In 2008 the initial recommendations of IFCC-LM are revised and new guidelines are published by the Clinical and Laboratory Standards Institute (CLSI C28-A3). Fundamentals of the theory of reference values are not changed, but new avenues are explored: RIs transference, multicenter reference intervals, and a robust method for deriving RIs from small number of subjects. Concomitantly, other statistical methods are published such as bootstraps calculation and partitioning procedures. An alternative to recruiting healthy subjects proposes the use of biobanks conditional to the availability of controlled preanalytical conditions and of bioclinical data. The scope is also widening to include veterinary biology! During the early 2000s, several groups proposed the concept of 'Universal RIs' or 'Global RIs'. Still controversial, their applications await further investigations. The fourth movement, finale: beyond the methodological issues (statistical and analytical essentially), important questions remain unanswered. Do RIs intervene appropriately in medical decision-making? Are RIs really useful to the clinicians? Are evidence-based decision limits more appropriate? It should be appreciated that many laboratory tests represent a continuum that weakens the relevance of RIs. In addition, the boundaries between healthy and pathological states are shady areas influenced by many biological factors. In such a case the use of a single threshold is questionable. Wherever it will apply, individual reference values and reference change values have their place. A variation on an old theme! It is strange that in the period of personalized medicine (that is more stratified medicine), the concept of reference values which is based on stratification of homogeneous subgroups of healthy people could not be discussed and developed in conjunction with the stratification of sick patients. That is our message for the celebration of the 50th anniversary of Clinical Chemistry and Laboratory Medicine. Prospects are broad, enthusiasm is not lacking: much remains to be done, good luck for the new generations!
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Affiliation(s)
- Gerard Siest
- University of Lorraine, Research Unit EA 4373, Génétique Cardiovasculaire, Nancy, France.
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Affiliation(s)
- John H Lazarus
- Thyroid Research Group, Institute of Molecular Medicine, University Hospital of Wales, Cardiff University Medical School, Heath Park, Cardiff, CF14 4XN, UK,
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Incidence of elevation of serum thyroid-stimulating hormone during controlled ovarian hyperstimulation for in vitro fertilization. Eur J Obstet Gynecol Reprod Biol 2014; 173:53-7. [DOI: 10.1016/j.ejogrb.2013.11.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 10/15/2013] [Accepted: 11/02/2013] [Indexed: 11/19/2022]
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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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Qian W, Zhang L, Han M, Khor S, Tao J, Song M, Fan J. Screening for thyroid dysfunction during the second trimester of pregnancy. Gynecol Endocrinol 2013; 29:1059-62. [PMID: 24020892 DOI: 10.3109/09513590.2013.829448] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The primary objective of this study is to explore the influence of different screening strategies on the prevalence of thyroid dysfunction and the missed diagnosis during pregnancy. A total of 1889 pregnant women (13-27 weeks) were divided into high-risk and low-risk groups according to the backgrounds of them collected by questionnaire. We detected the prevalence of thyroid dysfunction in high-risk groups and low-risk pregnant women by normal reference range during the second trimester in our research. High-risk groups accounted for 10.69% of all the pregnant women in this study. Using targeted high-risk case screening strategy, misdiagnosis rate of pregnancy with hyperthyroidism, subclinical hyperthyroidism, pregnancy with hypothyroidism, subclinical hypothyroidism, low T4 syndrome and positive TPOAb were 87.5% (14 cases), 87.08% (155 cases), 87.08% (155 cases), 83.93% (47 cases), 89.47% (17 cases) and 88.35% (91 cases), respectively. Furthermore, there was no statistically significant difference between high-risk group and low-risk group in the prevalence of thyroid dysfunction. Therefore, we believe that universal screening to pregnant women can effectively reduce misdiagnosis rate of thyroid dysfunction. Further, we recommend universal screening for thyroid function in second trimester of pregnancy.
