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

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Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and Postpartum THYROID PREGNANCY AND FETAL DEVELOPMENT Volume 21, Number 10, 2011 ª Mary Ann Liebert, Inc. DOI: 10.1089/thy.2011.0087 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and Postpartum The American Thyroid Association Taskforce on Thyroid Disease During Pregnancy and Postpartum Alex Stagnaro-Green (Chair),1 Marcos Abalovich,2 Erik Alexander,3 Fereidoun Azizi,4 Jorge Mestman,5 Roberto Negro,6 Angelita Nixon,7 Elizabeth N. Pearce,8 Offie P. Soldin,9 Scott Sullivan,10 and Wilmar Wiersinga11 INTRODUCTION Knowledge regarding the interaction between the thyroid and pregnancy/the postpartum period is advancing at a regnancy has a profound impact on the thyroid gland rapid pace. Only recently has a TSH of 2.5 mIU/L been ac- Pand thyroid function. The gland increases 10% in size cepted as the upper limit of normal for TSH in the first tri- during pregnancy in iodine-replete countries and by 20%– mester. This has important implications in regards to 40% in areas of iodine deficiency. Production of thyroxine interpretation of the literature as well as a critical impact for (T4) and triiodothyronine (T3) increases by 50%, along with a the clinical diagnosis of hypothyroidism. Although it is well 50% increase in the daily iodine requirement. These physi- accepted that overt hypothyroidism and overt hyperthy- ological changes may result in hypothyroidism in the later roidism have a deleterious impact on pregnancy, studies are stages of pregnancy in iodine-deficient women who were now focusing on the potential impact of subclinical hypo- euthyroid in the first trimester. The range of thyrotropin thyroidism and subclinical hyperthyroidism on maternal and (TSH), under the impact of placental human chorionic go- fetal health, the association between miscarriage and preterm nadotropin (hCG), is decreased throughout pregnancy with delivery in euthyroid women positive for TPO and/or Tg the lower normal TSH level in the first trimester being antibody, and the prevalence and long-term impact of post- poorly defined and an upper limit of 2.5 mIU/L. Ten percent partum thyroiditis. Recently completed prospective ran- to 20% of all pregnant women in the first trimester of domized studies have begun to produce critically needed data pregnancy are thyroid peroxidase (TPO) or thyroglobulin on the impact of treating thyroid disease on the mother, fetus, (Tg) antibody positive and euthyroid. Sixteen percent of the and the future intellect of the unborn child. women who are euthyroid and positive for TPO or Tg an- It is in this context that the American Thyroid Association tibody in the first trimester will develop a TSH that exceeds (ATA) charged a task force with developing clinical guide- 4.0 mIU/L by the third trimester, and 33%–50% of women lines on the diagnosis and treatment of thyroid disease during who are positive for TPO or Tg antibody in the first tri- pregnancy and the postpartum. The task force consisted of mester will develop postpartum thyroiditis. In essence, international experts in the field of thyroid disease and pregnancy is a stress test for the thyroid, resulting in hy- pregnancy, and included representatives from the ATA, Asia pothyroidism in women with limited thyroidal reserve or and Oceania Thyroid Association, Latin American Thyroid iodine deficiency, and postpartum thyroiditis in women Society, American College of Obstetricians and Gynecolo- with underlying Hashimoto’s disease who were euthyroid gists, and the Midwives Alliance of North America. Inclusion prior to conception. of thyroidologists, obstetricians, and midwives on the task 1Departments of Medicine and Obstetrics/Gynecology, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia. 2Endocrinology Division, Durand Hospital, Favaloro University, Buenos Aires, Argentina. 3Division of Endocrinology, Diabetes, and Hypertension, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts. 4Internal Medicine and Endocrinology, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medicine Sciences, Tehran, Iran. 5Department of Medicine and Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California. 6Division of Endocrinology, V. Fazzi Hospital, Lecce, Italy. 7Angelita Nixon, CNM, LLC, Scott Depot, West Virginia. 8Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, Boston, Massachusetts. 9Departments of Medicine, Oncology, and Obstetrics and Gynecology, Georgetown University Medical Center, Washington, District of Columbia. 10Department of Obstetrics/Gynecology, Medical University of South Carolina, Charleston, South Carolina. 11Endocrinology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. 