Thyroid disease in pregnancy

doi:10.1016/j.beem.2011.07.010

Best Practice & Research Clinical Endocrinology & Metabolism

Volume 25, Issue 6, December 2011, Pages 927-943

https://doi.org/10.1016/j.beem.2011.07.010 Get rights and content

Thyroid diseases are common in women of childbearing age and it is well known that untreated thyroid disturbances result in an increased rate of adverse events, particularly miscarriage, preterm birth and gestational hypertension. Furthermore, thyroid autoimmunity per se seems to be associated with complications such as miscarriage and preterm delivery. While strong evidence clearly demonstrates that overt dysfunctions (hyper- or hypothyroidism) have deleterious effects on pregnancy, subclinical disease, namely subclinical hypothyroidism, has still to be conclusively defined as a risk factor for adverse outcomes. Additionally, other conditions, such as isolated hypothyroxinemia and thyroid autoimmunity in euthyroidism, are still clouded with uncertainty regarding the need for substitutive treatment.

Introduction

Thyroid disease in pregnancy is common. At least 2–3% of women are affected by thyroid dysfunction and around 10% suffer from autoimmune thyroid disease despite euthyroidism. In the last twenty years, the understanding of thyroid physiology in pregnancy and the association between thyroid dysfunction and obstetrical/neonatal adverse outcomes have greatly improved and, as a result, the scientific community has released specific guidelines. The first guidelines, endorsed by the Endocrine Society, were published in 2007 and, just three years later, these will be updated. Concurrently, the American Thyroid Association recently released its own guidelines this year. Pregnancy influences thyroid function and untreated thyroid dysfunction (hyperthyroidism or hypothyroidism) is associated with increased rate of adverse outcomes. This raises the need for an awareness of thyroid disease in pregnancy with the aim of reducing the rate of complications. Furthermore, this field involves different patients (i.e., the pregnant woman and, indirectly, the fetus) as well as different specialists, namely obstetricians and endocrinologists. Therefore, appropriate knowledge is necessary for proper management.

In this paper, we aimed to summarise and translate the results of the literature into evidence-based and clinically useful practical recommendations. The key clinical issues of diagnosis, treatment and patient management were addressed in order to help the endocrinologist in decision-making processes. Management of thyroid disease in pregnancy is an evolving field, still characterized by areas of uncertainty. Ongoing studies over the next few years will hopefully provide definitive answers to unresolved questions.

Section snippets

Thyroid function test in pregnancy

Following conception, circulating total T4 and thyroxine binding globulin (TBG) concentrations increase at around 4–8 weeks. The thyrotropic activity of human chorionic gonadotropin (hCG) causes a decrease in serum thyroid-stimulating hormone (TSH) in the first trimester so that pregnant women have lower serum TSH concentrations than non-pregnant women.1, 2 Many studies also report a substantial decrease in serum-free thyroxine (FT4) concentrations with progression of gestation, even though

Overt hypothyroidism

Overt hypothyroidism (OH) is defined as a low FT4 with high TSH levels.

While worldwide iodine deficiency is the main cause of OH, in areas where iodine intake is sufficient, the most frequent cause is autoimmune thyroiditis. Other causes are prior thyroidectomy, radioiodine therapy, the use of drugs such as amiodarone, anti-thyroid drugs and lithium, congenital hypothyroidism, pituitary or hypothalamic disease, and immunoglobulin binding to the TSH receptor (blocking its activity). The

Subclinical hypothyroidism

Subclinical hypothyroidism (SH) is defined as a normal FT4 with high TSH levels. SH is by far the most frequent thyroid dysfunction occurring in pregnancy. The prevalence of SH varies from one study to another, depending on the definition of SH, ethnicity, iodine intake, and study design. In most cases, prevalence is between 1.5 and 4.0%.7, 8, 9, *10

As with OH, SH also has several obstetrical complications associated with the condition. Findings from various studies are unclear, perhaps due to

Thyroid autoimmunity

Positivity for thyroid antibodies is quite a common finding in women of childbearing age, accounting around 10%, and is by far the most common autoimmune disease.

Stagnaro-Green et al. published the first paper to demonstrate an association between pregnancy loss and thyroid antibodies.²⁶ The authors, evaluating the course of 550 pregnancies, serendipitously found that patients who were positive for Tg-Ab or TPOAb had a 2-fold increase in the risk of pregnancy loss (17% vs 8.4%). Since then,

Isolated hypothyroxinemia

The condition of isolated hypothyroxinemia in pregnancy is defined as the presence of an FT4 value below the 2.5th percentile with a TSH level within the normal range.

