2011年ATA妊娠和产后甲状腺疾病诊疗指南

1、Guideli nes of the America n Thyroid Associati onfor the Diag no sis and Man ageme nt of Thyroid DiseaseDuring Preg nancy 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 America n Thyroid Associati on Taskforce on Thyroid Disease During Preg nancyand Postpartum美国甲状腺协会妊娠期和产后甲状腺疾病特别工作组Tran slated by Wang

2、Xinjun Bin zhou people s hospital,B in zhou Medical College 王新军译滨州医学院附属滨州市人民医院INTRODUCTION.、八、-刖言Preg nancy has a profo und impact on the thyroid gla ndand thyroid fun cti on. The gla nd in creases 10% in size duri ng preg nancy in iodi ne-replete coun tries and by 20%0% in areas of iodine deficienc

3、y. Production of thyroxine(T4) and triiodothyronine (T3) in creases by 50%, along with a 50% in crease in the daily iodi ne requireme nt. These physiological cha nges may result in hypothyroidism in the later stages of preg nancy in iodine-deficient women who were euthyroid in the first trimester.妊娠

4、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 gon adotrop in (hCG), is decreased throughout preg nancy with the lower no rmal

5、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 thyroglobuli n (Tg) an tibody 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

6、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。Sixtee n perce nt of the wome n who are euthyroid and positive for TPO or Tg an tibody 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 f

7、or TPO or Tg antibody in the first trimester will develop postpartum thyroiditis. In esse nee, preg nancy 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 diseas

8、e who were euthyroid prior to con cepti on.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。Kno wledge regard ing the in teracti on betwee n the thyroid and preg nan

9、 cy/the postpartum period is adva ncing 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 in terpretati on of the literature as well as a critical impact for the cli nical dia

10、g no sis 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 preg nancy, studies are now focus ing on the pote ntial impact

11、 of subcli ni cal hypothyroidism and subcli ni cal hyperthyroidism on maternal and fetal health, the associati on betwee n miscarriage and preterm delivery in euthyroid wome n positive for TPO an d/or Tg an tibody, and the prevale nee and Ion g-term impact of postpartum thyroiditis. Rece ntly comple

12、ted prospective ran domized studies have begu n to produce critically n eeded 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

13、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。It is in this con text that the America n Thyroid Associatio n (ATA) charged a task force with develop ing cli ni cal guideli nes on the diag no sis and treatme nt of thyroid disease duri ng preg nancy and the po

14、stpartum. The task force con sisted of intern ati onal experts in the field of thyroid disease and preg nan cy, and in cluded represe ntatives from the ATA, Asia and Ocea nia Thyroid Associati on, Lati n America n Thyroid Society, America n College of Obstetricia ns and Gyn ecologists, and the Midwi

15、ves Alliance of North America. Inclusion of thyroidologists, obstetricians, and midwives on the task force was esse ntial to en suri ng widespread accepta nce and adopti on of the developed guideli nes.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

16、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 1Trimester-specific refere nce ran ges for TSH, as defi ned in populati ons with optimal iodi ne in take, should be applied. Level B-USPSTF1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 2If tr

17、imester-specific reference ranges for TSH are not available in the laboratory, the followi ng refere nce ran ges are recomme nded: first trimester, 0.12.5 mIU/L; sec ond trimester, 0.230 mIU/L; third trimester, 0.3 30 mIU/L. Level I-USPSTF2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0.12.5 mIU/L;妊娠

18、中期三个月，0.2-3.0 MIU / L ;孕晚 期三个月，0.3-3.0 MIU/ L。I级证据& RECOMMENDATION 3The optimal method to assess serum FT4 duri ng preg nancy is measureme nt of T4 in the dialysate or ultrafiltrate ofserum samples employi ng on-I ine extractio n/liquid chromatography/ta ndem mass spectrometry (LC/MS/MS). Level A-US

19、PSTF3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& RECOMMENDATION 4If 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

20、accurate indication of thyroid status in preg nancy tha n any of these alter native methods. Level A-USPSTF4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 5In view of the wide variation in the results of FT4 assays, method

21、-specific and trimester-specific refere nee ran ges of serum FT4 are required. Level B-USPSTF5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6 RECOMMENDATION 6OH should be treated in pregnancy. This includes women with a TSH concentration above the trimester-specific refere nee in terval with a de

22、creased FT4, and all wome n with a TSH concentration above 10.0 mIU/L irrespective of the level of FT4. Level A-USPSTF6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 7Isolated hypothyrox in emia should not be treated in preg nancy. Leve

23、l 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 8SCH has bee n associated with adverse maternal and fetal outcomes. However, due to the lack of ran domized con trolled trials there is in sufficie nt evide nee to recomme nd for or aga inst uni versal LT4 treatme nt in TAb_ preg nant wome n with S

