Professional Documents
Culture Documents
C l i n i c a l P r a c t i c e G u i d e l i n e
Leslie De Groot, Marcos Abalovich, Erik K. Alexander, Nobuyuki Amino, Linda Barbour,
Rhoda H. Cobin, Creswell J. Eastman, John H. Lazarus, Dominique Luton,
Objective: The aim was to update the guidelines for the management of thyroid dysfunction
during pregnancy and postpartum published previously in 2007. A summary of changes between
the 2007 and 2012 version is identified in the Supplemental Data (published on The Endocrine
Society’s Journals Online web site at http://jcem.endojournals.org).
Evidence: This evidence-based guideline was developed according to the U.S. Preventive Service Task Force,
grading items level A, B, C, D, or I, on the basis of the strength of evidence and magnitude of net benefit
(benefits minus harms) as well as the Grading of Recommendations, Assessment, Development, and Eval-
uation (GRADE) system to describe both the strength of recommendations and the quality of evidence.
Consensus Process: The guideline was developed through a series of e-mails, conference calls, and one
face-to-face meeting. An initial draft was prepared by the Task Force, with the help of a medical writer, and
reviewed and commented on by members of The Endocrine Society, Asia and Oceania Thyroid Association,
and the Latin American Thyroid Society. A second draft was reviewed and approved by The Endocrine
Society Council. At each stage of review, the Task Force received written comments and incorporated
substantive changes.
Conclusions: Practice guidelines are presented for diagnosis and treatment of patients with thyroid-related
medical issues just before and during pregnancy and in the postpartum interval. These include evidence-
based approaches to assessing the cause of the condition, treating it, and managing hypothyroidism,
hyperthyroidism, gestational hyperthyroidism, thyroid autoimmunity, thyroid tumors, iodine nutrition,
postpartum thyroiditis, and screening for thyroid disease. Indications and side effects of therapeutic agents
used in treatment are also presented. (J Clin Endocrinol Metab 97: 2543–2565, 2012)
ISSN Print 0021-972X ISSN Online 1945-7197 This revised guideline replaces the previous version published in 2007: Abalovich M, Amino
Printed in U.S.A. N, Barbour LA, Cobin RH, De Groot LJ, Glinoer D, Mandel SJ, Stagnaro-Green A. Man-
Copyright © 2012 by The Endocrine Society agement of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society
doi: 10.1210/jc.2011-2803 Received October 11, 2011. Accepted March 5, 2012. Clinical Practice Guideline. J Clin Endocrinol Metab 2007 Aug;92(8 Suppl):S1–S47.
This guideline is also available with CME. Go to http://www.endo-society.org/guidelines/
For editorials see pages 2619, 2629, and 2632
Current-Clinical-Practice-Guidelines.cfm for more details.
Abbreviations: ATD, Antithyroid drug; DM, diabetes mellitus; FNA, fine-needle aspiration; GH,
gestational hyperthyroidism; hCG, human chorionic gonadotropin; MMI, methimazole; PPD, post-
partum depression; PPT, postpartum thyroiditis; PTU, propylthiouracil; RAI, radioactive iodine; RNI,
recommended nutrient intake; SCH, subclinical hypothyroidism; TG, thyroglobulin; TPO-Ab⫺, thy-
roidperoxidaseantibodynegative;TPO-Ab⫹,TPO-Abpositive;TRAb,TSHreceptorantibodies;UIC,
urinary iodine concentration; UIE, urinary iodine excretion; USI, universal salt iodization.
