Desvelando Secretos Hormonales: una revisión del Hipotiroidismo en el Embarazo a través de Casos Clínicos

Andrés Felipe García Ramos; Claudia Monsalve Arango; Jose Fernando Botero Arango; Natalia Aristizabal Henao; Nathalia Buitrago Gómez; William Fernando Cabarcas Lopez

doi:10.31053/1853.0605.v81.n4.44304

Autores

Andrés Felipe García Ramos Universidad de Occidente
Claudia Monsalve Arango Clínica las Américas AUNA. Departamento de Endocrinología.
Jose Fernando Botero Arango IPS NEURUM. Departamento de Endocrinología
Natalia Aristizabal Henao Clínica las Américas AUNA. Departamento de Endocrinología
Nathalia Buitrago Gómez Universidad Pontificia Bolivariana
William Fernando Cabarcas Lopez IPS NEURUM. Departamento de Epidemiología.

DOI:

https://doi.org/10.31053/1853.0605.v81.n4.44304

Palavras-chave:

complicações na gravidez, hipotireoidismo, atenção primária à saúde, glândula tireoide

Resumo

Antecedentes: A disfunção tireoidiana durante a gestação impacta negativamente a mulher e sua descendência, sendo o período inicial da gestação crítico para possíveis repercussões. Estabelecer estratégias de atenção prévia e durante a concepção é crucial para resultados favoráveis na gravidez. Objetivo: Esta revisão tem como objetivo reunir as evidências científicas mais recentes para orientar a abordagem diagnóstica e terapêutica baseada em casos clínicos, incluindo a descrição da fisiologia tireoidiana durante a gravidez e estratégias de identificação de pacientes de alto risco para tratamento. Método: Esta revisão bibliográfica combinou termos DeCs e MeSH da pergunta PICOT, abrangendo o período entre 2015 e 2022 em 5 bases de dados. Foram incluídos artigos em inglês e espanhol que respondessem à pergunta PICOT e contribuíssem para a explicação de dois relatos de casos. Resultados: Foram coletados 1452 artigos, os quais, após uma eliminação por duplicidade em primeira instância e posterior filtragem de acordo com critérios de inclusão e exclusão realizada por 2 revisores de maneira cega, resultaram em 32 artigos incluídos nesta revisão. Conclusões: O hipotiroidismo manifesto está relacionado a desfechos negativos materno-fetais e seu tratamento melhora essas complicações. No entanto, em estados limítrofes como hipotiroidismo subclínico, hipotireoidismo isolado e autoimunidade tireoidiana, a incerteza sobre o impacto do tratamento persiste devido à escassez de ensaios controlados. É enfatizada a importância de que todos os médicos estejam familiarizados com essa condição durante a gestação.

Downloads

Os dados de download ainda não estão disponíveis.

Biografia do Autor

Andrés Felipe García Ramos, Universidad de Occidente

Clínica Imbanaco. Departamento de Endocrinología. Cali; Colombia. Universidad del Valle. Departamento de medicina interna; Cali; Colombia.

Médico Endocrinólogo egresado de la pontificia universidad Bolivariana en Medellín – Colombia, Endocrinólogo en la clínica de Occidente en Cali - Colombia, Docente de la universidad del valle en Cali – Colombia.
Claudia Monsalve Arango , Clínica las Américas AUNA. Departamento de Endocrinología.

Clínica las Américas AUNA. Departamento de Endocrinología. Universidad Pontificia Bolivariana, Medellín; Colombia

Médico Endocrinólogo egresado de la pontificia universidad Bolivariana en Medellín – Colombia, Endocrinólogo en la clínica las Américas AUNA, Medellín – Colombia
Jose Fernando Botero Arango, IPS NEURUM. Departamento de Endocrinología

IPS NEURUM. Departamento de Endocrinología. Universidad Pontificia Bolivariana. Medellín; Colombia

Médico Endocrinólogo, Docente de la especialización en endocrinología de la pontificia universidad Bolivariana en Medellín – Colombia, Endocrinólogo en la clínica integral de diabetes en Medellín – Colombia.
Natalia Aristizabal Henao, Clínica las Américas AUNA. Departamento de Endocrinología

Clínica las Américas AUNA. Departamento de Endocrinología. Universidad Pontificia Bolivariana, Medellín; Colombia.

Médico Endocrinólogo egresado de la pontificia universidad Bolivariana en Medellín – Colombia, Endocrinólogo en la clínica las Américas AUNA, Medellín – Colombia.
Nathalia Buitrago Gómez , Universidad Pontificia Bolivariana

Clínica de Occidente. Departamento de Endocrinología. Universidad Pontificia Bolivariana. Medellín; Colombia.