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Affiliation(s)
- Wei Qian
- Department of Gynecology and Obstetrics, Shanghai Jiao Tong University Affiliated International Peace Maternity and Child Health Hospital , Shanghai , China
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Khalid AS, Marchocki Z, Hayes K, Lutomski JE, Joyce C, Stapleton M, O’Mullane J, O’Donoghue K. Establishing trimester-specific maternal thyroid function reference intervals. Ann Clin Biochem 2013; 51:277-83. [DOI: 10.1177/0004563213496394] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Thyroid disorders are common in women of childbearing age and are associated with adverse pregnancy outcomes. Physiological changes in pregnancy and the lack of pregnancy-specific reference ranges make managing thyroid disorders in pregnancy challenging. Our aim was to establish trimester-specific thyroid function reference intervals throughout pregnancy, and to examine the prevalence of thyroid autoimmunity in otherwise euthyroid women. Method This was a prospective, cross-sectional study of thyroid function tests (TFTs) in pregnant women attending a large, tertiary referral maternity hospital. Patients with known thyroid disorders, autoimmune disease, recurrent miscarriage, hyperemesis gravidarum and pre-eclampsia were excluded. TFTs were analysed in the CUH biochemistry laboratory using Roche Modular E170 electrochemiluminescent immunoassay. Trimester-specific reference ranges (2.5th, 50th and 97.5th centiles) were calculated. Results Three-hundred-and-fifty-one women were included into the analysis. Median maternal age was 30. Thyroid-stimulating hormone concentrations showed slightly increasing median centile throughout gestation. Free thyroxine (T4) and T3 decreased throughout gestation. Table 1 demonstrates the calculated percentiles according to gestational weeks. Conclusion We established pregnancy-specific thyroid function reference intervals for our pregnant population, for use in clinical practice.
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Affiliation(s)
- Azy S Khalid
- Anu Research Centre, Department of Obstetrics and Gynaecology, University College Cork, Cork University Maternity Hospital, Cork, Republic of Ireland
| | - Zbigniew Marchocki
- Anu Research Centre, Department of Obstetrics and Gynaecology, University College Cork, Cork University Maternity Hospital, Cork, Republic of Ireland
| | - Kevin Hayes
- Department of Mathematics and Statistics, University of Limerick, Limerick, Republic of Ireland
| | | | - Caroline Joyce
- Department of Biochemistry, Cork University Hospital, Cork, Republic of Ireland
| | - Mary Stapleton
- Department of Biochemistry, Cork University Hospital, Cork, Republic of Ireland
| | - John O’Mullane
- Department of Biochemistry, Cork University Hospital, Cork, Republic of Ireland
| | - Keelin O’Donoghue
- Anu Research Centre, Department of Obstetrics and Gynaecology, University College Cork, Cork University Maternity Hospital, Cork, Republic of Ireland
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Garber JR, Cobin RH, Gharib H, Hennessey JV, Klein I, Mechanick JI, Pessah-Pollack R, Singer PA, Woeber KA. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract 2013; 18:988-1028. [PMID: 23246686 DOI: 10.4158/ep12280.gl] [Citation(s) in RCA: 591] [Impact Index Per Article: 53.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Hypothyroidism has multiple etiologies and manifestations. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions. This paper describes evidence-based clinical guidelines for the clinical management of hypothyroidism in ambulatory patients. METHODS The development of these guidelines was commissioned by the American Association of Clinical Endocrinologists (AACE) in association with American Thyroid Association (ATA). AACE and the ATA assembled a task force of expert clinicians who authored this article. The authors examined relevant literature and took an evidence-based medicine approach that incorporated their knowledge and experience to develop a series of specific recommendations and the rationale for these recommendations. The strength of the recommendations and the quality of evidence supporting each was rated according to the approach outlined in the American Association of Clinical Endocrinologists Protocol for Standardized Production of Clinical Guidelines-2010 update. RESULTS Topics addressed include the etiology, epidemiology, clinical and laboratory evaluation, management, and consequences of hypothyroidism. Screening, treatment of subclinical hypothyroidism, pregnancy, and areas for future research are also covered. CONCLUSIONS Fifty-two evidence-based recommendations and subrecommendations were developed to aid in the care of patients with hypothyroidism and to share what the authors believe is current, rational, and optimal medical practice for the diagnosis and care of hypothyroidism. A serum thyrotropin is the single best screening test for primary thyroid dysfunction for the vast majority of outpatient clinical situations. The standard treatment is replacement with L-thyroxine. The decision to treat subclinical hypothyroidism when the serum thyrotropin is less than 10 mIU/L should be tailored to the individual patient.
