Sixteen percent of the women who are euthyroid and positive for TPO or Tg antibody in the first trimester will develop a TSH that exceeds 4.0 miu/l by

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1 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and Postpartum 美国甲状腺协会妊娠期和产后甲状腺疾病的诊断和治疗指南 The American Thyroid Association Taskforce on Thyroid Disease During Pregnancy and Postpartum 美国甲状腺协会妊娠期和产后甲状腺疾病特别工作组 Translated by Wang Xinjun Binzhou people s hospital,binzhou Medical College 王新军译滨州医学院附属滨州市人民医院 INTRODUCTION 前言 Pregnancy has a profound impact on the thyroid glandand thyroid function. The gland increases 10% in size during pregnancy in iodine-replete countries and by 20% 40% in areas of iodine deficiency. Production of thyroxine(t4) and triiodothyronine (T3) increases by 50%, along with a 50% increase in the daily iodine requirement. These physiological changes may result in hypothyroidism in the later stages of pregnancy in iodine-deficient women who were euthyroid in the first trimester. 妊娠对甲状腺和甲状腺功能具有明显影响 在点充足地区, 妊娠期间甲状腺腺体大小增加 10%, 在碘缺乏地区, 增加约 20%~40% 甲状腺素 (T4) 和三碘甲状腺原氨酸 (T3) 增加 50%, 每天碘需求量增加 50% 这些生理的变化可能导致妊娠前三个月甲状腺功能正常的碘缺乏妇女在妊娠后期发生甲减 The range of thyrotropin (TSH), under the impact of placental human chorionic gonadotropin (hcg), is decreased throughout pregnancy with the lower normal TSH level in the first trimester being poorly defined and an upper limit of 2.5 miu/l. Ten percent to 20% of all pregnant women in the first trimester of pregnancy are thyroid peroxidase (TPO) or thyroglobulin (Tg) antibody positive and euthyroid. 促甲状腺激素 (TSH) 的范围在胎盘绒毛膜促性腺激素 (hcg) 的影响下, 在整个妊娠期间均下降, 在妊娠前三个月正常低限但尚未充分界定, 上限为 2.5 MIU/ L 妊娠前三个月大约 10% 到 20% 的妇女甲状腺过氧化物酶 (TPO) 或甲状腺球蛋白 (Tg) 抗体阳性且甲状腺功能正常

2 Sixteen percent of the women who are euthyroid and positive for TPO or Tg antibody in the first trimester will develop a TSH that exceeds 4.0 miu/l by the third trimester, and 33% 50% of women who are positive for TPO or Tg antibody in the first trimester will develop postpartum thyroiditis. In essence, pregnancy is a stress test for the thyroid, resulting in hypothyroidism in women with limited thyroidal reserve or iodine deficiency, and postpartum thyroiditis in women with underlying Hashimoto s disease who were euthyroid prior to conception. 妊娠前三个月甲状腺功能正常 TPO 或 TG 抗体阳性的妇女中, 约 16% 在妊娠后三个月其促甲状腺激素会超过 4.0 miu/ L, 妊娠前三个月 TPO 或 Tg 抗体阳性的妇女有 33%~50% 会发生产后甲状腺炎 从本质上讲, 妊娠是甲状腺的应激试验, 在甲状腺功能储备有限或碘缺乏的妇女会发生甲状腺功能减退, 而在怀孕前甲状腺功能正常但有潜在桥本甲状腺疾病的妇女会发生产后甲状腺炎 Knowledge regarding the interaction between the thyroid and pregnancy/the postpartum period is advancing at a rapid pace. Only recently has a TSH of 2.5 miu/l been accepted as the upper limit of normal for TSH in the first trimester. This has important implications in regards to interpretation of the literature as well as a critical impact for the clinical diagnosis of hypothyroidism. 关于甲状腺和妊娠 / 产后期相互作用的只是进展很快 直到最近, 促甲状腺激素 2.5 MIU/ L, 为怀孕前三个月 TSH 的正常上限才被接受 这对于文献的解释及甲状腺功能减退的临床诊断的关键影响具有重要意义 Although it is well accepted that overt hypothyroidism and overt hyperthyroidism have a deleterious impact on pregnancy, studies are now focusing on the potential impact of subclinical hypothyroidism and subclinical hyperthyroidism on maternal and fetal health, the association between miscarriage and preterm delivery in euthyroid women positive for TPO and/or Tg antibody, and the prevalence and long-term impact of postpartum thyroiditis. Recently completed prospective randomized studies have begun to produce critically needed data on the impact of treating thyroid disease on the mother, fetus, and the future intellect of the unborn child. 虽然显性甲状腺功能减退和显性甲状腺功能亢进症对妊娠具有不利影响已被广泛接受, 目前研究集中在亚临床甲状腺功能减退症和亚临床甲状腺功能亢进症对产妇和胎儿健康的潜在影响 在甲状腺功能正常 TPO 和 / 或 Tg 抗体阳性的妇女流产和早产之间的关系, 产后甲状腺炎的流行病学和长期影响方面 最近完成的前瞻性随机研究已经开始给出关于治疗甲状腺疾病对母亲 胎儿的影响, 未出生的孩子将来智力的影响方面急需的数据

