3099-GMI

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GAZZ MED ITAL - ARCH SCI MED 2014;173:1-2

Prevalence of pregnancy induced thyroid

dysfunction and the characteristics of the associated
anaemia in primigravida Saudi women during
the first trimester: A cross-sectional study
B. REFAAT

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Aim. Aim of the study was to measure the Laboratory Medicine Department
prevalence and types of thyroid disorders us- Faculty of Applied Medical Sciences
ing the American Thyroid Association guide- Umm Al‑Qura University
lines and to investigate their relationship Al Abdeyah, Makkah, KSA

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with anemia frequency in primigravida fe-
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males during the first trimester.
Methods. Blood samples were collected from
500 primigravida females with no history
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of thyroid disease, chronic diseases and/
T hyroid dysfunction is a worldwide phe-
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or anaemia to measure serum TSH, free T4, nomenon in women and the preva-
erythrocyte indices and iron parameters.
lence increases during pregnancy.1, 2 Mater-
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Results. Thyroid disorders were detected in

162 participants (32.4%) and the most prev- nal thyroid disorders can lead to obstetric
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alent disorder was occult hypothyroidism complications and irreversible effects on

(102/162), followed by overt hypothyroidism the neonates neurodevelopment.2 A vari-
(32/162) and hypothyroxinaemia (24/162). ety of thyroid disorders have been report-
Anaemia was detected in 66 females with ab-
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ed during pregnancy and the prevalence

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normal thyroid profile (40.7%) and the preva-

lence was significantly higher (P<0.05) com- of hypothyroidism (2.5%) is higher than
pared to euthyroid (15.4%). The RBCs count, hyperthyroidism (0.2%).1 Isolated hypothy-
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haemoglobin, haematocrit value, serum iron roxinaemia, another thyroid dysfunction

and serum ferritin were significantly lower associated with pregnancy, have also been
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in thyroid disorder compared to euthyroid described and the reported prevalence

group (P<0.05). Serum free T4 significantly
correlated with RBCs count, haemoglobin and ranges between 1.3-30%.3 This condition
haematocrit, while TSH correlated with ferri- is characterised by isolated decrease in se-
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tin and total iron binding capacity (P<0.05).
Conclusion. Thyroid disorders are common
in primigravida Saudi females during the
first trimester and they are associated with
an increase in the frequency of anaemia.
Further studies are needed to identify the
mechanism(s) by which thyroid dysfunction
induces anaemia during pregnancy.
Key words: Thyroid - Anemia - Pregnancy.
Corresponding author: B. Refaat, Department of Labora-
tory Medicine, Faculty of Applied Medical Sciences, Umm
Al-Qura University, Makkah, PO Box 7607, KSA.
E-mail: bassem.refaat@yahoo.co.uk
rum free thyroxin (FT4) and normal thyroid
stimulating hormone (TSH) levels.3
Thyroid dysfunctions have also been
associated with the development of anae-
mia 4-9 and it has been found that all haema-
tological parameters return to normal when
a euthyroid state is achieved.10-14 Anaemia
is another major health problem affecting
women during pregnancy and the World
Health Organization has estimated that 58%
of pregnant women are anaemic in devel-
oping countries.15 Anaemia during early

