Title

Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum

Authoring Organization

American Thyroid Association

Publication Month/Year

March 1, 2017

Last Updated Month/Year

November 5, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

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.

Target Patient Population

Thyroid Disease During Pregnancy and the Postpartum

PICO Questions

  1. How do thyroid function tests change during pregnancy?

  2. What is the normal reference range for serum TSH concentrations in each trimester of pregnancy?

  3. What is the optimal method to assess serum T4 concentration during pregnancy?

  4. What is the impact of severe iodine deficiency on the mother, fetus, and child?

  5. What is the impact of mild to moderate iodine deficiency on the mother, fetus, and child?

  6. What is the iodine status of pregnant and breastfeeding women in the United States?

  7. What is the iodine status of pregnant and breastfeeding women worldwide?

  8. Does iodine supplementation in pregnancy and lactation improve outcomes in severe iodine deficiency?

  9. Does iodine supplementation in pregnancy and lactation improve outcomes in mildly to moderately iodine-deficient women?

  10. What is the recommended daily iodine intake in women planning pregnancy, women who are pregnant, and women who are breastfeeding?

  11. What is the safe upper limit for iodine consumption in pregnant and breastfeeding women?

  12. What is the prevalence of thyroid autoantibodies in pregnant women?

  13. What is the natural history of antithyroid antibodies in pregnant women?

  14. How should euthyroid women who are thyroid antibody (Ab)-positive be monitored during pregnancy?

  15. Should euthyroid women with thyroid autoimmunity be treated with selenium?

  16. Is there an association between thyroid antibodies and sporadic spontaneous pregnancy loss in euthyroid women?

  17. Is there an association between thyroid antibodies and recurrent spontaneous pregnancy loss in euthyroid women?

  18. Does treatment with LT4 or intravenous immunoglobulin therapy decrease the risk for pregnancy loss in euthyroid women with thyroid autoimmunity?

  19. Is there an association between thyroid autoantibody positivity and premature delivery?

  20. Does LT4 treatment of euthyroid women who are thyroid autoantibody positive reduce risk for premature delivery?

  21. Is thyroid autoimmunity in euthyroid pregnant women associated with adverse obstetric or child outcomes other than pregnancy loss and premature birth?

  22. Is overt thyroid dysfunction associated with infertility in women?

  23. Is subclinical hypothyroidism associated with infertility in women?

  24. Is thyroid autoimmunity linked to infertility in women?

  25. Is maternal subclinical hypothyroidism associated with worse ART outcomes?

  26. Does treatment of subclinically hypothyroid women improve ART outcomes?

  27. Is treated maternal hypothyroidism associated with worse ART outcomes compared to healthy controls?

  28. Is maternal antithyroid Ab positivity associated with poorer outcomes following ART?

  29. Does treatment of antithyroid Ab–positive euthyroid women improve ART outcomes?

  30. Does ovarian hyperstimulation alter thyroid function?

  31. What is the definition of hypothyroidism in pregnancy?

  32. How is isolated hypothyroxinemia defined in pregnancy?

  33. What adverse outcomes are associated with overt hypothyroidism during pregnancy?

  34. What adverse outcomes are associated with subclinical hypothyroidism during pregnancy?

  35. What adverse outcomes are associated with isolated hypothyroxinemia in pregnancy?

  36. Should women with overt hypothyroidism be treated in pregnancy?

  37. Should women with subclinical hypothyroidism be treated in pregnancy?

  38. Should women with isolated hypothyroxinemia be treated with LT4 in pregnancy?

  39. What is the optimal method of treating hypothyroidism in pregnant women?

  40. What is the biochemical goal when treating hypothyroidism in pregnant women?

  41. Are there circumstances in which euthyroid women are at risk for hypothyroidism once pregnant?

  42. How should women with hypothyroidism or at risk for hypothyroidism be monitored through pregnancy?

  43. How do treated hypothyroid women (receiving LT4) differ from other patients during pregnancy? What changes can be anticipated in such patients during gestation?

  44. What proportion of treated hypothyroid women (receiving LT4 prenatally) require changes in their LT4 dose during pregnancy?

  45. How should preconception LT4 be adjusted in treated hypothyroid women (receiving LT4) planning pregnancy?

  46. How should LT4 be adjusted postpartum?

  47. What is the outcome and long-term prognosis when maternal hypothyroidism is effectively treated through gestation?

  48. Except for measurement of maternal thyroid function, should additional maternal or fetal testing occur in treated hypothyroid women during pregnancy?

  49. What are the causes of thyrotoxicosis in pregnancy?

  50. What is the appropriate initial evaluation of a suppressed serum TSH concentration during the first trimester of pregnancy?

  51. How can gestational transient thyrotoxicosis be differentiated from Graves' hyperthyroidism in pregnancy?

  52. What is the appropriate management of gestational transient thyrotoxicosis?

  53. How should women with GD seeking future pregnancy be counseled?

  54. What is the management of patients with Graves' hyperthyroidism during pregnancy?

  55. Should antithyroid medication be withdrawn or modified in early pregnancy?

  56. What are the principles of thyroid testing and ATD administration when treating Graves' hyperthyroidism during pregnancy?

  57. What are the indications and timing for thyroidectomy in the management of GD during pregnancy?

  58. How should pregnant patients with GD be prepared for urgent nonthyroid surgery?

  59. What is the value of TRAb measurement in the evaluation of a pregnant woman with Graves' hyperthyroidism?

  60. Under what circumstances should additional fetal ultrasound monitoring for growth, heart rate, and goiter be performed in women with Graves' hyperthyroidism in pregnancy?