3 It is in this context that the American Thyroid Association (ATA) charged a task force with developing clinical guidelines on the diagnosis and treatment of thyroid disease during pregnancy and the postpartum. The task force consisted of international experts in the field of thyroid disease and pregnancy, and included representatives from the ATA, Asia and Oceania Thyroid Association, Latin American Thyroid Society, American College of Obstetricians and Gynecologists, and the Midwives Alliance of North America. Inclusion of thyroidologists, obstetricians, and midwives on the task force was essential to ensuring widespread acceptance and adoption of the developed guidelines. 正是在这种背景下, 美国甲状腺协会 (ATA) 成立了一个特别工作组负责制定妊娠和产后甲状腺疾病诊断和治疗的临床指南 特别工作组由甲状腺疾病和妊娠领域的国际专家 ATA 的代表 亚洲和大洋洲甲状腺协会的代表 拉丁美洲甲状腺协会的代表 美国妇产科学院的代表和北美助产士联盟的代表组成 工作组包括甲状腺疾病专家 妇产科医生和助产士以确保新指南被广泛的接受和采用 & RECOMMENDATION 1 Trimester-specific reference ranges for TSH, as defined in populations with optimal iodine intake, should be applied. Level B-USPSTF 1 应该应用最佳的碘摄入量的人群中妊娠早 中 晚期特定的 TSH 参考值范围 B 级证据 & RECOMMENDATION 2 If trimester-specific reference ranges for TSH are not available in the laboratory, the following reference ranges are recommended: first trimester, miu/l; second trimester, miu/l; third trimester, miu/l. Level I-USPSTF 2 如果实验室无妊娠早 中 晚期特异的 TSH 具体参考值范围, 建议参考以下参考值范围 : 妊娠前三月 0.1~2.5 miu/ L; 妊娠中期三个月, MIU / L; 孕晚期三个月, MIU/ L I 级证据 & RECOMMENDATION 3 The optimal method to assess serum FT4 during pregnancy is measurement of T4 in the dialysate or ultrafiltrate of serum samples employing on-line extraction/liquid chromatography/tandem mass spectrometry (LC/MS/MS). Level A-USPSTF 3 在怀孕期间评估血清 FT4 的最佳方法, 是用在线萃取 / 液相色谱 / 串联质谱 (LC / MS /MS) 测量透析或超滤血清样本的 T4 A 级证据

4 & RECOMMENDATION 4 If FT4 measurement by LC/MS/MS is not available, clinicians should use whichever measure or estimate of FT4 is available in their laboratory, being aware of the limitations of each method. Serum TSH is a more accurate indication of thyroid status in pregnancy than any of these alternative methods. Level A-USPSTF 4 如果没有条件用 LC / MS/ MS 测定 FT4, 临床医生应该使用其他方法或用他们实验室中的方法估计 FT4 的值, 但应知道每种方法的局限性 和这些指标相比, 血清 TSH 是妊娠期间甲状腺功能状态更准确的一个指标 A 级证据 & RECOMMENDATION 5 In view of the wide variation in the results of FT4 assays, method-specific and trimester-specific reference ranges of serum FT4 are required. Level B-USPSTF 5 鉴于 FT4 的检测结果差异很大, 必需制定方法特异性的和妊娠早 中 晚期特异性的参考值范围 B 级证据 & RECOMMENDATION 6 OH should be treated in pregnancy. This includes women with a TSH concentration above the trimester-specific reference interval with a decreased FT4, and all women with a TSH concentration above 10.0 miu/l irrespective of the level of FT4. Level A-USPSTF 6 在怀孕期间明显的甲状腺功能减退症 (OH) 应该治疗 这包括 TSH 浓度高于妊娠特异性参考值范围及 FT4 水平下降的妇女和不论 FT4 浓度如何但 TSH 浓度高于 10.0 miu/ L 的妇女 A 级证据 & RECOMMENDATION 7 Isolated hypothyroxinemia should not be treated in pregnancy. Level C-USPSTF 妊娠期间单纯的低甲状腺素血症不应该治疗 C 级证据 & RECOMMENDATION 8 SCH has been associated with adverse maternal and fetal outcomes. However, due to the lack of randomized controlled trials there is insufficient evidence to recommend for or against universal LT4 treatment in TAb_ pregnant women with SCH. Level I-USPSTF 8 亚临床甲状腺功能减退症 (SCH) 与产妇和胎儿结局不利有关 然而, 由于缺乏随机对照试验, 尚无足够的证据建议对 Tab 的 SCH 孕妇用或不用 LT4 治疗 I 级证据