Vol. 173 - No. 1 GAZZETTA MEDICA ITALIANA - ARCHIVIO PER LE SCIENZE MEDICHE 1
REFAAT Thyroid disorders and anaemia in pregnancy
pregnancy is also associated with preterm
deliveries, low birth weight and perinatal
mortality.15
Little is known about the prevalence of
thyroid disorders and the characteristics of
associated anaemia during pregnancy in
Saudi Arabia.
Therefore, the aim of the current study
was to measure the prevalence of thyroid
disorders according to the new guidelines
set by the American thyroid Association for
the diagnosis and management of thyroid
disease during pregnancy 16 and to study
their relationship with types and frequency
of anaemia, erythrocyte indices and iron
parameters in primigravida females during
the first trimester. O compared with those obtained from the
Materials and methods
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Ethical approval
Ethical approval was obtained from Umm
Al-Qura Institution Review Ethics Commit-
tee before starting the study and all blood
samples were collected following obtaining
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informed written consent from all the par-
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ticipants.
Study design
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Five millilitres of blood samples were col-
lected from 500 primigravida women (age
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range between 22 and 34 years) during the
first trimester (gestational age range be-
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Table I.—Main inclusion and exclusion criteria.
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Principle inclusion criteria
Primigravida
Patient age ≥ 18 ≤ 35 years.
Spontaneous conception
First trimester of pregnancy (<14 weeks)
Singleton pregnancy
Not taking vitamin and/or iron supplementation
No history of thyroid disorder
Not known to be anaemic
No history of autoimmune condition (e.g. type 1 DM,
rheumatoid arthritis, etc.)
No concurrent chronic disease (e.g. renal, respiratory,
cardiac, liver, type 2 diabetes mellitus and hypertension)
2 GAZZETTA MEDICA ITALIANA - ARCHIVIO PER LE SCIENZE MEDICHE ?? 2014
tween 4 and 12 weeks) according to the in-
clusion and exclusion criteria (Table I) dur-
ing their initial visit to the antenatal clinic in
the University Health Care Centre. Half of
the blood sample (2.5 mL) was collected on
EDTA and the rest was on plain tube.
This trial is a cross-sectional study to
measure the prevalence of thyroid disorders
and the characteristics of their associated
anaemia during pregnancy in Saudi females.
Following the identification of thyroid dys-
function, the participants were divided into
2 groups according to their thyroid profile
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results. Females with normal thyroid profile
served as “control group” and their haema-
tological results and iron parameters were
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“thyroid disorder” group.
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Measurements of thyroid hormones
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Whole blood samples (2.5 mL) were col-
lected through venepuncture, centrifuged at
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3000 rpm for 20 minutes, and then the ob-
tained serum samples were frozen at -20 °C
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for storage till used. The quantitative meas-
urement of thyroid stimulating hormone
(TSH) and free thyroxin hormone (FT4) was
done using electro-chemiluminescence im-
munoassay (ECLIA) on Cobas e411 (Roche
Diagnostics International Ltd, Switzerland)
according to the manufacturer protocol.
The normal range according to the manu-
facturer for TSH and free T4 was 0.27-4.20
µIU/mL and 12-22 pmol/L, respectively. The
detection sensitivity was 0.005 µIU/mL for
Principle exclusion criteria
Multiparous
Patient age < 18 or > 35 years.
Assisted conception
Second/third trimester (> 14 weeks)
Multiple pregnancy
Taking vitamin and/or iron supplementation
History or known current thyroid disorder
Known to be anaemic
Autoimmune condition (e.g. type 1 DM, rheumatoid
arthritis, etc.)
Concurrent chronic disease (e.g. renal, respiratory, cardiac,
liver, type 2 diabetes mellitus and hypertension)
Thyroid disorders and anaemia in pregnancy REFAAT
TSH and 0.3 pmol/L for FT4. The intra- and
interassay coefficients of variations for FT4
were 1.7 and 3.9% and for TSH were 1.4%
and 3.4%, respectively.
The classification of thyroid dysfunctions
were based on the guidelines of the Ameri-
can thyroid Association for the diagnosis
and management of thyroid disease during
pregnancy.16 The normal range for FT4 dur-
ing pregnancy (10.5 to 22.3 pmol/L) was
adapted from the currently available report
that included normal pregnant participants
from the Gulf Region.17 Hypothyroidism
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was considered when TSH >2.5 µIU/mL and
the level of FT4 defined the type as either
primary (FT4 <10.5 pmol/L) or subclinical
(FT4 ≥10.5 pmol/L). Hyperthyroidism was
O Mann-Whitney were used to compare be-
considered for TSH ≤0.03 µIU/mL and/or
FT4 >22.3 pmol/L. Hypothyroxinaemia was
define by the presence of low FT4 (≤10.5
pmol/L) with normal serum TSH levels
(<2.5 µIU/mL).
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Determination of hematological profile
Whole blood samples (2.5 mL) collected
on EDTA were processed on Sysmex XS 500
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with 5-parameter differential (Sysmex, IL,
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USA) for the measurement of haemoglobin
concentrations, RBCs count, packed cell
volume (PCV), mean corpuscular volume
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(MCV) and mean corpuscular haemoglobin
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(MCH). Anaemia was defined by haemo-
globin level <11 g/dL, microcytosis by MCV
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<80 fL, macrocytosis by MCV >98 fL, and
hypochromic by MCH <25 pg.18
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Iron parameters
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The quantitative measurement of serum
iron, ferritin and total iron binding capac-
ity (TIBC) were performed on Cobas e411
(Roche Diagnostics International Ltd, Swit-
zerland) according to the manufacturer pro-
tocol. Transferrin saturation (TfSat) was cal-
culated as follow: [Serum iron/TIBC] X100.
Iron normal range according to the man-
ufacturer was 37-145 µg/dL, kit sensitivity
of 5µg/dL and the intra- and interassay vari-
ation was <4% and 6.2%, respectively. The
TIBC normal range was 228-428 µg/dL as
Vol. 173 - No. 1 GAZZETTA MEDICA ITALIANA - ARCHIVIO PER LE SCIENZE MEDICHE 3
defined by the manufacturer, sensitivity was
16.8 µg/dL and the intra- and interassay was
1.6% and 2.4%, respectively. The normal
range for the ferritin kit was 7-283 ng/mL,
sensitivity was 0.5 ng/mL and the intra- and
interassay was 5.5% and 7.1%, respectively.
Statistical analysis
Statistical analysis of the results was
performed using SPSS version 16. Cross-
tabulation followed by Chi square (X2) test
were used for frequency analysis. Normal-
ity and homogeneity of data were assessed
with the Kolmogorov and Smirnoff test and
Levene test, respectively. Student’s t test or
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tween 2 groups, based on normality. One
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way ANOVA followed by LSD post hoc test
were used to compare between more than
2 groups. Correlations were determined us-
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ing Pearson’s test. P value < 0.05 was con-
sidered significant.
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Results
Prevalence and types of thyroid disorders
and anaemia
Overall, thyroid disorders and anae-
mia were detected in 162 (32.4%) and
118 (23.6%) out of 500 pregnant females,
respectively. Anaemia was detected in 52
out of 338 participants with normal thyroid
profile (15.3%) and in 66 out 162 females
(40.7%) with thyroid abnormalities (Table
II). The prevalence of anaemia was statis-
tically different between the “control” and
“thyroid disorder” groups (P=0.00003).
There was no significant difference
(P>0.05) in the mean age between the
“control” (28.6±4.9 years) and the “thyroid
disorder” (29.2±5 years) groups or between
“Non-anaemic” (28.8±4.8 years) and “anae-
mic” (28.7±5.4 years) groups (P>0.05). Addi-
tionally, there was no significant difference
in the gestational age between “euthyroid”
(6±2.6 weeks) and “thyroid disorder” group
(5.8±2.3 weeks).
Furthermore, the mean ± standard devia-
REFAAT Thyroid disorders and anaemia in pregnancy