Médico Internista egresado de la Universidad Libre en Cali - Colombia Fellow en Endocrinología en la pontificia universidad Bolivariana en Medellín – Colombia.
William Fernando Cabarcas Lopez, IPS NEURUM. Departamento de Epidemiología.

IPS NEURUM. Departamento de Epidemiología. Grupo de investigación en riesgo cardiovascular, renal y metabólico (COL0239921). Medellín; Colombia.

Médico Epidemiólogo de la Universidad de caldas en Manizales Colombia, Médico Asistencial clínica integral de diabetes en Medellín – Colombia

Referências

Dong AC, Stagnaro-Green A. Differences in Diagnostic Criteria Mask the True Prevalence of Thyroid Disease in Pregnancy: A Systematic Review and Meta-Analysis. Thyroid. 2019 Feb;29(2):278-289. doi: 10.1089/thy.2018.0475.

Levie D, Korevaar TIM, Bath SC, Murcia M, Dineva M, Llop S, Espada M, van Herwaarden AE, de Rijke YB, Ibarluzea JM, Sunyer J, Tiemeier H, Rayman MP, Guxens M, Peeters RP. Association of Maternal Iodine Status With Child IQ: A Meta-Analysis of Individual Participant Data. J Clin Endocrinol Metab. 2019 Dec 1;104(12):5957-5967. doi: 10.1210/jc.2018-02559.

Burrow GN, Fisher DA, Larsen PR. Maternal and fetal thyroid function. N Engl J Med. 1994 Oct 20;331(16):1072-8. doi: 10.1056/NEJM199410203311608.

Moog NK, Entringer S, Heim C, Wadhwa PD, Kathmann N, Buss C. Influence of maternal thyroid hormones during gestation on fetal brain development. Neuroscience. 2017 Feb 7;342:68-100. doi: 10.1016/j.neuroscience.2015.09.070.

Stagnaro-Green A. Approach to the patient with postpartum thyroiditis. J Clin Endocrinol Metab. 2012 Feb;97(2):334-42. doi: 10.1210/jc.2011-2576

Taylor PN, Zouras S, Min T, Nagarahaj K, Lazarus JH, Okosieme O. Thyroid Screening in Early Pregnancy: Pros and Cons. Front Endocrinol (Lausanne). 2018 Oct 25;9:626. doi: 10.3389/fendo.2018.00626.

Stagnaro-Green A, Dong A, Stephenson MD. Universal screening for thyroid disease during pregnancy should be performed. Best Pract Res Clin Endocrinol Metab. 2020 Jul;34(4):101320. doi: 10.1016/j.beem.2019.101320.

Alexander EK, Pearce EN, Brent GA, Brown RS, Chen H, Dosiou C, Grobman WA, Laurberg P, Lazarus JH, Mandel SJ, Peeters RP, Sullivan S. 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum. Thyroid. 2017 Mar;27(3):315-389. doi: 10.1089/thy.2016.0457. Erratum in: Thyroid. 2017 Sep;27(9):1212. doi: 10.1089/thy.2016.0457.correx.

Glinoer D. The regulation of thyroid function in pregnancy: pathways of endocrine adaptation from physiology to pathology. Endocr Rev. 1997 Jun;18(3):404-33. doi: 10.1210/edrv.18.3.0300.

Salmeen KE, Block-Kurbisch IJ. Thyroid Physiology During Pregnancy, Postpartum, and Lactation. In: Kovacs VB, Deal CL. Editors. Maternal-Fetal and Neonatal Endocrinology: Physiology, Pathophysiology, and Clinical Management. Academic Press; 2019 p. 53–60. doi: 10.1016/B978-0-12-814823-5.00004-0.

Okosieme OE, Khan I, Taylor PN. Preconception management of thyroid dysfunction. Clin Endocrinol (Oxf). 2018 Sep;89(3):269-279. doi: 10.1111/cen.13731

Moleti M, Trimarchi F, Vermiglio F. Thyroid physiology in pregnancy. Endocr Pract. 2014 Jun;20(6):589-96. doi: 10.4158/EP13341.RA.

Glinoer D. The importance of iodine nutrition during pregnancy. Public Health Nutr. 2007 Dec;10(12A):1542-6. doi: 10.1017/S1368980007360886.

Pearce EN. What do we know about iodine supplementation in pregnancy? J Clin Endocrinol Metab. 2009 Sep;94(9):3188-90. doi: 10.1210/jc.2009-1512.

