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Pregnancy induces complex hormonal and immunological changes that modify normal thyroid physiology. Therefore, evaluation of thyroid function during pregnancy should be interpreted according to these changes. In our opinion, the high prevalence of pregnancy-related thyroid disorders and their important consequences for both mother and fetus indicate the need for routine thyroid function screening both before and during pregnancy. Once thyroid dysfunction is diagnosed, the management of the disorder requires frequent monitoring to adjust treatment accurately. The goal of treating hyperthyroidism with thionamide drugs is to maintain serum thyroxin (T4) in the upper normal range (free T4, 2-2.5ng/dl; total T4, 12.0-18.0μg/dl) using the lowest possible dose of the drug, while in hypothyroidism the goal is to return serum thyrotropin to the range between 0.5 and 2.5mU/l.
Key words:
Pregnancy
Hyperthyroidism
Hypothyroidism
Postpartum
Management
El embarazo comporta una serie de cambios hormonales e inmunológicos que dan lugar a modificaciones en la fisiología normal del tiroides. Por tanto, la evaluación de la función tiroidea durante el embarazo debe interpretarse teniendo en cuenta estos cambios. En nuestra opinión, la gran prevalencia de trastornos tiroideos asociados al embarazo y las graves consecuencias que pueden causar a la madre y el feto apoyan la necesidad de realizar pruebas de cribado de disfunción tiroidea de manera sistemática, tanto antes como durante el embarazo. Una vez se ha diagnosticado una disfunción tiroidea será necesario realizar una monitorización frecuente para ajustar el tratamiento de forma precisa. El objetivo del tratamiento del hipertiroidismo con fármacos antitiroideos es lograr que la concentración de tiroxina sérica (T4) se mantenga en el límite alto del rango normal (T4 libre, 2-2,5ng/dl; T4 total, 12-18μg/dl) con la mínima dosis posible, mientras que, en el caso del hipotiroidismo, el objetivo es conseguir que la concentración de tirotropina se mantenga entre 0,5 y 2,5mU/l.
Palabras clave:
Embarazo
Hipertiroidismo
Hipotiroidismo
Posparto
Manejo
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Bibliografía
[1.]
J.H. Lazarus, A. Kokandi.
Thyroid disease in relation to pregnancy: a decade of change.
Clin Endocrinol, 53 (2000), pp. 265-278
[2.]
R.C. Smallridge, D. Glinoer, J.G. Hollowell, G. Brent.
Thyroid function inside and outside of pregnancy: what do we know and what don’t we know?.
Thyroid, 15 (2005), pp. 54-59
[3.]
D. Glinoer, P. De Nayer, P. Bourdoux, M. Lemone, C. Robyn, A. Van Steirteghem, et al.
Regulation of maternal thyroid during pregnancy.
J Clin Endocrinol Metab, 71 (1990), pp. 276-287
[4.]
K.B. Ain, Y. Mori, S. Refetoff.
Reduced clearance rate of thyroxine-binding globulin (TBG) with increased sialylation: a mechanism for estrogen-induced elevation of serum TBG concentration.
J Clin Endocrinol Metab, 65 (1987), pp. 689-696
[5.]
S.J. Mandel, C.A. Spencer, J.G. Hollowell.
Are detection and treatment of thyroid insufficiency in pregnancy feasible?.
Thyroid, 15 (2005), pp. 44-53
[6.]
D.V. Becker, L.E. Braverman, F. Delange, J.T. Dunn, J.A. Franklyn, J.G. Hollowell, et al.
Iodine supplementation for pregnancy and lactation-United States and Canada: recommendations of the American Thyroid Association.
Thyroid, 16 (2006), pp. 949-951
[7.]
S.O. LeBeau, S.J. Mandel.
Thyroid disorders during pregnancy.
Endocrinol Metab Clin North Am, 35 (2006), pp. 1 17-136
[8.]
D.A. Somerset, Y. Zheng, M.D. Kilby, D.M. Sansom, M.T. Drayson.
Normal human pregnancy is associated with an elevation in the immune suppressive CD25+ CD4+ regulatory T-cell subset.
Immunology, 1 12 (2004), pp. 38-43
[9.]
V.R. Aluvihare, M. Kallikourdis, A.G. Betz.
Regulatory T cells mediate maternal tolerance to the fetus.