Table II.—The prevalence and types of thyroid disorders and anaemia (a = P<0.05 compared to normal thyroid;
b = P<0.05 compared to primary hypothyroidism; c = P<0.05 compared to subclinical hypothyroidism and
d = P<0.05 compared to primary hyperthyroidism).
Thyroid disorder (162 females)
Normal thyroid Overt Occult
(n = 338) Hyperthyroidism Hypothyroxinaemia
hypothyroidism hypothyroidism (n = 6) (n = 24)
(n = 32) (n = 102)
Non-anaemic 286 females 16 females 66 females 6 females 10 females
(n = 382) (84.6%) (50%) (62.5%) a (100%) (41.6%) a
Anaemic Microcytic 40 females 12 females 32 females Zero female 2 females
(n = 118) Hypochromic (11.8%) (37.5%) a (31.4%) a (0%) (8.4%) b,c
(86 females)
Normocytic 12 females 4 females 4 females Zero female 12 females
Normochromic (3.6%) (12.5%) (3.9%) (0%) (50%) a,b,c
(32 females)

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Figure 1.—Mean ± SD of (1) RBCs count, (2) haemoglobin concentration, (3) PCV and (4) MCV in normal and abnor-
mal thyroid (* =P<0.05 compared to normal thyroid).

tion (SD) of RBCs count (4.1±0.5 X 106/µL),
haemoglobin concentration (11.5±1.3 gm/
dL), PCV (35.7±1.3 %) (Figure 1), median of
serum iron (67.2 µg/dL; range: 8-141 µg/dL),
ferritin (30.5 ng/mL; range: 3.15-200 ng/mL)
and TfSat (21.2%; range: 1-45%) were signif-
icantly lower and median TIBC was signifi-
cantly higher (394.3 µg/dL; range: 200-889
µg/dL) in the ‘thyroid disorder’ group when
compared to the “control” group (Figure 2).
However, there was no significant differ-
ence for the MCV and MCH between the
2 groups. Significant differences were de-
tected between the different thyroid groups

