妊娠合并甲状腺功能减的研究进展

甲状腺疾病是常见的疾病,近年来我国发病率呈上升趋势,而育龄妇女是甲状腺疾病的高发人群。甲状腺功能减退是大多数甲状腺疾病的最终转归,妊娠合并甲状腺减退症（甲减）,由于症状隐匿,往往被忽视。妊娠合并甲减的发生率0．2％～0．3％,其中临床甲减的发生率2％-3％,亚临床甲减占甲减患者的90％。越来越多的研究证明：甲减对妊娠可造成不良影响,甚至影响胎儿的脑发育。     

妊娠合并甲状腺机能亢进255例临床分析

目的探讨妊娠合并甲状腺机能亢进患者的围产期发病率,药物治疗剂量及规范治疗后的母婴结局。方法收集我院1995年1月～2007年12月的妊娠合并甲亢患者的临床资料255例,分为控制组153例,未控制组102例,选择同期正常妊娠315例作为对照组,控制组均在我院产科高危门诊定期产前保健,每1～1.5月监测FT4,FT3,调整抗甲状腺药物（ATD）的剂量。对妊娠合并甲亢的发生率,控制组的抗甲状腺药物剂量以及3组母儿结局进行回顾性分析。结果（1）发病率：我院近13年来妊娠合并甲亢的发病率0.26%,呈逐年上升的趋势（0.17%～0.32%）。（2）抗甲状腺药物剂量（ATD）：控制组（116例）ATD的平均剂量孕前、孕早期、孕中晚期分别为：126.27±109.92,174.58±121.42,125.21±110.77,孕前与孕早期比较,差异有统计学意义（P〈0.05=;孕早期与孕中、晚期比较,差异有统计学意义（P〈0.05）;孕前与孕中、晚期比较,差异无统计学意义（P〉0.05）。（3）母婴结局：未控制组的子痫前期、早产、胎儿生长不良、胎儿窘迫发生率与控制组比较,差异有统计学意义,控制组与正常妊娠比较,差异无统计学意义。结论妊娠合并甲亢的发病率逐年升高,孕期需及时调整抗甲状腺药物治疗量,规律治疗能明显改善母儿结局。     

甲亢孕妇妊娠结局的临床分析

目的探讨妊娠合并甲亢规范化治疗对妊娠结局的影响。方法选取四年间于我院建档并分娩、资料完整的妊娠合并甲亢患者77例,对其妊娠结局进行临床分析。结果甲亢未治疗组甲状腺激素水平明显增高,妊娠并发症增多,与治疗组相比,差异有显著性（P〈0.01）;未治疗组新生儿体重明显低于治疗组,差异有显著性（P〈0.05）;但两组的剖宫产率及新生儿甲状腺功能差异无统计学意义（P〉0.05）。结论及时诊断并规范治疗妊娠甲亢,可降低妊娠并发症发生率,改善妊娠结局。     

妊娠合并甲状腺功能亢进症55例临床分析

目的探讨妊娠合并甲状腺功能亢进症的母儿结局和临床处理。方法回顾性分析2003年1月至2007年12月在我院住院分娩的55例妊娠合并甲状腺功能亢进症患者的临床资料，将其分为病情控制组（37例）和病情未控制组（18例），并进行对照研究。结果妊娠合并甲状腺功能亢进症发生率5．4‰，病情控制组／病情未控制组妊娠糖尿病、妊娠高血压疾病、甲亢性心脏病、引产、早产、流产、小于胎龄儿、死胎发生率分别为2．7％／38．9％、0％／27．8％、0％／27．8％、0％／22．2％、2．7％／50．0％、0％／16．7％、8．1％／44，4％、0％／27，8％，病情控制组明显低于病情未控制组（P〈0．01或0．05）；无孕产妇死亡，无新生儿出生缺陷。病情未控制组患者的医疗费用显著高于病情控制组（P〈0．001）。以丙基硫氧嘧啶为主的药物治疗安全有效。结论妊娠合并甲状腺功能亢进症孕前和孕期及早发现并规范治疗，并监测以FT3、FT4为主而非TSH的甲状腺功能，维持其正常、稳定，可以有效减少母儿并发症的发生。     

