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Doctors at odds over thyroid function testing.

VANCOUVER, B. C. -- Two recent multidisciplinary conferences on thyroid disease in pregnancy underscore major philosophical differences between obstetricians and endocrinologists regarding the appropriate use of thyroid function testing to identify pregnant women with subclinical hypothyroidism.

Most endocrinologists advocate a liberal approach to such case finding. That is, they utilize an extensive list of patient risk factors that trigger a search for maternal subclinical hypothyroidism. Obstetricians are at the opposite extreme, Dr. Gregory A. Brent said at a satellite symposium held in conjunction with the annual meeting of the American Thyroid Association.

Endocrinologists are in general eager to identify and treat pregnant patients with subclinical hypothyroidism because they find persuasive the mounting evidence that suggests the disorder is associated with adverse neurodevelopmental outcomes in offspring. Through long experience, they are comfortable with the safety and benefits of L-thyroxine therapy, he observed at the symposium, which was supported by King Pharmaceuticals Inc.

Obstetricians, in contrast, tend to draw a tightly circumscribed circle around their case finding for subclinical hypothyroidism. An American College of Obstetricians and Gynecologists practice bulletin states, "It is appropriate to perform indicated testing of thyroid function in women with a personal history of thyroid disease or symptoms of thyroid disease. The performance of thyroid function tests in asymptomatic pregnant women who have a mildly enlarged thyroid is not warranted."

Most endocrinologists would disagree. Indeed, practice guidelines from the American Association of Clinical Endocrinologists (AACE) urge serum thyrotropin testing to detect subclinical hypothyroidism in all pregnant women with a goiter, noted Dr. Brent, professor of medicine and physiology at the University of California, Los Angeles, and chief of the endocrinology and diabetes division at Veterans Affairs Greater Los Angeles Healthcare System.

Other criteria for case finding for subclinical hypothyroidism during pregnancy advocated in the AACE guidelines are a personal or family history of thyroid disease, a history of type 1 diabetes or other autoimmune endocrine disease, a high antithyroid antibody titer, and symptoms of hypothyroidism.

These were essentially the same case-finding criteria suggested in an expert panel's recent comprehensive evidence-based recommendations regarding subclinical thyroid disease (JAMA 2004;291:228-38).

That panel concluded that "pregnant women, or women of child-bearing potential planning to become pregnant, who are found to have an elevated serum TSH should be treated to restore the serum TSH concentration to the reference range.... Although there are no published intervention trials assessing the benefits of thyroid hormone replacement ... the potential benefit-risk ratio of levothyroxine therapy justifies its use."

Dr. Brent was a participant in the two multidisciplinary conferences on maternal thyroid disease held earlier this year. One was sponsored by the Centers for Disease Control and Prevention and the American Thyroid Association, the other by ATA and AACE.


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Title Annotation:Obstetrics
Author:Jancin, Bruce
Publication:OB GYN News
Date:Nov 15, 2004
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