Summary of Recommendations of less than 2.5 mIU/liter (in an assay using the Interna-
tional Standard) in the first trimester (or 3 mIU/liter in
1.0. Management of hypothyroidism: maternal second and third trimesters) or to trimester-specific TSH
and fetal aspects ranges. Thyroid function tests should be remeasured
1.1. We recommend caution in the interpretation of within 30 – 40 d and then every 4 – 6 wk. USPSTF recom-
serum free T4 levels during pregnancy and that each lab- mendation level: A; evidence, good (1ⱍQQQQ).
oratory establish trimester-specific reference ranges for 1.2.6. Women with thyroid autoimmunity who are eu-
pregnant women if using a free T4 assay. The nonpregnant thyroid in the early stages of pregnancy are at risk of de-
total T4 range (5–12 g/dl or 50 –150 nmol/liter) can be veloping hypothyroidism and should be monitored every
adapted in the second and third trimesters by multiplying 4 – 6 wk for elevation of TSH above the normal range for
approximately equal to 100 –150 mg of PTU. Recent anal- evidence, good (1ⱍQQQE). There are no data for or against
yses reported by the U.S. Food and Drug Administration recommending termination of pregnancy after 131I expo-
(FDA) indicate that PTU may rarely be associated with sure. USPSTF recommendation level: I; evidence, poor
severe liver toxicity. For this reason we recommend that (2ⱍQEEE).
clinicians change treatment of patients from PTU to MMI 2.2.3. In women with TRAb or thyroid-stimulating Ig
after the completion of the first trimester. Available data elevated at least 2- to 3-fold the normal level and in women
indicate that MMI and PTU are equally efficacious in the treated with ATD, maternal free T4 and fetal thyroid dys-
treatment of pregnant women. Practitioners should use function should be screened for during the fetal anatomy
their clinical judgment in choosing the ATD therapy, ultrasound done in the 18th-22nd week and repeated ev-
including the potential difficulties involved in switching ery 4 – 6 wk or as clinically indicated. Evidence of fetal
4.0. Autoimmune thyroid disease and miscarriage 5.4. Radioactive iodine (RAI) with 131I should not be
4.1. A positive association exists between the presence given to women who are breastfeeding or for at least 4 wk
of thyroid antibodies and pregnancy loss. Universal after nursing has ceased. USPSTF recommendation level:
screening for antithyroid antibodies, and possible treat- A; evidence, good (1ⱍQQQQ). Furthermore, pregnancy
ment, cannot be recommended at this time. As of January should be avoided for 6 months to 1 yr in women with
2011, only one randomized interventional trial has sug- thyroid cancer who receive therapeutic RAI doses to en-
gested a decrease in the first trimester miscarriage rate in sure stability of thyroid function and confirm remission of
euthyroid antibody-positive women, but treatment dura- thyroid cancer. USPSTF recommendation level: B; evi-
tion was very brief before the outcome of interest. How- dence, fair (1ⱍQQEE).
ever, because women with elevated anti-TPO antibodies
milk provides 100 g iodine per day to the infant. USPSTF surement of serum TSH is recommended. If it is above 2.5
recommendation level: A; evidence, good (1ⱍQQQE). mIU/liter, the test should be confirmed by repeat assay. Al-
though no randomized controlled trials are available to guide
7.0. Postpartum thyroiditis a response, the committee believes it is appropriate to give
7.1. There are insufficient data to recommend screening low-dose T4 treatment to bring TSH below 2.5 mIU/liter.
of all women for postpartum thyroiditis (PPT). USPSTF This treatment can be discontinued if the woman does not
recommendation level: I; evidence, poor (2ⱍQEEE). become pregnant or postpartum. USPSTF recommendation