Nat Immunol, 5 (2004), pp. 266-271
[10.]
T. Ando, T.F. Davies.
Self-recognition and the role of fetal microchimerism.
Best Pract Res Clin Endocrinol Metab, 18 (2004), pp. 197-211
[11.]
D. Glinoer, M. Lemone, P. Bourdoux, P. De Nayer, F. DeLange, J. Kinthaert, et al.
Partial reversibility during late postpartum of thyroid abnormalities associated with pregnancy.
J Clin Endocrinol Metab, 74 (1992), pp. 453-457
[12.]
A.C. Bianco, D. Salvatore, B. Gereben, M.J. Berry, P.R. Larsen.
Biochemistry, cellular and molecular biology, and physiological roles of the iodothyronine selenodeiodinases.
Endocr Rev, 23 (2002), pp. 38-89
[13.]
A.C. Bianco, B.W. Kim.
Deiodinases: implications of the local control of thyroid hormone action.
J Clin Invest, 116 (2006), pp. 2571-2579
[14.]
G. Hennemann, R. Docter, E.C. Friesema, M. De Jong, E.P. Krenning, T.J. Visser.
Plasma membrane transport of thyroid hormones and its role in thyroid hormone metabolism and bioavailability.
Endocr Rev, 22 (2001), pp. 451-476
[15.]
K. Tohyama, H. Kusuhara, Y. Sugiyama.
Involvement of multispecific organic anion transporter, Oatp14 (Slc21a14), in the transport of thyroxine across the blood-brain barrier.
Endocrinology, 145 (2004), pp. 4384-4391
[16.]
H. Heuer, M.K. Maier, S. Iden, J. Mittag, E.C. Friesema, T.J. Visser, et al.
The monocarboxylate transporter 8 linked to human psychomotor retardation is highly expressed in thyroid hormonesensitive neuron populations.
Endocrinology, 146 (2005), pp. 1701-1706
[17.]
I.B. Rosen, M. Korman, P.G. Walfish.
Thyroid nodular disease in pregnancy: current diagnosis and management.
Clin Obstet Gynecol, 40 (1997), pp. 81-89
[18.]
T.T. Lao.
Thyroid disorders in pregnancy.
Curr Opin Obstet Gynecol, 17 (2005), pp. 123-127
[19.]
D. Glinoer.
Management of hypo- and hyperthyroidism during pregnancy.
Growth Horm IGF Res, 13 (2003), pp. S45-S54
[20.]
American College of Obstetrics and Gynecology.
ACOG practice bulletin. Thyroid disease in pregnancy. Number 37, August 2002. American College of Obstetrics and Gynecology.
Int J Gynaecol Obstet, 79 (2002), pp. 171-180
[21.]
M.I. Surks, E. Ortiz, G.H. Daniels, C.T. Sawin, N.F. Col, R.H. Cobin, et al.
Subclinical thyroid disease: scientific review and guidelines for diagnosis and management.
JAMA, 291 (2004), pp. 228-238
[22.]
H. Gharib, R.M. Tuttle, H.J. Baskin, L.H. Fish, P.A. Singer, M.T. McDermott.
Subclinical thyroid dysfunction: a joint statement on management from the American Association of Clinical Endocrinologists, the American Thyroid Association, and the Endocrine Society.
J Clin Endocrinol Metab, 90 (2005), pp. 581-585
[23.]
D.S. Cooper.
Subclinical thyroid disease: consensus or conundrum?.
Clin Endocrinol, 60 (2004), pp. 410-412
[24.]
M.I. Surks.
Subclinical thyroid dysfunction: A Joint Statement on Management from the American Association of Clinical Endocrinologists, the American Thyroid Association, and the Endocrine Society.
J Clin Endocrinol Metab, 90 (2005), pp. 586-587
[25.]
M.D. Ringel, E.L. Mazzaferri.
Subclinical thyroid dysfunction – can there be a consensus about the consensus?.
J Clin Endocrinol Metab, 90 (2005), pp. 588-590
[26.]
A. Pinchera.
Subclinical thyroid disease: to treat or not to treat?.
Thyroid, 15 (2005), pp. 1-2
[27.]
T. Ando, T.F. Davies.
Postpartum autoimmune thyroid disease: the potential role of fetal microchimerism.