The leading cause of IH is iodine deficiency. The National Health and Nutrition Examination Survey 2003–2004 demonstrated that the population in the United States was generally iodine sufficient, as measured by urinary iodine concentration (UIC = 160 μg/L), but showed that low UIC values (<50 μg/L) were found in 11.3% of the

Hyperthyroidism

Hyperthyroidism is defined as an excessive production of thyroid hormones by the thyroid gland. Causes of hyperthyroidism may be mainly divided into (1) immune and (2) non-immune thyroid disease. Graves’ disease is an autoimmune disease and may result in maternal and fetal complications if not properly controlled. The most common cause of non-immune hyperthyroidism is “Transient Hyperthyroidism of Hyperemesis Gravidarum” (THHG), defined as “transient hyperthyroidism, limited to the first

Clinical presentation

Diagnosis of non-immune Transient Hyperthyroidism is confirmed by the presence of suppressed or undetectable serum TSH levels in the presence of elevated FT4. Since the low-normal range of serum TSH in normal first trimester pregnancy may be as low as 0.03 mIU/L, an elevated serum FT4 is necessary for the diagnosis.⁵² This is due to a significant increase concentration of human Chorionic Gonadotrophin (hCG) above normal levels for pregnancy or hCG abnormal molecular variants with higher

Management

Effective treatment of hyperthyroidism is paramount to prevent maternal, fetal, and neonatal complications. ATDs remain the treatment of choice. The goal is to use the lowest possible dose of anti-thyroid medication necessary to maintain FT4 levels in the upper one-third of the normal non-pregnant range or just above the normal range.⁷⁰ Excessive doses of ATDs may affect fetal thyroid function, with the development of hypothyroidism and/or goiter.71, 72 The dose of ATD should be adjusted every

Summary

In summary, knowledge of the interplay between thyroid function and pregnancy is becoming even more extensive but several points still need to be clarified. A TSH trimester-specific range should be applied to correctly interpret thyroid function during pregnancy. The upper limit of TSH in the first trimester should be 2.5 mIU/L, and 3.0 mIU/L in the second and the third trimesters; low-normal TSH concentrations in the first trimester should be considered physiological. While subclinical

References (99)

O.P. Soldin et al.
Trimester-specific reference intervals for thyroxine and triiodothyronine in pregnancy in iodine-sufficient women using isotope dilution tandem mass spectrometry and immunoassays
Clinica Chimica Acta
(2004)
T.O. Tan et al.
Are women who are treated for hypothyroidism at risk for pregnancy complications?
American Journal of Obstetrics and Gynecology
(2006)
T. IIjima et al.
Effects of autoantibodies on the course of pregnancy and fetal growth
Obstetrics & Gynecology
(1997)
R.B. Stricker et al.
Successful treatment of immunologic abortion with low-dose intravenous immunoglobulin
Fertility and Sterility
(2000)
E. Anckaert et al.
FT4 immunoassays may display a pattern during pregnancy similar to the equilibrium dialysis ID-LC/tandem MS candidate reference measurement procedure in spite of susceptibility towards binding protein alterations
Clinica Chimica Acta
(2010)
J.M. Hershman
Physiological and pathological aspects of the effect of human chorionic gonadotropin on the thyroid
Best Practice & Research Clinical Endocrinology & Metabolism
(2004)
J.Y. Tan et al.
Transient hyperthyroidism of hyperemesis gravidarum
British Journal of Obstetrics and Gynaecology
(2002)
J.H. Mestman
Hyperthyroidism in pregnancy
Best Practice & Research Clinical Endocrinology & Metabolism
(2004)
K. Patil-Sisodia et al.
Graves hyperthyroidism and pregnancy: a clinical update
Endocrine Practice
(2010)
D. Peleg et al.
The relationship between maternal serum Thyroid-stimulating immunoglobulin and fetal and neonatal thyrotoxicosis
Obstetrics & Gynecology
(2002)

M. Polak et al.

Fetal and neonatal thyroid function in relation to maternal Graves’ disease

Best Practice & Research Clinical Endocrinology & Metabolism

(2004)

L.E. Davis et al.

Thyrotoxicosis complicating pregnancy

American Journal of Obstetrics and Gynecology

(1989)

S.H. Mandel et al.

Neonatal hypopituitary hypothyroidism associated with maternal thyrotoxicosis

Journal of Pediatric

(1990)

S.F. Thung et al.

