Slide 1

Born in 1942, in Tehran, the capital city of Iran, Fereidoun Azizi obtained his MD from Tehran University, School of Medicine in 1966, Dr. Azizi then completed his internal medicine speciality, endocrinology and methabolism subspeciality and nuclear medicine speciality from Tufts University, School of Medicine, Boston, USA and obtained three American Boards of Internal Medicine, Endocrinology and Metabolism, and Nuclear Medicine in 1972, 1973 and 1974, respectively. He was appointed assistant professor of medicine at Tufts University, and Chief of Endocrinology and acting-chief of Nuclear Medicine at St. Elizabeths Hospital of Boston, Tufts Medical School from 1974 until 1979, when he returned to Iran. He began his affilation with Beheshti University, and has since served as associate professor in 1979 and as professor of medicine and endocrinology since 1985. His appointements have been Dean of the medical school, Chancellor of Shahid Beheshti University of Medical Sciences, Head of the medical group of Supreme Council for Educational Programming and Director of Medical Commission of Council for Scientific Research in the Islamic Republic of Iran. He has served as President of Iranian College of Internal Medicine and is currently the president of the Iran Endocrine Society. Professor Azizi has been the Leading Professor and Director of Endocrine Division at Taleghani Medical center, Shahid Beheshti University of Medical Sciences since 1989 and Director of Endocrine Research Center since 1994. He has had a large endocrine practice since 1979. Professor Azizis many research contributions have been in various fields of endocrinology and metabolism, in particular the hypothalamic-pituitary-thyroid axis. He began his work with Professor L.E. Braverman in Boston and continued his interest in thyroid pathophysiology in Iran. He focused many of his research projects in 80s in iodine deficiency in Iran, presented the results to the Minister of Health of Iran in 1988 and initiated the first national IDD survey, which led to the formation of National Council for Control of Iodine Deficiency Disorders in Iran in 1989; Slide 2 in order to ensure sustained elimination of iodine deficiency in the last 20 years in Iran. He also directed the national research project of Tehran Lipid and Glucose Study in the last 14 years. Professot Azizi was the Regional Coordinator for the Middle East and North Africa of Internaltional Council for Control of Iodine Deficiency Disorders (ICCIDD) and has served as consultant and advisor to WHO and UNICEF on multiple occasions. He is the Editor-in-Chief of the International Journal of Endocrinology and Metabolism. Professor Azizi has 1040 publications including 486 peer reviewed international paper and 524 scientific papers in Iranian medical Journals and 30 full text or chapters in scientific books. He is an invited reviewer for more than 26 scientific medical journals. He has received many awards including five awards from presidents of I.R. Iran for Distinguished Professor, Research Excellence, Kharazmi Feitival, Distinguished Research Centerand Health Promition in 1992, 1994, 1997, 2002 and 2008; State of Kwait Prize for excellence in diabetes in Eastern Mediterranean Region in 2007 and Nagataki Prize from Asia-Oceania Congress of Endocrinology in 2009. He was selected, as Distinguished Scienctist of the Year by Iranian Academy of Medical Sciences in 2011. Slide 3 Slide 4 CONFLICT OF INTEREST Speakers Name FEREIDOUN AZIZI .. I have the following potential conflicts of interest to report: Research Contracts Consulting Employment in the Industry Stockholder of a healthcare company Owner of a healthcare company Other(s) I declare that I have no potential conflict of interest. Slide 5 Thyroid and Pregnancy Fereidoun Azizi Research Institute for Endocrine Sciences Shahid Beheshti University of Medical Sciences Tehran, I.R. Iran Meet the professor 1 Slide 6 Objectives To review and discuss: Changes in thyroid economy during pregnancy Challenges with diagnosis of thyroid derangement in pregnancy Challenges with treatment of thyroid disease in pregnancy Slide 7 Changes in Thyroid economy during pregnancy Slide 8 goiter Tg TSH TBG E FT4 iodine TPO Ab TSH TSH placental DI III T4 TSH FT4 HCG Factors for thyroid stimulation during pregnancy Delange: Int.J. Endocrinol. Metab. 