  61. When should umbilical blood sampling be considered in women with GD in pregnancy?

  62. How should hyperthyroidism caused by autonomous thyroid nodules be handled in pregnancy?

  63. What are the etiologies of thyrotoxicosis in the postpartum period?

  64. How should Graves' hyperthyroidism be treated in lactating women?

  65. What is the prevalence of thyroid nodules during pregnancy?

  66. What is the prevalence of thyroid cancer in women with thyroid nodules discovered during pregnancy?

  67. What is the optimal diagnostic strategy for thyroid nodules detected during pregnancy?

  68. Does pregnancy impact the prognosis of newly diagnosed thyroid carcinoma?

  69. What are the perioperative risks to mother and fetus of thyroid surgery during pregnancy?

  70. How should cytologically benign thyroid nodules be managed during pregnancy?

  71. What are the TSH goals for pregnant women with previously treated thyroid cancer receiving LT4 therapy?

  72. What is the effect of therapeutic radioactive iodine treatment on subsequent pregnancies?

  73. What type of monitoring should be performed during pregnancy in a patient who has already been treated for DTC prior to pregnancy?

  74. What is the relationship between maternal and fetal thyroid hormone status?

  75. Is maternal thyroid hormone (thyroxine or LT4) transferred to the newborn via breast milk?

  76. Should diagnostic or therapeutic radiopharmaceuticals be administered to breastfeeding or lactating women?

  77. Once the thyrotoxic phase of PPT resolves, how often should TSH be measured to screen for the hypothyroid phase?

  78. How often should thyroid function testing be performed after the hypothyroid phase of PPT resolves?

Inclusion Criteria

Female, Adult

Health Care Settings

Ambulatory

Intended Users

Nurse, nurse midwife, nurse practitioner, physician, physician assistant

Scope

Counseling, Diagnosis, Assessment and screening, Management, Prevention

Keywords

pregnancy, Thyroid Disease

Methodology

Number of Source Documents
621
Literature Search Start Date
January 1, 1990
Literature Search End Date
May 29, 2016
Description of External Review Process
The guidelines were then provided to the ATA membership for review and comments over a 2-week period.
Description of Public Comment Process
ATA sent to membership. There is no information that they promoted to patient groups or the public.
Specialties Involved
Endocrinology, Family Medicine, Obstetrics And Gynecology, Thyroidology, Endocrinology
Description of Systematic Review
The literature review for each section included an analysis of all primary studies in the area published since 1990 and SELECTIVE review of the primary literature published prior to 1990 that was seminal in the field. Electronic databases were used. Standard data collection form was used.
List of Questions
111 Key Questions. 97 Recommendations.
Description of Study Criteria
Studies were selected according to the following criteria: N ≥ 500, exclusion of thyroid peroxidase antibody (TPOAb)-positive women and availability of data from the manuscript or via personal communication. Iodine status was estimated based on references from article, WHO iodine status reports or from the Vitamin and Mineral Nutrition Information System (VMNIS).
Description of Search Strategy
No formal workplan was developed, reviewed, and approved. The guideline mentions "standard data collection form" and "electronic databases" (at least we know: no meeting abstracts). Also: “The literature review for each section included an analysis of all primary studies in the area published since 1990 and selective review of the primary literature published prior to 1990 that was seminal in the field.” Opinion: "selective review" is not a search strategy (it's cherry picking). There is also no end date listed.
Description of Study Selection
Prior to initiating the reviews, all task force members were provided written and verbal group advice on conducting electronic literature searches, critical appraisal of articles, and rationale for formulating strength of recommendations. Standard data collection forms were used by all reviewers. For each question, a primary reviewer performed a literature search, appraised relevant literature, and generated recommendations, accompanying text, and a relevant bibliography. This information was then reviewed by both chairs, revised as needed, and presented for review by the entire panel. Feedback and suggestions for revisions from the Chairs and panel members were obtained via e-mail, regularly scheduled teleconferences, and face-to-face meetings. Once the manuscript was drafted, all suggestions for revisions were regularly reviewed by the entire panel in the form of a tracked changes draft manuscript and teleconferences. The draft document continued to be revised until no suggestions for further revisions were requested by any panel members. Thus, general consensus on acceptability of recommendations and manuscript text was achieved, with the fundamental understanding that not all recommendations may be feasible in all practice settings and adaptation of the guideline recommendations to individual care may be needed.
Description of Evidence Analysis Methods
The draft document continued to be revised until no suggestions for further revisions were requested by any panel members. Thus, general consensus on acceptability of recommendations and manuscript text was achieved, with the fundamental understanding that not all recommendations may be feasible in all practice settings and adaptation of the guideline recommendations to individual care may be needed.
Description of Evidence Grading
ATA referred to clinical methodology of The American College of Physicians. "In accordance with current ATA policies, the American College of Physicians Grading System was adopted for use in these guidelines (Tables 1 and 2)."
Description of Recommendation Grading
In accordance with current ATA policies, the American College of Physicians Grading System was adopted for use in these guidelines (Tables 1 and 2)
Description of Funding Source
ATA provides funding for Guideline Development.
Company/Author Disclosures
Competing interests of all task force members were reviewed at inception of the group, yearly, and upon completion of the guidelines and are included with this document.These guidelines were funded by the ATA without support from any commercial sources.
Percentage of Authors Reporting COI
100