Controversial Screening for Thyroid Dysfunction in Preconception and Pregnancy: An Evidence-Based Review
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Abstract
Objective: To evaluate the recommendations on the most adequate screening method (universal or selective) for thyroid dysfunction. Although thyroid dysfunction is a common disorder in fertile women and untreated cases may have negative maternal, fetal and neonatal outcomes, its screening in preconception and early pregnancy is controversial.
Materials and methods: An evidence-based review was conducted to identify publications since 2017 of American Thyroid Association (ATA) guidelines, according to the following Population, Intervention, Comparison, Outcomes and Study (PICOS): women in preconception or pregnancy without thyroid disease who underwent universal or selective screening for thyroid dysfunction. Study selection obeyed the PRISMA criteria.
Results: We included 15 of 325 publications. The 2017 ATA guidelines recommend selective screening in both preconception and pregnancy. The only two reviews on preconception recommended universal screening. For pregnancy, nine articles suggested universal screening, while a prospective study advocated selective screening. The main benefits advocated for universal screening were easy and low-cost tests; absence of missed diagnosis; safe and inexpensive treatment and its potential in preventing negative outcomes. Iodine deficiency is a decisive indication, but it was not evaluated in all clinical studies. Screening harms and knowledge gaps were the main arguments against universal screening. There are very few cost-effectiveness studies.
Conclusion: We recommend universal screening for thyroid dysfunction in early pregnancy, which is a distinct point of view from 2017 ATA guidelines (weak recommendation, low-quality evidence). It is not possible to make a formal recommendation for preconception (insufficient evidence). We strongly suggest an individualized analysis by each country.
1. De Groot L, Abalovich M, Alexander EK, Amino N, Barbour L, Cobin RH, et al. Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2012; 97: 2543-65.
2. Alexander EK, Pearce EN, Brent GA, Brown RS, Chen H, Dosiou C, et al. 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum. Thyroid 2017; 27: 315-89.
3. Martinez M, Soldevila B, Lucas A, Velasco I, Vila L, Puig-Domingo M. Hypothyroidism during pregnancy and its association to perinatal and obstetric morbidity: a review. Endocrinol Diabetes Nutr 2018; 65: 107-13.
4. Stagnaro-Green A. Clinical guidelines: Thyroid and pregnancy-time for universal screening? Nat Rev Endocrinol 2017; 13: 192-4.
5. Koehler VF, Auernhammer CJ, Spitzweg C. [The Thyroid and Pregnancy]. Dtsch Med Wochenschr 2019; 144: 1681-5.
6. Sitoris G, Veltri F, Kleynen P, Cogan A, Belhomme J, Rozenberg S, et al. The Impact of Thyroid Disorders on Clinical Pregnancy Outcomes in a Real-World Study Setting. Thyroid 2020; 30: 106-15.
7. Lee SY, Cabral HJ, Aschengrau A, Pearce EN.
Associations Between Maternal Thyroid Function in Pregnancy and Obstetric and Perinatal Outcomes. J Clin Endocrinol Metab 2020; 105: e2015-e23
8. Cigrovski Berkovic M, Herman Mahecic D, Marinkovic Radosevic J, Strinovic Moric M, Bilic-Curcic I. Hypothyroidism and pregnancy: still a controversial issue. Gynecol Endocrinol 2020; 36: 776-780.
9. Poppe K, Velkeniers B, Glinoer D. The role of thyroid autoimmunity in fertility and pregnancy. Nat Clin Pract Endocrinol Metab 2008; 4: 394-405.
10. Liu H, Shan Z, Li C, Mao J, Xie X, Wang W et al. Maternal subclinical hypothyroidism, thyroid autoimmunity, and the risk of miscarriage: a prospective cohort study. Thyroid 2014; 24: 1642-9.
11. Kalra S, Baruah MP, Unnikrishnan AG. Hypothyroidism in pregnancy: From unanswered questions to questionable answers. Indian J Endocrinol Metab 2013; 17: 200-2.
12. Negro R, Formoso G, Mangieri T, Pezzarossa A, Dazzi D, Hassan H. Levothyroxine treatment in euthyroid pregnant women with autoimmune thyroid disease: effects on obstetrical complications. J Clin Endocrinol Metab 2006; 91: 2587-91.
13. Korevaar TI. Evidence-Based Tightrope Walking: The 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum. Thyroid 2017; 27: 309-11.