2: 1, 2004 Slide 9 Slide 10 Iodine Requirement in Pregnancy ( g/day) During pregnancy Basal 150 40-50 % increased T4 requirements 50-100 transfer of T4 and I from mother to fetus 50 Increased renal clearance of I ? 250-300 Delange: Int.J. Endocrinol. Metab. 2: 1, 2004 Slide 11 Guidelines on thyroid and pregnancy The rapidly evolving data on the management of thyroid disorders during pregnancy have been the impetus for development of many guidelines during the past few years. It is noteworthy that two guidelines on thyroid and pregnancy were documented in October 2011 and August 2012 by American Thyroid Association and Endocrine Society, respectively. Slide 12 Guideline of the American Thyroid Association for the diagnosis and Management of Thyroid Disease during Pregnancy and Postpartum The American Thyroid Association Taskforce on Thyroid Disease During Pregnancy and postpartum Alex Stargnaro-Green (Chair), Marcos Abalovich, Erik Alexander, Fereidoun Azizi, Jorge Mestman, Roberto Negro, Angelina Nixon, Elizabeth N. Pearce, Office P. Soldin, Scott Sullivan and Wilmar Wiersinga 84 Questions 76 Recommendations Thyroid 2011; 21: 1081-1125 Slide 13 Management of Thyroid Dysfunction during Pregnancy and Postpartum: An Endocrine Society Clinical Practice Guideline Management of Thyroid Dysfunction during Pregnancy and Postpartum: An Endocrine Society Clinical Practice Guideline Leslie De Groot, Marcos Abalovich, Erik K. Alexander, Nobuyuki Amino, Linda Barbour, Rhoda H. Cobin, Creswell J. Eastman, John H. Lazarus, Dominique Luton, Susan J. Mandel, Jorge Mestman, Joanne Rovet, and Scott Sullivan J Clin Endocrinol Metab, August 2012; 97 (8): 2543-2565 Slide 14 Challenges with diagnosis Slide 15 A 25 year-old woman in the 8th week of pregnancy has serum TSH of 0.1 mU/L and serum free T4 of 2.5 and 1.4 ng/dl by two different laboratories. Pulse rate is 90/min, thyroid in not enlarged and there are no physical findings for Graves disease or hyperthyroidism. Slide 16 Which one of the following would be your advise? a)Obtain T4, resin T3 uptake and free T4 index b)Measure free T4 by tandem mass spectrometry c)Repeat free T4 measurement by a dependable lab d)Measure serum Free T3 16 Slide 17 Physiologic changes in pregnancy that influence thyroid function tests Physiologic changeThyroid function test change Thyroid-binding globulin Serum total T4 and T3 First trimester hCG elevation Free T4 and TSH Plasma volume T4 and T3 pool size Type III 5-deiodinase (inner-ring deiodination) T4 and T3 degradation (resulting in requirement for increased hormone production) Thyroid enalrgement (in some women) Serum thyroglobulin Iodine clearance Hormone production in iodine- deficient areas hCG= human chorionic gonadotropin; TSH= Thyroid-stimulating hormone; T3= triiodothyronine; T4= thyroxine; = increased; =decreased Lazarus JH. Treat Endocrinol 2005; 4:31 Slide 18 Glinoer, Endocr Rev 1997;18:404-433 Slide 19 Sample trimester-specific reference intervals for TSH* Reference1st trimester2nd trimester3rd trimester Haddow0.94 (0.08-2.73)1.29 (0.39-2.70) Stricker1.04 (0.09-2.83)1.02 (0.20-2.79)1.14 (0.31-2.90) Panesar0.80 (0.03-2.30)1.10 (0.03-3.10)1.30 (0.13-3.50) Soldin0.98 (0.24-2.99)1.09 (0.46-2.95)1.20 (0.43-2.78) Bocos-Terraz0.92 (0.03-2.65)1.12 (0.12-2.64)1.29 (0.23-3.56) Marwaha2.10 (0.60-5.00)2.40 (0.43-5.78)2.10 (0.74-5.70) * median TSH mIU/L with 5th and 95th centiles or P2.5 and P 97.5 between brackets. Soldin OP et al. Clin Chem Acta 2004; 349: 181 Haddow JE et al. J Med Screen 2004; 11: 170 Panesar NS et al. Ann Clin Biocliem 2001; 34: 67 Slide 20 0.31 0.12 0.03 1.03 2.15 3.67 0.09 0.53 1.23 2.51 4.16 0.20 1.35 2.93 4.80 1 2 3 4 5 6 0 First trimester (n=7) Second trimester (n=5) Third trimester (n=2) Serum TSH (mU/l) TSH changes during pregnancy. The graph shows median values versus the range of 2.5 th and 97.5 th percentiles for each trimester of pregnancy Glinoer D, Spencer CA. Nat Rev Endocrinol 2010; 6: 526 Slide 21 Guidelines for Serum TSH During Pregnancy Recommendation 1 Trimester-specific reference ranges for TSH, as defined in populations with optimal iodine intake, should be applied Recommendation 2 If trimester-specific reference ranges for TSH are not available in the laboratory, the following references ranges are recommend: 1 st trimester, 0.1-2.5 mIU/L; 2 nd trimester, 0.2-3.0 mIU/L; 3 rd trimester, 0.3-3.0 mIU/L Slide 22 Recommendations Topic American Thyroid Association (2011) Endocrine Society (2012) Thyroid function tests In the presence of a suppressed serum TSH in the first trimester (TSH