The wealth of new information, published over the past two decades, has led an international committee (under the auspices of the American Endocrine Society) to propose clinical guidelines for the management of thyroid diseases associated with the pregnant state. These guidelines were reviewed and endorsed by the four world Thyroid Associations (ETA, ATA, LATS, AOTA) and the Endocrine Society. They have been published in August 2007 as a supplement to the Journal of Clinical Endocrinology and Metabolism (Vol: 92; pp S1S47).
The topics under scrutiny were maternal & foetal aspects related to both maternal hypothyroidism & hyperthyroidism (including Graves disease & GTT gestational transient non-autoimmune thyrotoxicosis), infertility and miscarriage, postpartum thyroid disorders, iodine nutritional status, thyroid nodules & cancer diagnosed during pregnancy, and finally the heated subject of universal screening. Altogether, 35 recommendations for good clinical practice were edited, based on a systematic review of all publications related to each of these topics, published over the past two decades. For each recommendation, grading of the evidence was achieved based on the USPSTF system and, when possible, on the GRADE system.
Management of thyroid diseases during pregnancy involves many different care providers (family doctors, obstetricians, endocrinologists, nurse midwives, etc.) thus making the development of such guidelines all the more needed. Also, thyroid diseases during pregnancy require special consideration because pregnancy per se induces significant changes in thyroid function and, conversely, maternal thyroid disease can have adverse effects on the pregnancy and foetal development.
Since it is not possible, in the time allotted for this lecture, to review systematically the entirety of the 35 recommendations, we will focus our attention on the following topics: a) the difficulties encountered in grading the available scientific evidence and lack of sufficient randomized clinical trials; b) the need for continuing and better education of the multiple care providers concerning thyroid disease in pregnancy; c) the difficult issue of targeted versus universal screening of pregnant women to search for thyroid autoimmunity features and mild thyroid dysfunction, and finally d) an attempt to draw perspectives on where to go to in the near future.
In summary, pregnancy has profound effects on the regulation of thyroid function in healthy women and in patients with thyroid disorders. These effects need to be recognized, precisely assessed, clearly interpreted, and correctly managed in order to drastically reduce the detrimental effects of thyroid dysfunction on pregnancy outcome.
25 - 29 Apr 2009
European Society of Endocrinology