7.2. Women known to be TPO-Ab⫹ should have TSH level: I; evidence, poor (2ⱍQEEE).
measured at 6 –12 wk gestation and at 6 months postpar- 8.2a. All women considering pregnancy with known
tum, or as clinically indicated. USPSTF recommendation thyroid dysfunction and receiving levothyroxine should
abnormalities at the time of their first visit. These members a recommendation is graded A, B, C, D, or I (if insuffi-
strongly support aggressive case finding to identify and cient), and evidence is graded good, fair, or poor. In the
test high-risk women (Table 1) for elevated TSH concen- GRADE system strong recommendations use the number
trations by the ninth week or at the time of their first visit 1, and weak recommendations use the number 2. Cross-
before and during pregnancy, and they recognize that in filled circles indicate the quality of the evidence, such that
some situations ascertainment of the individual’s risk sta- QEEE denotes very low quality evidence; QQEE, low
tus may not be feasible. In such cases, and where the local quality; QQQE, moderate quality; and QQQQ, high qual-
practice environment is appropriate, testing of all women ity. The task force has confidence that persons who receive
by wk 9 of pregnancy or at the first prenatal visit is rea- care according to the strong recommendations will derive,
sonable. USPSTF recommendation level: I; evidence, poor on average, more good than harm. Weak recommenda-
and profoundly changed the ways in which these patients potential benefits outweigh the potential risks, the panel
are managed. recommends T4 replacement in women with SCH. For
Thyroid problems during pregnancy encompass at least obstetrical outcome: USPSTF recommendation level, C;
eight different conditions, and we have therefore divided evidence, fair (2ⱍQQEE) (4 –9); for neurological outcome:
our report into the following sections: USPSTF recommendation level, I; evidence, poor
(2ⱍEEEE) (4 –7, 9).
1. Management of hypothyroidism: maternal and fetal
1.2.3. If hypothyroidism has been diagnosed before
aspects
pregnancy, we recommend adjustment of the preconcep-
2. Management of hyperthyroidism: maternal and fetal
tion T4 dose to reach before pregnancy a TSH level not
aspects
higher than 2.5 mIU/liter. USPSTF recommendation level:
weight, and neonatal respiratory distress. There may be range is reduced to 0.1–2.5 mIU/liter (2, 24). Thus, a se-
more fetal and perinatal death, and gestational hyperten- rum TSH within the classical reference range (0.4 – 4.0
sion may also contribute to the overall increase in neonatal mIU/liter) might be misdiagnosed as “normal” in women
risks. Women with gestational SCH were found in one who have a slight TSH elevation, or hyperthyroidism may
study to have more preterm deliveries (20), and the off- be wrongly suspected in normal women who have a
spring have more admissions to neonatal intensive care blunted serum TSH.
and an increased rate of respiratory distress syndrome (4). Serum T4 distinguishes between SCH and overt hypo-
Even maternal TSH levels in the upper normal range are thyroidism, if normal, or clearly below normal for gesta-
associated with increased fetal loss, as compared with tional age, respectively. Reference ranges provided by the
lower “normal” levels (11). manufacturers of most free T4 measurement kits have been
and gestational thyrotoxicosis because of the adverse trimester. USPSTF recommendation level: C; evidence,
effects of overt hyperthyroidism on the mother and fe- fair (2ⱍQEEE) (35–37).
tus. Differentiation of Graves’ disease from gestational 2.1.5. There is no evidence that treatment of subclin-
thyrotoxicosis is supported by the presence of clinical ical hyperthyroidism improves pregnancy outcome, and
evidence of autoimmune thyroid disease, a typical goi- treatment could potentially adversely affect fetal out-
ter, and the presence of TRAb. TPO-Ab may be present come. USPSTF recommendation level: C; evidence, fair
in either case. USPSTF recommendation level: B; evi- (2ⱍQEEE) (27, 38).
dence, fair (1ⱍQQQE) (24 –26).
2.1.2. For overt hyperthyroidism due to Graves’ disease or 2.2. Management of maternal hyperthyroidism: fetal
thyroid nodules, ATD therapy should be either initiated (be- aspects
should be evaluated by a medical care provider for thyroid porting System of the FDA has focused attention on the
dysfunction and treated if necessary. USPSTF recommen- relation between hepatotoxicity and PTU (29). This find-
dation level: B; evidence, fair (1ⱍQQQE) (40, 48, 52). ing has led to a recommendation that PTU use in preg-
nancy be limited to the first trimester, and then treatment
2.1.1–2.2.5. Background and evidence be switched to MMI. Use of MMI during the first trimester
The prevalence of hyperthyroidism in pregnancy has been associated with a possible embryopathy.