Lee SY, Pearce EN. Assessment and treatment of thyroid disorders in pregnancy and the postpartum period. Nat Rev Endocrinol. 2022 Mar;18(3):158-171. doi: 10.1038/s41574-021-00604-z.

Taylor PN, Vaidya B. Iodine supplementation in pregnancy - is it time? Clin Endocrinol (Oxf). 2016 Jul;85(1):10-4. doi: 10.1111/cen.13065.

Vargas-Uricoechea H, Pinzón-Fernández MV, Bastidas-Sánchez BE, Jojoa-Tobar E, Ramírez-Bejarano LE, Murillo-Palacios J. Iodine Status in the Colombian Population and the Impact of Universal Salt Iodization: A Double-Edged Sword? J Nutr Metab. 2019 Apr 1;2019:6239243. doi: 10.1155/2019/6239243.

Weeke J, Dybkjaer L, Granlie K, Eskjaer Jensen S, Kjaerulff E, Laurberg P, Magnusson B. A longitudinal study of serum TSH, and total and free iodothyronines during normal pregnancy. Acta Endocrinol (Copenh). 1982 Dec;101(4):531-7. doi: 10.1530/acta.0.1010531.

Glinoer D, de Nayer P, Bourdoux P, Lemone M, Robyn C, van Steirteghem A, Kinthaert J, Lejeune B. Regulation of maternal thyroid during pregnancy. J Clin Endocrinol Metab. 1990 Aug;71(2):276-87. doi: 10.1210/jcem-71-2-276.

The American College of Obstetricians and Gynecologists. Thyroid Disease in Pregnancy: ACOG Practice Bulletin, Number 223. Obstet. Gynecol. 2020, 135 (6), e261–e274 DOI:10.1097/aog.0000000000003893.

Lee RH, Spencer CA, Mestman JH, Miller EA, Petrovic I, Braverman LE, Goodwin TM. Free T4 immunoassays are flawed during pregnancy. Am J Obstet Gynecol. 2009 Mar;200(3):260.e1-6. doi: 10.1016/j.ajog.2008.10.042.

Hales C, Taylor PN, Channon S, McEwan K, Thapar A, Langley K, Muller I, Draman MS, Dayan C, Gregory JW, Okosieme O, Lazarus JH, Rees DA, Ludgate M. Controlled Antenatal Thyroid Screening II: Effect of Treating Maternal Suboptimal Thyroid Function on Child Behavior. J Clin Endocrinol Metab. 2020 Mar 1;105(3):dgz098. doi: 10.1210/clinem/dgz098.

Pop VJ, Ormindean V, Mocan A, Meems M, Broeren M, Denollet JK, Wiersinga WM, Bunevicius A. Maternal cognitive function during pregnancy in relation to hypo- and hyperthyroxinemia. Clin Endocrinol (Oxf). 2019 Dec;91(6):824-833. doi: 10.1111/cen.14107.

Tsakiridis I, Giouleka S, Kourtis A, Mamopoulos A, Athanasiadis A, Dagklis T. Thyroid Disease in Pregnancy: A Descriptive Review of Guidelines. Obstet Gynecol Surv. 2022 Jan;77(1):45-62. doi: 10.1097/OGX.0000000000000960.

Han Y, Gao X, Wang X, Zhang C, Gong B, Peng B, Li J, Liu A, Shan Z. A Systematic Review and Meta-Analysis Examining the Risk of Adverse Pregnancy and Neonatal Outcomes in Women with Isolated Hypothyroxinemia in Pregnancy. Thyroid. 2023 May;33(5):603-614. doi: 10.1089/thy.2022.0600.

Thyroid Disease in Pregnancy: ACOG Practice Bulletin, Number 223. Obstet Gynecol. 2020 Jun;135(6):e261-e274. doi: 10.1097/AOG.0000000000003893.

Practice Committee of the American Society for Reproductive Medicine. Subclinical hypothyroidism in the infertile female population: a guideline. Fertil Steril. 2015 Sep;104(3):545-53. doi: 10.1016/j.fertnstert.2015.05.028.

Lazarus J, Brown RS, Daumerie C, Hubalewska-Dydejczyk A, Negro R, Vaidya B. 2014 European thyroid association guidelines for the management of subclinical hypothyroidism in pregnancy and in children. Eur Thyroid J. 2014 Jun;3(2):76-94. doi: 10.1159/000362597.