J Clin Endocrinol Metab, 88 (2003), pp. 2965-2971
[28.]
J.H. Lazarus, L.D. Premawardhana.
Screening for thyroid disease in pregnancy.
J Clin Pathol, 58 (2005), pp. 449-452
[29.]
American Association of Clinical Endocrinologists.
American Association of Clinical Endocrinologists medical guidelines for clinical practice for the evaluation and treatment of hyperthyroidism and hypothyroidism.
Endocr Pract, 8 (2002), pp. 457-469
[30.]
A. Stagnaro-Green, S.H. Roman, R.H. Cobin, E. el-Harazy, M. Alvarez-Marfany, T.F. Davies.
Detection of at-risk pregnancy by means of highly sensitive assays for thyroid autoantibodies.
JAMA, 264 (1990), pp. 1422-1425
[31.]
D. Glinoer.
Miscarriage in women with positive anti-TPO antibodies: is thyroxine the answer?.
J Clin Endocrinol Metab, 91 (2006), pp. 2500-2502
[32.]
G. Morreale de Escobar, M.J. Obregon, F. Escobar del Rey.
Is neuropsychological development related to maternal hypothyroidism or to maternal hypothyroxinemia?.
J Clin Endocrinol Metab, 85 (2000), pp. 3975-3987
[33.]
J.S. Dashe, B.M. Casey, C.E. Wells, D.D. McIntire, E.W. Byrd, K.J. Leveno, et al.
Thyroid-stimulating hormone in singleton and twin pregnancy: importance of gestational age-specific reference ranges.
Obstet Gynecol, 106 (2005), pp. 753-757
[34.]
O.P. Soldin, R.E. Tractenberg, J.G. Hollowell, J. Jonklaas, N. Janicic, S.J. Soldin.
Trimester-specific changes in maternal thyroid hormone, thyrotropin, and thyroglobulin concentrations during gestation: trends and associations across trimesters in iodine sufficiency.
Thyroid, 14 (2004), pp. 1084-1090
[35.]
J.E. Haddow, G.E. Palomaki, W.C. Allan, J.R. Williams, G.J. Knight, J. Gagnon, et al.
Maternal thyroid deficiency during pregnancy and subsequent neuropsychological development of the child.
N Engl J Med, 341 (1999), pp. 549-555
[36.]
D. Glinoer, P. De Nayer, C. Robyn, B. Lejeune, J. Kinthaert, S. Meuris.
Serum levels of intact human chorionic gonadotropin (hCG) and its free alpha and beta subunits, in relation to maternal thyroid stimulation during normal pregnancy.
J Endocrinol Invest, 16 (1993), pp. 881-888
[37.]
T.F. Davies.
The thyroid immunology of the postpartum period.
Thyroid, 9 (1999), pp. 675-684
[38.]
A. Stagnaro-Green, S.H. Roman, R.H. Cobin, E. el-Harazy, S. Wallenstein, T.F. Davies.
A prospective study of lymphocyte-initiated immunosuppression in normal pregnancy: evidence of a T-cell etiology for postpartum thyroid dysfunction.
J Clin Endocrinol Metab, 74 (1992), pp. 645-653
[39.]
Y. Merbl, M. Zucker-Toledano, F.J. Quintana, I.R. Cohen.
Newborn humans manifest autoantibodies to defined self molecules detected by antigen microarray informatics.
J Clin Invest, 117 (2007), pp. 712-718
[40.]
D.L. Jacobson, S.J. Gange, N.R. Rose, N.M. Graham.
Epidemiology and estimated population burden of selected autoimmune diseases in the United States.
Clin Immunol Immunopathol, 84 (1997), pp. 223-243
[41.]
A.P. Weetman.
Autoimmune thyroid disease.
Endocrinology, 5th ed, pp. 1979-1993
[42.]
R. Negro, G. Formoso, T. Mangieri, A. Pezzarossa, D. Dazzi, H. Hassan.
Levothyroxine treatment in euthyroid pregnant women with autoimmune thyroid disease: effects on obstetrical complications.
J Clin Endocrinol Metab, 91 (2006), pp. 2587-2591
[43.]
A. Stagnaro-Green.
Postpartum thyroiditis.
J Clin Endocrinol Metab, 87 (2002), pp. 4042-4047
[44.]