ranges from 0.1 to 0.4%, with Graves’ disease accounting
for 85% of cases (28, 57, 58). The activity level of Graves’ 3.0 Gestational hyperemesis and hyperthyroidism
disease may fluctuate during gestation, with exacerbation
Recommendations
during the first trimester and improvement by late gesta-
perplacentosis and hyperreactio luteinalis, have been re- abnormalities before pregnancy, as well as during the first
ported. The condition can cause severe morbidity and may and second trimesters of pregnancy. USPSTF recommen-
require frequent visits to the emergency room or admis- dation level: C; evidence, fair (2ⱍQEEE) (69 –72).
sion to the hospital for management of dehydration, elec-
trolyte abnormalities, psychological support, and occa- 4.1. Background and evidence
sionally parenteral nutrition (25, 26). A 2- to 5-fold increased risk of miscarriage has been
In women with GH, the serum TSH is suppressed or found in unselected populations of euthyroid women with
undetectable; serum total T4 and free T4 are elevated, but autoimmune thyroid disease (70). Most but not all studies
the free T3 is elevated less frequently. Women with hyper- have also demonstrated an association between thyroid
emesis and elevated thyroid hormone levels most com- antibodies and recurrent miscarriage in euthyroid patients
(40% on treatment by 8 wk and 79% by 12 wk). It should Intellectual and motor development score evaluations
also be taken into account that TSH levels during preg- were performed at 25–30 months of age on the children
nancy were significantly higher, whereas free T4 levels from 34 euthyroid mothers with elevated titers of TPO-Ab
were significantly lower (although in the normal range) in at 16 –20 wk gestation. The mean intelligence score was 10
group B than in group C. points lower and the mean motor score 9 points lower than
In a retrospective study in Belgium, 42 TPO-Ab⫹ pa- those of the controls (P ⫽ 0.001 and P ⬍ 0.001, respec-
tients received levothyroxine treatment during pregnancy, tively) (80). More studies are necessary to confirm
and their evolution was compared with 709 TPO-Ab⫺ whether thyroid autoimmunity could be considered a risk
women. No significant differences in the obstetrical com- factor for impaired neurodevelopment, independent of the
plications rate were observed between the groups, but thyroid function.
avoided for 6 months to 1 yr in women with thyroid data that surgery undergone during pregnancy as com-
cancer who receive therapeutic RAI doses to ensure sta- pared with immediately postpartum affects survival.
bility of thyroid function and confirm remission of thy- If a nodule suspicious of cancer is discovered in the third
roid cancer. USPSTF recommendation level: B; evi- trimester, further workup and treatment can be delayed
dence, fair (1ⱍQQEE) (87– 89). until after delivery unless the nodule is rapidly growing or
associated with a poor prognosis. Exogenously adminis-
5.1.–5.4 Background and evidence tered thyroid hormone is recommended for suspicious or
There is biological plausibility that pregnancy could pro- malignant nodules to achieve a suppressed TSH with a free
mote the onset of growth of a benign or malignant nodule T4 or total T4 in the upper normal range for pregnancy to
due to a pregnancy-induced relative iodine deficiency, the avoid both maternal and fetal complications.
to the iodine intake level in a given population. Differ- should continue to have an intake of 250 g iodide per day
ent situations must therefore be distinguished: 1) coun- during lactation. A World Health Organization expert
tries with iodine sufficiency and/or with a well-estab- panel (97) recommended iodine intake of 200 –300 g/d in
lished USI program; 2) countries without a USI program pregnant and breastfeeding women, based on population
or with an established USI program where the coverage studies, noting prevention of maternal hypothyroidism
is known to be only partial; and 3) remote areas with no and goiter and fetal goiter.
accessible USI program and difficult socioeconomic Environmental iodine varies widely geographically, as
conditions. USPSTF recommendation level: A; evi- does iodine supplementation of food, salt, or oil. The best
dence, good (1ⱍQQQQ) (100 –104). parameter to evaluate the adequacy of iodine nutrition in
6.5. We recommend that once-daily prenatal vitamins a population is urinary iodine excretion (UIE). During
cannot be implemented, massive annual doses of slow- roxine. Symptomatic women and women with a TSH
release iodinated oil are given to children and to women in above normal and who are attempting pregnancy should
the reproductive age group. Four hundred milligrams of be treated with levothyroxine. USPSTF recommendation
oral iodine will cover the thyroidal needs for an adult for level: B; evidence, fair (2ⱍQQEE) (112).