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Affiliation(s)
- Jeffrey R Garber
- Endocrine Division, Harvard Vanguard Medical Associates, Boston, Massachusetts 02215, USA.
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Trimester-specific reference ranges for thyroid hormones in Iranian pregnant women. J Thyroid Res 2013; 2013:651517. [PMID: 23841018 PMCID: PMC3690831 DOI: 10.1155/2013/651517] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 04/29/2013] [Indexed: 11/24/2022] Open
Abstract
Background. Due to many physiological changes during pregnancy, interpretation of thyroid function tests needs trimester-specific reference intervals for a specific population. There is no normative data documented for thyroid hormones on healthy pregnant women in Iran. The present survey was conducted to determine trimester-specific reference ranges for serum TSH, thyroxine (TT4), and triiodothyronine (TT3). Methods. The serum of 215 cases was analyzed for measurement of thyroid function tests by immunoassay method of which 152 iodine-sufficient pregnant women without thyroid autoantibodies and history of thyroid disorder or goiter were selected for final analysis. Reference intervals were defined as 5th and 95th percentiles. Results. Reference intervals in the first, second, and third trimesters were as follows: TSH (0.2–3.9, 0.5–4.1, and 0.6–4.1 mIU/l), TT4 (8.2–18.5, 10.1–20.6, and 9–19.4 μg/dl), and TT3 (137.8–278.3, 154.8–327.6, and 137–323.6 ng/dl), respectively. No correlation was found between TSH and TT4 or TT3. Significant correlation was found between TT4 and TT3 in all trimesters (r = 0.35, P < 0.001). Conclusion. The reference intervals of thyroid function tests in pregnant women differ among trimesters. Applying trimester-specific reference ranges of thyroid hormones is warranted in order to avoid misclassification of thyroid dysfunction during pregnancy.
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The Use of TSH in Determining Thyroid Disease: How Does It Impact the Practice of Medicine in Pregnancy? J Thyroid Res 2013; 2013:148157. [PMID: 23762775 PMCID: PMC3665256 DOI: 10.1155/2013/148157] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 04/09/2013] [Indexed: 11/17/2022] Open
Abstract
During the last four decades, there have been considerable advances in the efficacy and precision of serum thyroid function testing. The development of the third generation assays for the measurement of serum thyroid stimulating hormone (TSH, thyrotropin) and the log-linear relationship with free thyroxine (T4) established TSH as the hallmark of thyroid function testing. While it is widely accepted that TSH outside of the normal range is consistent with thyroid dysfunction, a vast multitude of additional factors must be considered before an accurate clinical diagnosis can be made. This is especially important during pregnancy, when the thyroid is under considerable additional pregnancy-related demands requiring significant maternal physiological changes. This paper examines serum TSH measurement in pregnancy and some associated potential confounding factors.
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Garber JR, Cobin RH, Gharib H, Hennessey JV, Klein I, Mechanick JI, Pessah-Pollack R, Singer PA, Woeber KA. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Thyroid 2012; 22:1200-35. [PMID: 22954017 DOI: 10.1089/thy.2012.0205] [Citation(s) in RCA: 527] [Impact Index Per Article: 43.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hypothyroidism has multiple etiologies and manifestations. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions. This paper describes evidence-based clinical guidelines for the clinical management of hypothyroidism in ambulatory patients. METHODS The development of these guidelines was commissioned by the American Association of Clinical Endocrinologists (AACE) in association with American Thyroid Association (ATA). AACE and the ATA assembled a task force of expert clinicians who authored this article. The authors examined relevant literature and took an evidence-based medicine approach that incorporated their knowledge and experience to develop a series of specific recommendations and the rationale for these recommendations. The strength of the recommendations and the quality of evidence supporting each was rated according to the approach outlined in the American Association of Clinical Endocrinologists Protocol for Standardized Production of Clinical Guidelines-2010 update. RESULTS Topics addressed include the etiology, epidemiology, clinical and laboratory evaluation, management, and consequences of hypothyroidism. Screening, treatment of subclinical hypothyroidism, pregnancy, and areas for future research are also covered. CONCLUSIONS Fifty-two evidence-based recommendations and subrecommendations were developed to aid in the care of patients with hypothyroidism and to share what the authors believe is current, rational, and optimal medical practice for the diagnosis and care of hypothyroidism. A serum thyrotropin is the single best screening test for primary thyroid dysfunction for the vast majority of outpatient clinical situations. The standard treatment is replacement with L-thyroxine. The decision to treat subclinical hypothyroidism when the serum thyrotropin is less than 10 mIU/L should be tailored to the individual patient.