1081 1082 STAGNARO-GREEN ET AL. force was essential to ensuring widespread acceptance and Level D. The USPSTF recommends against routinely pro- adoption of the developed guidelines. viding (the service) to asymptomatic patients. The USPSTF The clinical guidelines task force commenced its activities found at least fair evidence that (the service) is ineffective or that in late 2009. The guidelines are divided into the following harms outweigh benefits. nine areas: 1) thyroid function tests, 2) hypothyroidism, 3) thy- Level I. The USPSTF concludes that evidence is insufficient rotoxicosis, 4) iodine, 5) thyroid antibodies and miscarriage/ to recommend for or against routinely providing (the ser- preterm delivery, 6) thyroid nodules and cancer, 7) postpartum vice). Evidence that (the service) is effective is lacking, or poor thyroiditis, 8) recommendations on screening for thyroid dis- quality, or conflicting, and the balance of benefits and harms ease during pregnancy, and 9) areas for future research. Each cannot be determined. section consists of a series of questions germane to the clinician, followed by a discussion of the questions and concluding with The organization of these guidelines is presented in Table 1. recommendations. A complete list of the Recommendations is included in the Literature review for each section included an analysis of Appendix. It should be noted that although there was una- all primary papers in the area published since 1990 and selective nimity in the vast majority of recommendations there review of the primary literature published prior to 1990 that was were two recommendations for which one of the committee seminal in the field. In the past 15 years there have been a members did not agree with the final recommendation. The number of recommendations and guideline statements relating two recommendations for which there were dissenting opin- to aspects of thyroid and pregnancy (1,2). In deriving the pres- ions are Recommendations 9 and 76. The alternative view ent guidelines the task force conducted a new and compre- points are included in the body of the report. hensive analysis of the primary literature as the basis for all of The final document was approved by the ATA Board of the recommendations. The strength of each recommendation Directors and officially endorsed by the American Association of was graded according to the United States Preventive Services Clinical Endocrinologists (AACE), British Thyroid Association Task Force (USPSTF) Guidelines outlined below (3). (BTA), Endocrine Society of Australia (ESA), European Asso- ciation of Nuclear Medicine (EANM), European Thyroid Asso- Level A. The USPSTF strongly recommends that clinicians ciation (ETA), Italian Association of Clinical Endocrinologists provide (the service) to eligible patients. The USPSTF found (AME), Korean Thyroid Association (KTA), and Latin American good evidence that (the service) improves important health outcomes Thyroid Society (LATS). and concludes that benefits substantially outweigh harms. Finally, the committee recognizes that knowledge on Level B. The USPSTF recommends that clinicians provide the interplay between the thyroid gland and pregnancy/ (this service) to eligible patients. The USPSTF found at least fair postpartum is dynamic, and new data will continue to come evidence that (the service) improves important health outcomes and forth at a rapid rate. It is understood that the present guide- concludes that benefits outweigh harms. lines are applicable only until future data refine our under- standing, define new areas of importance, and perhaps even Level C. The USPSTF makes no recommendation for or refute some of our recommendations. In the interim, it is our against routine provision of (the service). The USPSTF found at hope that the present guidelines provide useful information to least fair evidence that (the service) can improve health outcomes but clinicians and help achieve our ultimate goal of the highest concludes that the balance of benefits and harms is too close to justify quality clinical care for pregnant women and their unborn a general recommendation. children. Table 1. Organization of Pregnancy Management Guidelines: Sections, Questions, and Recommendations Page number INTRODUCTION THYROID FUNCTION TESTS IN PREGNANCY Q 1 How do thyroid function tests change during pregnancy? 1086 Q 2 What is the normal range for TSH in each trimester? 1086 R1Trimester-Specific Reference Ranges for TSH, # 1 1087 R2Trimester-Specific Reference Ranges for TSH, # 2 1087 Q 3 What is the optimal method to assess FT4 during pregnancy? 1087 R3FT4 Assay Methods, # 1 1088 R4FT4 Assay Methods, # 2 1088 R5FT4 Assay Methods, # 3 1088 HYPOTHYROIDISM
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