The cost-effectiveness of universal screening in pregnancy for subclinical hypothyroidism

American Journal of Obstetrics and Gynecology

(2009)

O.P. Soldin et al.

Trimester-specific changes in maternal thyroid hormone, thyrotropin, and thyroglobulin concentrations during gestation: trends and associations across trimesters in iodine sufficiency

Thyroid

(2004)

R. Negro

Significance and management of low TSH in pregnancy

N. Kahric-Janicic et al.

Tandem mass spectrometry improves the accuracy of free thyroxine measurements during pregnancy

Thyroid

(2007)

J.E. Haddow et al.

The reference range and within-person variability of thyroid stimulating hormone during the first and second trimesters of pregnancy

Journal of Medical Screening

(2004)

R. Stricker et al.

Evaluation of maternal thyroid function during pregnancy: the importance of using gestational age-specific reference intervals

European Journal of Endocrinology

(2007)

W.C. Allan et al.

Maternal thyroid deficiency and pregnancy complications: implications for population screening

Journal of Medical Screening

(2000)

M.L. Mitchell et al.

Iodine sufficiency and measurements of thyroid function in maternal hypothyroidism

Clinical Endocrinology (Oxford)

(2003)

B.M. Casey et al.

Subclinical hypothyroidism and pregnancy outcomes

Obstetrics & Gynecology

(2005)

B. Vaidya et al.

Detection of thyroid dysfunction in early pregnancy: universal screening or targeted high-risk case finding?

Journal of Clinical Endocrinology and Metabolism

(2007)

J.E. Haddow et al.

Maternal thyroid deficiency during pregnancy and subsequent neuropsychological development of the child

The New England Journal of Medicine

(1999)

G.E. Krassas et al.

Thyroid function and human reproductive health

Endocrine Reviews

(2010)

M. Abalovich et al.

Overt and subclinical hypothyroidism complicating pregnancy

Thyroid

(2002)

R. Negro et al.

Universal screening versus case finding for detection and treatment of thyroid hormonal dysfunction during pregnancy

Journal of Clinical Endocrinology and Metabolism

(2010)

M. Abalovich et al.

Management of thyroid dysfunction during pregnancy and postpartum: an endocrine society clinical practice guideline

Journal of Clinical Endocrinology and Metabolism

(2007)

L. Yassa et al.

Thyroid hormone early adjustment in pregnancy (the THERAPY) trial

Journal of Clinical Endocrinology and Metabolism

(2010)

E.K. Alexander et al.

Timing and magnitude of increases in levothyroxine requirements during pregnancy in women with hypothyroidism

The New England Journal of Medicine

(2004)

A. Caixàs et al.

Postpartum thyroiditis in women with hypothyroidism antedating pregnancy?

Journal of Clinical Endocrinology and Metabolism

(1999)

N. Benhadi et al.

Higher maternal TSH levels in pregnancy are associated with increased risk for miscarriage, fetal or neonatal death

European Journal of Endocrinology

(2009)

G. Ashoor et al.

Maternal thyroid function at 11 to 13 weeks of gestation and subsequent fetal death

Thyroid

(2010)

R. Negro et al.

Increased pregnancy loss rate in thyroid antibody negative women with TSH levels between 2.5 and 5.0 in the first trimester of pregnancy

Journal of Clinical Endocrinology and Metabolism

(2010)

J. Cleary-Goldman et al.

Maternal thyroid hypofunction and pregnancy outcome

Obstetrics & Gynecology

(2008)

T. Männistö et al.

Perinatal outcome of children born to mothers with thyroid dysfunction or antibodies: a prospective population-based cohort study

Journal of Clinical Endocrinology and Metabolism

(2009)

R. Negro et al.

Levothyroxine treatment in euthyroid pregnant women with autoimmune thyroid disease: effects on obstetrical complications

Journal of Clinical Endocrinology and Metabolism

(2006)

A. Stagnaro-Green et al.

Detection of at-risk pregnancy by means of highly sensitive assays for thyroid autoantibodies

Journal of the American Medical Association

(1990)

S. Thangaratinam et al.

Thyroid auto-antibodies are strongly associated with miscarriage and preterm birth: a meta-analysis of evidence

British Medical Journal

(2011)

K. Poppe et al.

Assisted reproduction and thyroid autoimmunity: an unfortunate combination?