14. Maheshwari A, Bhide P, Pundir J, Bhattacharya S. Routine serum thyroid-stimulating hormone testing-optimizing pre-conception health or generating toxic knowledge? Hum Reprod 2017; 32: 1779-85.
15. Kalra B, Gupta Y, Kalra S. Preconception management of thyroid disorders. JPMA The Journal of the Pakistan Medical Association 2017; 67: 645-7.
16. Velasco I, Taylor P. Identifying and treating subclinical thyroid dysfunction in pregnancy: emerging controversies. Eur J Endocrinol 2018; 178: D1-D12.
17. Springer D, Jiskra J, Limanova Z, Zima T, Potlukova E. Thyroid in pregnancy: From physiology to screening. Crit Rev Clin Lab Sci 2017; 54: 102-16.
18. Taylor PN, Zouras S, Min T, Nagarajah K, Lazarus JH, Okosieme O. Thyroid screening in early pregnancy: pros and cons. Frontiers in endocrinology 2018; 9: 626.
19. Akram FH, Johansson B, Mollerstrom G, Landgren BM, Stavreus-Evers A, Skjoldebrand-Sparre L. Incidence of Subclinical Hypothyroidism and Hypothyroidism in Early Pregnancy. J Womens Health (Larchmt) 2017; 26: 1231-5.
20. Pop VJ, Broeren MA, Wiersinga WM, Stagnaro-Green A. Thyroid disease symptoms during early pregnancy do not identify women with thyroid hypofunction that should be treated. Clin Endocrinol (Oxf) 2017; 87: 838-43.
21. Rosario PW. Selective screening for thyroid dysfunction in pregnant women: How often do low-risk women cease to be treated following the new guidelines of the American Thyroid Association? Arch Endocrinol Metab 2018; 62: 641-3.
22. Akter F, Kamrul-Hasan A, Ahmed E, Selim S, Aalpona F, Emran M, et al. Thyroid Dysfunction and Autoimmunity in First Trimester of Pregnancy, Single Center Experience in Bangladesh. Mymensingh medical journal: MMJ 2018; 27: 603-9.
23. Sitoris G, Veltri F, Kleynen P, Belhomme J, Rozenberg S, Poppe K. Screening for thyroid dysfunction in pregnancy with targeted high-risk case finding: can it be improved? J Clin Endocrinol Metab 2019; 104: 2346-54
24. Koren R, Wiener Y, Or K, Benbassat CA, Koren S. Thyroid Disease in Pregnancy: A Clinical Survey among Endocrinologists, Gynecologists, and Obstetricians in Israel. Isr Med Assoc J 2018; 20: 167-71.
25. Vila L, Velasco I, Gonzalez S, Morales F, Sanchez E, Lailla JM, et al. Detection of thyroid dysfunction in pregnant women: universal screening is justified. Endocrinol Nutr 2012; 59: 547-60.
26. Wilson JMG, Jungner G, Organization WH. Principles and practice of screening for disease. Bol Oficina Sanit Panam 1968; 65: 281-393.
27. Vanderpump MP. The epidemiology of thyroid disease. British medical bulletin 2011; 99: 39-51.
28. Limbert E, Prazeres S, Sao Pedro M, Madureira D, Miranda A, Ribeiro M et al. Iodine intake in Portuguese pregnant women: results of a countrywide study. Eur
J Endocrinol 2010; 163: 631-5.
29. Zimmermann MB, Boelaert K. Iodine deficiency and thyroid disorders. Lancet Diabetes Endocrinol 2015; 3: 286-95.
30. Pearce EN, Andersson M, Zimmermann MB. Global iodine nutrition: Where do we stand in 2013? Thyroid 2013; 23: 523-8.
31. DeLong GR, Leslie PW, Wang SH, Jiang XM, Zhang ML, Rakeman M, et al. Effect on infant mortality of iodination of irrigation water in a severely iodine-deficient area of China. Lancet 1997; 350: 771-3.
32. O'Donnell KJ, Rakeman MA, Zhi-Hong D, Xue-Yi C, Mei ZY, DeLong N, et al. Effects of iodine supplementation during pregnancy on child growth and development at school age. Dev Med Child Neurol 2002; 44: 76-81.
33. Vandevijvere S, Amsalkhir S, Mourri AB, Van Oyen H, Moreno-Reyes R. Iodine deficiency among Belgian pregnant women not fully corrected by iodine-containing multivitamins: a national cross-sectional survey. Br J Nutr 2013; 109: 2276-84.