5 & RECOMMENDATION 9 Women who are positive for TPOAb and have SCH should be treated with LT4. Level B-USPSTF 9 TPOAb 阳性的 SCH 妇女应该用 LT4 治疗 B 级证据 & RECOMMENDATION 10 The recommended treatment of maternal hypothyroidism is with administration of oral LT4. It is strongly recommended not to use other thyroid preparations such as T3 or desiccated thyroid. Level A-USPSTF 10 甲状腺功能减退的孕妇建议口服 LT4 治疗 强烈建议不用其他甲状腺制剂如 T3 或干甲状腺治疗 A 级证据 & RECOMMENDATION 11 The goal of LT4 treatment is to normalize maternal serum TSH values within the trimester-specific pregnancy reference range (first trimester, miu/l; second trimester, miu/l; third trimester, miu/l). Level A-USPSTF 11 LT4 治疗的目标是使产妇血清 TSH 值保持在妊娠特异性的参考值范围正常值以内 ( 头三个月 miu/ L; 妊娠中三个月, miu/ L; 孕晚期三个月, miu/ L) A 级证据 & RECOMMENDATION 12 Women with SCH in pregnancy who are not initially treated should be monitored for progression to OH with a serum TSH and FT4 approximately every 4 weeks until weeks gestation and at least once between 26 and 32 weeks gestation. This approach has not been prospectively studied. Level I-USPSTF 12 没有进行治疗的亚临床甲减孕妇应监测是否进展为明显的甲状腺功能减退症, 16~20 周前应每 4 周测定 TSH 和 FT4, 在孕 26 到 32 周之间至少测定一次 这种方法尚无前瞻性研究 I 级证据

6 & RECOMMENDATION 13 Treated hypothyroid patients (receiving LT4) who are newly pregnant should independently increase their dose of LT4 by *25% 30% upon a missed menstrual cycle or positive home pregnancy test and notify their caregiver promptly. One means of accomplishing this adjustment is to increase LT4 from once daily dosing to a total of nine doses per week (29% increase). Level B-USPSTF 13 正在接受治疗 (LT4) 的甲状腺功能低下的新怀孕患者一个月经周期后或妊娠试验阳性后应增加 LT4 剂量 25%~30%, 并及时通知他们的照护者 一种完成这种调整的方法是由 LT4 每日 1 次剂量增加到每周 9 次 ( 增加 29%) B 级证据 & RECOMMENDATION 14 There exists great interindividual variability regarding the increased amount of T4 (or LT4) necessary to maintain a normal TSH throughout pregnancy, with some women requiring only 10% 20% increased dosing, while others may require as much as an 80% increase. The etiology of maternal hypothyroidism, as well as the preconception level of TSH, may provide insight into the magnitude of necessary LT4 increase. Clinicians should seek this information upon assessment of the patient after pregnancy is confirmed. Level A-USPSTF 14 为保持怀孕期间 TSH 正常,T4( 或 LT4) 的增加量个体间变异很大, 有些妇女仅需增加剂量 10%~20%, 而其他妇女可能需要增加了 80% 孕妇甲状腺功能减退的病因, 以及孕前 TSH 水平, 可能影响 LT4 增加的量 临床医师应搜集这些信息以评估怀孕后患者的病情 A 级证据 & RECOMMENDATION 15 Treated hypothyroid patients (receiving LT4) who are planning pregnancy should have their dose adjusted by their provider in order to optimize serum TSH values to <2.5 miu/l preconception. Lower preconception TSH values (within the nonpregnant reference range) reduce the risk of TSH elevation during the first trimester. Level B-USPSTF 15 正在治疗 (LT4) 的甲状腺功能低下的患者, 如果计划怀孕应该在医师指导下调整剂量, 使 TSH 值优化到 <2.5MIU/ L 较低的 TSH 值 ( 未孕的参考范围内 ) 会减少妊娠前三个月 TSH 值升高的风险 B 级证据

7 & RECOMMENDATION 16 In pregnant patients with treated hypothyroidism, maternal serum TSH should be monitored approximately every 4 weeks during the first half of pregnancy because further LT4 dose adjustments are often required. Level B-USPSTF 16 正在治疗的甲状腺功能减退症的孕妇, 在怀孕的前半个时期应大约每 4 周检测一次 TSH, 因为往往需要进一步调整 LT4 的剂量 B 级证据 & RECOMMENDATION 17 In pregnant patients with treated hypothyroidism, maternal TSH should be checked at least once between 26 and 32 weeks gestation. Level I-USPSTF 17 正在治疗的甲状腺功能减退症孕妇, 在孕 26 和 32 周之间应至少检查一次 TSH I 级证据 & RECOMMENDATION 18 Following delivery, LT4 should be reduced to the patient s preconception dose. Additional TSH testing should be performed at approximately 6 weeks postpartum. Level B-USPSTF 18 分娩后,LT4 应减少到孕前剂量 应在产后约 6 周再次检测 TSH 值 B 级证据 & RECOMMENDATION 19 In the care of women with adequately treated Hashimoto s thyroiditis, no other maternal or fetal thyroid testing is recommended beyond measurement of maternal thyroid function (such as serial fetal ultrasounds, antenatal testing, and/or umbilical blood sampling) unless for other pregnancy circumstances. Level A-USPSTF 19 在已经适当治疗的桥本甲状腺炎妇女, 不建议除检测母体甲状腺功能以外进行其他母体或胎儿甲状腺检测 ( 如串行胎儿超声波检查, 产前检测和 / 或脐带血采样 ), 除非其他怀孕情况 A 级证据 & RECOMMENDATION 20 Euthyroid women (not receiving LT4) who are TAbt require monitoring for hypothyroidism during pregnancy. Serum TSH should be evaluated every 4 weeks during the first half of pregnancy and at least once between 26 and 32 weeks gestation. Level B-USPSTF 20 TAb+ 甲状腺功能正常的妇女 ( 未服用 LT4) 在怀孕期间需要监测甲状腺功能减退 血清 TSH 在怀孕前一半时间应每 4 周评估一次, 在 26 至 32 周至少评估一次 B 级证据

