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There was no consensus about those at low risk however. Similar were found with local data through the analysis of 6, TSH from pregnant women tested in a Victorian private pathology laboratory over a 12 month period using the Roche Cobas e Test s and median TSH concentrations were plotted against weeks of gestation Figure.

The ATA guidelines highlighted two studies from southern Italy, a region with mild iodine deficiency similar to Australia.

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The notable features were the popularity of week 10 as a collection time, presumably coinciding with other antenatal testing, and the decrease in TSH to its lowest point toward the end of the first trimester. Try out PMC Labs and tell us what you think. The There have now been numerous papers showing that a more realistic figure is between 3.

It is interesting that the unusual complication of placental abruption was only demonstrated in one study 30 but not in four others.

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The median time for starting thyroxine was 13 weeks three days and the target TSH was less than 1. The American Thyroid Association ATA guidelines recommended that the interpretation of thyroid function in pregnancy be based on trimester specific reference ranges as defined in populations with optimal iodine intake. The thyrotrophic effect of hCG causes increased thyroid hormone production resulting in a transient increase in free thyroxine FT4 towards the end of the first trimester.

Two excellent recent reviews cover many of these areas.

Reporting thyroid function tests in pregnancy

A meta-analysis of eight case-control and 10 longitudinal studies found an association between thyroid autoimmunity and miscarriage odds ratios 2. There are several physiological changes during pregnancy that affect maternal thyroid function and thyroid hormone levels.

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There is general agreement that overt hypothyroidism can cause harm to the mother and baby although this condition is uncommon today and much of the evidence is from times when the epidemiology thyroid disease and diagnostic methods were very different. Two separate Chinese studies of approximately women each found a link between maternal hypothyroidism and developmental problems in children tested at six months or two years of age.

Gestational age will have a major effect on thyroid function tests through the first trimester as hCG concentrations rise and fall. The first is a paper from in which the children of 62 women with raised TSH in pregnancy were evaluated at 7—9 years of age with a battery of psychometric tests. It reached a peak at 9—11 weeks which coincided with the trough in TSH. TSH concentrations at 4—6 weeks of gestation were the same as women who were not pregnant. A recent review tabulated a summary of 16 studies, mostly from the last five years.

Pregnant tf stories binding globulin TBG increases by 2—3 times compared with the pre-pregnancy level by the 20th week of gestation. Most anxiety relates to the diagnosis of hypothyroidism, the most common thyroid disease in our community and the focus of this review.

A recent meta-analysis of 14 studies of women with subclinical hypothyroidism demonstrated a ificant increased risk of pregnancy loss odds ratio 1.

Pregnant tf stories women are known to have thyroid disease before pregnancy and require monitoring to ensure no harm comes to them or their baby. There was inadequate detail of the visual defects that were found given the potential seriousness of this complication and the fact that they have not been described before.

A recent publication from Sweden indicated that thyroid testing and management in pregnancy in that country was often suboptimal. The studies were heterogeneous in terms of the populations studied, of subjects, and the calculation of the reference intervals. Thyroid function testing in pregnancy is an area of concern for pregnant women, doctors and laboratories.

The optimal timing of testing is probably toward the end of the first trimester or before pregnancy in those at high risk. The diagnosis of subclinical hypothyroidism rests on the recognition of an increased serum concentration of TSH which may be affected by many factors including gestational age, analytical method, the antibody status of the mother, ethnicity, iodine nutrition and even the time of day when the blood is collected. Three guidelines have been recently published by expert groups in North America and Europe regarding the diagnosis and management of thyroid disease in pregnancy.

This elevation causes an increase of total triiodothyronine TT3 and thyroxine TT4 by an average of 1.

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There are suggestions that ethnicity may also have a ificant effect on TSH and FT4 reference limits in pregnancy. The second study involved a birth cohort of women in Northern Finland followed for 20 years. In recognition of the fact that there may not be appropriate trimester-specific reference intervals for individual populations, they stated that the default TSH values should be 0. All of the guidelines warned against the uncritical use of FT4 in pregnancy. Learn More.