Journal of Clinical Endocrinology and Metabolism

(2003)

R. Negro et al.

Levothyroxine treatment in thyroid peroxidase antibody-positive women undergoing assisted reproduction technologies: a prospective study

Human Reproduction

(2005)

K.A. Toulis et al.

Risk of spontaneous miscarriage in euthyroid women with thyroid autoimmunity undergoing IVF: a meta-analysis

European Journal of Endocrinology

(2010)

D. Glinoer et al.

Risk of subclinical hypothyroidism in pregnant women with asymptomatic autoimmune thyroid disorders

Journal of Clinical Endocrinology and Metabolism

(1994)

F. Ghafoor et al.

Role of thyroid peroxidase antibodies in the outcome of pregnancy

Journal of College of Physicians and Surgeons Pakistan

(2006)

J.E. Haddow et al.

Thyroperoxidase and thyroglobulin antibodies in early pregnancy and preterm delivery

Obstetrics & Gynecology

(2010)

R. Negro

Thyroid autoimmunity and pre-term delivery: brief review and meta-analysis

Journal of Endocrinological Investigation

(2011)

D.D. Kiprov et al.

The use of intravenous immunoglobulin in recurrent pregnancy loss associated with combined alloimmune and autoimmune abnormalities

American Journal of Reproductive Immunology

(1996)

E. Vaquero et al.

Mild thyroid abnormalities and recurrent spontaneous abortion: diagnostic and therapeutical approach

American Journal of Reproductive Immunology

(2000)

K.L. Caldwell et al.

Iodine status of the U.S. population, National Health and Nutrition Examination Survey 2003–2004

Thyroid

(2008)

Cited by (115)