34. Chen W, Sang Z, Tan L, Zhang S, Dong F, Chu Z, et al. Neonatal thyroid function born to mothers living with long-term excessive iodine intake from drinking water. Clin Endocrinol (Oxf) 2015; 83: 399-404.
35. Thung SF, Funai EF, Grobman WA. The cost-effectiveness of universal screening in pregnancy for subclinical hypothyroidism. Am J Obstet Gynecol 2009; 200: 267 e1-7.
36. Dosiou C, Barnes J, Schwartz A, Negro R, Crapo L, Stagnaro-Green A. Cost-effectiveness of universal and risk-based screening for autoimmune thyroid disease in pregnant women. J Clin Endocrinol Metab 2012; 97: 1536-46.
37. Donnay Candil S, Balsa Barro JA, Alvarez Hernandez J, Crespo Palomo C, Perez-Alcantara F, Polanco Sanchez C. [Cost-effectiveness analysis of universal screening for thyroid disease in pregnant women in Spain]. Endocrinol Nutr 2015; 62: 322-30.
38. Zhou Q, Acharya G, Zhang S, Wang Q, Shen H, Li X. A new perspective on universal preconception care in China. Acta Obstet Gynecol Scand 2016; 95: 377-81.
39. Hubalewska-Dydejczyk A, Trofimiuk-Müldner M. The development of guidelines for management of thyroid diseases in pregnancy – current status. Thyroid Res 2015; 8: A11.
40. Ramos T, Mariano C, Bourbon M. [Analysis of thyroid function in the Portuguese adult population] Boletim Epidemiológico Observações 2017; 6: 13-6.
41. Raposo L, Martins S, Ferreira D, Guimarães JT, Santos AC. Metabolic Syndrome, Thyroid Function and Autoimmunity-The PORMETS Study. Endocr Metab Immune Disord Drug Targets 2019; 19: 75-83.
42. Portuguese Institute of Statistics (INE). [Health Statistics: 2017]. Lisboa: INE, 2019. Available at: https://www.ine.pt/xurl/pub/320460040.
43. Central Administration of the Health System (ACSS). [Report on diagnostic tests and therapies, 2017]. Available at: http://www.acss.min-saude.pt/2016/10/03/tabelas-meios-complementares-de-diagnostico-e-terapeutica/.
44. Andersson M, De Benoist B, Darnton-Hill I, Delange F. Iodine deficiency in Europe: a continuing public health problem: World Health Organization Geneva, 2007.
45. Trumpff C, De Schepper J, Tafforeau J, Van Oyen H, Vanderfaeillie J, Vandevijvere S. Mild iodine deficiency in pregnancy in Europe and its consequences for cognitive and psychomotor development of children: a review. J Trace Elem Med Biol 2013; 27: 174-83.
46. Portuguese Directorate-General of Health (DGS). Iodine intake in women in preconception, pregnancy and breastfeeding; national guideline 011/2013.
2. Alexander EK, Pearce EN, Brent GA, Brown RS, Chen H, Dosiou C, et al. 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum. Thyroid 2017; 27: 315-89.
3. Martinez M, Soldevila B, Lucas A, Velasco I, Vila L, Puig-Domingo M. Hypothyroidism during pregnancy and its association to perinatal and obstetric morbidity: a review. Endocrinol Diabetes Nutr 2018; 65: 107-13.
4. Stagnaro-Green A. Clinical guidelines: Thyroid and pregnancy-time for universal screening? Nat Rev Endocrinol 2017; 13: 192-4.
5. Koehler VF, Auernhammer CJ, Spitzweg C. [The Thyroid and Pregnancy]. Dtsch Med Wochenschr 2019; 144: 1681-5.
6. Sitoris G, Veltri F, Kleynen P, Cogan A, Belhomme J, Rozenberg S, et al. The Impact of Thyroid Disorders on Clinical Pregnancy Outcomes in a Real-World Study Setting. Thyroid 2020; 30: 106-15.
7. Lee SY, Cabral HJ, Aschengrau A, Pearce EN.
Associations Between Maternal Thyroid Function in Pregnancy and Obstetric and Perinatal Outcomes. J Clin Endocrinol Metab 2020; 105: e2015-e23
8. Cigrovski Berkovic M, Herman Mahecic D, Marinkovic Radosevic J, Strinovic Moric M, Bilic-Curcic I. Hypothyroidism and pregnancy: still a controversial issue. Gynecol Endocrinol 2020; 36: 776-780.