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Other studies have looked at the association of thyroid antibodies rather than hypothyroidism with adverse pregnancy outcomes. This proposition has been supported by a of Dutch studies which found an association between euthyroid hypothyroxinaemia and delayed cognitive development at different ages.

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There are numerous other studies in this area which have reached different conclusions. The following discussion covers the different factors that must be considered when interpreting thyroid function tests in pregnancy. A follow up study of the same children now aged 7—10 years is underway. Screening is favoured by the frequency of disease, the difficulty of making a clinical diagnosis and the relatively ease of measuring TSH.

Arguing against screening are the uncertainties about the harm caused by untreated subclinical hypothyroidism and the lack of evidence that early thyroxine treatment makes any difference. The TSH was measured with the Roche assay. At the same time there were two large, well-organised studies that came to the opposite conclusion.

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The argument for the precedence of hypothyroxinaemia is that the mother is the only source of thyroid hormones for the foetus until at least 12 weeks gestation. The evidence that mild maternal hypothyroidism can cause neurological injury in the developing foetus is even less certain than the evidence regarding obstetric complications. The primary endpoint was IQ testing at three years Pregnant tf stories age which showed no difference between the two groups.

The concentrations were low in both groups however and the s above the upper reference limit were no different. Only four reported the 2. It is also needed to supply the increased production of maternal thyroid hormone which rises to match the increased concentration of TBG. Extra thyroid hormone may also be required to counter losses through placental deiodination. The guidelines varied in their recommendations on the way that subclinical hypothyroidism defined as an increased TSH and normal FT4 should be managed.

Regarding the interpretation of thyroid function tests in pregnancy the guidelines were similar with all recommending 2. The experts agreed that high risk women for example, older women or those with a personal or family history of autoimmune thyroid disease should be screened. Regarding obstetric complications, there is evidence linking subclinical hypothyroidism with selected adverse events.

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The second paper of interest described an intervention study in in which 21, pregnant women were screened for hypothyroidism before 16 weeks. The Endocrine Society reference intervals were based on six studies, amongst which there was ificant variation. There has been vigorous debate about the relative importance of hypothyroidism i. Others may have unrecognised disease and there has been debate about the merits of screening, the potential harm caused by mild hypothyroidism, and how women should be tested. The changes in thyroid function tests with gestational age were elegantly shown in a study of 13, singleton pregnancies assessed at one week intervals from week 6 to term where serum TSH fell to a trough at week 10 followed by a progressive increase to term.

Severe iodine Pregnant tf stories was more common in the past and laboratory methods were primitive. Many early reports were small series from high risk clinics and the findings were not replicated in large population studies. One of the subtleties is that neurological injuries at different times of gestation may have different effects requiring specific tests later in childhood. In the latter study hCG was also measured.

During pregnancy hCG peaks towards the end of the first trimester followed by a decrease to a plateau in second and third trimesters. Two studies are most often quoted in this area, one positive and one negative. Maternal iodine requirements increase in pregnancy for a of reasons.

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Some of this relates to the difficulty studying this area where the timing and type of assessment of the child are critical along with correction for confounding factors. This can present practical problems in laboratories that do not record gestational age or cannot adjust reference intervals to match different stages of pregnancy.

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A study of almost 6, Finnish women also demonstrated a decline in TSH from very early pregnancy to a low point at 11 weeks 54 and a similar pattern was found in 4, pregnant Chinese women studied between 4 to 12 weeks gestation. While the guidelines were in agreement in many regards it is not known whether this is what doctors actually do.

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Whilst placental abruption is often quoted as a potential complication of subclinical hypothyroidism it is obvious that getting good data on uncommon events like this is very difficult. Most important is that human chorionic gonadotropin hCG is structurally similar to TSH, and has a direct stimulating effect on the thyroid gland mediated through the TSH receptor.

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There is no clear evidence to date that either of these adverse events can be prevented with thyroxine or any other treatment. Those with known thyroid disease will also need to have their treatment reviewed. There are several preliminary observations about the research in this area. Studies are still quoted that used butanol extractable iodine to measure thyroid hormones, a method that was abandoned long ago. There were mixed views about screening women for thyroid disease.

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