22例妊娠合并甲状腺功能亢进的临床研究

目的对妊娠合并甲状腺功能亢进病例进行临床分析，为加强围产期治疗与防护措施提供依据。方法对22例妊娠合并甲状腺功能亢进病例的临床资料作回顾性研究。结果22例妊娠合并甲状腺功能亢进患者易并发妊高征、心衰、胎膜早破、死胎等妊娠合并症与并发症，尤其是重度病例早产与新生儿窒息的发生率明显高于轻、中度患者（P〈0．05），有一例重度患者发生甲亢危象。结论应重视妊娠期甲亢患者的及时诊断与合理治疗，重度甲亢患者应加强围产期监护以减少不良妊娠结局的发生，改善母儿预后。     

甲状腺功能减低和妊娠结局相关性研究

目的妊娠甲状腺功能减低是妊娠的高危因素,研究表明妊娠期甲状腺功能减退症能够导致后代智力受损,及时诊断和有效的治疗有可能预防这些危害。方法回顾性分析124例妊娠合并甲减患者的资料,采用化学发光测定孕妇血清促甲状腺激素（TSH）、游离三碘甲状腺原氨酸FT3、游离甲状腺素FT4、总甲状腺素TT4、总三碘甲状腺原氨酸FT3浓度及其对妊娠结局和胎儿的影响。结果妊娠合并甲减孕妇的并发症、早产、新生儿甲减发生率均明显升高,治疗组高于对照组P〈0.05）。结论妊娠合并甲减患者妊娠合并症明显增加。妊娠期甲状腺功能异常的及时筛查、诊断和处理,对母婴有着极其重要的意义。     

妊娠合并甲状腺疾病的围产结局（28例临床分析）

分析39578例娠中合并甲腺疾病者，共28例，占分娩总数的0．0007％，有关合并症依次为甲亢（占64％），甲状（占17．9％），单纯甲状腺肿大（占7％），甲状腺瘤（占7％），甲状腺炎（占3．6％），其发病率分别为0．045％，013％，0．005％，0．005％及0．0025％，临床实践显示，妊娠合并甲亢，甲碱者，只要孕早期满意控制激素水平，甲状腺功能基本正常，则母儿预后大多正常，否则母儿的并发征均明显增加，其他甲状腺疾病，如单纯甲状脓肿大，甲状腺瘤，甲状腺炎，无论治疗与否，不影响妊娠结局，影响围产结局的主要因素是孕期的甲状腺功能水平，孕前及孕期对母体进行甲腺功能监测并给予及时恰当的治疗十分重要。     

妊娠合并甲状腺疾病对妊娠结局和新生儿的影响

目的分析妊娠合并甲状腺疾病对妊娠结局和新生儿的影响。方法选取本院2017年4月至2018年11月收治的96例孕妇作为研究对象,根据甲状腺功能筛查情况分为甲状腺功能正常组、甲状腺功能亢进组及甲状腺功能减退组。记录三组孕妇早产、引产、自然分娩等妊娠结局及Apgar评分;比较三组胎儿宫内生长受限、胎儿宫内窘迫、低出生体质量儿、孕妇妊娠期糖尿病及妊娠期高血压疾病等不良反应发生情况。结果甲减组孕妇血清促甲状腺素(TSH)水平明显高于正常组和甲亢组,血清游离甲状腺素(FT4)与血清游离三碘甲状腺原氨酸(FT3)水平明显低于正常组和甲亢组(P0.05);甲亢组孕妇FT_4与FT_3水平明显高于甲减组和正常组,TSH水平明显低于正常组,差异具有统计学意义(P0.05);正常组剖宫产率、自然分娩率、新生儿Apgar评分明显高于甲减组和甲亢组,早产率、自然流产率、引产率明显低于甲减组和甲亢组(P0.05);正常组发生胎儿宫内生长受限、胎儿宫内窘迫、低出生体质量儿、孕妇妊娠期糖尿病及妊娠期高血压疾病的发生率明显低于甲减组和甲亢组(P0.05),但甲减组与甲亢组不良反应发生率比较无差异(P0.05)。结论妊娠合并甲状腺疾病对妊娠结局和新生儿均会产生一定的不良影响,临床上需引起重视,早期诊断积极控制病情,有利于保障母婴安全以及改善预后。     