Yang Y, Guo T, Fu J, Kuang J, Wang Y, Zhang Y, Zhang H, He Y, Peng Z, Wang Q, Shen H, Zhang Y, Yan D, Ma X, Guan H. Preconception Thyrotropin Levels and Risk of Adverse Pregnancy Outcomes in Chinese Women Aged 20 to 49 Years. JAMA Netw Open. 2021 Apr 1;4(4):e215723. doi: 10.1001/jamanetworkopen.2021.5723.

Taylor PN, Minassian C, Rehman A, Iqbal A, Draman MS, Hamilton W, Dunlop D, Robinson A, Vaidya B, Lazarus JH, Thomas S, Dayan CM, Okosieme OE. TSH levels and risk of miscarriage in women on long-term levothyroxine: a community-based study. J Clin Endocrinol Metab. 2014 Oct;99(10):3895-902. doi: 10.1210/jc.2014-1954.

Lazarus JH, Bestwick JP, Channon S, Paradice R, Maina A, Rees R, Chiusano E, John R, Guaraldo V, George LM, Perona M, Dall'Amico D, Parkes AB, Joomun M, Wald NJ. Antenatal thyroid screening and childhood cognitive function. N Engl J Med. 2012 Feb 9;366(6):493-501. doi: 10.1056/NEJMoa1106104. Erratum in: N Engl J Med. 2012 Apr 26;366(17):1650.

Hales C, Taylor PN, Channon S, Paradice R, McEwan K, Zhang L, Gyedu M, Bakhsh A, Okosieme O, Muller I, Draman MS, Gregory JW, Dayan C, Lazarus JH, Rees DA, Ludgate M. Controlled Antenatal Thyroid Screening II: Effect of Treating Maternal Suboptimal Thyroid Function on Child Cognition. J Clin Endocrinol Metab. 2018 Apr 1;103(4):1583-1591. doi: 10.1210/jc.2017-02378.

de Escobar GM, Obregón MJ, del Rey FE. Maternal thyroid hormones early in pregnancy and fetal brain development. Best Pract Res Clin Endocrinol Metab. 2004 Jun;18(2):225-48. doi: 10.1016/j.beem.2004.03.012.

Maraka S, Ospina NM, O'Keeffe DT, Espinosa De Ycaza AE, Gionfriddo MR, Erwin PJ, Coddington CC 3rd, Stan MN, Murad MH, Montori VM. Subclinical Hypothyroidism in Pregnancy: A Systematic Review and Meta-Analysis. Thyroid. 2016 Apr;26(4):580-90. doi: 10.1089/thy.2015.0418.

Consortium on Thyroid and Pregnancy—Study Group on Preterm Birth; Korevaar TIM, Derakhshan A, Taylor PN, Meima M, Chen L, Bliddal S, Carty DM, Meems M, Vaidya B, Shields B, Ghafoor F, Popova PV, Mosso L, Oken E, Suvanto E, Hisada A, Yoshinaga J, Brown SJ, Bassols J, Auvinen J, Bramer WM, López-Bermejo A, Dayan C, Boucai L, Vafeiadi M, Grineva EN, Tkachuck AS, Pop VJM, Vrijkotte TG, Guxens M, Chatzi L, Sunyer J, Jiménez-Zabala A, Riaño I, Murcia M, Lu X, Mukhtar S, Delles C, Feldt-Rasmussen U, Nelson SM, Alexander EK, Chaker L, Männistö T, Walsh JP, Pearce EN, Steegers EAP, Peeters RP. Association of Thyroid Function Test Abnormalities and Thyroid Autoimmunity With Preterm Birth: A Systematic Review and Meta-analysis. JAMA. 2019 Aug 20;322(7):632-641. doi: 10.1001/jama.2019.10931. Erratum in: JAMA. 2019 Nov 5;322(17):1718. doi: 10.1001/jama.2019.16269.

Casey BM, Thom EA, Peaceman AM, Varner MW, Sorokin Y, Hirtz DG, Reddy UM, Wapner RJ, Thorp JM Jr, Saade G, Tita AT, Rouse DJ, Sibai B, Iams JD, Mercer BM, Tolosa J, Caritis SN, VanDorsten JP; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network. Treatment of Subclinical Hypothyroidism or Hypothyroxinemia in Pregnancy. N Engl J Med. 2017 Mar 2;376(9):815-825. doi: 10.1056/NEJMoa1606205.

Männistö T, Vääräsmäki M, Pouta A, Hartikainen AL, Ruokonen A, Surcel HM, Bloigu A, Järvelin MR, Suvanto-Luukkonen E. Perinatal outcome of children born to mothers with thyroid dysfunction or antibodies: a prospective population-based cohort study. J Clin Endocrinol Metab. 2009 Mar;94(3):772-9. doi: 10.1210/jc.2008-1520.

