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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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The new guidelines include 76 specific recommendations highlighting the role of thyroid function tests, hypothyroidism, thyrotoxicosis, iodine, thyroid antibodies and miscarriage/preterm delivery, thyroid nodules and cancer, postpartum thyroiditis, recommendations on screening for thyroid disease during pregnancy, and areas for future research.
Among the specific recommendations are the following:
* Oral levothyroxine is indicated for women with overt hypothyroidism, which is associated with greater risks for fetal loss and premature birth, and for those with subclinical hypothyroidism who test positive for TPO antibodies.
* To treat maternal hypothyroidism, use of triiodothyronine, desiccated thyroid, or other thyroid preparations is strongly recommended against.
* Women who are already receiving thyroid replacement therapy should increase their dose by 25% to 30% when they become pregnant.
* Women with subclinical hypothyroidism in pregnancy who are not initially treated should be monitored for progression to overt hypothyroidism. Serum thyroid-stimulating hormone (TSH) and free thyroxine (FT4) levels should be measured approximately every 4 weeks until 16 to 20 weeks' gestation and at least once between 26 and 32 weeks' gestation.
* In the first trimester, normal range for TSH level is 0.1 to 2.5 mIU/L; this level increases to 0.2 to 3.0 mIU/L in the second trimester and 0.3 to 3.0 mIU/L in the third trimester.
* Serum levels of FT4 during pregnancy should be measured with online solid phase extraction–liquid chromatography, or tandem mass spectrometry on serum dialysate or ultrafiltrate.
Treatment is not needed for women with isolated low FT4 levels.
* During pregnancy and lactation, the minimal suggested daily recommended allowance for iodine is 250 μg. The risk for fetal hypothyroidism may increase when total daily iodine intake from diet and/or supplements is or exceeds 500 μg.
* Pregnant women should not undergo radioactive iodine thyroid scanning, but fine-needle aspiration of thyroid nodules may be performed if indicated.
* Evidence is insufficient to recommend for or against routine screening for antithyroid antibodies among women with miscarriage, or universal TSH screening in the first trimester. However, screening for FT4 level is not recommended.
* Antithyroid drugs are not indicated for gestational hyperthyroidism, which can be managed supportively. However, women in the first trimester in whom Graves' hyperthyroidism develops should receive propylthiouracil.
* During the thyrotoxic phase of postpartum thyroiditis, antithyroid drugs are not needed. To monitor women for development of hypothyroidism once the thyrotoxic phase has ended, screening should be performed every 2 months for 1 year.
* At approximately 6 to 12 months after starting treatment of postpartum thyroiditis for their patients, clinicians should try to taper thyroid replacement therapy.
30.07.2011, 14:20
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