妊娠亚临床甲减患者血清TSH、TPO-AB水平与妊娠结局的相关性研究

目的探讨妊娠期合并亚临床甲状腺功能减退(亚甲减)患者血清促进甲状腺素(TSH),甲状腺过氧化物酶抗体(TPOAb)水平与妊娠结局的关系。方法选取2016年1月至2017年2月在我院定期接受产前检查、定期围产保健且住院分娩的亚甲减患者300例,根据有无接受治疗分为亚甲减治疗组(n=189)和亚甲减未治疗组(n=111);根据血清TSH中位数水平分为高TSH水平组(n=95)和低TSH水平组(n=205);并根据血清TPOAb检测是否为阳性分为TPOAb阳性组(n=182)与TPOAb阴性组(n=118)。另选取同期300例健康孕妇为对照组。对各组妊娠结局进行统计分析。结果亚甲减未治疗组流产、早产、GDM、妊娠期高血压疾病、胎儿生长受限、低出生体重儿发生率均明显高于亚甲减治疗组及对照组(P<0.05)。亚甲减孕妇中,高TSH水平组流产、早产、GDM、妊娠期高血压疾病、胎儿生长受限、低出生体重儿发生率均明显高于低TSH水平组(P<0.05);TPOAb阳性组流产、早产、GDM、妊娠期高血压疾病、低出生体重儿发生率均明显高于TPOAb阴性组(P<0.05)。结论妊娠合并亚甲减可增加流产、早产、GDM、妊娠期高血压疾病、胎儿生长受限、低出生体重儿发生率,且血清TSH水平越高及TPOAb阳性,不良妊娠结局风险越高。     

孕期间母亲合并甲状腺功能亢进症和服用抗甲状腺药物对新生儿甲状腺功能的影响

目的 探讨分析孕期间母亲合并甲状腺功能亢进症(甲亢)和服用抗甲状腺药物(ATDs)对新生儿甲状腺功能的影响.方法 选取我院2012年4月至2015年3月期间接收治疗的孕期间母亲合并甲状腺功能亢进症孕妇102例作为研究分析对象,所选研究对象均按照各治疗方式随机各选取51例(孕妇和孕妇家属均知晓治疗方式,并签字确认),划分为对照组和研究组,所分娩出的新生儿也按照产妇所在组别进行划分,回顾分析所选研究对象临床资料,总结分析对新生儿甲状腺功能的影响状况.结果 比较两组新生儿甲状腺功能指标,包含TSH、FT4、FT3、TT4、TT3等方面,孕期母亲接受过抗甲状腺药物治疗的研究组明显优孕期母亲未接受抗甲状腺药物的对照组,且组间数据有统计学意义(P＜0.05).比较两组患者妊娠结局,研究组足月产儿率、早产儿率、剖宫产率分别为78.43％、21.57％、19.61％,对照组足月产儿率、早产儿率、剖宫产率分别为54.9％、45.09％、35.29％,组间差异均有统计学意义(P＜0.05).比较两组产妇并发症总发生率、胎儿窘迫率、胎儿畸形率、新生儿甲状腺功能异常率,研究组11.76％、3.92％、1.96％、23.53％,对照组29.41％、13.72％、15.68％、50.98％,组间差异均有统计学意义(P＜0.05).结论 孕期间母亲合并甲状腺功能亢进症需早期及时给予诊断和治疗,可使新生儿甲状腺功能异常发生率得到降低,对新生儿出生质量也有明显改善作用,临床应给予足够重视.     

余姚地区孕妇甲状腺激素水平筛查及优生意义

目的研究余姚地区妊娠期妇女甲状腺激素水平的变化,并评价其优生优育的重要意义。方法选取在产科门诊产前检查的1180例单胎孕妇（观察组）,测定其妊娠期甲状腺激素水平,并对甲状腺功能异常的孕妇进行治疗干预,与同期未进行甲状腺激素水平筛查及治疗的单胎孕妇956例（对照组）进行比较。结果观察组1180例孕妇中甲状腺功能正常996例（84．41％）,临床甲减53例（4．49％）,亚临床甲减59例（5．00％）,临床甲亢8l例（6．84％）,亚临床甲亢31例（2．63％）。观察组早产、因胎儿窘迫行破宫产、新生儿并发症、妊娠期高血压明显低于对照组（P〈O．01）。结论妊娠期妇女早期进行甲状腺功能检查,能及早发现甲状腺功能异常,以便及时治疗干预,对母婴的健康及优生优育有重要的意义．     