8 & RECOMMENDATION 21 A single RCT has demonstrated a reduction in postpartum thyroiditis from selenium therapy. No subsequent trials have confirmed or refuted these findings. At present, selenium supplementation is not recommended for TPOAbt women during pregnancy. Level C-USPSTF 21 一项随机对照试验显示用硒治疗可减少产后甲状腺炎 没有后续试验证实或推翻这些结论 目前, 不建议 TPOAb+ 的妇女在怀孕期间补充硒 C 级证据 & RECOMMENDATION 22 In the presence of a suppressed serum TSH in the first trimester (TSH <0.1 miu/l), a history and physical examination are indicated. FT4 measurements should be obtained in all patients. Measurement of TT3 and TRAb may be helpful in establishing a diagnosis of hyperthyroidism. Level B-USPSTF 22 如果在妊娠前 3 个月存在血清 TSH 抑制 (TSH<0.1 MIU/ L), 应该询问病史并进行体格检查 所有患者应检测 FT4 检测 TT3 和 TRAb 或许有助于明确甲状腺功能亢进症的诊断 B 级证据 & RECOMMENDATION 23 There is not enough evidence to recommend for or against the use of thyroid ultrasound in differentiating the cause of hyperthyroidism in pregnancy. Level I-USPSTF 23 有没有足够的证据支持或反对应用甲状腺超声鉴别孕妇的甲状腺功能亢进症 I 级证据 & RECOMMENDATION 24 Radioactive iodine (RAI) scanning or radioiodine uptake determination should not be performed in pregnancy. Level D-USPSTF 24 在怀孕期间不应进行放射性碘 (RAI) 扫描或放射性碘摄取测定 D 级证据 & RECOMMENDATION 25 The appropriate management of women with gestational hyperthyroidism and hyperemesis gravidarum includes supportive therapy, management of dehydration, and hospitalization if needed. Level A-USPSTF 25 妊娠妇女甲状腺功能亢进症和妊娠剧吐的合适治疗包括支持治疗 补液, 如果需要, 可以住院治疗 A 级证据

9 & RECOMMENDATION 26 ATDs are not recommended for the management of gestational hyperthyroidism. Level D-USPSTF 妊娠甲状腺功能亢进症不建议用抗甲状腺药物治疗 D 级证据 & RECOMMENDATION 27 Thyrotoxic women should be rendered euthyroid before attempting pregnancy. Level A-USPSTF 27 甲亢妇女在计划怀孕前应该将甲状腺功能控制到正常 A 级证据 & RECOMMENDATION 28 PTU is preferred for the treatment of hyperthyroidism in the first trimester. Patients on MMI should be switched to PTU if pregnancy is confirmed in the first trimester. Following the first trimester, consideration should be given to switching to MMI. Level I-USPSTF 28 在妊娠前三个月, 首选丙基硫氧嘧啶治疗甲亢 正在用甲巯咪唑治疗的患者如果确定怀孕, 在前三个月应该改用丙基硫氧嘧啶 三个月后, 应该考虑改回甲巯咪唑 I 级证据 & RECOMMENDATION 29 A combination regimen of LT4 and an ATD should not be used in pregnancy, except in the rare situation of fetal hyperthyroidism. Level D-USPSTF 29 在怀孕期间不应该联用 LT4 和抗甲状腺药物, 除非在极少数胎儿甲状腺功能亢进症时 D 级证据 & RECOMMENDATION 30 In women being treated with ATDs in pregnancy, FT4 and TSH should be monitored approximately every 2 6 weeks. The primary goal is a serum FT4 at or moderately above the normal reference range. Level B-USPSTF 30 在怀孕期间用抗甲状腺药物进行治疗的妇女, 应该每 2~6 周检测一次 FT4 和 TSH 主要目标是血清 FT4 在正常或略高于正常参考值范围 B 级证据 & RECOMMENDATION 31 Thyroidectomy in pregnancy is rarely indicated. If required, the optimal time for thyroidectomy is in the second trimester. Level A-USPSTF 31 在怀孕期间很少建议甲状腺切除术 如果需要, 甲状腺切除术的最佳时间是在妊娠中期 A 级证据