about a 1-yr period (99). 7.6. There is insufficient evidence to conclude whether
Fortification should begin as soon as possible in a preg- an association exists between PPD and either PPT or thy-
nant woman, ideally no later than the first trimester to roid antibody positivity (in women who did not develop
allow rapid adaptation to the increased needs of preg- PPT). USPSTF recommendation level: I; evidence, poor
nancy. It is important to note that even in a population (2ⱍQEEE). However, because hypothyroidism is a poten-
judged to be iodine sufficient, individual women may have tially reversible cause of depression, women with PPD
rotoxic phase of PPT and Graves’ disease presenting de be reevaluated in 4 – 8 wk. When a TSH above the refer-
novo in the postpartum period. Symptoms during the thy- ence range continues postpartum, women should be
rotoxic phase of PPT tend to be milder than during hy- treated with levothyroxine. Women with a TSH between
perthyroidism due to Graves’ disease. Furthermore, 95% 4 and 10 mIU/liter who are either symptomatic or attempt-
of women with Graves’ disease are TSH receptor antibody ing to become pregnant should be treated with T4.
positive. In contrast to Graves’ disease, PPT is character-
ized by decreased RAI uptake (measurement of 131I uptake Follow-up for women with PPT. Postpartum thyroid dys-
is contraindicated in lactating women). From 20 –30% of function is typically transient in nature, with the majority
patients who develop PPT have only thyrotoxic symp- of women returning to euthyroidism by the end of the first
toms. Fatigue, palpitations, weight loss, heat intolerance, postpartum year. However, even after recovery from hy-
8.2a. All women considering pregnancy with known practice environment is appropriate, testing of all women
thyroid dysfunction and receiving levothyroxine should by wk 9 of pregnancy or at the first prenatal visit is rea-
be tested for abnormal TSH concentrations before preg- sonable. USPSTF recommendation level: I; evidence, poor
nancy. USPSTF recommendation level: B; evidence, fair (2ⱍQEEE) (72, 80, 137, 138) (Authors supporting: M.A.,
(1ⱍQQEE) (134, 135). E.K.A., J.M., L.B., S.S., S.J.M., D.L., R.H.C.).
8.2b. If hypothyroidism has been diagnosed before 8.4b. If serum TSH is greater than 2.5 mIU/liter at the
pregnancy, we recommend adjustment of the preconcep- time of testing (or ⬎3.0 mIU/liter in the second trimes-
tion T4 dose to reach before pregnancy a TSH level not ter), levothyroxine therapy should be instituted. For
higher than 2.5 mIU/liter. USPSTF recommendation level: overt hypothyroidism, USPSTF recommendation level:
C; evidence, fair (2ⱍQQEE) (132–134, 136). A; evidence, good (1ⱍQQQQ); for SCH and obstetrical
ternal overt hypothyroidism prevents these complications Two studies have assessed the efficacy of targeted
(9, 72, 139). screening of pregnant women for evidence of hypothy-
Maternal SCH is associated with increased incidence of roidism. In the report of Vaidya et al. (133), 7.4% of
adverse outcomes of pregnancy including preterm deliv- “high-risk” pregnancies were found to have TSH above
ery, placental abruption, respiratory distress, early preg- 4.2 mIU/liter. This represents 1.3% of the entire popula-
nancy loss, and admissions to the intensive care unit (4, 5, tion studied. In this study, targeted screening failed to de-
21, 81, 137). Randomized, prospective study documents tect 28% of pregnancies with elevated TSH, representing
an increase in pregnancy complications among women 0.7% of the total population. Li et al. (81) found in a
with elevated serum TSH concentrations of 2.5–5.0 mIU/ similar study that targeted screening missed 36% of all
liter in the first trimester without TPO antibodies (138). individuals with a TSH above 4.0 mIU/liter.