Cleary-Goldman J, Malone FD, Lambert-Messerlian G, Sullivan L, Canick J, Porter TF, Luthy D, Gross S, Bianchi DW, D'Alton ME. Maternal thyroid hypofunction and pregnancy outcome. Obstet Gynecol. 2008 Jul;112(1):85-92. doi: 10.1097/AOG.0b013e3181788dd7.

Velasco I, Vila L, Goya M, Oleaga A, de la Calle M, Santamaria FJ. Executive summary of the SEEN (Sociedad Española de Endocrinología y Nutrición[Spanish Society of Endocrinology and Nutrition])-SEGO (Sociedad Española deGinecología y Obstetricia [Spanish Society of Gynaecology and Obstetrics]) consensusdocument on the management of thyroid dysfunction during pregnancy. Endocrinol Diabetes Nutr (Engl Ed). 2023 Mar;70 Suppl 1:38-50. doi: 10.1016/j.endien.2022.11.008.

Chen S, Zhou X, Zhu H, Yang H, Gong F, Wang L, Zhang M, Jiang Y, Yan C, Li J, Wang Q, Zhang S, Pan H. Preconception TSH and pregnancy outcomes: a population-based cohort study in 184 611 women. Clin Endocrinol (Oxf). 2017 Jun;86(6):816-824. doi: 10.1111/cen.13329.

Abdel Rahman AH, Aly Abbassy H, Abbassy AA. Improved in vitro fertilization outcomes after treatment of subclinical hypothyroidism in infertile women. Endocr Pract. 2010 Sep-Oct;16(5):792-7. doi: 10.4158/EP09365.OR. Erratum in: Endocr Pract. 2011 May-Jun;17(3):526.

Kim CH, Ahn JW, Kang SP, Kim SH, Chae HD, Kang BM. Effect of levothyroxine treatment on in vitro fertilization and pregnancy outcome in infertile women with subclinical hypothyroidism undergoing in vitro fertilization/intracytoplasmic sperm injection. Fertil Steril. 2011 Apr;95(5):1650-4. doi: 10.1016/j.fertnstert.2010.12.004.

Lemieux P, Yamamoto JM, Nerenberg KA, Metcalfe A, Chin A, Khurana R, Donovan LE. Thyroid Laboratory Testing and Management in Women on Thyroid Replacement Before Pregnancy and Associated Pregnancy Outcomes. Thyroid. 2021 May;31(5):841-849. doi: 10.1089/thy.2020.0609.

Davis LE, Leveno KJ, Cunningham FG. Hypothyroidism complicating pregnancy. Obstet Gynecol. 1988 Jul;72(1):108-12.

Leung AS, Millar LK, Koonings PP, Montoro M, Mestman JH. Perinatal outcome in hypothyroid pregnancies. Obstet Gynecol. 1993 Mar;81(3):349-53.

Sheehan PM, Nankervis A, Araujo Júnior E, Da Silva Costa F. Maternal Thyroid Disease and Preterm Birth: Systematic Review and Meta-Analysis. J Clin Endocrinol Metab. 2015 Nov;100(11):4325-31. doi: 10.1210/jc.2015-3074./

Wang J, Gong XH, Peng T, Wu JN. Association of Thyroid Function During Pregnancy With the Risk of Pre-eclampsia and Gestational Diabetes Mellitus. Endocr Pract. 2021 Aug;27(8):819-825. doi: 10.1016/j.eprac.2021.03.014.

Levie D, Korevaar TIM, Bath SC, Dalmau-Bueno A, Murcia M, Espada M, Dineva M, Ibarluzea JM, Sunyer J, Tiemeier H, Rebagliato M, Rayman MP, Peeters RP, Guxens M. Thyroid Function in Early Pregnancy, Child IQ, and Autistic Traits: A Meta-Analysis of Individual Participant Data. J Clin Endocrinol Metab. 2018 Aug 1;103(8):2967-2979.

Pearce EN. Management of Hypothyroidism and Hypothyroxinemia During Pregnancy. Endocr Pract. 2022 Jul;28(7):711-718. doi: 10.1016/j.eprac.2022.05.004.

Alexander EK, Marqusee E, Lawrence J, Jarolim P, Fischer GA, Larsen PR. Timing and magnitude of increases in levothyroxine requirements during pregnancy in women with hypothyroidism. N Engl J Med. 2004 Jul 15;351(3):241-9. doi: 10.1056/NEJMoa040079.