Evaluation of the thyroid gland vascularity during pregnancy using 2-dimensional color Superb Microvascular İmaging vascularization index technique
2024, European Journal of Obstetrics and Gynecology and Reproductive Biology
We aimed to investigate maternal thyroid parenchymal vascularity with 2-dimensional color superb microvascular imaging vascularization index (2D-cSMIVI) levels and thyroid gland volume in the first, second and third trimesters.
This longitudinal prospective study was carried out with participants selected from 30 healthy asymptomatic pregnant women. Ultrasonography (US) for the thyroid gland was performed in each trimester. The vascularization index (VI) values obtained by manually drawing the contours of the thyroid parenchyma in the longutidinal plane, using the free region of interest (ROI) with 2DcSMIVI mode. VI values obtained in each trimester, thyroid hormone levels (TSH, T3, T4) and thyroid volumes were compared.
We have detected that thyroid gland vascularity increased significantly as pregnancy progresses. The mean VI values of thyroid gland in third trimester were significantly higher than first and second trimester (p < 0.001), and the mean VI values of the thyroid gland in the second trimester were significantly higher than first trimester (p < 0.001). During pregnancy, we detected the increase in VI values, TSH levels and thyroid gland volumes.
Maternal thyroid gland gray scale findings, parenchymal vascularization, thyroid volumes should be evaluated routinely for the healthy fetal development. 2D-cSMIVI method allows us to evaluate vascularization with quantitative numerical values objectively. We have detected that the VI values and volume of the thyroid gland increases as pregnancy progresses. In the complex situation of pregnancy process, the thyroid gland can be evaluated quantitatively with SMI method effectively.
Delayed entry into prenatal care among women with pre-pregnancy health conditions, National Birth Defects Prevention Study, 1997–2011
2022, Preventive Medicine
Citation Excerpt :
At least two potential explanations for this finding exist. First, thyroid disease is common among women of reproductive age and thyroid disfunction is known to increase the risk of pregnancy losses and other adverse outcomes (Negro and Mestman, 2011; Mannisto et al., 2013). Therefore, women undergoing treatment for thyroid disease diagnosed before pregnancy may be more likely to be counseled on the importance of maintaining thyroid levels before and during pregnancy, and may also be in regular care for their thyroid disorder.
First trimester entry into prenatal care is recommended for all women, and especially women with pre-pregnancy conditions. Our objective was to determine whether women with pre-pregnancy conditions were at lower risk of entry after the first trimester (delayed entry) into prenatal care than women without a pre-pregnancy health condition. We used data from 10,890 participants in the National Birth Defects Prevention Study who delivered liveborn infants without birth defects. Women reported pre-pregnancy conditions and timing of entry into prenatal care during a computer-assisted telephone interview. Multivariable logistic regression analyses were conducted to evaluate whether having a pre-pregnancy condition was associated with delayed entry into prenatal care compared to women without pre-pregnancy conditions. Approximately 13% of women reported delayed entry into prenatal care, and 18% of women reported a pre-pregnancy condition. Delayed entry into prenatal care was not associated with pre-pregnancy cardiometabolic or neurologic conditions. Women with thyroid conditions were less likely to report delayed entry into prenatal care (prevalence odds ratio (OR), 95% confidence interval (CI): 0.55 [0.32, 0.94]), but women with hematologic and respiratory conditions were more likely to report delayed entry into prenatal care (OR: 1.95 [1.00, 3.82] and 1.27 [0.95, 1.72], respectively), compared to those without any chronic conditions. Future research investigating the success of early prenatal care among women with thyroid conditions could identify ways to reduce delayed prenatal care among women with other pre-pregnancy conditions.
Congenital hypothyroidism in India: A systematic review and meta-analysis of prevalence, screen positivity rates, and etiology
2022, The Lancet Regional Health - Southeast Asia
Congenital hypothyroidism (CH) is the leading cause of preventable mental retardation, which is currently not universally screened in India. Knowledge of the country-specific prevalence of the disease can guide in establishing a universal screening program.
We performed a systematic review and meta-analysis to assess the prevalence, screen positivity rates, compliance to recall and etiology of CH in India. The databases of PubMed, Embase, Google scholar and IMSEAR were searched on 1^st October 2021. All observational studies reporting at least one of the outcomes of interest were included. Two reviewers independently extracted the data and appraised the quality of studies using the Joanna Briggs tool for prevalence studies. Estimates were pooled using a random-effects model with double arcsine transformation (MetaXL software). PROSPERO database registration number was CRD42021277523.
Of the 2 073 unique articles retrieved, 70 studies were eligible for inclusion. The prevalence of CH (per 1 000 neonates screened) was 0·97 (95% confidence intervals/CI: 0·9, 1·04) in non-endemic areas (54 studies and 819 559 neonates), 79 (95% CI: 72, 86) in endemic areas (3 studies, 5 060 neonates), 50 (95% CI: 31, 72) in neonates born to mothers with thyroid disorders, and 14 (95% CI: 8, 22) in preterm neonates. At thyroid stimulation hormone cut-off of 20 mIU/L, the screen positivity rates were 5·6% (95% CI: 5·4%, 5·9%) for cord blood samples and 0·19% (95% CI: 0·18%, 0·2%) for postnatal sample. About 70% (95% CI: 70, 71) of screen positive neonates were retested with diagnostic tests. Among neonates with permanent hypothyroidism, thyroid dysgenesis 56·6% (95% CI: 50·9%, 62·2%) was more common than dyshormonogenesis 38·7% (95% CI: 33·2%, 44·3%).
The prevalence of congenital hypothyroidism in India is higher than global estimates. Screen positivity rate was higher for cord blood screening when compared to postnatal screening. Compliance with confirmatory testing was higher for cord blood screening.
The study was not funded by any source.
The antigenic link between thyroid autoimmunity and breast cancer
2020, Seminars in Cancer Biology
The association between breast cancer and benign thyroid disorders, in particular thyroid autoimmunity, has been debated for decades. Autoantibodies to thyroid peroxidase, the hallmark of thyroid autoimmunity, have a higher prevalence among patients with breast cancer compared with the general population. Furthermore a correlation between their positivity and a better prognosis of breast cancer was found in several independent small-scale studies, even if such observation was not confirmed in a subsequent retrospective study conducted on the largest patient cohort to date.
The thyroid and mammary glands present several biological similarities, therefore the hypothesis of an immune response to shared thyroid/breast antigens could in part explain the association between thyroid autoimmunity and breast cancer. The sodium iodide symporter is expressed in both glands, however it seems unlikely to be the key common antigen, considering that autoantibodies targeting it are rare. Instead thyroid peroxidase, one of the major thyroid autoantigens, is also expressed in breast tissue and therefore represents the main antigenic link between thyroid autoimmunity and breast cancer. Furthermore lactoperoxidase, an enzyme of the same family that shares structural similarities with thyroid peroxidase, is expressed in neoplastic breast cells and is responsible for the cross-reactivity with some autoantibodies to thyroid peroxidase.
Novel strategies for the diagnosis and treatment of breast cancer might take advantage of the antigenic link between thyroid and breast tissues.
Associations between Hypothyroidism in Pregnancy and Adverse Maternal and Neonatal Outcomes: A cohort study
2024, Research Square
Thyroid and Pregnancy
2023, Experimental and Applied Biomedical Research (EABR)

View all citing articles on Scopus

^c: Tel.: +1 323 442 6179; Fax: +1 323 442 6180.