10 & RECOMMENDATION 32 If the patient has a past or present history of Graves disease, a maternal serum determination of TRAb should be obtained at weeks gestation. Level B-USPSTF 32 如果病人有 Graves 病或曾患 Graves 病, 应该在妊娠 20~24 周检测孕妇的血清 TRAb B 级证据 & RECOMMENDATION 33 Fetal surveillance with serial ultrasounds should be performed in women who have uncontrolled hyperthyroidism and/or women with high TRAb levels (greater than three times the upper limit of normal). A consultation with an experienced obstetrician or maternal fetal medicine specialist is optimal. Such monitoring may include ultrasound for heart rate, growth, amniotic fluid volume, and fetal goiter. Level I-USPSTF 33 如果孕妇的甲亢未控制和 / 或孕妇的 TRAb 较高 ( 高于三倍正常值上限 ), 则应该用串行超声进行胎儿监测 最好咨询经验丰富的产科医生或母婴专家 这种超声监测可以包括心率 生长状况 羊水量和胎儿甲状腺肿大 I 级证据 & RECOMMENDATION 34 Cordocentesis should be used in extremely rare circumstances and performed in an appropriate setting. It may occasionally be of use when fetal goiter is detected in women taking ATDs to help determine whether the fetus is hyperthyroid or hypothyroid. Level I-USPSTF 34 在极少数情况下, 可以在合适的机构进行脐带血采样 这在孕妇服用抗甲状腺药物胎儿甲状腺中大时或许有用, 以辅助确定胎儿是否甲状腺功能亢进或甲状腺功能减退 I 级证据 & RECOMMENDATION 35 MMI in doses up to mg/d is safe for lactating mothers and their infants. PTU at doses up to 300mg/d is a second-line agent due to concerns about severe hepatotoxicity. ATDs should be administered following a feeding and in divided doses. Level A-USPSTF 35 MMI 的剂量在 20-30mg/ d 对哺乳期的妇女和婴儿是安全的 因为严重的肝毒性, PTU 300mg/ d 是二线药物 抗甲状腺药物应该分次服用, 并在喂食后给药 A 级证据

11 & RECOMMENDATION 36 All pregnant and lactating women should ingest a minimum of 250 mg iodine daily. Level A-USPSTF 36 所有孕妇和哺乳期妇女每天最低应摄取 250 mg 碘 A 级证据 & RECOMMENDATION 37 To achieve a total of 250 mg iodine ingestion daily in North America all women who are planning to be pregnancy or are pregnant or breastfeeding should supplement their diet with a daily oral supplement that contains 150 mg of iodine. This is optimally delivered in the form of potassium iodide because kelp and other forms of seaweed do not provide a consistent delivery of daily iodide. Level B-USPSTF 37 在北美, 要达到 250mg 的碘摄入量, 所有计划怀孕或已经怀孕或哺乳期的妇女应该在每天饮食中口服补充 150mg 碘 最好补充碘化钾, 因为海带和其他紫菜中的碘含量并不稳定 B 级证据 & RECOMMENDATION 38 In areas of the world outside of North America, strategies for ensuring adequate iodine intake during preconception, pregnancy, and lactation should vary according to regional dietary patterns and availability of iodized salt. Level A-USPSTF 38 在北美的世界其他地区, 在孕前 怀孕和哺乳期为确保足够的碘摄入量应根据不同区域的饮食习惯和是否有碘盐而制定补碘方案 A 级证据 & RECOMMENDATION 39 Pharmacologic doses of iodine exposure during pregnancy should be avoided, except in preparation for thyroid surgery for Graves disease. Clinicians should carefully weigh the risks and benefits when ordering medications or diagnostic tests that will result in high iodine exposure. Level C-USPSTF 39 在怀孕期间应该避免服用药理剂量的碘, 除非在 Graves' 病甲状腺手术的准备时 临床医师在为患者处方可能高碘的药物或进行诊断试验时应仔细权衡风险和收益 C 级证据 & RECOMMENDATION 40 Sustained iodine intake from diet and dietary supplements exceeding mg daily should be avoided due to concerns about the potential for fetal hypothyroidism. Level C-USPSTF 40 应该避免饮食和膳食补充剂碘摄入量持续每日超过 500~1100mg, 因为这可能导致胎儿潜在的甲状腺功能减退 C 级证据