4 GAZZETTA MEDICA ITALIANA - ARCHIVIO PER LE SCIENZE MEDICHE ?? 2014

Thyroid disorders and anaemia in pregnancy REFAAT
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Figure 2.—Median of (1) serum iron, (2) TIBC, (3) ferritin and (4) transferrin saturation in normal and abnormal thy-
roid (* = P<0.05 compared to normal thyroid).
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in erythrocyte indices and iron parameters
(Table III).
In the 500 study participants, 32 females
had primary hypothyroidism (6.4%), 102
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subclinical hypothyroidism (20.4%), 6 pri-
mary hyperthyroidism (1.2%) and 24 with
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hypothyroxinaemia (4.8%). Statistical analy-
sis showed that the prevalence of subclinical
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thyroiditis was significantly higher (P<0.01)
compared to the other types (Table II).
The types of anaemia detected in the
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“anaemic group” (118 participants) were: 86
females with microcytic hypochromic (72.8%)
and 32 normocytic normochromic (27.2%)
anaemia. The prevalence of microcytic hy-
pochromic anaemia was significantly higher
(P=0.0003) compared to the other type.
Prevalence and types of anaemia according
to thyroid profile
In participants with normal thyroid pro-
file (N.=338), 40 females had microcytic
Vol. 173 - No. 1 GAZZETTA MEDICA ITALIANA - ARCHIVIO PER LE SCIENZE MEDICHE 5
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hypochromic anaemia (11.8%) and 12 fe-
males with normocytic normochromic
(3.6%). On the other hand, microcytic hy-
pochromic anaemia was detected in 46 fe-
males (28.4%) and normocytic normochro-
mic in 20 (12.3%) out of 162 participants
with thyroid dysfunction. The prevalence
of microcytic hypochromic and normocytic
normochromic anaemia was significant-
ly higher in the “thyroid disorder” group
when compared to the “euthyroid” group
(Figure 3). Furthermore, microcytic hy-
pochromic anaemia was significantly more
prevalent within the ‘normal thyroid’ and
‘thyroid disorder’ groups compared to nor-
mocytic normochromic anaemia (P<0.05).
In the 32 females with primary hypothy-
roidism, anaemia was detected in 16 cases
(50%). Twelve cases were diagnosed with
microcytic hypochromic anaemia (37.5%)
and 4 females with normocytic normochro-
mic anaemia (12.5%). Anaemia was detect-
ed in 36 out of 102 females with subclini-
REFAAT Thyroid disorders and anaemia in pregnancy

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Figure 3.—Prevalence of anaemia according to (1) thyroid status, (2) the different types of thyroid disorders and (3)
types and prevalence of anaemia according the different types of thyroid disorder.

6 GAZZETTA MEDICA ITALIANA - ARCHIVIO PER LE SCIENZE MEDICHE ?? 2014

Thyroid disorders and anaemia in pregnancy REFAAT

Table III.—Mean ±SD of erythrocyte indices and median of iron parameters (a = P< 0.05 compared to
normal thyroid; b = P < 0.05 compared to primary hypothyroidism; c = P < 0.05 compared to subclinical
hypothyroidism and d = P < 0.05 compared to primary hyperthyroidism).
Overt Occult
Normal thyroid Hyperthyroidism Hypothyroxinaemia
hypothyroidism hypothyroidism
RBCs count (X106/µL) 4.6 ±0.43 4.1 ±0.2a 4.3 ±0.3a 4.5 ±0.15b,c 3.9 ±0.5a,d
Hb (g/dL) 12.4 ± 1.1 11.3 ±0.7a 10.9 ±1.5a 12 ±1.3b,c 11.1 ±1.2a,d
PCV (%) 37.2 ±3.6 35.6 ±2.8a 37.3 ±3.5 37 ±1.6 33.8 ±3.5a,c,d
MCV (fL) 84.7 ±7.3 84.6 ±5.8 82.5 ±8.1 85.7 ±2.6 85.1 ±6.1
MCH (pg) 27.9 ±2.8 27.6 ±2 27 ±3 27.5 ±2.3 28.2 ±2.6
96.6 61.3 66 107.2 70
Serum iron (µg/dL)
(range: 5.6-155) (range: 8.6-132) a (range: 13-141) a (range: 45-120) (range: 11-108) a
352 386 398 357 375
TIBC (µg/dL)
(range: 198-889) (range: 200-821) (range: 226-821) (range: 319-375) (range: 259-889)
77 24.2 30.3 72.5 46.8