View full text

6Thyroid disease in pregnancy

Introduction

Section snippets

Thyroid function test in pregnancy

Overt hypothyroidism

Subclinical hypothyroidism

Thyroid autoimmunity

Isolated hypothyroxinemia

Hyperthyroidism

Clinical presentation

Management

Summary

Clinica Chimica Acta

American Journal of Obstetrics and Gynecology

Obstetrics & Gynecology

Fertility and Sterility

Clinica Chimica Acta

Best Practice & Research Clinical Endocrinology & Metabolism

British Journal of Obstetrics and Gynaecology

Best Practice & Research Clinical Endocrinology & Metabolism

Endocrine Practice

Obstetrics & Gynecology

Best Practice & Research Clinical Endocrinology & Metabolism

American Journal of Obstetrics and Gynecology

Journal of Pediatric

American Journal of Obstetrics and Gynecology

Trimester-specific changes in maternal thyroid hormone, thyrotropin, and thyroglobulin concentrations during gestation: trends and associations across trimesters in iodine sufficiency

Thyroid

Significance and management of low TSH in pregnancy

Tandem mass spectrometry improves the accuracy of free thyroxine measurements during pregnancy

Thyroid

The reference range and within-person variability of thyroid stimulating hormone during the first and second trimesters of pregnancy

Journal of Medical Screening

Evaluation of maternal thyroid function during pregnancy: the importance of using gestational age-specific reference intervals

European Journal of Endocrinology

Maternal thyroid deficiency and pregnancy complications: implications for population screening

Journal of Medical Screening

Iodine sufficiency and measurements of thyroid function in maternal hypothyroidism

Clinical Endocrinology (Oxford)

Subclinical hypothyroidism and pregnancy outcomes

Obstetrics & Gynecology

Detection of thyroid dysfunction in early pregnancy: universal screening or targeted high-risk case finding?

Journal of Clinical Endocrinology and Metabolism

Maternal thyroid deficiency during pregnancy and subsequent neuropsychological development of the child

The New England Journal of Medicine

Thyroid function and human reproductive health

Endocrine Reviews

Overt and subclinical hypothyroidism complicating pregnancy

Thyroid

Universal screening versus case finding for detection and treatment of thyroid hormonal dysfunction during pregnancy

Journal of Clinical Endocrinology and Metabolism

Management of thyroid dysfunction during pregnancy and postpartum: an endocrine society clinical practice guideline

Journal of Clinical Endocrinology and Metabolism

Thyroid hormone early adjustment in pregnancy (the THERAPY) trial

Journal of Clinical Endocrinology and Metabolism

Timing and magnitude of increases in levothyroxine requirements during pregnancy in women with hypothyroidism

The New England Journal of Medicine

Postpartum thyroiditis in women with hypothyroidism antedating pregnancy?

Journal of Clinical Endocrinology and Metabolism

Higher maternal TSH levels in pregnancy are associated with increased risk for miscarriage, fetal or neonatal death

European Journal of Endocrinology

Maternal thyroid function at 11 to 13 weeks of gestation and subsequent fetal death

Thyroid

Increased pregnancy loss rate in thyroid antibody negative women with TSH levels between 2.5 and 5.0 in the first trimester of pregnancy

Journal of Clinical Endocrinology and Metabolism

Maternal thyroid hypofunction and pregnancy outcome

Obstetrics & Gynecology

Perinatal outcome of children born to mothers with thyroid dysfunction or antibodies: a prospective population-based cohort study

Journal of Clinical Endocrinology and Metabolism

Levothyroxine treatment in euthyroid pregnant women with autoimmune thyroid disease: effects on obstetrical complications

Journal of Clinical Endocrinology and Metabolism

Detection of at-risk pregnancy by means of highly sensitive assays for thyroid autoantibodies

Journal of the American Medical Association

Thyroid auto-antibodies are strongly associated with miscarriage and preterm birth: a meta-analysis of evidence

British Medical Journal

Assisted reproduction and thyroid autoimmunity: an unfortunate combination?

Journal of Clinical Endocrinology and Metabolism

Levothyroxine treatment in thyroid peroxidase antibody-positive women undergoing assisted reproduction technologies: a prospective study

Human Reproduction

Risk of spontaneous miscarriage in euthyroid women with thyroid autoimmunity undergoing IVF: a meta-analysis

6
Thyroid disease in pregnancy