tablets per week instead of seven tablets) can substan- American Thyroid Association, Association of Program
tially reduce the risk of maternal hypothyroidism dur- Directors in Endocrinology, Diabetes and Metabolism;
ing the first trimester (135). Significant Financial Interest or Leadership Position:
none disclosed. Jorge Mestman, M.D.—Financial or
Business/Organizational Interests: American Thyroid
Acknowledgments Association; Significant Financial Interest or Leader-
ship Position: none disclosed. Joanne Rovet, Ph.D.—
Address all correspondence and requests for reprints to: The
Financial or Business/Organizational Interests: Ameri-
Endocrine Society, 8401 Connecticut Avenue, Suite 900, Chevy
can Thyroid Association, Pediatric Endocrine Society;
Chase, Maryland 20815. E-mail: govt-prof@endo-society.org,
Significant Financial Interest or Leadership Position:
13. Kaplan MM 1992 Monitoring thyroxine treatment during preg- 35. Burrow GN 1985 The management of thyrotoxicosis in preg-
nancy. Thyroid 2:147–152 nancy. N Engl J Med 313:562–565
14. Alexander EK, Marqusee E, Lawrence J, Jarolim P, Fischer GA, 36. Stice RC, Grant CS, Gharib H, van Heerden JA 1984 The man-
Larsen PR 2004 Timing and magnitude of increases in levothy- agement of Graves’ disease during pregnancy. Surg Gynecol Obstet
roxine requirements during pregnancy in women with hypothy- 158:157–160
roidism. N Engl J Med 351:241–249 37. Brodsky JB, Cohen EN, Brown Jr BW, Wu ML, Whitcher C 1980
15. Loh JA, Wartofsky L, Jonklaas J, Burman KD 2009 The magnitude Surgery during pregnancy and fetal outcome. Am J Obstet Gynecol
of increased levothyroxine requirements in hypothyroid pregnant 138:1165–1167
women depends upon the etiology of the hypothyroidism. Thyroid 38. Casey BM, Dashe JS, Wells CE, McIntire DD, Leveno KJ, Cun-
19:269 –275 ningham FG 2006 Subclinical hyperthyroidism and pregnancy out-
16. Sapin R, D’Herbomez M, Schlienger JL 2004 Free thyroxine mea- comes. Obstet Gynecol 107:337–341
sured with equilibrium dialysis and nine immunoassays decreases 39. Laurberg P, Nygaard B, Glinoer D, Grussendorf M, Orgiazzi J
1998 Guidelines for TSH-receptor antibody measurements in preg-
58. Niswander KR, Gordon M, Berendes HW 1972 The women and rie C 2009 To treat or not to treat euthyroid autoimmune disorder
their pregnancies. In: Niswander KR, Gordon M, eds. The collab- during pregnancy? Gynecol Obstet Invest 67:178 –182
orative perinatal study of the National Institute of Neurologic Dis- 77. Vaquero E, Lazzarin N, De Carolis C, Valensise H, Moretti C,
ease and Stroke. Philadelphia: WB Saunders: 246 –249 Ramanini C 2000 Mild thyroid abnormalities and recurrent spon-
59. Glinoer D, de Nayer P, Bourdoux P, Lemone M, Robyn C, van taneous abortion: diagnostic and therapeutical approach. Am J
Steirteghem A, Kinthaert J, Lejeune B 1990 Regulation of maternal Reprod Immunol 43:204 –208
thyroid during pregnancy. J Clin Endocrinol Metab 71:276 –287 78. Al-Kunani AS, Knight R, Haswell SJ, Thompson JW, Lindow SW
60. Glinoer D, De Nayer P, Robyn C, Lejeune B, Kinthaert J, Meuris 2001 The selenium status of women with a history of recurrent
S 1993 Serum levels of intact human chorionic gonadotropin miscarriage. BJOG 108:1094 –1097
(HCG) and its free ␣- and -subunits, in relation to maternal thy- 79. Gärtner R, Gasnier BC, Dietrich JW, Krebs B, Angstwurm MW
roid stimulation during normal pregnancy. J Endocrinol Invest 16: 2002 Selenium supplementation in patients with autoimmune thy-
881– 888 roiditis decreases thyroid peroxidase antibodies concentrations.