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Affiliation(s)
- Jeffrey R Garber
- Endocrine Division, Harvard Vanguard Medical Associates, Boston, Massachusetts 02215, USA.
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Iodine Intake and Thyroid Function in Pregnant Women in a Private Clinical Practice in Northwestern Sydney before Mandatory Fortification of Bread with Iodised Salt. J Thyroid Res 2012; 2012:798963. [PMID: 23209946 PMCID: PMC3503401 DOI: 10.1155/2012/798963] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 08/28/2012] [Indexed: 11/17/2022] Open
Abstract
Aim. The primary objective of the study was to assess the iodine nutritional status, and its effect on thyroid function, of pregnant women in a private obstetrical practice in Sydney. Methods. It was a cross-sectional study undertaken between November 2007 and March 2009. Blood samples were taken from 367 women at their first antenatal visit between 7 and 11 weeks gestation for measurement of thyroid stimulating hormone (TSH) and free thyroxine (FT4) levels and spot urine samples for urinary iodine excretion were taken at the same time as blood collection. Results. The median urinary iodine concentration (UIC) for all women was 81 μg/l (interquartile range 41-169 μg/l). 71.9% of the women exhibited a UIC of <150 μg/l. 26% of the women had a UIC <50 μg/l, and 12% had a UIC <20 μg/l. The only detectable influences on UIC were daily milk intake and pregnancy supplements. There was no statistically significant association between UIC and thyroid function and no evidence for an effect of iodine intake on thyroid function. Conclusions. There is a high prevalence of mild to moderate iodine deficiency in women in Western Sydney but no evidence for a significant adverse effect on thyroid function. The 6.5% prevalence of subclinical hypothyroidism is unlikely to be due to iodine deficiency.
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Vila L, Velasco I, González S, Morales F, Sánchez E, Lailla JM, Martinez-Astorquiza T, Puig-Domingo M. Detección de la disfunción tiroidea en la población gestante: está justificado el cribado universal. ACTA ACUST UNITED AC 2012; 59:547-60. [DOI: 10.1016/j.endonu.2012.06.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2012] [Accepted: 06/14/2012] [Indexed: 01/14/2023]
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Vila L, Velasco I, González S, Morales F, Sánchez E, Lailla JM, Martinez-Astorquiza T, Puig-Domingo M. Detection of thyroid dysfunction in pregnant women: Universal screening is justified. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.endoen.2012.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Vila L, Velasco I, González S, Morales F, Sánchez E, Lailla JM, Martinez-Astorquiza T, Puig-Domingo M. [Detection of thyroid dysfunction in pregnant women: universal screening is justified]. Med Clin (Barc) 2012; 139:509.e1-509.e11. [PMID: 22981085 DOI: 10.1016/j.medcli.2012.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2012] [Revised: 06/09/2012] [Accepted: 06/14/2012] [Indexed: 01/14/2023]
Abstract
There is a controversy among different scientific societies in relation to the recommendations on whether universal screening for the detection of thyroid dysfunction during gestation should be performed or not. Although various studies have shown an association between subclinical hypothyroidism or hypothyroxinemia with obstetric problems and/or neurocognitive impairment in the offspring, no evidence on the possible positive effects of treatment of such conditions with thyroxin has been demonstrated so far. However, there is a general agreement about the need for treatment of clinical hypothyroidism during pregnancy and the risks of not doing so. Because it is a common, easily diagnosed and effectively treated disorder without special risk, the working Group of Iodine Deficiency Disorders and Thyroid Dysfunction of the Spanish Society of Endocrinology and Nutrition and Spanish Society of Gynaecology and Obstetrics recommends an early evaluation (before week 10) of thyroid function in all pregnant women. Given the complex physiology of thyroid function during pregnancy, hormone assessment should be performed according to reference values for each gestational trimester and generated locally in each reference laboratory. Thyrotropin determination would be sufficient for screening purposes and only if it is altered, free thyroxin or total thyroxin would be required. Adequate iodine nutrition is also highly recommended before and during pregnancy to contribute to a normal thyroid function in the pregnant women and fetus.