12 & RECOMMENDATION 41 There is insufficient evidence to recommend for or against screening all women for anti-thyroid antibodies in the first trimester of pregnancy. Level I-USPSTF 41 没有足够的证据支持或反对在妊娠前三个月对所有妇女筛选查抗甲状腺抗体 I 级证据 & RECOMMENDATION 42 There is insufficient evidence to recommend for or against screening for anti-thyroid antibodies, or treating in the first trimester of pregnancy with LT4 or IVIG, in euthyroid women with sporadic or recurrent abortion or in women undergoing in vitro fertilization (IVF). Level I-USPSTF 42 没有足够的证据支持或反对筛查抗甲状腺抗体, 或在甲状腺功能正常的妇女 偶发或复发性流产的妇女或体外受精 (IVF) 的妇女在妊娠前三个月用 LT4 或静脉免疫球蛋白治疗 I 级证据 & RECOMMENDATION 43 There is insufficient evidence to recommend for or against LT4 therapy in TAbt euthyroid women during pregnancy. Level I-USPSTF 43 没有足够的证据支持或反对在怀孕期间用 LT4 治疗 TAb+ 甲状腺功能正常的妇女 I 级证据 & RECOMMENDATION 44 There is insufficient evidence to recommend for or against LT4 therapy in euthyroid TAbt women undergoing assisted reproduction technologies. Level I-USPSTF 44 没有足够的证据支持或反对用 LT4 治疗甲状腺功能正常 TAb+ 接受辅助生育技术的妇女 I 级证据 & RECOMMENDATION 45 There is insufficient evidence to recommend for or against screening for anti-thyroid antibodies in the first trimester of pregnancy, or treating TAbt euthyroid women with LT4, to prevent preterm delivery. Level I-USPSTF 45 没有足够的证据支持或反对在妊娠前三个月筛查抗甲状腺抗体, 或用 LT4 治疗 TAb+ 甲状腺功能正常的妇女防止早产 I 级证据

13 & RECOMMENDATION 46 The optimal diagnostic strategy for thyroid nodules detected during pregnancy is based on risk stratification. All women should have the following: a complete history and clinical examination, serum TSH testing, and ultrasound of the neck. Level A-USPSTF 46 在妊娠期间检测到的甲状腺结节最佳的诊断策略是进行危险分层 所有妇女应当有以下内容 : 完整的病史和临床检查, 血清 TSH 检测和颈部超声 A 级证据 & RECOMMENDATION 47 The utility of measuring calcitonin in pregnant women with thyroid nodules is unknown. Level I-USPSTF 47 甲状腺结节的孕妇测量降钙素是否有用仍不清楚 I 级证据 & RECOMMENDATION 48 Thyroid or lymph node FNA confers no additional risks to a pregnancy. Level A-USPSTF 48 孕妇进行甲状腺或淋巴结活检无额外危险 A 级证据 & RECOMMENDATION 49 Thyroid nodules discovered during pregnancy that have suspicious ultrasound features, as delineated by the 2009 ATA guidelines, should be considered for FNA. In instances in which nodules are likely benign, FNA may be deferred until after delivery based on patients preference. Level I-USPSTF 49 在怀孕期间发现的甲状腺结节如果根据 2009 年 ATA 指南其超声特点的可疑, 应考虑细针穿刺活检 在可能是良性结节的病例, 细针穿刺活检可根据患者的意愿推迟到分娩后进行 I 级证据 & RECOMMENDATION 50 The use of radioiodine imaging and/or uptake determination or therapeutic dosing is contraindicated during pregnancy. Inadvertent use of radioiodine prior to 12 weeks of gestation does not appear to damage the fetal thyroid. Level A-USPSTF 50 在怀孕期间使用碘成像和 / 或碘摄取决定治疗剂量是禁忌的 在怀孕前 12 周前不慎使用放射性碘不会损害胎儿甲状腺 A 级证据

14 & RECOMMENDATION 51 Because the prognosis of women with well-differentiated thyroid cancer identified but not treated during pregnancy is similar to that of nonpregnant patients, surgery may be generally deferred until postpartum. Level B-USPSTF 51 由于患分化良好的甲状腺癌的妇女在怀孕期间不治疗与非妊娠妇女的预后类似, 所以手术一般可以推迟到产后 B 级证据 & RECOMMENDATION 52 The impact of pregnancy on women with medullary carcinoma is unknown. Surgery is recommended during pregnancy in the presence of a large primary tumor or extensive lymph node metastases. Level I-USPSTF 52 妊娠对妇女髓样癌的影响仍不清楚 妊娠期间如患大的原发性肿瘤或广泛淋巴结转移, 建议手术 I 级证据 & RECOMMENDATION 53 Surgery for thyroid carcinoma during the second trimester of pregnancy has not been demonstrated to be associated with increased maternal or fetal risk. Level B-USPSTF 53 在妊娠中期进行甲状腺癌手术未见与产妇或胎儿的风险增加相关 B 级证据 & RECOMMENDATION 54 Pregnant women with thyroid nodules that are read as benign on FNA cytology do not require surgery during pregnancy except in cases of rapid nodule growth and/or if severe compressive symptoms develop. Postpartum, nodules should be managed according to the 2009 ATA guidelines. Level B-USPSTF 54 患甲状腺结节的孕妇如果细针穿刺细胞学检查显示为良性, 除非结节生长较快和 / 或出现严重的压迫症状, 一般不需手术 产后, 甲状腺结节应根据 2009 年的 ATA 指南处理 B 级证据 & RECOMMENDATION 55 When a decision has been made to defer surgery for welldifferentiated thyroid carcinoma until after delivery, neck ultrasounds should be performed during each trimester to assess for rapid tumor growth, which may indicate the need for surgery. Level I-USPSTF 55 对于分化良好的甲状腺癌如果决定将手术推迟到产后进行, 应该每 3 个月进行一次超声检查, 以评估肿瘤的生长速度, 如果肿瘤快速生长, 则是需要手术的指证 I 级证据