9. Poppe K, Velkeniers B, Glinoer D. The role of thyroid autoimmunity in fertility and pregnancy. Nat Clin Pract Endocrinol Metab 2008; 4: 394-405.
10. Liu H, Shan Z, Li C, Mao J, Xie X, Wang W et al. Maternal subclinical hypothyroidism, thyroid autoimmunity, and the risk of miscarriage: a prospective cohort study. Thyroid 2014; 24: 1642-9.
11. Kalra S, Baruah MP, Unnikrishnan AG. Hypothyroidism in pregnancy: From unanswered questions to questionable answers. Indian J Endocrinol Metab 2013; 17: 200-2.
12. Negro R, Formoso G, Mangieri T, Pezzarossa A, Dazzi D, Hassan H. Levothyroxine treatment in euthyroid pregnant women with autoimmune thyroid disease: effects on obstetrical complications. J Clin Endocrinol Metab 2006; 91: 2587-91.
13. Korevaar TI. Evidence-Based Tightrope Walking: The 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum. Thyroid 2017; 27: 309-11.
14. Maheshwari A, Bhide P, Pundir J, Bhattacharya S. Routine serum thyroid-stimulating hormone testing-optimizing pre-conception health or generating toxic knowledge? Hum Reprod 2017; 32: 1779-85.
15. Kalra B, Gupta Y, Kalra S. Preconception management of thyroid disorders. JPMA The Journal of the Pakistan Medical Association 2017; 67: 645-7.
16. Velasco I, Taylor P. Identifying and treating subclinical thyroid dysfunction in pregnancy: emerging controversies. Eur J Endocrinol 2018; 178: D1-D12.
17. Springer D, Jiskra J, Limanova Z, Zima T, Potlukova E. Thyroid in pregnancy: From physiology to screening. Crit Rev Clin Lab Sci 2017; 54: 102-16.
18. Taylor PN, Zouras S, Min T, Nagarajah K, Lazarus JH, Okosieme O. Thyroid screening in early pregnancy: pros and cons. Frontiers in endocrinology 2018; 9: 626.
19. Akram FH, Johansson B, Mollerstrom G, Landgren BM, Stavreus-Evers A, Skjoldebrand-Sparre L. Incidence of Subclinical Hypothyroidism and Hypothyroidism in Early Pregnancy. J Womens Health (Larchmt) 2017; 26: 1231-5.
20. Pop VJ, Broeren MA, Wiersinga WM, Stagnaro-Green A. Thyroid disease symptoms during early pregnancy do not identify women with thyroid hypofunction that should be treated. Clin Endocrinol (Oxf) 2017; 87: 838-43.
21. Rosario PW. Selective screening for thyroid dysfunction in pregnant women: How often do low-risk women cease to be treated following the new guidelines of the American Thyroid Association? Arch Endocrinol Metab 2018; 62: 641-3.
22. Akter F, Kamrul-Hasan A, Ahmed E, Selim S, Aalpona F, Emran M, et al. Thyroid Dysfunction and Autoimmunity in First Trimester of Pregnancy, Single Center Experience in Bangladesh. Mymensingh medical journal: MMJ 2018; 27: 603-9.
23. Sitoris G, Veltri F, Kleynen P, Belhomme J, Rozenberg S, Poppe K. Screening for thyroid dysfunction in pregnancy with targeted high-risk case finding: can it be improved? J Clin Endocrinol Metab 2019; 104: 2346-54
24. Koren R, Wiener Y, Or K, Benbassat CA, Koren S. Thyroid Disease in Pregnancy: A Clinical Survey among Endocrinologists, Gynecologists, and Obstetricians in Israel. Isr Med Assoc J 2018; 20: 167-71.
25. Vila L, Velasco I, Gonzalez S, Morales F, Sanchez E, Lailla JM, et al. Detection of thyroid dysfunction in pregnant women: universal screening is justified. Endocrinol Nutr 2012; 59: 547-60.
26. Wilson JMG, Jungner G, Organization WH. Principles and practice of screening for disease. Bol Oficina Sanit Panam 1968; 65: 281-393.
27. Vanderpump MP. The epidemiology of thyroid disease. British medical bulletin 2011; 99: 39-51.
28. Limbert E, Prazeres S, Sao Pedro M, Madureira D, Miranda A, Ribeiro M et al. Iodine intake in Portuguese pregnant women: results of a countrywide study. Eur
J Endocrinol 2010; 163: 631-5.