Screening for thyroid disease in pregnancy

Although gestational hyperthyroidism is uncommon (0.2%), hypothyroidism (autoimmune disease or suboptimal iodine intake) occurs in 2.5% of women and is predictive of reduced neonatal and child neuropsychological development and maternal obstetric complications. Postpartum thyroid dysfunction (PPTD) occurs in 5-9% of women and is associated with antithyroid peroxidase antibodies (antiTPOAb) in 10% of women in early pregnancy. Therefore, screening for thyroid dysfunction in pregnancy should be considered. T4 and thyroid stimulating hormone measurements could be used to screen for hypothyroidism, which would require levothyroxine intervention treatment. T4 supply is crucial to fetal nervous system maturation; currently, the recommended daily iodine intake is 200 microg, and this is not always achieved, even in the UK. At present, a randomised prospective trial is ongoing to provide the evidence base for this screening strategy. Meanwhile, it is reasonable to (a) optimise iodine nutrition during pregnancy; (b) ascertain women with known thyroid disease; (c) identify women at increased risk of thyroid disease-for example, those with other autoimmune diseases. PPTD can be predicted by measurement of antiTPOAb in early gestation.     

Thyroid physiology and autoimmunity in pregnancy and after delivery

During pregnancy and after delivery, the maternal thyroid gland faces several metabolic, hemodynamic and immunologic changes. In this article we first summarize the current knowledge on the physiologic adaptation of the healthy thyroid to pregnancy, including variations of thyroid-stimulating hormone and free thyroid hormones, as well as variations of thyroid volume. Our second aim is to illustrate the background of thyroid autoimmunity in this period, which characteristically ameliorates during pregnancy and aggravates after delivery. Although rare during pregnancy, Graves’ disease is the most frequent cause of hyperthyroidism, while Hashimoto’s thyroiditis is the most frequent cause for hypothyroidism. Both types of thyroid dysfunction may lead to detrimental complications in mother and child and therefore timely recognition and treatment is essential. Postpartum autoimmunity most frequently exacerbates in the form of postpartum thyroiditis, which presents with diverse clinical presentations and may lead to permanent hypothyroidism.     

Thyroid physiology and autoimmunity in pregnancy and after delivery

During pregnancy and after delivery, the maternal thyroid gland faces several metabolic, hemodynamic and immunologic changes. In this article we first summarize the current knowledge on the physiologic adaptation of the healthy thyroid to pregnancy, including variations of thyroid-stimulating hormone and free thyroid hormones, as well as variations of thyroid volume. Our second aim is to illustrate the background of thyroid autoimmunity in this period, which characteristically ameliorates during pregnancy and aggravates after delivery. Although rare during pregnancy, Graves' disease is the most frequent cause of hyperthyroidism, while Hashimoto's thyroiditis is the most frequent cause for hypothyroidism. Both types of thyroid dysfunction may lead to detrimental complications in mother and child and therefore timely recognition and treatment is essential. Postpartum autoimmunity most frequently exacerbates in the form of postpartum thyroiditis, which presents with diverse clinical presentations and may lead to permanent hypothyroidism.     

妊娠期单纯TPO抗体阳性对妊娠结局的影响

目的研究单纯TPO抗体阳性、甲状腺功能正常的孕妇随着妊娠进展出现甲状腺功能减退的比例,并评估TPO抗体对妊娠结局的影响。方法 2011年9月∽2013年1月对筛查出的839例单纯TPO抗体阳性、甲状腺功能正常且既往无糖尿病史的单胎孕妇在孕24∽28w和/或32∽36w随访甲状腺功能。随机选择1685例同期分娩的TPO抗体阴性、既往无甲状腺疾病史和糖尿病史、甲状腺功能正常且TSH〈3mIU/L的单胎孕妇作为对照组。分析TPO抗体阳性对妊娠结局如妊娠期高血压疾病、妊娠期糖尿病、胎盘早剥、前置胎盘、胎盘植入、臀位、低出生体重儿、早产儿、巨大儿的影响。结果单纯TPO抗体阳性、初次筛查甲状腺功能正常孕妇约4.5%随着妊娠进展出现亚临床甲减,无1例出现甲减。校正孕妇年龄及孕次后Logistic回归法分析发现单纯TPO抗体阳性并不增加妊娠期高血压疾病、妊娠期糖尿病、胎盘早剥、前置胎盘、臀位、低出生体重儿、早产、巨大儿的危险性,而胎盘植入的危险性是正常对照组的3倍（OR值3.02）。结论妊娠期常规筛查TPO抗体价值有限,并不改善母儿预后。     

131I治疗甲亢后早发甲减的多因素分析

为了解131I治疗甲亢后早发甲减的影响因素,对接受131I治疗的120例甲亢患者在1年内跟踪随访,对可能与早发甲减有关的多个因素用二项分类Logistic进行了回归分析.结果显示:①每克甲状腺组织给予131I平均剂量,回归系数为正值,为危险因素;甲状腺的质量的回归系数为负值,为保护因素;②对研究对象进行Logistic回归判别,早发甲减与不发甲减的准确率分别为53.3%及96.1%,总准确率为46.7%.结论为131I治疗甲亢后早发甲减可能受多种因素影响,在治疗前主要根据甲状腺的质量适当调整剂量,可一定程度减少早发甲减的发生率.     