24、CH. Level I-USPSTF8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& RECOMMENDATION 9Wome n who are positive for TPOAb and have SCH should be treated with LT4. Level B-USPSTF9TPOAb阳性的SCH妇女应该用LT4治疗。B级证据& RECOMMENDATION 10The recomme nded treatme nt of maternal hypothyroi

25、dism is with admi nistratio n of oral LT4. It is strongly recommended not to use other thyroid preparations such as T3 or desiccated thyroid. Level A-USPSTF10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 11The goal of LT4 treatment is to normalize maternal serum TSH values within

26、 the trimester-specific preg nancy refere nee range (first trimester, 0.12.5 mIU/L; sec ond trimester, 0.230 mIU/L; third trimester, 0.3 30 mIU/L). Level A-USPSTF 11LT4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0.1-2.5 mIU/L ;妊娠中三个月，0.2-3.0 mIU/L ;孕晚期三个月， 0.3-3.0 mIU/L )。A级证据& RECOMMENDATION 12Women w

27、ith SCH in pregnancy who are not initially treated should be monitored for progressi on to OH with a serum TSH and FT4 approximately every 4 weeks un til 16-20 weeks gestation and at least once between 26 and 32 weeks gestation. This approach has not bee n prospectively studied. Level I-USPSTF12没有进行

28、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， 1620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& RECOMMENDATION 13Treated hypothyroid patie nts (recei ving LT4) who are n ewly preg nant should in depe nden tly in crease their dose of LT4 by *25%0% upon a missed men strual cycle or positive home preg nancy tes

29、t and no tify their caregiver promptly. One means of accomplish ing this adjustme nt is to in crease LT4 from once daily dos ing to a total of nine doses per week (29% in crease). Level B-USPSTF13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%

30、)。 B级证据& RECOMMENDATION 14There exists great in teri ndividual variability regard ing the in creased amount of T4 (or LT4) necessary to maintain a normal TSH throughout pregnancy, with some women requiri ng only 10% -20% in creased dos ing, while others may require as much as an 80% in crease. The e

31、tiology of mater nal hypothyroidism, as well as the prec on cepti on level of TSH, may provide in sight into the magn itude of n ecessary LT4 in crease.Clinicians should seek this information upon assessment of the patient after preg nancy is con firmed. Level A-USPSTF14为保持怀孕期间TSH正常，T4 (或LT4)的增加量个体间

32、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 15Treated hypothyroid patie nts (recei ving LT4) who are pla nning preg nancy should have their dose adjusted by their provider in order to optimize serum TSH values to 2.5 mIU/

33、L prec on cepti on. Lower prec on cepti on TSH values (within the non preg nant reference range) reduce the risk of TSH elevation during the first trimester. Level B-USPSTF15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V2.5MIU/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& RECOMMENDATION 16In preg

34、 nant patie nts with treated hypothyroidism, mater nal serum TSH should be mon itored approximately every 4 weeks duri ng the first half of preg nancy because further LT4 dose adjustme nts are ofte n required. Level B-USPSTF16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& RECOMMEN

35、DATION 17In preg nant patie nts with treated hypothyroidism, mater nal TSH should be checked at least once betwee n 26 and 32 weeks gestati on. Level I-USPSTF17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 18Follow ing delivery, LT4 should be reduced to the patie nt prec on cepti on dose

36、. Additi onal TSH testi ng should be performed at approximately 6 weeks postpartum. Level B-USPSTF18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 19In the care of women with adequately treated Hashimoto thyroiditis, no other maternal or fetal thyroid test ing is recomme nded bey ond measureme

37、 nt of maternal thyroid fun cti on (such as serial fetal ultraso un ds, an ten atal testi ng, an d/or umbilical blood sampli ng) uni ess for other preg nancy circumsta nces. Level A-USPSTF19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 20Euth

38、yroid wome n (not recei ving LT4) who are TAbt require mon itori ng for hypothyroidism duri ng preg nancy. 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-USPSTF20TAb+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TS

39、H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& RECOMMENDATION 21A sin gle RCT has dem on strated a reducti on in postpartum thyroiditis from sele nium therapy. No subseque nt trials have con firmed or refuted these findin gs. At prese nt, sele nium suppleme ntati on is not recomme nded for TPOAbt wome n dur

40、i ng preg nan cy. Level C-USPSTF21一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 22In the prese nee of a suppressed serum TSH in the first trimester (TSH 0.1 mIU/L), a history and physical exam in ati on are in dicated. FT4 measureme nts should be obta ined in

41、all patie nts. Measureme nt of TT3 and TRAb may be helpful in establishi ng a diag no sis of hyperthyroidism. Level B-USPSTF22如果在妊娠前3个月存在血清TSH抑制(TSHvO.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 23There is not eno ugh evide nee to recomme nd for or aga in

