Thyroid Diseases: Stagnaro-Green A

Abalovich M, Amino N, Barbour LA, Cobin RH, De Groot LJ, Glinoer D, Mandel SJ, Stagnaro-Green A. · Endocrinology Division, Durand Hospital, Buenos Aires, Argentina. · J Clin Endocrinol Metab. · Pubmed #17948378 links to  free full text

Abstract: OBJECTIVE: The objective is to provide clinical guidelines for the management of thyroid problems present during pregnancy and in the postpartum. PARTICIPANTS: The Chair was selected by the Clinical Guidelines Subcommittee (CGS) of The Endocrine Society. The Chair requested participation by the Latin American Thyroid Society, the Asia and Oceania Thyroid Society, the American Thyroid Association, the European Thyroid Association, and the American Association of Clinical Endocrinologists, and each organization appointed a member to the task force. Two members of The Endocrine Society were also asked to participate. The group worked on the guidelines for 2 yr and held two meetings. There was no corporate funding, and no members received remuneration. EVIDENCE: Applicable published and peer-reviewed literature of the last two decades was reviewed, with a concentration on original investigations. The grading of evidence was done using the United States Preventive Services Task Force system and, where possible, the GRADE system. CONSENSUS PROCESS: Consensus was achieved through conference calls, two group meetings, and exchange of many drafts by E-mail. The manuscript was reviewed concurrently by the Society's CGS, Clinical Affairs Committee, members of The Endocrine Society, and members of each of the collaborating societies. Many valuable suggestions were received and incorporated into the final document. Each of the societies endorsed the guidelines. CONCLUSIONS: Management of thyroid diseases during pregnancy requires special considerations because pregnancy induces major changes in thyroid function, and maternal thyroid disease can have adverse effects on the pregnancy and the fetus. Care requires coordination among several healthcare professionals. Avoiding maternal (and fetal) hypothyroidism is of major importance because of potential damage to fetal neural development, an increased incidence of miscarriage, and preterm delivery. Maternal hyperthyroidism and its treatment may be accompanied by coincident problems in fetal thyroid function. Autoimmune thyroid disease is associated with both increased rates of miscarriage, for which the appropriate medical response is uncertain at this time, and postpartum thyroiditis. Fine-needle aspiration cytology should be performed for dominant thyroid nodules discovered in pregnancy. Radioactive isotopes must be avoided during pregnancy and lactation. Universal screening of pregnant women for thyroid disease is not yet supported by adequate studies, but case finding targeted to specific groups of patients who are at increased risk is strongly supported.

Stagnaro-Green A. · Touro University College of Medicine, Hackensack, New Jersey 07601, USA. · J Clin Endocrinol Metab. · Pubmed #18984665 No free full text.

Abstract: CONTEXT: Preterm delivery is the leading cause of perinatal morbidity and mortality in the United States, and its incidence is increasing. The present manuscript reviews the literature on the relationship of hypothyroidism and/or autoimmune thyroid disease to preterm delivery. EVIDENCE ACQUISITION: A PubMed search was used to identify all relevant articles. A reference search of all retrieved articles was undertaken. All articles identified in the search were included in the review. EVIDENCE SYNTHESIS: Uncontrolled case series were discussed in the manuscript but not included in drawing conclusions from the literature. CONCLUSIONS: Hypothyroidism and autoimmune thyroid disease in euthyroid women are associated with preterm delivery. A single intervention trial has documented a dramatic decrease in the incidence of preterm delivery in thyroid antibody-positive women treated with levothyroxine. Confirmatory studies are needed before universal screening and intervention can be recommended.

Joffe RT, Brimacombe M, Levitt AJ, Stagnaro-Green A. · Department of Psychiatry, UMDNJ-New Jersey Medical School, Newark, NJ, USA, and Sunnybrook Hospital, Toronto, Ontario, Canada. · Psychosomatics. · Pubmed #17878495 links to  free full text

Abstract: Thyroxine is the standard replacement therapy for patients with clinical hypothyroidism. However, there has been recent interest in examining the potential advantages of combined thyroxine and triiodothyronine treatment for the treatment of hypothyroidism. The authors review the nine studies to-date and conclude that the variability and limitations in study design make definitive and clinically useful recommendations difficult. They therefore conducted a metaanalysis of the nine controlled studies examining the impact of combined thyroxine-plus-triiodothyronine versus thyroxine alone, with measures of psychiatric symptoms as the primary outcome. Their analysis reveals no significant difference in treatment effect on psychiatric symptoms in the nine controlled studies to date.

Stagnaro-Green A. · UMDNJ-New Jersey Medical School, Division of Endocrinology and Metabolism, Department of Medicine, 185 South Orange Avenue, MSB C-652, Newark, NJ 07103, USA. · Best Pract Res Clin Endocrinol Metab. · Pubmed #15157842 No free full text.

Abstract: Postpartum thyroiditis (PPT) is the occurrence, in the postpartum period, of transient hyperthyroidism and/or transient hypothyroidism, with most women returning to the euthyroid state by 1 year postpartum. The prevalence of PPT varies from 1.1 to 16.7%, with a mean prevalence of 7.5%. Women with type I diabetes mellitus have a three-fold increase in the prevalence of PPT. PPT is an autoimmune disorder which is a transient form of Hashimoto's thyroiditis occurring postpartum as a consequence of the immunologic flare following the immune suppression of pregnancy. Women experience symptoms in both the hyperthyroid and hypothyroid phase, but the association between PPT and postpartum depression remains undefined. Approximately 25% of women with a history of PPT will develop permanent hypothyroidism in the ensuing 10 years. Treatment for the hyperthyroid phase, when required, is a short dose of beta-blockers. Women with a TSH greater than 10 mU/l, or between 4 and 10 mU/l with symptoms or attempting pregnancy, require thyroid hormone replacement. Whether or not to screen for PPT remains controversial.

