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Thyroid disorders in pregnancy

Nature Reviews Endocrinology volume 8, pages 650–658 (2012)Cite this article

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Abstract

The thyroid gland is substantially challenged during pregnancy. Total T3 and T4 levels increase by 50% during pregnancy owing to a 50% increase in thyroxine-binding globulin levels. Serum TSH levels decrease in the first trimester and increase in the second and third trimesters; however, not to prepregnancy levels. Hypothyroidism is present in up to 3% of all pregnant women. Subclinical hypothyroidism during pregnancy is associated with an increased rate of miscarriage and preterm delivery, and a decrease in the IQ of the child. Overt hyperthyroidism is present in less than 1% of pregnant women but is linked to increased rates of miscarriage, preterm delivery and maternal congestive heart failure. In women who are euthyroid, thyroid autoantibodies are associated with an increased risk of spontaneous miscarriage and preterm delivery. Postpartum thyroiditis occurs in 5.4% of all women following pregnancy; moreover, 50% of women who are euthyroid in the first trimester of pregnancy but test positive for thyroid autoantibodies will develop postpartum thyroiditis. The need for the essential nutrient iodine increases during pregnancy and in women who are breastfeeding, and the effect of treatment of mild iodine deficiency on maternal and fetal outcomes is consequently being evaluated in a prospective study. The debate regarding the pros and cons of universal screening for thyroid disease during pregnancy is ongoing.

Key Points

  • Nonpregnant reference ranges for thyroid function tests do not apply to pregnant women; laboratory-specific, trimester-specific normal ranges for T3, T4 and TSH should be used when available

  • Overt hypothyroidism has adverse fetal and obstetric effects and should always be treated, whereas treatment for subclinical hypothyroidism in pregnancy remains controversial

  • In overtly hyperthyroid pregnant women, Graves disease must be distinguished from gestational thyrotoxicosis

  • Although the presence of thyroid autoantibodies in euthyroid pregnant women is associated with adverse obstetric outcomes, treatment of these women is not currently recommended by obstetric or endocrine societies

  • Adequate iodine intake is essential in pregnancy and iodine supplementation is recommended in areas of the world where dietary iodine intake is not sufficient

  • Screening for thyroid dysfunction in pregnant women is controversial and current guidelines provide conflicting recommendations

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Figure 1: An algorithm for treatment and follow-up of women with postpartum thyroiditis.

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  1. Department of Medicine, George Washington University School of Medicine and Health Sciences, 2300 I Street Northwest, Ross Hall-Suite 712, 20037, Washington, DC, USA

    Alex Stagnaro-Green

  2. Section of Endocrinology, Diabetes and Nutrition, Boston University School of Medicine, 72 East Concord Street, Boston, 02118, MA, USA

    Elizabeth Pearce

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Stagnaro-Green, A., Pearce, E. Thyroid disorders in pregnancy. Nat Rev Endocrinol 8, 650–658 (2012). https://doi.org/10.1038/nrendo.2012.171

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