A. Stagnaro-Green, X. Chen, J.D. Bogden, T.F. Davies, T.O. Scholl.
The thyroid and pregnancy: a novel risk factor for very preterm delivery.
Thyroid, 15 (2005), pp. 351-357
[45.]
M. Imaizumi, A. Pritsker, M. Kita, L. Ahmad, P. Unger, T. Davies.
Pregnancy and murine thyroiditis: thyroglobulin immunization leads to fetal loss in specific allogeneic pregnancies.
Endocrinology, 142 (2001), pp. 823-829
[46.]
K.M. Trokoudes, N. Skordis, M.K. Picolos.
Infertility and thyroid disorders.
Curr Opin Obstet Gynecol, 18 (2006), pp. 446-451
[47.]
V.J. Pop, E. de Vries, A.L. van Baar, J.J. Waelkens, H.A. de Rooy, M. Horsten, et al.
Maternal thyroid peroxidase antibodies during pregnancy: a marker of impaired child development?.
J Clin Endocrinol Metab, 80 (1995), pp. 3561-3566
[48.]
D. Glinoer.
Thyroid hyperfunction during pregnancy.
Thyroid, 8 (1998), pp. 859-864
[49.]
G.N. Burrow.
The management of thyrotoxicosis in pregnancy.
N Engl J Med, 313 (1985), pp. 562-565
[50.]
L.E. Davis, M.J. Lucas, G.D. Hankins, M.L. Roark, F.G. Cunningham.
Thyrotoxicosis complicating pregnancy.
Am J Obstet Gynecol, 160 (1989), pp. 63-70
[51.]
J. Anselmo, D. Cao, T. Karrison, R.E. Weiss, S. Refetoff.
Fetal loss associated with excess thyroid hormone exposure.
JAMA, 292 (2004), pp. 691-695
[52.]
I.P. Stafford, G.A. Dildy 3rd, J.M. Miller Jr.
Severe Graves’ ophthalmopathy in pregnancy.
Obstet Gynecol, 105 (2005), pp. 1221-1223
[53.]
S.J. Mandel, G.A. Brent, P.R. Larsen.
Review of antithyroid drug use during pregnancy and report of a case of aplasia cutis.
Thyroid, 4 (1994), pp. 129-133
[54.]
S. Mandel, D. Cooper.
The use of antithyroid drugs in pregnancy and lactation.
J Clin Endocrinol Metab, 86 (2001), pp. 2354-2359
[55.]
I.H. Sherif, W.T. Oyan, S. Bosairi, S.M. Carrascal.
Treatment of hyperthyroidism in pregnancy.
Acta Obstet Gynecol Scand, 70 (1991), pp. 461-463
[56.]
D. Luton, I. Le Gac, E. Vuillard, M. Castanet, J. Guibourdenche, M. Noel, et al.
Management of Graves’ disease during pregnancy: the key role of fetal thyroid gland monitoring.
J Clin Endocrinol Metab, 90 (2005), pp. 6093-6098
[57.]
N. Momotani, T. Hisaoka, J. Noh, N. Ishikawa, K. Ito.
Effects of iodine on thyroid status of fetus versus mother in treatment of Graves’ disease complicated by pregnancy.
J Clin Endocrinol Metab, 75 (1992), pp. 738-744
[58.]
S.S. Stoffer, J.I. Hamburger.
Inadvertent 131I therapy for hyperthyroidism in the first trimester of pregnancy.
J Nucl Med, 17 (1976), pp. 146-149
[59.]
A.W. Kung, B.M. Jones.
A change from stimulatory to blocking antibody activity in Graves’ disease during pregnancy.
J Clin Endocrinol Metab, 83 (1998), pp. 514-518
[60.]
N. Amino, Y. Izumi, Y. Hidaka, K. Takeoka, Y. Nakata, K.I. Tatsumi, et al.
No increase of blocking type anti-thyrotropin receptor antibodies during pregnancy in patients with Graves’ disease.
J Clin Endocrinol Metab, 88 (2003), pp. 5871-5874
[61.]
Z. Nachum, Y. Rakover, E. Weiner, E. Shalev.
Graves’ disease in pregnancy: prospective evaluation of a selective invasive treatment protocol.
Am J Obstet Gynecol, 189 (2003), pp. 159-165
[62.]
J.H. Lazarus.