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Ferritin (ng/mL)
(range: 1-231) (range: 4-200) a (range: 3-199) a (range: 50-94) b,c (range: 3-178) a,d
25 16.9 19.7 26.3 21.8
Transferrin saturation (%)
(range: 1-55) (range: 1-37) a (range: 2-45.2) a (range: 11-43) b,c (range: 1-40) a,d

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cal hypothyroidism (35.3%) and according
to the type of anaemia 32 females had
microcytic hypochromic anaemia (31.4%)
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detected only in 6 females and all were not
anaemic. In the hypothyroxinaemia group
(N.=24), 14 females were found anaemic

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and 4 females had normocytic normochro- (58.3%), with 2 females diagnosed with mi-
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mic (3.9%). Primary hyperthyroidism was crocytic hypochromic anaemia (8.3%) and
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Figure 4.—Correlation of serum free T4 with (1) RBCs count, (2) haemoglobin concentration, (3) MCV; and (4) cor-
relation of serum TSH with serum ferritin.

Vol. 173 - No. 1 GAZZETTA MEDICA ITALIANA - ARCHIVIO PER LE SCIENZE MEDICHE 7
REFAAT Thyroid disorders and anaemia in pregnancy

Table IV.—Results of correlation analysis using Pearson’s test for the haematological indices with
TSH and FT4.
Transferrin
RBCs Hb HCT MCV MCH IRON TIBC Ferritin Saturation
R value -0.033 -0.052 -0.021 -0.033 -0.036 -0.166* 0.127* -0.230* -0.195*
TSH
P value 0.4 0.2 0.6 0.4 0.4 0.009 0.004 0.003 0.002
R value 0.335* 0.395* 0.402* 0.036 0.041 0.060 -0.136* 0.009 0.086
FT4 P value 0.0005 0.00002 0.00003 0.4 0.3 0.1 0.002 0.8 0.5

12 females with normocytic normochromic The prevalence of anaemia was significantly

(50%). higher in females with thyroid abnormalities
Microcytic hypochromic anaemia was and it was associated with a decrease in se-
significantly more prevalent in the hy- rum iron, ferritin and transferrin saturation.

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pothyroidism groups while the prevalence Additionally, the prevalence of anaemia was
of normocytic normochromic was signifi- higher in the primary hypothyroidism and
cantly higher in the “hypothyroxinaemia” hypothyroxinaemia groups compared to

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group (P<0.05). Significant difference were
O the other groups. The most common type
also detected in the RBCs count, haemo- of anaemia was microcytic hypochromic

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globin concentrations, PCV, serum iron, and it was more prevalent in females with
ferritin and transferrin saturation between overt and occult hypothyroidism. Alterna-
the different types of thyroid disorders (Ta- tively, normocytic normochromic anaemia

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ble III). was more common in females with hy-
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pothyroxinaemia. Furthermore, serum FT4

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correlated significantly with RBCs count,
Correlations between thyroid hormones
haemoglobin concentrations and PCV. On
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and erythrocyte indices
the other hand, TSH correlated negatively
Significant positive correlation was de- with serum iron, ferritin, transferrin satura-
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tected for serum FT4 with RBCs count, tion and positively with TIBC.
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haemoglobin concentrations and PCV (Fig- The present results suggest that thyroid
ure 4). Additionally, TSH correlated posi- disorders are common in primigravida
tively with TIBC and negatively with se- Saudi women from the Western province
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rum iron, ferritin and transferrin saturation of the kingdom during the first trimester.
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(Table IV). Additionally, it appears that both TSH and

thyroxin play an important role in the proc-
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ess of erythropoiesis during pregnancy and

Discussion that pregnancy induced thyroid disorders
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increases the prevalence of hypochromic

Thyroid disorders and anaemia are com- normocytic and normocytic normochromic
mon health problems and their prevalence in primigravida females during the first tri-
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increases during pregnancy.18-20 Herein, mester of pregnancy.

