Long Term Follow-Up and HLA Association in Patients With Postpartum Hypothyroidism*

Tachi, Junko; Amino, Nobuyuki; Tamaki, Haruo; Aozasa, Mieko; Iwatani, Yoshinori; Miyai, Kiyoshi

doi:10.1210/jcem-66-3-480

Cited by 110 publications

(40 citation statements)

References 24 publications

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“…We had shown that PPTD patients, who remained euthyroid after T 4 withdrawal, had significantly higher values for TSH, as compared with the control group and 73.3% had TPOAb above the normal limit (15). This finding is in agreement with a previous report that euthyroid women with a previous history of PPTD have a permanent subtle defect in thyroid hormone synthesis, as evidenced by an abnormal iodine-perchlorate discharge test (18).…”

Section: Discussionsupporting

confidence: 91%

The occurrence of permanent thyroid failure in patients with subclinical postpartum thyroiditis

Azizi

2005

eur j endocrinol

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Objective: The long-term effect of the subclinical form of postpartum thyroid dysfunction (PPTD) has not been well established. This study was conducted to evaluate the outcome of permanent hypothyroidism in a large cohort of women with PPTD. Design and methods: Of 213 women with PPTD, 172 (81%) returned for follow-up. There were 27 (16%) with subclinical (group 1) and 145 (84%) with overt hypothyroidism (group 2). They were all treated with levothyroxine for 23^16 months and followed-up for thyroid function after thyroxine (T 4 ) withdrawal. Results: In group 1, the time of occurrence of PPTD was longer, serum T 4 was higher and TSH was lower than in group 2. After T 4 withdrawal, 59 and 64% of patients became hypothyroid in groups 1 and 2 respectively; however, serum TSH was increased in group 2 as compared with group 1 (29.7^8.4 vs 16.4^15.4 mU/l, P , 0.002). The duration of euthyroidism, serum free T 4 and triiodothyronine indices and thyroperoxidase antibodies were not significantly different between the two groups. Conclusion: It was concluded that a high percentage of patients with the subclinical form of PPTD proceed to permanent thyroid failure. The timely recognition of mild to severe cases of PPTD is important for the improvement of life for mothers and infants.

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Section: Discussionsupporting

confidence: 91%

The occurrence of permanent thyroid failure in patients with subclinical postpartum thyroiditis

Azizi

2005

eur j endocrinol

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“…The impact of PPT on long-term thyroid function has been evaluated in six studies (284,(293)(294)(295)(296)(297). The data demonstrate that within 1 year, 10%-20% of women who were euthyroid following their initial hypothyroid phase of PPT develop permanent hypothyroidism.…”

Section: And Recommendation 69mentioning

confidence: 99%

2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum

Alexander

Pearce

Brent

et al. 2017

Thyroid

2,059

2,716

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INTRODUCTION Pregnancy has a profound impact on the thyroid gland and thyroid function. The gland increases 10% in size during pregnancy in iodine-replete countries and by 20%-40% in areas of iodine deficiency. Production of thyroxine (T 4 ) and triiodothyronine (T 3 ) increases by 50%, along with a 50% increase in the daily iodine requirement. These physiological changes may result in hypothyroidism in the later stages of pregnancy in iodine-deficient women who were euthyroid in the first trimester. The range of thyrotropin (TSH), under the impact of placental human chorionic gonadotropin (hCG), is decreased throughout pregnancy with the lower normal TSH level in the first trimester being poorly defined and an upper limit of 2.5 mIU/L. Ten percent to 20% of all pregnant women in the first trimester of pregnancy are thyroid peroxidase (TPO) or thyroglobulin (Tg) antibody positive and euthyroid. Sixteen percent of the women who are euthyroid and positive for TPO or Tg antibody in the first trimester will develop a TSH that exceeds 4.0 mIU/L by the third trimester, and 33%-50% of women who are positive for TPO or Tg antibody in the first trimester will develop postpartum thyroiditis. In essence, pregnancy is a stress test for the thyroid, resulting in hypothyroidism in women with limited thyroidal reserve or iodine deficiency, and postpartum thyroiditis in women with underlying Hashimoto's disease who were euthyroid prior to conception.Knowledge regarding the interaction between the thyroid and pregnancy/the postpartum period is advancing at a rapid pace. Only recently has a TSH of 2.5 mIU/L been accepted as the upper limit of normal for TSH in the first trimester. This has important implications in regards to interpretation of the literature as well as a critical impact for the clinical diagnosis of hypothyroidism. Although it is well accepted that overt hypothyroidism and overt hyperthyroidism have a deleterious impact on pregnancy, studies are now focusing on the potential impact of subclinical hypothyroidism and subclinical hyperthyroidism on maternal and fetal health, the association between miscarriage and preterm delivery in euthyroid women positive for TPO and/or Tg antibody, and the prevalence and long-term impact of postpartum thyroiditis. Recently completed prospective randomized studies have begun to produce critically needed data on the impact of treating thyroid disease on the mother, fetus, and the future intellect of the unborn child.It is in this context that the American Thyroid Association (ATA) charged a task force with developing clinical guidelines on the diagnosis and treatment of thyroid disease during pregnancy and the postpartum. The task force consisted of international experts in the field of thyroid disease and pregnancy, and included representatives from the ATA, Asia and Oceania Thyroid Association, Latin American Thyroid Society, American College of Obstetricians and Gynecologists, and the Midwives Alliance of North America. Inclusion of thyroidologists, obstetricians, and midwives ...