Epidemiology and prevention of thyroid disease in pregnancy.
Thyroid, 12 (2002), pp. 861-865
[63.]
Y. Nakagawa, K. Mori, S. Hoshikawa, M. Yamamoto, S. Ito, K. Yoshida.
Postpartum recurrence of Graves’ hyperthyroidism can be prevented by the continuation of antithyroid drugs during pregnancy.
Clin Endocrinol, 57 (2002), pp. 467-471
[64.]
D. Benhaim Rochester, T.F. Davies.
Increased risk of Graves’ disease after pregnancy.
Thyroid, 15 (2005), pp. 1287-1290
[65.]
S.J. Mandel.
Hypothyroidism and chronic autoimmune thyroiditis in the pregnant state: maternal aspects.
Best Pract Res Clin Endocrinol Metab, 18 (2004), pp. 213-224
[66.]
K. Kamijo, T. Saito, M. Sato, A. Yachi, A. Mukai, M. Fukusi, et al.
Transient subclinical hypothyroidism in early pregnancy.
Endocrinol Jpn, 37 (1990), pp. 397-403
[67.]
R.S. Brown, R.L. Bellisario, D. Botero, L. Fournier, C.A. Abrams, M.L. Cowger, et al.
Incidence of transient congenital hypothyroidism due to maternal thyrotropin receptor-blocking antibodies in over one million babies.
J Clin Endocrinol Metab, 81 (1996), pp. 1147-1151
[68.]
M. Abalovich, S. Gutierrez, G. Alcaraz, G. Maccallini, A. Garcia, O. Levalle.
Overt and subclinical hypothyroidism complicating pregnancy.
Thyroid, 12 (2002), pp. 63-68
[69.]
A.S. Leung, L.K. Millar, P.P. Koonings, M. Montoro, J.H. Mestman.
Perinatal outcome in hypothyroid pregnancies.
Obstet Gynecol, 81 (1993), pp. 349-353
[70.]
E. Auso, R. Lavado-Autric, E. Cuevas, F.E. Del Rey, G. Morreale de Escobar, P. Berbel.
A moderate and transient deficiency of maternal thyroid function at the beginning of fetal neocorticogenesis alters neuronal migration.
Endocrinology, 145 (2004), pp. 4037-4047
[71.]
D. Glinoer.
Iodine nutrition requirements during pregancy.
Thyroid, 16 (2006), pp. 947-948
[72.]
S.J. Mandel, P.R. Larsen, E.W. Seely, G.A. Brent.
Increased need for thyroxine during pregnancy in women with primary hypothyroidism.
N Engl J Med, 323 (1990), pp. 91-96
[73.]
E.K. Alexander, E. Marqusee, J. Lawrence, P. Jarolim, G.A. Fischer, P.R. Larsen.
Timing and magnitude of increases in levothyroxine requirements during pregnancy in women with hypothyroidism.
N Engl J Med, 351 (2004), pp. 241-249
[74.]
A. Toft.
Increased levothyroxine requirements in pregnancy why, when, and how much?.
N Engl J Med, 351 (2004), pp. 292-294
[75.]
I. Idris, R. Srinivasan, A. Simm, R.C. Page.
Maternal hypothyroidism in early and late gestation: effects on neonatal and obstetric outcome.
Clin Endocrinol, 63 (2005), pp. 560-565
[76.]
M.M. Kaplan.
Monitoring thyroxine treatment during pregnancy.
Thyroid, 2 (1992), pp. 147-152
[77.]
M. Centanni, L. Gargano, G. Canettieri, N. Viceconti, A. Franchi, G. Delle Fave, et al.
Thyroxine in goiter, Helicobacter pylori infection, and chronic gastritis.
N Engl J Med, 354 (2006), pp. 1787-1795
[78.]
I.J. Chopra, K. Baber.
Treatment of primary hypothyroidism during pregnancy: is there an increase in thyroxine dose requirement in pregnancy?.
Metabolism, 52 (2003), pp. 122-128
[79.]
A. Caixas, M. Albareda, A. Garcia-Patterson, J. Rodriguez-Espinosa, A. de Leiva, R. Corcoy.
Postpartum thyroiditis in women with hypothyroidism antedating pregnancy?.
J Clin Endocrinol Metab, 84 (1999), pp. 4000-4005
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