• Pregnancy is thyroid stress test

(1)Known hypothyroidism preconception

Target TSH before gestation

The aim for most adult should be to reach stable serum TSH
in the lower half of the reference range (0.4-2.5mU/L) (2w )

Women with SCH and those with overt hypothyroidism

desiring pregnancy should take levothyroxine in a dose to
ensure a TSH level < 2.5mU/L (2S)
Evidence behind guideline trial done in china in last April
study the relation between preconception TSH and adverse
pregnancy outcome in over 5 million female they found the
optimal preconception TSH level between 0.37-2.5 mU/l
prevent adverse pregnancy outcome
TSH out of range result in
preterm birth
small for gestational age
perinatal infant death
How to manage L T4 dose
Recommendation 36
Hypothyroid patients receiving LT4 treatment with a suspected or
confirmed pregnancy (e.g. positive home pregnancy test) should
independently increase their dose of LT4 by ~20-30% and urgently
notify their caregiver for prompt testing and further evaluation.
One means of accomplishing this is to administer 2 additional
tablets weekly of the patient’s current daily levothyroxine dosage.
(Strong recommendation, High quality evidence)
Target TSH during gestation

The TSH level should be monitored in pregnant women being treated

for hypothyroidism and the dose of levothyroxine should be adjusted
accordingly with goal TSH level between lower limit of the reference
range and 2.5 mU/l
Between 50% and 85% of LT4 treated hypothyroidism women need to
increase exogenous LT4 dosing during pregnancy .
Dosage augmentation should occur as soon as possible when a missed
menstruation or suspected pregnancy occurs
This should be discussed with every patient in the pre- pregnancy
setting
Causes of early increase demand
 Increase estrogen level in early pregnancy
 Increase maternal plasma volume
 Trans placental passage of T4 to the fetus
 Increase peripheral metabolism of TH from high levels of type3
deiodinase in the developing placenta
 Increase maternal renal clearance of thyroid hormone
 The incremental increase largely depend on
 The underlying etiology of the hypothyroidism ( thyroid functional
reserve )
Preconception level of TSH
(1)The etiology of hypothyroidism
Sub clinical hypothyroidism
(mild thyroid failure )
Overt hypothyroidism due to hashimoto thyroiditis
(Some thyroid reserve)
Hypothyroidism due to thyroid ablation (thyroidectomy or RAI)
(No thyroid reserve )
Cancer thyroid (thyroidectomy +/-RAI)
(Requiring TSH suppression)
Hashimoto thyroiditis vs ablative hypothyroidism
Hashimoto thyroiditis 45%
Ablative hypothyroidism 49%
Subclinical vs overt hypothyroidism
Subclinical hypothyroidism 70%
Hashimoto thyroiditis 45%
In summary
Ablative hypothyroidism has high range of increased requirements
50% or 0.5ug/kg/day
Overt hypothyroidism due to hashimoto thyroiditis has a lower
range increase requirements
45% according to target TSH or 0.23 ug/kg /day
Subclinical hypothyroidism has the highest range increased
requirement
70% due to under replacement before conception
(2)Preconception TSH
If it in the lowest quartile of normal (0.3 --<1.2mU/L)
Decrease the need to increase LT4 dose
Decrease the amount of L T4 dose increment
Titration by daily dose
daily dose 125ug/day

TSH>10 TSH 5-10 TSH 2.5-5 TSH .1 -2.5 TSH <.1

+75ug/day +50ug/day +25ug/day no change -50ug/day

Titration by weekly dose
weekly dose
regardless of current LT4dose

TSH>10 TSH 5-10 TSH 2.5-5 TSH0.1 -2.5 TSH <0.1

+3dose /week +2dose /week +1dose /week no change -2dose /week

How to manage LT4 dose after delivery
Recommendation 37
Following delivery, LT4 should be reduced to the patient’s
preconception dose. Additional thyroid function testing should be
performed at approximately 6 weeks postpartum. (Strong
recommendation, Moderate quality evidence)
(2)Newly diagnose SCH in pregnancy

