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Recommendation 85
All patients with depression, including
postpartum depression, should be
screened for thyroid dysfunction.
(Strong recommendation, Low quality
evidence)
QUESTION 103 - WHAT IS THE TREATMENT FOR THE
THYROTOXIC PHASE OF POSTPARTUM THYROIDITIS?
Recommendation 86
During the thyrotoxic phase of PPT, symptomatic women
may be treated with beta-blockers. A beta-blocker which
is safe for lactating women, such as Propranolol or
Metoprolol, at the lowest possible dose to alleviate
symptoms is the treatment of choice. Therapy is
typically required for a few weeks. (Strong
recommendation, Moderate quality evidence)
Recommendation 87
Antithyroid drugs are not recommended for
the treatment of the thyrotoxic phase of
PPT.
(Strong recommendation, High quality
evidence)
QUESTION 104 - ONCE THE THYROTOXIC PHASE OF POSTPARTUM
THYROIDITIS RESOLVES, HOW OFTEN SHOULD TSH BE
MEASURED TO SCREEN FOR THE HYPOTHYROID PHASE?
Recommendation 88
Following the resolution of the thyrotoxic phase
of PPT, serum TSH should be measured in
approximately 4-8 weeks (or if new symptoms
develop) to screen for the hypothyroid phase.
(Strong recommendation, High quality evidence)
QUESTION 105 - WHAT IS THE TREATMENT FOR THE
HYPOTHYROID PHASE OF POSTPARTUM THYROIDITIS?
Recommendation 89
Levothyroxine should be considered for women with
symptomatic hypothyroidism due to PPT. If treatment is
not initiated, their TSH level should be repeated every 4-8
weeks until thyroid function normalizes. Levothyroxine
should also be started in hypothyroid women who are
attempting pregnancy or who are breastfeeding. (Weak
recommendation, Moderate quality evidence)
QUESTION 106 - HOW LONG SHOULD LEVOTHYROXINE
BE CONTINUED ONCE INITIATED?
Recommendation 90
If levothyroxine is initiated for PPT, discontinuation
of therapy should be attempted after 12 months.
Tapering of levothyroxine should be avoided when
a woman is actively attempting pregnancy or is
pregnant. (Weak recommendation, Low quality
evidence)
QUESTION 107 - HOW OFTEN SHOULD THYROID FUNCTION
TESTING BE PERFORMED AFTER THE HYPOTHYROID PHASE OF
POSTPARTUM THYROIDITIS RESOLVES?
Recommendation 91
Women with a prior history of PPT should
have TSH testing annually to evaluate for the
development of permanent hypothyroidism.
(Strong recommendation, High quality
evidence)
QUESTION 108 - DOES TREATMENT OF THYROID ANTIBODY
POSITIVE EUTHYROID WOMEN DURING PREGNANCY PREVENT
POSTPARTUM THYROIDITIS?
Recommendation 92
Treatment of euthyroid thyroid antibody positive
pregnant woman with either levothyroxine or
iodine to prevent PPT is ineffective and is not
recommended. (Strong recommendation,
High quality evidence)
XIII. Screening for Thyroid
Dysfunction Before or During
Pregnancy
QUESTION 111 – SHOULD WOMEN BE UNIVERSALLY TESTED FOR
THYROID FUNCTION BEFORE OR DURING PREGNANCY?
Recommendation 93
There is insufficient evidence to
recommend for or against universal
screening for abnormal TSH
concentrations in early pregnancy. (No
recommendation, Insufficient evidence)
Recommendation 94
There is insufficient evidence to recommend for
or against universal screening for abnormal
TSH concentrations preconception, with the
exception of women planning assisted
reproduction or those known to have positive
TPOAb. (No recommendation, Insufficient
evidence)
Recommendation 95
Universal screening to detect low free
thyroxine concentrations in pregnant
women is not recommended. (Weak
recommendation, Moderate quality
evidence)
Recommendation 96
All pregnant women should be verbally
screened at the initial prenatal visit for any
history of thyroid dysfunction, and prior or
current use of either thyroid hormone (LT4) or
anti-thyroid medications (MMI, CM, or PTU).
(Strong recommendation, High quality
evidence)
Recommendation 97
All patients seeking pregnancy, or newly pregnant, should
undergo clinical evaluation. If any of the following risk
factors are identified, testing for serum TSH is recommended.
1. A history of hypothyroidism/hyperthyroidism or current
symptoms/signs of thyroid dysfunction
2. Known thyroid antibody positivity or presence of a goiter
3. History of head or neck radiation or prior thyroid surgery
4. Age >30 years
5. Type 1 diabetes or other autoimmune disorders
6. History of pregnancy loss, preterm delivery, or infertility
7. Multiple prior pregnancies (> 2)
8. Family history of autoimmune thyroid disease or thyroid
dysfunction
9. Morbid obesity (BMI > 40 kg/m2)
10. Use of amiodarone or lithium, or recent administration of
iodinated radiologic contrast
11. Residing in an area of known moderate to severe iodine
insufficiency (Strong recommendation, Moderate quality
XIV. Future Research Directions
A study evaluating the impact of iodine supplementation in pregnant
women with the mildest form of iodine deficiency (median urinary
iodine concentrations 100-150 μg/L).
A RCT of early levothyroxine intervention (at 4-8 weeks) in women
with either subclinical hypothyroidism or isolated hypothyroxinemia
to determine effects on child IQ.
A study focused on the effects of iodine supplementation during
lactation on infant thyroid function and cognition.
A study to determine safe upper limits for iodine ingestion in
pregnancy and lactation.
A comprehensive study to assess the iodine status of
pregnant and lactating women in the United States.
A trial assessing the optimal targeted free T4 level in
pregnant women treated for hyperthyroidism.
Another well powered, prospective, randomized
interventional trial of levothyroxine in euthyroid patients who
are anti-TPO positive for the prevention of miscarriage and
preterm delivery.
A study to evaluate the impact of levothyroxine therapy in
euthyroid thyroid antibody positive women with recurrent
pregnancy loss.
Basic and clinical studies aimed at elucidating the mechanisms
underlying thyroid antibody-associated adverse pregnancy
outcomes.
Studies examining the effects of TGAb on pregnancy outcomes.
A study investigating the best criteria that can be used to predict
which patients with hyperthyroidism can safely tapered off
antithyroid medication in the first trimester
A study evaluating the safest timing of administration of the
different antithyroid
drugs for management of hyperthyroidism in pregnancy.
Novel ways to differentiate fetal hyperthyroidism from fetal
hypothyroidism when a fetal goiter is detected.