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Affiliation(s)
- Lluís Vila
- Servicio de Endocrinología y Nutrición, Hospital de Sant Joan Despí Moisès Broggi (SEEN), Sant Joan Despí, Barcelona, España.
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Schneuer FJ, Nassar N, Tasevski V, Morris JM, Roberts CL. Association and predictive accuracy of high TSH serum levels in first trimester and adverse pregnancy outcomes. J Clin Endocrinol Metab 2012; 97:3115-22. [PMID: 22723328 DOI: 10.1210/jc.2012-1193] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT High serum levels of TSH have been associated with adverse pregnancy outcomes by some studies, and not by others. OBJECTIVE The aim of the study was to assess the association between high levels of TSH in the first trimester of pregnancy and adverse pregnancy outcomes; and to examine the predictive accuracy as a screening test. SETTING AND PARTICIPANTS Serum levels of TSH were measured in a cohort of 2801 women with a singleton pregnancy attending first trimester Down syndrome screening. Information on maternal and infant outcomes was obtained through record linkage to population-based birth and hospital data. Association between high TSH (>95th and >97.5th centiles) multiple of the median levels, and risk of adverse pregnancy outcomes was evaluated using multivariable logistic regression, and the predictive accuracy of models was assessed. MAIN OUTCOMES Rates of infants being small for gestational age (SGA), preterm birth, preeclampsia, miscarriage, and stillbirth were investigated. RESULTS High TSH multiple of the median levels were associated with SGA (<10th centile) [adjusted odds ratio (aOR), 1.71; 95% confidence interval (CI), 0.99-2.94]; preterm birth at less than 37 wk gestation (aOR, 2.59; 95% CI, 1.21-5.53); miscarriage (aOR, 3.66; 95% CI, 1.59-8.44); and a composite measure of any study outcome (aOR, 2.10; 95% CI, 1.23-3.59). The area under the receiver operator characteristic curves were 0.69 (95% CI, 0.65-0.73) for SGA; 0.56 (95% CI, 0.51-0.61) for preterm birth; 0.70 (95% CI, 0.61-0.79) for miscarriage; and 0.63 (95% CI, 0.60-0.65) for any adverse pregnancy outcome. CONCLUSIONS High TSH serum levels during the first trimester of pregnancy were associated with adverse pregnancy outcomes; however, the predictive accuracy was poor. Screening for high TSH levels in the first trimester would be of no benefit to identify women at risk.
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Affiliation(s)
- Francisco J Schneuer
- Clinical and Population Perinatal Health Research, Kolling Institute of Medical Research, University of Sydney, Sydney, New South Wales (NSW) 2065, Australia.