29. Zimmermann MB, Boelaert K. Iodine deficiency and thyroid disorders. Lancet Diabetes Endocrinol 2015; 3: 286-95.
30. Pearce EN, Andersson M, Zimmermann MB. Global iodine nutrition: Where do we stand in 2013? Thyroid 2013; 23: 523-8.
31. DeLong GR, Leslie PW, Wang SH, Jiang XM, Zhang ML, Rakeman M, et al. Effect on infant mortality of iodination of irrigation water in a severely iodine-deficient area of China. Lancet 1997; 350: 771-3.
32. O'Donnell KJ, Rakeman MA, Zhi-Hong D, Xue-Yi C, Mei ZY, DeLong N, et al. Effects of iodine supplementation during pregnancy on child growth and development at school age. Dev Med Child Neurol 2002; 44: 76-81.
33. Vandevijvere S, Amsalkhir S, Mourri AB, Van Oyen H, Moreno-Reyes R. Iodine deficiency among Belgian pregnant women not fully corrected by iodine-containing multivitamins: a national cross-sectional survey. Br J Nutr 2013; 109: 2276-84.
34. Chen W, Sang Z, Tan L, Zhang S, Dong F, Chu Z, et al. Neonatal thyroid function born to mothers living with long-term excessive iodine intake from drinking water. Clin Endocrinol (Oxf) 2015; 83: 399-404.
35. Thung SF, Funai EF, Grobman WA. The cost-effectiveness of universal screening in pregnancy for subclinical hypothyroidism. Am J Obstet Gynecol 2009; 200: 267 e1-7.
36. Dosiou C, Barnes J, Schwartz A, Negro R, Crapo L, Stagnaro-Green A. Cost-effectiveness of universal and risk-based screening for autoimmune thyroid disease in pregnant women. J Clin Endocrinol Metab 2012; 97: 1536-46.
37. Donnay Candil S, Balsa Barro JA, Alvarez Hernandez J, Crespo Palomo C, Perez-Alcantara F, Polanco Sanchez C. [Cost-effectiveness analysis of universal screening for thyroid disease in pregnant women in Spain]. Endocrinol Nutr 2015; 62: 322-30.
38. Zhou Q, Acharya G, Zhang S, Wang Q, Shen H, Li X. A new perspective on universal preconception care in China. Acta Obstet Gynecol Scand 2016; 95: 377-81.
39. Hubalewska-Dydejczyk A, Trofimiuk-Müldner M. The development of guidelines for management of thyroid diseases in pregnancy – current status. Thyroid Res 2015; 8: A11.
40. Ramos T, Mariano C, Bourbon M. [Analysis of thyroid function in the Portuguese adult population] Boletim Epidemiológico Observações 2017; 6: 13-6.
41. Raposo L, Martins S, Ferreira D, Guimarães JT, Santos AC. Metabolic Syndrome, Thyroid Function and Autoimmunity-The PORMETS Study. Endocr Metab Immune Disord Drug Targets 2019; 19: 75-83.
42. Portuguese Institute of Statistics (INE). [Health Statistics: 2017]. Lisboa: INE, 2019. Available at: https://www.ine.pt/xurl/pub/320460040.
43. Central Administration of the Health System (ACSS). [Report on diagnostic tests and therapies, 2017]. Available at: http://www.acss.min-saude.pt/2016/10/03/tabelas-meios-complementares-de-diagnostico-e-terapeutica/.
44. Andersson M, De Benoist B, Darnton-Hill I, Delange F. Iodine deficiency in Europe: a continuing public health problem: World Health Organization Geneva, 2007.
45. Trumpff C, De Schepper J, Tafforeau J, Van Oyen H, Vanderfaeillie J, Vandevijvere S. Mild iodine deficiency in pregnancy in Europe and its consequences for cognitive and psychomotor development of children: a review. J Trace Elem Med Biol 2013; 27: 174-83.
46. Portuguese Directorate-General of Health (DGS). Iodine intake in women in preconception, pregnancy and breastfeeding; national guideline 011/2013.
| Files | ||
| Issue | Vol 14, No 4 (December 2020) | |
| Section | Review Articles | |
| DOI | https://doi.org/10.18502/jfrh.v14i4.5204 | |
| Keywords | ||
| Screening Thyroid Function Preconception Pregnancy Endocrinology Primary Health Care Maternal Health | ||
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How to Cite
1.
Lima Ferreira J, Gomes M, Príncipe RM. Controversial Screening for Thyroid Dysfunction in Preconception and Pregnancy: An Evidence-Based Review. J Family Reprod Health. 2020;14(4):209-220.
