ABSTRACT
Background: The American Thyroid Association Guidelines on Thyroid Disease During Pregnancy and the Postpartum (ATA Guidelines) were published in 2017, with an update not expected for another 5 years. Since release of the 2017 ATA Guidelines, greater than 500 articles have been published in the field. Furthermore, there are presently 14 prospective, interventional trials in progress registered at Clinicaltrials.gov Static guidelines updated every 5-7 years fail to provide timely evidence-based guidance to practicing clinicians. Consequently, guideline development should move toward the creation of dynamic documents. The present article reviews the literature published since the 2017 ATA Guidelines, both to benefit clinicians in practice and to make the case for Dynamic ATA Guidelines. Methods: Using the search terms "thyroid" and "pregnancy," a systematic review of literature published in Pubmed from 3/1/2017 to 12/31/2018 was conducted. The titles and/or abstracts of all articles were reviewed. All articles were classified by subject headings used in the 2017 ATA Guidelines. English-text articles classified under "hypothyroidism" or "thyroid autoimmunity" were examined in full-text. Using the questions and recommendations put forth by the previous ATA Guidelines, relevant articles were selected for discussion in this review. Results: At the time of the search, 659 unique articles on "thyroid and pregnancy" were identified, including 66 original studies on hypothyroidism and 26 on thyroid autoimmunity. Of these, 26 studies on hypothyroidism and 18 studies on thyroid autoimmunity were selected for inclusion in this review based on specific questions in the 2017 ATA Guidelines. Based on these 44 articles, we propose two specific changes to the 2017 ATA Guidelines. Conclusion: Based on new research, we recommend the 2017 ATA Guidelines be updated to recommend against treating thyroid antibody-negative women diagnosed with subclinical hypothyroidism in the second trimester or later; to reflect new, moderate-quality evidence supporting the treatment of thyroid peroxidase antibody-negative women with elevated thyroid stimulating hormone levels in the first trimester or earlier; and to recommend against treatment of euthyroid, thyroid peroxidase antibody-positive women undergoing assisted reproductive technology. Transitioning to a Dynamic ATA Guidelines would allow for these and future recommendations to be implemented in real time.
Subject(s)
Needs Assessment , Practice Guidelines as Topic , Pregnancy Complications/therapy , Puerperal Disorders/therapy , Thyroid Diseases/therapy , Female , History, 21st Century , Humans , Postpartum Period/physiology , Practice Guidelines as Topic/standards , Practice Patterns, Physicians'/standards , Practice Patterns, Physicians'/statistics & numerical data , Pregnancy , Pregnancy Complications/epidemiology , Publications/history , Publications/statistics & numerical data , Puerperal Disorders/epidemiology , Societies, Medical/standards , Thyroid Diseases/epidemiology , United States/epidemiologyABSTRACT
OBJECTIVE: To determine whether overt/subclinical hypothyroidism and/or thyroid autoimmunity is associated with recurrent pregnancy loss (RPL) and whether treatment improves outcomes. DESIGN: Systematic review and meta-analysis. SETTING: University obstetrics and gynecology departments. PATIENT(S): Women with RPL and overt/subclinical hypothyroidism, and/or thyroid autoimmunity. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Associations between RPL and overt/subclinical hypothyroidism and/or thyroid autoimmunity and any effects of treatment. RESULT(S): After our review of articles from PubMed, EMBASE, Web of Science, and CENTRAL, we found two interventional studies in which levothyroxine did not improve the subsequent live-birth rate in women with subclinical hypothyroidism with or without thyroid antibodies. A meta-analysis of five studies revealed the prevalence of subclinical hypothyroidism in RPL to be 12.9% (95% confidence interval [CI], 0%-35.2%). A meta-analysis of 17 studies revealed a statistically significant association between RPL and thyroid autoimmunity (odds ratio 1.94; 95% CI, 1.43-2.64). However, a randomized study suggested that levothyroxine does not benefit euthyroid women with thyroid autoimmunity. CONCLUSION(S): Based on the limited observational studies available, no association exists between RPL and subclinical hypothyroidism, nor does levothyroxine improve subsequent pregnancy outcomes. An association exists between RPL and thyroid autoimmunity, but levothyroxine does not improve subsequent pregnancy outcomes. Women with RPL should be screened/treated for overt thyroid disease but not thyroid autoimmunity. Thyroid antibody screening is not supported by the published studies, and further randomized studies are needed. No recommendation regarding the treatment of subclinical hypothyroidism can be made at this time; prospective and randomized studies are urgently needed.
Subject(s)
Abortion, Habitual/epidemiology , Abortion, Habitual/etiology , Hypothyroidism/epidemiology , Thyroiditis, Autoimmune/epidemiology , Abortion, Habitual/immunology , Asymptomatic Diseases , Female , Humans , Hypothyroidism/complications , Pregnancy , Pregnancy Complications/epidemiology , Pregnancy Complications/etiology , Pregnancy Outcome , Prenatal Diagnosis/methods , Risk Factors , Thyroid Function Tests , Thyroiditis, Autoimmune/complicationsABSTRACT
A 22-year-old G1P1 Caucasian female had hysteroscopic removal of a perforated intrauterine device during which the steroid reservoir of the intrauterine device was lost. Isolated steroid reservoirs are radiolucent on plain film radiography. We located the reservoir in the peritoneal cavity with magnetic resonance imaging and removed it via laparoscopy.