15 & RECOMMENDATION 56 Surgery in women with well-differentiated thyroid carcinoma may be deferred until postpartum without adversely affecting the patient s prognosis. However, if substantial growth of the well-differentiated thyroid carcinoma occurs or the emergence of lymph node metastases prior to midgestation occurs, then surgery is recommended. Level B-USPSTF 56 在分化良好的甲状腺癌妇女手术可以推迟到产后进行而对病人的预后无不良影响 但是, 如果分化良好的甲状腺癌生长较快, 或在孕中期出现淋巴结转移, 则建议手术 B 级证据 & RECOMMENDATION 57 Thyroid hormone therapy may be considered in pregnant women who have deferred surgery for welldifferentiated thyroid carcinoma until postpartum. The goal of LT4 therapy is a serum TSH level of mIU/L. Level I-USPSTF 57 患分化良好的甲状腺癌的妇女如果推迟手术可以考虑甲状腺激素治疗一直到产后 LT4 治疗的目标是血清 TSH 水平 0.1~1.5mIU/ L I 级证据 & RECOMMENDATION 58 Pregnant patients with an FNA sample that is suspicious for thyroid cancer do not require surgery while pregnant except in cases of rapid nodular growth and/or the appearance of lymph node metastases. Thyroid hormone therapy is not recommended. Level I-USPSTF 58 怀孕的患者如果细针穿刺活检显示可疑甲状腺癌, 怀孕期间不需手术, 除非结节快速增长和 / 或出现淋巴结转移 不建议甲状腺激素治疗 I 级证据 & RECOMMENDATION 59 The preconception TSH goal in women with DTC, which is determined by risk stratification, should be maintained during pregnancy. TSH should be monitored approximately every 4 weeks until weeks of gestation and once between 26 and 32 weeks of gestation. Level B-USPSTF 59 患分化型甲状腺癌的妇女孕前 TSH 的目标根据危险分层决定, 且应在怀孕期间维持这一目标 在妊娠 16~20 周前应该大约每 4 周测定 TSH 一次, 在妊娠 26 和 32 周之间应该检测一次 B 级证据

16 & RECOMMENDATION 60 There is no evidence that previous exposure to radioiodine affects the outcomes of subsequent pregnancies and offspring. Pregnancy should be deferred for 6 months following RAI treatment. LT4 dosing should be stabilized following RAI treatment before pregnancy is attempted. Level B-USPSTF 60 没有证据表明曾接触放射性碘影响以后怀孕和子女的结局 RAI 治疗后怀孕应推迟到 6 个月以后 RAI 后, 在计划怀孕前应将 LT4 剂量调整稳定 B 级证据 & RECOMMENDATION 61 Ultrasound and Tg monitoring during pregnancy in patients with a history of previously treated DTC is not required for low-risk patients with no Tg or structural evidence of disease prior to pregnancy. Level B-USPSTF 61 以前有分化型甲状腺癌病史的患者怀孕期间, 在怀孕前没有 Tg 或影像学表现的低危患者不需进行超声和 Tg 监测 B 级证据 & RECOMMENDATION 62 Ultrasound monitoring should be performed each trimester during pregnancy in patients with previously treated DTC and who have high levels of Tg or evidence of persistent structural disease prior to pregnancy. Level B-USPSTF 62 以前有分化型甲状腺癌病史的患者怀孕期间, 在怀孕前有高水平 Tg 或影像学表现的患者应该每三个月进行超声监测 & RECOMMENDATION 63 Women with postpartum depression should have TSH, FT4, and TPOAb tests performed. Level B-USPSTF 63 产后抑郁的妇女应该进行 TSH FT4 和 TPOAb 检测 B 级证据 & RECOMMENDATION 64 During the thyrotoxic phase of PPT, symptomatic women may be treated with beta blockers. Propranolol at the lowest possible dose to alleviate symptoms is the treatment of choice. Therapy is typically required for a few months. Level B-USPSTF 64 在产后甲状腺炎的甲状腺毒症期, 有症状的妇女可以用 β- 受体阻滞剂治疗 最低有效剂量的普萘洛尔治疗以减轻症状是治疗的选择 治疗通常需要几个月 B 级证据