Stagnaro-Green A, Glinoer D. · UMDNJ-New Jersey Medical School, Division of Endocrinology and Metabolism, Department of Medicine, 185 South Orange Avenue, MSB C-652, Newark, NJ 07101, USA. · Best Pract Res Clin Endocrinol Metab. · Pubmed #15157834 No free full text.

Abstract: Approximately one-third of all pregnancies end in miscarriage. The etiology of recurrent abortion remains unknown in approximately 50% of all women. In the early 1990s it was discovered that unselected euthyroid women who present with thyroid antibodies (thyroid peroxidase and thyroglobulin) in the first trimester of pregnancy have a two-four-fold increase in their miscarriage rates. The majority of studies investigating women with recurrent abortion have also found a significant increase in thyroid antibody positivity compared with controls. Although the etiology of miscarriage in thyroid antibody women remains unknown, recent data have revealed a potential direct effect of thyroglobulin antibodies on pregnancy loss in a murine model. Uncontrolled studies assessing the effect of levothyroxine on decreasing the miscarriage rate in euthyroid antibody positive women, have demonstrated a decreased miscarriage rate.

Shah MS, Davies TF, Stagnaro-Green A. · Division of Endocrinology and Metabolism, Department of Medicine, UMDNJ, New Jersey Medical School, Newark, NJ 17103, USA. · Minerva Endocrinol. · Pubmed #14605605 No free full text.

Abstract: Pregnancy and the postpartum are times of marked and rapid change in the thyroid gland. Normal physiological changes include enhanced thyroid hormone production, modulation of thyroid hormone metabolism by placental deiodinases, and decreasing titers of thyroid antibodies in thyroid antibody positive women. Hyperemesis gravidarum is associated with suppressed thyroid stimulating hormone levels and free T4 elevations. Graves' disease typically becomes quiescent during pregnancy, followed by a postpartum flare. Women with pre-existing hypothyroidism frequently require an increase in their levothryoxine requirement in the 1(st) trimester, and subclinical hypothyroidism early in pregnancy is linked to both miscarriage and impaired neurological development in the unborn child. Postpartum thyroiditis occurs in 7.2% of women, and euthyroid women who are thyroid antibody positive in the 1(st) trimester of pregnancy have a doubling of the miscarriage rate.

Stagnaro-Green A. · Division of Endocrinology, Diabetes and Bone Diseases, Mount Sinai School of Medicine, New York, New York 10029, USA. · J Clin Endocrinol Metab. · Pubmed #12213841 links to  free full text

This publication has no abstract.

Stagnaro-Green A. · Department of Medicine, Mount Sinai School of Medicine, New York, New York, USA. · Endocrinol Metab Clin North Am. · Pubmed #10874538 No free full text.

Abstract: Postpartum thyroiditis is the most common endocrinologic disorder, with an incidence that varies geographically from 5% to 10%. It has important clinical sequelae including symptoms of hyperthyroidism, hypothyroidism, and depression. Long-term follow-up of women who experience postpartum thyroiditis reveals a high recurrence rate in subsequent pregnancies. Postpartum thyroiditis is an autoimmune disorder, and thyroid antibody-positive women in the first trimester have a 33% to 50% chance of developing thyroiditis in the postpartum period. Whether or not to screen for postpartum thyroiditis remains controversial.

Amino N, Tada H, Hidaka Y, Crapo LM, Stagnaro-Green A. · Department of Laboratory Medicine, Osaka University Medical School, Japan. · J Clin Endocrinol Metab. · Pubmed #10372667 links to  free full text

This publication has no abstract.

Stagnaro-Green A, Chen X, Bogden JD, Davies TF, Scholl TO. · Department of Medicine, UMDNJ-New Jersey Medical School, Division of Endocrinology and Metabolism, 185 South Orange Avenue, Newark, NJ 17101-6035, USA. · Thyroid. · Pubmed #15876159 No free full text.

Abstract: The major cause of neonatal mortality and morbidity is preterm delivery in general (< 37 completed weeks), and especially very preterm delivery (< 32 completed weeks). The objective of this study is to determine if either thyroid hormonal dysfunction and/or the presence of thyroid autoantibodies in the mother are associated with an increased risk of preterm and/or very preterm delivery. Data were collected prospectively and analyzed as a nested-case control study. There were 953 delivered gravidas enrolled between 1996 and 2002. Samples were collected at entry to care and stored at -70 degrees C. Cases included all women with preterm delivery (n = 124). Controls (n = 124) were randomly selected from among the 829 women who delivered at term (> 37 completed weeks). All samples were assessed for thyroid stimulating hormone, thyroperoxidase antibody, and thyroglobulin antibody. Gravidas with high thyrotropin (TSH) levels had a greater than threefold increase in risk of very preterm delivery. In some analyses, gravidas who tested positive for thyroglobulin antibody at entry to prenatal care also had a better than twofold increased risk of very preterm delivery. There were no significant associations between TSH level or thyroglobulin antibody positivity and the risk of moderately preterm delivery.