The “Thyroid and Pregnancy Guidelines” is easily one of the most anticipated guidelines of 2024 for thyroid enthusiasts, first unveiled at the American Thyroid Association Meeting this past week in Washington, D.C.
For context, the last ATA Clinical Practice Guideline, focusing on thyroid disease during pregnancy and postpartum, was published in 2017 and has been cited over 2,500 times.
Over the past few years, I have leafed through and referred to these guidelines countless times, including incorporating their recommendations into clinical practice and my Epic “smart phrases.” Controversies such as whether to universally screen for thyroid disease during pregnancy, what the normal TSH range is during pregnancy, and whether to treat euthyroid TPO Antibody positive women remain conundrums endocrinologists (and obstetricians) are consulted about daily.
Given this enthusiasm, it was no surprise to me that at 7 a.m. this past Friday, a packed room with hundreds of attendees gathered and craned their necks to see the first glimpse of the slides and hear “sneak peek” updates of the upcoming 2024 Thyroid and Pregnancy Guidelines.
The writing group is co-chaired by Dr. Tim Korevaar and Dr. Angela Leung. The composition of the committee was very diverse — including location (numerous international members), specialties (surgeons, endocrinologists, and reproductive endocrinologists), gender (>75% female), and patient perspectives.
Anyone involved in guideline development knows how complex the process is, how each recommendation is carefully vetted, evidence weighted using the GRADE methodology, and final recommendations not revealed until all evidence has been assessed and consensus agreed upon by committee members. While no definitive recommendations were revealed at this session, there was a lot of insight into the working group, the extensive research that took place, and the major topics that will be addressed.
New data that we will likely see incorporated into the guideline:
- What is the effect of levothyroxine use in Thyroid Peroxidase (TPO) Antibody positive, euthyroid women?
- Behind the scenes: Three randomized controlled trials on preconception levothyroxine treatment for euthyroid TPO Ab positivity will be included. These studies found no reduction in adverse outcomes noted with treatment (including miscarriage, live birth, preterm birth), regardless of TSH, TPO Ab titer, or past medical history. There is a ~8% risk of development of subclinical hypothyroidism per year.
- What is the persistence of abnormal thyroid function level abnormalities upon repeat testing?
- What is the effect of levothyroxine treatment if started in the second trimester? Note: there is a significant remaining knowledge gap in the evidence that levothyroxine treatment is beneficial if started early.
- The committee initiated a study during the guideline process to assess thyroid disease risk factors (e.g., history of head/neck radiation, history of pregnancy loss, preterm delivery or infertility, family history of autoimmune thyroid disease, and morbid obesity, among other risk factors). A systematic review of risk factors is ongoing and will be published as well.
The countdown to the official publication has begun. Here’s hoping the guideline includes algorithms for frequent perusing — this guideline is going to get a lot of traction!
Dr. Pessah-Pollack has no conflicts of interest to report.
Image by Ken Tackett / Shutterstock