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“…This form of PPTD is the 'classical' form presenting with hyperthyroidism followed by hypothyroidism and is caused by exacerbation of a pre-existing AITD. These women with high TSH levels in combination with TPOAb appear to be really at risk for developing permanent hypothyroidism (Table 2) (30)(31)(32).…”

Section: Discussionmentioning

confidence: 99%

“…Identification of these women with great accuracy is important when an intervention (e.g. treatment with thyroxine) to prevent PPTD is considered, but also because of the considerable risk of developing permanent hypothyroidism (30,31). Therefore, we calculated the positive predictive values and sensitivity and specificity for TPOAb concentrations Ն100 and Ն300 U/ml respectively for TPOAbþ women at different time points.…”

Section: Discussionmentioning

confidence: 99%

Prediction of post partum thyroid dysfunction: can it be improved?

Kuijpens¹,

Pop

Vader³

et al. 1998

Eur J Endocrinol

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Background: Screening pregnant women for thyroid peroxidase antibodies (TPOAb) to identify those at risk for post partum thyroid dysfunction (PPTD) is controversial, mainly because of the low positive predictive value (ppv) of TPOAb. Objectives: To evaluate if the ppv of TPOAb can be enhanced, either by taking into account the time of TPOAb testing, or by combining this parameter with other putative determinants of PPTD such as smoking, family history or other autoimmune diseases. Methods: A prospective study was performed in the Kempenland region (southeastern Netherlands). Three hundred and ten unselected women were visited at 12 and 32 weeks gestation and 4, 12, 20, 28 and 36 weeks post partum. Serial thyroid stimulating hormone (TSH), free thyroxine (fT 4 ) and TPOAb testing was performed. Thyroid dysfunction (TD) was defined as abnormal TSH either in combination with abnormal fT 4 (overt TD) or without abnormal fT 4 (subclinical TD). PPTD was defined as overt TD post partum. Multivariate regression analysis was performed for determining independent risk factors for PPTD. The sensitivity and specificity of TPOAb at different time points and at different concentrations were calculated and presented in receiver operating characteristic (ROC) curves. Women who had experienced PPTD were followed for 2.5-3 years. Results: Data from 291 women were available for analysis. Serum fT 4 declined during pregnancy and returned to baseline values post partum. TD in gestation was present in 23 women (7.9%): serum TSH was transiently decreased in 13 (6 had overt gestational thyrotoxicosis (2.1%)) and increased in 10 (2 had TPOAb). Both point prevalence and concentration of TPOAb decreased during gestation and returned to baseline levels within 12 weeks post partum. TD in post partum was present in 36 women (12.4%): 21 had subclinical and 15 overt TD. Out of the 15 women with overt TD (incidence of PPTD: 5.2%) 10 were positive for TPOAb (TPOAbþ); 9 had thyrotoxicosis (4 TPOAbþ), 5 hypothyroidism (5 TPOAbþ) and 1 thyrotoxicosis followed by hypothyroidism (TPOAbþ). Independent risk factors for PPTD were TPOAb (relative risk (RR) ¼ 27.2), bottle feeding (RR ¼ 11.1) and smoking habits (ever smoked: RR ¼ 3.1; women with PPTD had smoked more cigarettes for a longer period of time). The sensitivity of TPOAb testing was highest at 12 weeks gestation (0.67). The ppv of TPOAb was 0.31-0.75 (depending on time of testing and concentration), increasing slightly to 0.38-0.80 when combined with bottle feeding or smoking habits. There appeared to be an autoimmune form of PPTD in 2/3 of cases and a nonautoimmune form; women with the autoimmune form were at risk for developing permanent hypothyroidism. Conclusions: A maximum of 2/3 of PPTD cases can be predicted from the presence of TPOAb because 1/3 remained negative for TPOAb. The most appropriate time for TPOAb testing is in the first trimester of pregnancy. The combination of TPOAb testing with anamnestic determinants of PPTD does not increase ppv substantially.

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Long Term Follow-Up and HLA Association in Patients With Postpartum Hypothyroidism*

Cited by 110 publications

References 24 publications

The occurrence of permanent thyroid failure in patients with subclinical postpartum thyroiditis

The occurrence of permanent thyroid failure in patients with subclinical postpartum thyroiditis

2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum

Prediction of post partum thyroid dysfunction: can it be improved?

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