Feldt-Rasmussen Ulla
Department of Nephrology and Endocrinology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
Institute of Clinical Medicine, Faculty of Health and Clinical Sciences, Copenhagen University, Copenhagen, Denmark.
Thyroid Res. 2025 May 27;18(1):22. doi: 10.1186/s13044-025-00235-w.
Appropriate management of thyroid dysfunction in pregnancy is challenging in both its primary, secondary and tertiary forms of the disease. Primary hypothyroidism is by far most prevalent globally. Main causes are insufficiency of iodide supplementation in developing countries and autoimmunity in developed countries. However, after a very successful global implementation by World Health Organisation over decades accompanied by specific recommendations for management of the iodide supplementation during pregnancy, recent studies found that women both in USA and EU are again mild to moderately iodide deficient during pregnancy or going through assisted fertility treatment. This poses a disturbing risk in relation to foetal neurological and brain development. The diagnosis and treatment monitoring of the thyroid function during pregnancy are very challenged due to the extensive physiological as well as pathophysiological adaptations of the thyroid axis hormones to encompass a sufficient foetal supply. This is distorting the hormone measurements, since the normal limits are exceeded, and current biochemical methods are not calibrated for the adapted concentrations. Even though clinical guidelines exist there are still gaps in the evidence-based recommendations to guide clinicians to thyroid function management during pregnancy. Debut of hypothyroidism during pregnancy requires immediate diagnosis as it can lead to poor foetal outcome with intrauterine growth restriction and foetal demise on top of the risk for the neurocognition. Hypothyroidism in stable replacement treatment needs careful monitoring during pregnancy to adapt to the physiological changes in the requirement of the thyroid hormone thyroxine, and combination therapy with triiodothyronine is contraindicated. The frequent use of assisted reproduction technology (ART) with controlled ovarian hyperstimulation in these patient groups having disease induced low fertility has created an unrecognised risk of under-replacement due to accelerated oestrogen stimulation with increased risk of severe complications for both the woman and foetus. Longitudinal studies of the thyroid function bridging pre-ART, through ART to pregnancy and postpartum in different clinical settings are recommended. The area needs consensus recommendations between gynaecologists and endocrinologists in specialised centres to alleviate such increased gestational risk. There is a strong need of more research on improvement of thyroid hormone replacement, and biomarkers for treatment optimisation in this field of non-communicable diseases, which suffers from both limited attention from the health authorities and poor funding.
孕期甲状腺功能障碍的适当管理在其原发性、继发性和三发性疾病形式中都具有挑战性。原发性甲状腺功能减退是目前全球最普遍的。主要原因在发展中国家是碘补充不足，在发达国家是自身免疫。然而，在世界卫生组织数十年来非常成功的全球实施以及针对孕期碘补充管理的具体建议之后，最近的研究发现，美国和欧盟的女性在孕期或接受辅助生育治疗期间再次出现轻度至中度碘缺乏。这对胎儿神经和大脑发育构成了令人不安的风险。由于甲状腺轴激素为确保胎儿有足够的供应而发生广泛的生理以及病理生理适应，孕期甲状腺功能的诊断和治疗监测面临很大挑战。这扭曲了激素测量结果，因为超出了正常范围，而且目前的生化方法未针对适应后的浓度进行校准。尽管有临床指南，但在指导临床医生进行孕期甲状腺功能管理的循证建议方面仍存在差距。孕期首次出现甲状腺功能减退需要立即诊断，因为它除了会导致神经认知风险外，还会导致胎儿结局不良，出现宫内生长受限和胎儿死亡。处于稳定替代治疗的甲状腺功能减退患者在孕期需要仔细监测，以适应甲状腺激素甲状腺素需求的生理变化，并且禁忌与三碘甲状腺原氨酸联合治疗。在这些因疾病导致生育力低下的患者群体中，频繁使用辅助生殖技术（ART）并进行控制性卵巢过度刺激，由于雌激素刺激加速，导致替代不足的风险未被认识到，这增加了女性和胎儿出现严重并发症的风险。建议在不同临床环境下对甲状腺功能进行纵向研究，涵盖ART前、ART期间直至孕期和产后。该领域需要专业中心的妇科医生和内分泌学家达成共识建议，以减轻这种增加的妊娠风险。迫切需要更多关于改善甲状腺激素替代的研究，以及在这个非传染性疾病领域用于优化治疗的生物标志物，该领域既受到卫生当局的关注有限，又缺乏资金支持。