Defining hypothyroidism in pregnancy

Recommendation 25
In the setting of pregnancy, maternal hypothyroidism is defined as a
TSH concentration elevated beyond the upper limit of the pregnancy-
specific reference range. (Strong recommendation, High quality
evidence)
Internal pregnancy specific reference range
Recommendation 26
The pregnancy-specific TSH reference range should be defined as follows:
When available, population and trimester-specific reference ranges for
serum TSH during pregnancy should be defined by a provider’s institute /
laboratory, and should represent the typical population for whom care is
provided. Reference ranges should be defined in healthy, TPOAb-
negative pregnant women with optimal iodine intake and without thyroid
illness. (Strong recommendation, High quality evidence)
Transferable pregnancy specific reference range
When this goal is not feasible pregnancy specific TSH reference range obtained from
similar patient population and performed using similar TSH assays should be
substituted

If no internal or transferable an upper reference limit of 4mU/L may be used for most
assay .this limit represent a reduction in the non pregnant TSH upper reference limit of
0.5mU/L
Additional to TSH order
Recommendation 28.
Pregnant women with TSH concentrations >2.5 mU/L should be
evaluated for TPO antibody status.
Treatment is recommended in
Recommendation 29
Subclinical hypothyroidism in pregnancy should be approached as
follows:
a) Levothyroxine therapy is recommended for:
- TPO antibody positive women with a TSH greater than the pregnancy
specific reference range (see Recommendation 1)
(Strong recommendation, Moderate quality evidence)
- TPO antibody negative women with a TSH greater than 10.0 mU/L.
(Strong recommendation, Low quality evidence)
b) Levothyroxine therapy may be considered for:
- TPO antibody positive women with TSH concentrations > 2.5 mU/L
and below the upper limit of the pregnancy specific reference range.
(Weak recommendation, Moderate quality evidence)
- women TPO antibody negative women with TSH concentrations
greater than the pregnancy specific reference range and below 10.0
mU/L. (Weak recommendation, Low quality evidence)
c) Levothyroxine therapy is not recommended for:
- TPO antibody negative women with a normal TSH (TSH within the
pregnancy specific reference range, or < 4.0 mU/L if unavailable).
(Strong recommendation, High quality evidence).
How to initiate dose

Empirical /universal dosing

75 ug per day
TSH based dosing

TSH 2.3---5 50ug/day

TSH 5----8 75ug/day

TSH 8---10 100ug/day

TSH and weight based dosing

TSH 2.5---- 4.2 1.2 ug /kg/day

TSH 4.2 ---10 1.42ug /kg/day

To continue or to stop LT4 treatment
114 women with new onset SCH during pregnancy
1 year follow up postpartum 75% were on treatment
25% were off treatment 1 year postpartum
Positive predictor for need of treatment was TSH >5mlU/L
Negative predictor for need of treatment was primiparity
Managing LT4 initiated in pregnancy
(Expert opinion )

Subclinical hypothyroidism (thyroid antibody positive ) half of final LT4 dose

Subclinical hypothyroidism (thyroid antibody negative )
If the last dose 25mcg DC LT4 postpartum
If the last dose 50mcg start 25 mcg LT4 postpartum
If the last dose 75 -100 mcg start 50mcg LT4 postpartum
If the last dose >100mcg start 1/2 final dose LT4 postpartum
(3)Newly diagnose Overt hypothyroidism in pregnancy

Recommendation 27
Treatment of overt hypothyroidism is recommended during pregnancy.
(Strong recommendation, Moderate quality evidence)
LT4 dose for overt hypothyroidism
2.33ug/kg /day
Managing LT4 in initiated pregnancy

Overt hypothyroidism in pregnancy

postpartum 2/3 of last dose (Expert opinion)