42、st the use of thyroid ultraso und in differe ntiati ng the cause of hyperthyroidism in preg nan cy. Level I-USPSTF23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 24Radioactive iodi ne (RAI) sca nning or radioiodi ne uptake determ in atio n should not be performed in preg nan cy. Level D-USP

43、STF24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 25The appropriate man ageme nt of wome n with gestati onal hyperthyroidism and hyperemesis gravidarum in cludes supportive therapy, man ageme nt of dehydrati on, and hospitalizati on if n eeded. Level A-USPSTF25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

44、果需要，可以住院治疗。A级证据& RECOMMENDATION 26ATDs are not recomme nded for the man ageme nt of gestati onal 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 27Thyrotoxic wome n should be ren dered euthyroid before attempt ing preg nan cy. Level A-USPSTF27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&

45、 RECOMMENDATION 28PTU is preferred for the treatme nt of hyperthyroidism in the first trimester. Patie nts on MMI should be switched to PTU if preg nancy is con firmed in the first trimester. Following the first trimester, consideration should be given to switching to MMI. Level I-USPSTF28在妊娠前三个月，首选

46、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 29A comb in atio n regime n of LT4 and an ATD should not be used in preg nan cy, except in the rare situation of fetal hyperthyroidism. Level D-USPSTF29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 3

47、0In wome n being treated with ATDs in preg nancy, FT4 and TSH should be moni tored approximately every 2-6 weeks. The primary goal is a serum FT4 at or moderately above the no rmal refere nee ran ge. Level B-USPSTF30在怀孕期间用抗甲状腺药物进行治疗的妇女，应该每26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

48、 31Thyroidectomy in preg nancy is rarely in dicated. If required, the optimal time for thyroidectomy is in the sec ond trimester. Level A-USPSTF31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& RECOMMENDATION 32If the patie nt has a past or prese nt history of Graves a mater naiseliuaase, determ in a

49、ti on of TRAb should be obta ined at 204 weeks gestati on. Level B-USPSTF32如果病人有Graves病或曾患Graves病，应该在妊娠2024周检测孕妇的血清TRAb。B级证据& RECOMMENDATION 33Fetal surveillanee with serial ultrasounds should be performed in women who have uncon trolled hyperthyroidism an d/or wome n with high TRAb levels (greater

50、tha n three times the upper limit of normal). A consultation with an experieneed obstetricia n or maternalfetal medici ne specialist is optimal. Such mon itori ng may include ultrasound for heart rate, growth, amniotic fluid volume, and fetal goiter. Level I-USPSTF33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)

51、，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 34Cordoce ntesis should be used in extremely rare circumsta nces and performed in an appropriate sett in g. It may occasi on ally be of use whe n fetal goiter is detected in wome n tak ing ATDs to help determ ine

52、whether the fetus is hyperthyroid or hypothyroid. Level I-USPSTF34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 35MMI in doses up to 20 0 mg/d is safe for lactating mothers and their infants. PTU at doses up to 300mg/d is a sec on d-l ine age nt due

53、to concerns about severe hepatotoxicity. ATDs should be administered following a feeding and in divided doses. Level A-USPSTF35MMI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& RECOMMENDATION 36All preg nant and lactati ng wome n should in gest a minimum of 250 m

54、g iod ine daily. Level A-USPSTF36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 37To achieve a total of 250 mg iod ine in gesti on daily in North America all wome n who are pla nning to be preg nancy or are preg nant or breastfeedi ng should suppleme nt their diet with a daily oral supplement that co

55、ntains 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 con siste nt delivery of daily iodide. Level B-USPSTF37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& RECOMMENDATIO

56、N 38In areas of the world outside of North America, strategies for en suri ng adequate iodine in take duri ng prec on cepti on, preg nan cy, and lactati on should vary accord ing to regi onal dietary patter ns and availability of iodized salt. Level A-USPSTF38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

57、饮食习惯和是否有碘盐而制定补碘方案。A级证据& RECOMMENDATION 39Pharmacologic doses of iod ine exposure duri ng preg nancy should be avoided, except in preparati on for thyroid surgery for Graves disease. Cli nicia ns should carefully weigh the risks and ben efits whe n orderi ng medicati ons or diag no stic tests that wi

58、ll result in high iod ine exposure. Level C-USPSTF39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 40Sustai ned iodi ne in take from diet and dietary suppleme nts exceedi ng 5100 mg daily should be avoided due to concerns about the pote ntial for fetal hypothyroidism. Level C-USPSTF40应该避免饮食和膳食补充剂碘摄入量持续每日超过5001100mg,因为这可能导致胎儿潜在的甲状腺功能减退。C级证据& RECOMMENDATION 41There