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Abstract
The high global prevalence of iodine deficiency and autoimmune thyroid disorders and the mental and physical consequences of these disorders creates a huge human and economic burden that can be prevented, in large part, by early detection and appropriate preventative or therapeutic measures. The availability of sophisticated, sensitive and accurate laboratory testing procedures provides an efficient and effective platform for the application of screening for these disorders. Measurement of urine iodine concentration (UIC) in school children or pregnant women is the recommended indicator for screening populations for iodine deficiency. The severity of the iodine deficiency is classified according to the UIC. Measurement of serum thyrotropin (TSH) as an indicator for population iodine deficiency is used only in neonates and is supplementary to UIC screening. Other indicators such as goitre rates, thyroid function and serum thyroglobulin levels are useful adjunctive but not frontline process indicators. The human and economic benefits of screening for congenital hypothyroidism by measurement of heel-prick TSH have been well documented and justify its universal application. Using this measurement for monitoring population iodine intake is recommended by the World Health Organization but further validation is required before it can be universally recommended. Subclinical thyroid dysfunction is readily detected by current highly sensitive serum TSH assays and its prevalence appears to increase with age, varies with iodine intake and ethnicity and may occur in up to 20% of older age people. Subclinical hyperthyroidism is the less common disorder and screening cannot be justified because of its low prevalence and minimal or insignificant clinical effects. The argument for screening for subclinical hypothyroidism in middle-aged and older women is stronger but lacks evidence of benefit from randomised controlled trials or cost benefit analyses of therapeutic intervention, so it cannot currently be recommended. The publication of recent Clinical Practice Guidelines for management of thyroid disease in pregnancy from the American Endocrine Society and American Thyroid Association provide persuasive arguments for early detection and treatment of overt and subclinical hypothyroidism to prevent obstetric complications and potential neurocognitive disorders in the offspring. Given the indisputable benefits of therapy, the sooner thyroid dysfunction is detected, before or as early as possible in gestation, the more likely there will be a better outcome. Because of the limitations of targeted case detection in women at risk of subclinical hypothyroidism, there has been a gradual shift in opinion to universal TSH screening of all women as soon as practicable in pregnancy. While a positive association exists between the presence of anti-thyroid antibodies and increased pregnancy loss, universal screening of all pregnant women for underlying autoimmune thyroid disease is difficult to justify until there is evidence of beneficial outcomes from randomised controlled trials. Vigorous and liberal targeted case detection remains the recommended strategy to address this problem.
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Abstract
The present manuscript provides a definition for, and evaluates the prevalence and maternal/fetal/child impact of, overt hyperthyroidism and overt hypothyroidism. The prevalence of overt hyperthyroidism is 0.5% and the prevalence of overt hyperthyroidism is 0.3%. Overt maternal hyperthyroidism is associated with heart failure, preeclampsia, preterm delivery, still birth, and neonatal mortality. Overt maternal hypothyroidism is associated with preeclampsia, gestational hypertension, cretinism, fetal deaths, and spontaneous abortion. A cost-effective analysis for screening and treating overt thyroid disease during pregnancy is warranted.
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Karakosta P, Chatzi L, Bagkeris E, Daraki V, Alegakis D, Castanas E, Kogevinas M, Kampa M. First- and Second-Trimester Reference Intervals for Thyroid Hormones during Pregnancy in "Rhea" Mother-Child Cohort, Crete, Greece. J Thyroid Res 2011; 2011:490783. [PMID: 22175032 PMCID: PMC3235891 DOI: 10.4061/2011/490783] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Revised: 08/26/2011] [Accepted: 09/09/2011] [Indexed: 11/20/2022] Open
Abstract
Estimation and interpretation of thyroid function tests in pregnant women is of utmost importance for maternal, fetal and neonatal health. Our objective was to calculate laboratory- and geography-specific reference intervals for thyroid hormones during pregnancy in an iodine-sufficient area of the Mediterranean, Crete, Greece. This project was performed in the context of “Rhea” mother-child cohort. Fulfillment of extensive questionnaires and estimation of free triiodothyronine (fT3), free thyroxine (fT4), thyroid-stimulating hormone (TSH), and antithyroid antibodies were performed. The reference population was defined using inclusion criteria regarding thyroidal, obstetric, and general medical status of women. Reference interval for TSH was 0.05–2.53 μIU/mL for the first and 0.18–2.73 μIU/mL for the second trimester. 6,8% and 5,9% of women in the first and second trimester, respectively, had TSH higher than the upper reference limit. These trimester-specific population-based reference ranges are essential in everyday clinical practice for the correct interpretation of thyroid hormone values and accurate classification of thyroid disorders.
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Affiliation(s)
- Polyxeni Karakosta
- Department of Social Medicine, Faculty of Medicine, University of Crete, P.O. Box 2208, 71003 Heraklion, Greece
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