17 & RECOMMENDATION 65 ATDs are not recommended for the treatment of the thyrotoxic phase of PPT. Level D-USPSTF 65 产后甲状腺炎的甲状腺毒症期不建议用抗甲状腺药物治疗 D 级证据 & RECOMMENDATION 66 Following the resolution of the thyrotoxic phase of PPT, TSH should be tested every 2 months (or if symptoms are present) until 1 year postpartum to screen for the hypothyroid phase. Level B-USPSTF 66 产后甲状腺炎甲状腺毒症期以后, 应每 2 月 ( 或出现症状时 ) 检测 TSH, 直到产后 1 年, 以筛查甲减 B 级证据 & RECOMMENDATION 67 Women who are symptomatic with hypothyroidism in PPT should either have their TSH level retested in 4 8 weeks or be started on LT4 (if symptoms are severe, if conception is being attempted, or if the patient desires therapy). Women who are asymptomatic with hypothyroidism in PPT should have their TSHlevel retested in 4 8 weeks. Level B-USPSTF 67 产后甲状腺炎的妇女如果有甲状腺功能减退的症状, 应该在 4~8 周重复检测或, 或开始 LT4 治疗 ( 如果症状严重, 如果计划怀孕, 或者如果病人希望治疗 ) 产后甲状腺炎伴无症状性甲状腺功能减退症的妇女, 应该在 4~8 周复查 TSH B 级证据 & RECOMMENDATION 68 Women who are hypothyroid with PPT and attempting pregnancy should be treated with LT4. Level A-USPSTF 68 产后甲状腺炎伴甲状腺功能低下的妇女如果计划怀孕应该用 LT4 治疗 A 级证据 & RECOMMENDATION 69 If LT4 is initiated for PPT, future discontinuation of therapy should be attempted. Tapering of treatment can be begun 6 12 months after the initiation of treatment. Tapering of LT4 should be avoided when a woman is actively attempting pregnancy, is breastfeeding, or is pregnant. Level C-USPSTF 69 产后甲状腺炎如果起始 LT4 治疗, 将来应该尝试停药 可以在开始治疗的 6~12 个月后逐渐减量 当妇女计划怀孕 哺乳或已经怀孕, 不应减量 C 级证据

18 & RECOMMENDATION 70 Women with a prior history of PPT should have an annual TSH test performed to evaluate for permanent hypothyroidism. Level A-USPSTF 70 有产后甲状腺炎病史的妇女应该每年测定 TSH 以评估永久性甲减 A 级证据 & RECOMMENDATION 71 Treatment of TAbteuthyroid pregnant woman with either LT4 or iodine to prevent PPT is ineffective and is not recommended. Level D-USPSTF 71 甲状腺功能正常 Tab+ 的孕妇用 LT4 或碘治疗预防产后甲状腺炎是无效的, 不予推荐 D 级证据 & RECOMMENDATION 72 There is insufficient evidence to recommend for or against universal TSH screening at the first trimester visit. Level I-USPSTF 72 没有足够的证据推荐或反对在妊娠前三个月进行普遍 TSH 筛查 I 级证据 & RECOMMENDATION 73 Because no studies to date have demonstrated a benefit to treatment of isolated maternal hypothyroximenia, universal FT4 screening of pregnant women is not recommended. Level D-USPSTF 因为目前尚无研究显示治疗单纯低甲状腺激素血症能够获益, 所以不建议对怀孕妇女进行 FT4 普查 D 级证据 & RECOMMENDATION 74 There is insufficient evidence to recommend for or against TSH testing preconception in women at high risk for hypothyroidism. Level I-USPSTF 74 没有足够的证据支持或反对在甲状腺功能减退症高危妇女孕前进行 TSH 检测 I 级证据 & RECOMMENDATION 75 All pregnant women should be verbally screened at the initial prenatal visit for any history of thyroid dysfunction and/or use of thyroid hormone (LT4) or anti-thyroid medications (MMI, carbimazole, or PTU). Level B-USPSTF 75 所有孕妇首次产前就诊时应询问甲状腺功能异常和 / 或使用甲状腺激素 (LT4) 或抗甲状腺药物 ( 甲巯咪唑 甲亢平或丙基硫氧嘧啶 ) 的病史 B 级证据

19 & RECOMMENDATION 76 Serum TSH values should be obtained early in pregnancy in the following women at high risk for overt hypothyroidism: History of thyroid dysfunction or prior thyroid surgery Age >30 years Symptoms of thyroid dysfunction or the presence of goiter TPOAb positivity Type 1 diabetes or other autoimmune disorders History of miscarriage or preterm delivery History of head or neck radiation Family history of thyroid dysfunction Morbid obesity (BMI _40 kg/m2) Use of amiodarone or lithium, or recent administration of iodinated radiologic contrast Infertility Residing in an area of known moderate to severe iodine insufficiency Level B-USPSTF 76 在以下甲状腺功能减退症的高危妇女中, 在妊娠早期应该检测 TSH: 有甲状腺功能异常或甲状腺手术的病史年龄 > 30 岁存在甲状腺功能减退症的症状或甲状腺肿 TPOAb 阳性 1 型糖尿病或其他自身免疫性疾病有流产或早产病史有头部或颈部放射史有甲状腺功能异常家族史严重肥胖 ( 体重指数 40 kg/m2) 正在使用胺碘酮或锂, 或最近曾使用碘造影剂不孕不育居住在中度至重度碘缺乏地区 B 级证据