J Clin Endocrinol Metab 87:1687–1691
ease shortly after delivery in thyroid cancer survivors. Thyroid man A, Swan JS, Steenkiste AR, Mccarthy BJ, Trucco M, Dorman
17:543–547 JS 1998 Hashimoto’s thyroiditis and insulin-dependent diabetes
96. Sawka AM, Lakra DC, Lea J, Alshehri B, Tsang RW, Brierley JD, mellitus: differences among individuals with and without abnor-
Straus S, Thabane L, Gafni A, Ezzat S, George SR, Goldstein DP mal thyroid function. J Clin Endocrinol Metab 83:1548 –1551
2008 A systematic review examining the effects of therapeutic ra- 117. Azizi F 2005 The occurrence of permanent thyroid failure in pa-
dioactive iodine on ovarian function and future pregnancy in fe- tients with subclinical postpartum thyroiditis. Eur J Endocrinol
male thyroid cancer survivors. Clin Endocrinol (Oxf) 69:479 – 490 153:367–371
97. Andersson M, de Benoist B, Delange F, Zupan J 2007 Prevention 118. Othman S, Phillips DI, Parkes AB, Richards CJ, Harris B, Fung H,
and control of iodine deficiency in pregnant and lactating women Darke C, John R, Hall R, Lazarus JH 1990 A long-term follow-up
and in children less than 2-years-old: conclusions and recommen- of postpartum thyroiditis. Clin Endocrinol (Oxf) 32:559 –564
dations of the Technical Consultation. Public Health Nutr 10: 119. Tachi J, Amino N, Tamaki H, Aozasa M, Iwatani Y, Miyai K 1988
1606 –1611 Long term follow-up and HLA association in patients with post-
98. Glinoer D 1997 Maternal and fetal impact of chronic iodine defi-
135. Yassa L, Marqusee E, Fawcett R, Alexander EK 2010 Thyroid body negative women with TSH levels between 2.5 and 5.0 in the
Hormone Early Adjustment in Pregnancy (the THERAPY) trial. first trimester of pregnancy. J Clin Endocrinol Metab 95:E44 –E48
J Clin Endocrinol Metab 95:3234 –3241 139. Tan TO, Cheng YW, Caughey AB 2006 Are women who are
136. Rotondi M, Mazziotti G, Sorvillo F, Piscopo M, Cioffi M, Amato treated for hypothyroidism at risk for pregnancy complications?
G, Carella C 2004 Effects of increased thyroxine dosage pre-con- Am J Obstet Gynecol 194:e1– e3
140. Lazarus JH, Bestwick JP, Channon S, Paradice R, Maina A, Rees
ception on thyroid function during early pregnancy. Eur J Endo-
R, Chiusano E, John R, Guaraldo V, George LM, Perona M,
crinol 151:695–700
Dall’Amico D, Parkes AB, Joomun M, Wald NJ 2012 Antenatal
137. Negro R, Schwartz A, Gismondi R, Tinelli A, Mangieri T, Stagn-
thyroid screening and childhood cognitive function. N Engl J Med
aro-Green A 2010 Universal screening versus case finding for de- 366:493–501
tection and treatment of thyroid hormonal dysfunction during 141. Stricker R, Echenard M, Eberhart R, Chevailler MC, Perez V,
pregnancy. J Clin Endocrinol Metab 95:1699 –1707 Quinn FA, Stricker R 2007 Evaluation of maternal thyroid func-
138. Negro R, Schwartz A, Gismondi R, Tinelli A, Mangieri T, Stagn- tion during pregnancy: the importance of using gestational age-