Screening for thyroid disease and iodine deficiency

The high global prevalence of iodine deficiency and autoimmune thyroid disorders and the mental and physical consequences of these disorders creates a huge human and economic burden that can be prevented, in large part, by early detection and appropriate preventative or therapeutic measures. The availability of sophisticated, sensitive and accurate laboratory testing procedures provides an efficient and effective platform for the application of screening for these disorders. Measurement of urine iodine concentration (UIC) in school children or pregnant women is the recommended indicator for screening populations for iodine deficiency. The severity of the iodine deficiency is classified according to the UIC. Measurement of serum thyrotropin (TSH) as an indicator for population iodine deficiency is used only in neonates and is supplementary to UIC screening. Other indicators such as goitre rates, thyroid function and serum thyroglobulin levels are useful adjunctive but not frontline process indicators. The human and economic benefits of screening for congenital hypothyroidism by measurement of heel-prick TSH have been well documented and justify its universal application. Using this measurement for monitoring population iodine intake is recommended by the World Health Organization but further validation is required before it can be universally recommended. Subclinical thyroid dysfunction is readily detected by current highly sensitive serum TSH assays and its prevalence appears to increase with age, varies with iodine intake and ethnicity and may occur in up to 20% of older age people. Subclinical hyperthyroidism is the less common disorder and screening cannot be justified because of its low prevalence and minimal or insignificant clinical effects. The argument for screening for subclinical hypothyroidism in middle-aged and older women is stronger but lacks evidence of benefit from randomised controlled trials or cost benefit analyses of therapeutic intervention, so it cannot currently be recommended. The publication of recent Clinical Practice Guidelines for management of thyroid disease in pregnancy from the American Endocrine Society and American Thyroid Association provide persuasive arguments for early detection and treatment of overt and subclinical hypothyroidism to prevent obstetric complications and potential neurocognitive disorders in the offspring. Given the indisputable benefits of therapy, the sooner thyroid dysfunction is detected, before or as early as possible in gestation, the more likely there will be a better outcome. Because of the limitations of targeted case detection in women at risk of subclinical hypothyroidism, there has been a gradual shift in opinion to universal TSH screening of all women as soon as practicable in pregnancy. While a positive association exists between the presence of anti-thyroid antibodies and increased pregnancy loss, universal screening of all pregnant women for underlying autoimmune thyroid disease is difficult to justify until there is evidence of beneficial outcomes from randomised controlled trials. Vigorous and liberal targeted case detection remains the recommended strategy to address this problem.     

妊娠中期妇女甲状腺功能筛查结果分析

目的 探讨妊娠中期妇女甲状腺功能筛查的重要性,为妊娠中期妇女甲状腺疾病的诊疗提供依据.方法 选择277例妊娠中期妇女为妊娠组,162位非妊娠育龄妇女为对照组.采用放射免疫法(RIA)检测FT3、FT4,采用免疫放射法(IRMA)检测TSH.结果 ①妊娠组甲状腺疾病总患病率为14.08％ (39/277),对照组甲状腺疾病总患病率为8.02％(13/162),两组比较差异有统计学意义(P＜0.05).②妊娠组中甲亢(包含亚临床甲亢)患病率为1.44％(4/277),和甲减(包含亚临床甲减)患病率为12.64％(35/277)比较,差异有统计学意义(P＜0.05).对照组甲亢(包含亚临床甲亢)患病率为1.23％(2/162),和甲减(包含亚临床甲减)患病率为6.79％(11/162),差异有统计学意义(P＜0.05).妊娠组甲减(包含亚临床甲减)患病率较对照组升高,差异有统计学意义(P＜0.05).③两组FT3、FT4、TSH结果比较,妊娠组FT4水平低于对照组,差异有统计学意义(P＜0.05);妊娠组TSH水平低于对照组,差异有统计学意义(P ＜0.05);FT3水平无显著差异(P＞0.05).结论 妊娠中期妇女甲状腺疾病患病率增高,以甲减(包含亚临床甲减)居多,对妊娠中期妇女甲状腺功能进行筛查具有重要意义,妊娠期特异性甲状腺激素参考值范围有待明确.