ACOG PRACTICE BULLETIN SUMMARY

Clinical Management Guidelines for Obstetrician–Gynecologists

NUMBER 223 (Replaces Practice Bulletin Number 148, April 2015)

For a comprehensive overview of these recommendations, the full-text Scan this QR code
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version of this
Practice Bulletin.

Committee on Practice Bulletins—Obstetrics. This Practice Bulletin was developed by the Committee on Practice Bulletins—
Obstetrics with the assistance of Brian M. Casey, MD and Torri D. Metz, MD, MS in collaboration with American Academy of
Family Physicians liaison Jeff Quinlan, MD.

Thyroid Disease in Pregnancy

Both thyrotoxicosis and hypothyroidism are associated with adverse pregnancy outcomes. There also is concern about
the effect of overt maternal thyroid disease on fetal development. In addition, medications that affect the maternal
thyroid gland can cross the placenta and affect the fetal thyroid gland. This document reviews the thyroid-related
pathophysiologic changes that occur during pregnancy and the effects of overt and subclinical maternal thyroid
disease on maternal and fetal outcomes. This Practice Bulletin has been updated with information on the diagnosis and
the management of thyroid disease in pregnant women and includes a new clinical algorithm on management of
thyroid disease in pregnancy.

Clinical Management Questions

< Which pregnant patients should be screened for thyroid disease?
< What laboratory tests are used to diagnose thyroid disease during pregnancy?
< What medications should be used to treat overt hyperthyroidism in pregnancy, and how should they be
administered and adjusted during pregnancy?
< What medications should be used to treat overt hypothyroidism in pregnancy, and how should they be
administered and adjusted during pregnancy?
< Is there a role for screening or testing for thyroid autoantibodies in pregnancy?
< What changes in thyroid function occur with hyperemesis gravidarum, and should thyroid function tests
be performed routinely in women with hyperemesis gravidarum?
< How are thyroid storm and thyrotoxic heart failure diagnosed and treated in pregnancy?

1496 VOL. 135, NO. 6, JUNE 2020 OBSTETRICS & GYNECOLOGY

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< How is thyroid function in the fetus evaluated?
< How should a thyroid nodule or thyroid cancer during pregnancy be assessed?
< How is postpartum thyroiditis diagnosed and treated?

end of the normal pregnancy range. Among women

Recommendations
The following recommendations are based on good and
consistent scientific evidence (Level A):
< Universal screening for thyroid disease in pregnancy
is not recommended because identification and
treatment of maternal subclinical hypothyroidism has
not been shown to result in improved pregnancy
outcomes and neurocognitive function in offspring.
< If indicated, the first-line screening test to assess thy-
roid status should be measurement of the TSH level.
< The TSH level should be monitored in pregnant
women being treated for hypothyroidism, and the
dose of levothyroxine should be adjusted accordingly
with a goal TSH level between the lower limit of the
reference range and 2.5 milliunits/L. Thyroid-
stimulating hormone typically is evaluated every 4–
6 weeks while adjusting medications.
< Pregnant women with overt hypothyroidism should be
treated with adequate thyroid hormone replacement
to minimize the risk of adverse outcomes.
< The level of free T4 should be monitored in pregnant
women being treated for hyperthyroidism, and the
dose of antithyroid drug (thioamide) should be
adjusted accordingly to achieve a free T4 at the upper
who also have T3 thyrotoxicosis, total T3 should be
monitored with a goal level at the upper end of nor-
mal pregnancy range.
< Pregnant women with overt hyperthyroidism should
be treated with antithyroid drugs (thioamides).
The following recommendation is based on limited or
inconsistent scientific evidence (Level B):
< Either propylthiouracil or methimazole, both thio-
amides, can be used to treat pregnant women with
overt hyperthyroidism. The choice of medication is
dependent on trimester of pregnancy, response to
prior therapy, and whether the thyrotoxicosis is pre-
dominantly T4 or T3.
The following recommendations are based primarily on
consensus and expert opinion (Level C):
< Indicated testing of thyroid function should be per-
formed in women with a personal or family history of
thyroid disease, type 1 diabetes mellitus, or clinical
suspicion of thyroid disease.
< Measurements of thyroid function are not recommended
in patients with hyperemesis gravidarum unless other
signs of overt hyperthyroidism are evident.

VOL. 135, NO. 6, JUNE 2020 Practice Bulletin No. 223 Summary 1497

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[Figure 1] Clinical Algorithm for Management of Thyroid Disease in Pregnancy. Abbreviations: T3, triiodothyronine; T4,
thyroxine; TRAB, thyroid receptor antibodies; TSH, thyroid-stimulating hormone; TSI, thyroid-stimulating immunoglobulin.
*Propylthiouracil should be used in the first trimester because methimazole has been associated with birth defects. Propranolol
can be started at 10–40 mg every 6–8 hours for women with symptomatic palpitations or other hypermetabolic symptoms.
†Total T normal range in pregnancy is 1.5 times the nonpregnant normal range.
3

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 Studies were reviewed and evaluated for quality
according to the method outlined by the U.S.
Preventive Services Task Force. Based on the highest
level of evidence found in the data, recommendations are
provided and graded according to the following
categories:
Level A—Recommendations are based on good and
consistent scientific evidence.
Level B—Recommendations are based on limited or
inconsistent scientific evidence.
Level C—Recommendations are based primarily on
consensus and expert opinion.

Full-text document published online on May 21, 2020.

Copyright 2020 by the American College of Obstetricians and

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American College of Obstetricians and Gynecologists
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Official Citation
Thyroid disease in pregnancy. ACOG Practice Bulletin No.
223. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2020;135:e261–74.

This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use
of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of
care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the
treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such
course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or
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VOL. 135, NO. 6, JUNE 2020 Practice Bulletin No. 223 Summary 1499

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and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.