the prevalence of thyroid disorders were
measured according to the American Thy-
roid Association guidelines in primigravida
females during the first trimester and the
frequency and types of anaemia were clas-
sified according to thyroid profile.
The results showed thyroid abnormalities
in 32.4% of the study population and the
most common thyroid disorder was sub-
clinical hypothyroidism followed by overt
hypothyroidism and hypothyroxinaemia.
Thyroid disorders are a major health
problem and hypothyroidism, either in the
form of overt or occult, is the most com-
mon type in pregnant and non-pregnant
females.7, 21-24 Thyroid diseases affect the
process of haematopoiesis and several
previous reports have shown and associa-
tion between the different types of thyroid
disease and haematological abnormalities.
The most prevalent haematological disor-
der with thyroiditis is anaemia.5, 21, 23, 25, 26

8 GAZZETTA MEDICA ITALIANA - ARCHIVIO PER LE SCIENZE MEDICHE ?? 2014

Thyroid disorders and anaemia in pregnancy REFAAT
The present study agrees with the pre-
vious findings as it showed an overall
prevalence of 32.4% for thyroid disorders.
The majority of cases were subclinical hy-
pothyroidism (20.4%) followed by primary
hypothyroidism (6.4%). The frequency of
both types was significantly higher than
hyperthyroidism (1.2%).
Studies on the frequency of thyroid dis-
orders during pregnancy in the Middle
East, specifically in Saudi Arabia, are limit-
ed in number. The prevalence of overt and
occult hypothyroidism is in the present
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study is higher than the previously report-
ed frequency from several Western socie-
ties (05-2.5% for overt and 4.6-12.5% for
occult hypothyroidism).27 Nevertheless, re-
O abs of Emirates 17 and, to the best of our
sults from pregnant Jordanian women have
shown similar frequency rates to the cur-
rent study for hypothyroidism.28 Therefore,
the observed high frequency of pregnancy
induced thyroid dysfunction merits further
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research and thyroid antibodies profile
and urine iodine should be included to
precisely identify the type and etiology of
thyroid disorder.
Additionally, the current data support
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the hypothesis that thyroid hormones
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play an important role in erythropoiesis
as a significant decrease in the number
of RBCs, haemoglobin concentration and
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packed cell volume was observed between
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the ‘thyroid disorder’ and ‘normal thyroid’
groups and anaemia was detected in 40.7%
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of the females suffering from thyroid dis-
orders compared to 15.3% in those with
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normal thyroid profile.
Maternal hypothyroxinaemia, which is
another form of thyroid disorder associ-
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ated with pregnancy, was first described
by Evelyn Man almost 40 years ago.29 This
condition is considered a milder form of
thyroid dysfunction and it is characterised
by a merely decrease in serum free T4 with
normal serum TSH levels.3 The currently
reported prevalence of hypothyroxinaemia
ranges between 1.3-30%.30-34
The prevalence of hypothyroxinaemia
is the present study was 4.8% and it cor-
relates with the aforementioned reports.
The decrease in Free T4 during early preg-
Vol. 173 - No. 1 GAZZETTA MEDICA ITALIANA - ARCHIVIO PER LE SCIENZE MEDICHE 9
nancy without change in TSH level could
be in part by the physiological effect of
β-chorionic gonadotropin on the serum
level of thyroxin binding globulin and the
subsequent increase in total T4 levels.20
The observed hypothyroxinaemia could
also be due to iodine deficiency, which
have been reported either in patients with
hypothyroidism or during pregnancy in the
same region of the Kingdom.35, 36 Hence,
the present data should be interpreted in
the light that evaluation of iodine deficien-
cy was not performed in the current study.
Additionally, the applied normal range in
the current study for FT4 was adopted
from a previous report from the United Ar-
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knowledge, this is the only study generat-
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ed from the Gulf region till present. There-
fore, the present report indicates the need
for further studies to measure the iodine
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intake during pregnancy and to determine
the normal range of thyroid hormones dur-
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ing pregnancy in the Saudi population as
recommended by several scientific socie-
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ties.19, 27, 37-40
Although anaemia was reported with
the different types of thyroiditis, it is more
common in patients with hypothyroidism
compared to hyperthyroidism.5, 10, 21, 22, 25, 41
