1. Guidelines on Thyroid Disease and Pregnancy - An Obstetric Viewpoint Michael S Marsh MD FRCOG Consultant/Senior Lecturer in Obstetrics Department of Obstetrics and Gynaecology King’s College Hospital London

2. RCOG Greentop Guidelines for Thyroid disease in Pregnancy Mr MS Marsh FRCOG, London (Lead developer) Dr K Boelaert, Honorary Consultant Endocrinologist, University of Birmingham Dr S Chan FRCOG, National University of Singapore Ms SM Chang, Specialist Midwife and Nurse Prescriber, King's College Hospital NHS Foundation Trust Dr C Evans, Clinical Biochemist, University Hospitals Cardiff and Vale NHS Trust Dr J Gilbert MRCP, Consultant Endocrinologist, King's College Hospital NHS Foundation Trust

3. RCOG greentop guidelines for Thyroid disease in Pregnancy

4. What are guidelines for ?

5. What are obstetricians for ?

6. Prevent maternal, fetal and neonatal death

7. Elizabeth of York (1503), queen of Henry VII of England, mother of Henry VIII Jane Seymour (1537), third wife of Henry VIII of England, after delivering Edward VI Catherine Parr (1548), sixth wife of Henry VIII of England

9. WHY MOTHERS DIE IN THE UK Causes of maternal mortality (numbers per 100,000)

10. Thyroid cancer in pregnancy 10% of thyroid cancers occurring in reproductive years are diagnosed during pregnancy / in the first year after birth Usually slow-growing well differentiated papillary or follicular carcinomas A good prognosis in this age group

11. www.ons.gov.uk

12. What are obstetricians for ? Prevent maternal, fetal and neonatal death

13. What are obstetricians for ? Prevent maternal, fetal and neonatal death Prevent maternal, fetal and neonatal morbidity

14. Overt hyperthyroidism in pregnancy Stagnaro-Green 2011

15. Overt hyperthyroidism in pregnancy Effect of treatment Author YearEffect of treatment vs no/inappropriate/ineffective treatment Davis et al1989*Preterm delivery reduced (33kw vs 39wk, p<0.05) Gestational weight increased (2Kg vs 3kg, p<0.05) Reduce stillbirth rate (from 80%) Millar 1994*Reduce low birth rate (OR 9) Preeclampsia (OR 5) * Cases since 1974

16. Overt hypothyroidism in pregnancy Stagnaro-Green 2011

17. Overt hypothyroidism in pregnancy Effect of treatment Author YearEffect of treatment vs no/inappropriate/ineffective treatment Abalovich2002Reduce miscarriage rate (from 60%) Jones1969Reduce preterm delivery/fetal death (20% vs 13%, p<0.025) Leung1993Reduce hypertension in pregnancy (22% vs 15%) Reduce birthweight <2.5Kg (22% vs 9%)

18. Subclinical hypothroidism and pregnancy outcome Maraka et al. Thyroid 2016 18 cohort studies eligible, 3995 pregnant women

19. Subclinical hypothroidism and pregnancy outcome Maraka et al. Thyroid 2016 *Miscarriage,intrauterine death, fetal loss *

20. Subclinical hypothroidism and pregnancy- treatment Recommend treatment of pregnant women with SCH and positive TPO antibodies (Level B, fair evidence—USPSTF) Insufficient evidence to recommend for or against universal levothyroxine treatment in pregnant women with SCH and negative TPO antibodies (Level I—USPSTF) Recommend levothyroxine replacement in all pregnant women with SCH (women with negative TPO antibodies, Obstetric outcome Level C, neurological Level I —USPSTF)

21. Subclinical hypothroidism and pregnancy- treatment SCH arising before conception or during gestation should be treated with levothyroxine. (GRADE: level 2 Strong) Trials ongoing- NICHD, TABLET and others

22. What are obstetricians for ? Prevent maternal, fetal and neonatal death Prevent maternal, fetal and neonatal morbidity

23. What are obstetricians for ? Prevent maternal, fetal and neonatal death Prevent maternal, fetal and neonatal morbidity Reduce maternal disability and disability of offspring

24. What are obstetricians for ? Prevent maternal, fetal and neonatal death Prevent maternal, fetal and neonatal morbidity Reduce maternal disability and disability of offspring Increase the IQ of the whole population

25. The benefits of a high IQ Better educational achievement Well-paid employment Enhanced social status Less criminal behaviour Longer life

26. The benefits of a high IQ Better educational achievement Well-paid employment Enhanced social status Less criminal behaviour Longer life The costs of a low IQ Every IQ point lost from the US average is estimated to have an annual cost of US$71 billion Muir T, Zegarac M. Environ Health Perspect 2001

27. Maternal free thyroxine and offspring IQ Korevaar et al 2016

28. Maternal free thyroxine and offspring brain morphology Korevaar et al 2016

29. What are obstetricians for ? Increase the IQ of the whole population Closely control thyroid disease in pregnancy Ensure sufficient iodine intake in pregnancy

30. Thank you