The decreased prevalence of anaemia with
hyperthyroidism could be explained by
the observed increase in erythrocyto-
sis.5, 21 The current study correlates with
the earlier observations as it demonstrates
a significant increase in the prevalence of
anaemia in both types of hypothyroidism
group compared to hyperthyroidism. Addi-
tionally, there was no significant difference
in the prevalence of anaemia in pregnant
females with overt hypothyroidism and
those with hypothyroxinaemia, support-
ing the hypothesis that thyroid hormones
play an important role in haematopoiesis.
However, the present results suggest that
the type of anaemia could be dependent
on the form of thyroid dysfunction as mi-
crocytic hypochromic anaemia was associ-
ated with hypothyroidism and normocytic
normochromic anaemia was frequent with
maternal hypothyroxinaemia.
REFAAT Thyroid disorders and anaemia in pregnancy
Several types of anaemia have been re-
ported with thyroid disorders and they
include normocytic normochromic, mi-
crocytic and/or macrocytic hypochromic,
and the severity of anaemia is related to
the degree of thyroid abnormality.12, 13
Anaemia of chronic disease, which is in
the form of normocytic normochromic, is
the most frequently encountered type of
anaemia in non-pregnant females suffering
from hypothyroidism.5, 21 It has been sug-
gested that thyroid hormones deficiency
may lead to bone marrow repression and/
or decrease in erythropoietin production
due to the reduction of O2 requirements.11
Hypochromic microcytic anaemia is less
frequently associated with hypothyroidism
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in non-pregnant females and it is mainly
due to iron deficiency.11-13
Although the types of anaemia detected
in the current study were similar to those
reported previously with hypothyroidism,
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the most common type was microcytic hy-
pochromic followed by normocytic nor-
mochromic anaemia. During pregnancy,
there is an increase demand for iron and
it has been reported that the thyroid hor-
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mones regulate the iron metabolism.42-44
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Additionally, decrease in serum iron levels
has been observed in patients with sub-
clinical hypothyroidism.45 Moreover, sub-
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clinical hypothyroidism was investigated
R
in iron-deficient patients and who did not
response to iron salt alone. Interestingly,
E
the combination of levothyroxine and iron
salt has shown a better performance com-
IN
pared to each treatment alone.43
The present study supports the hypoth-
esis that hypothyroidism, either in the form
M
of overt or occult, decreases the serum
concentrations of iron. This is further sup-
ported by the current observation of signif-
icant correlations of serum TSH positively
with TIBC and negatively with serum fer-
ritin, which are known to reflect the iron
stores in the body.46 Hence, more studies
are necessary to explore the nutritional
factors contributing to the development
of thyroid and anaemia during pregnancy
and the role of thyroid hormones in the
regulation of iron.
10 GAZZETTA MEDICA ITALIANA - ARCHIVIO PER LE SCIENZE MEDICHE ?? 2014
Currently there no report on the prev-
alence and types of anaemia associated
with hypothyroxinaemia. The present re-
sults showed that this thyroid disorder was
mainly associated with normocytic normo-
chromic anaemia, supporting the hypoth-
esis that thyroxin plays a key role in the
regulation of bone marrow activity and
erythropoiesis, which could be through
stimulating the production of erythropoie-
tin hormone.11, 47 However, it appears from
the present study that this hormone does
not affect the iron metabolism during the
F
first trimester of pregnancy as there was
no significant correlation between serum
A
free T4 and the iron parameters. Additional
IC
thyroxin on the production of erythropoi-
etin and the metabolism of iron.
In conclusion, thyroid disorders are com-
D
mon in primigravida Saudi females in the
western province of the kingdom and they
are associated with a decrease in RBCs
E
count, haemoglobin concentration, haema-
M
tocrit value, iron parameters and increase
in the frequency of anaemia. Further stud-
ies are needed to identify the underlying
mechanism(s) and aetiological factors con-
tributing to the development of thyroiditis
induced anaemia during pregnancy.
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Acknowledgments.—The author would like to thank Ms.
Bashayer Al-Barakati and Ms. Athar Khojah from the Labo-
ratory Medicine Department, Faculty of Applied Medical
Sciences, Umm Al-Qura University for processing the sam-
ples.
Conflicts of interest.—The authors certify that there is
no conflict of interest with any financial organization re-
garding the material discussed in the manuscript.
Received on July 17, 2014.
Accepted for publication on October 20, 2014.
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