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 8

Universal Screening for Thyroid Disorders in

Pregnancy: Experience of the Czech Republic
Eliska Potlukova1, Jan Jiskra1, Zdenek Telicka1,
Drahomira Springer2 and Zdenka Limanova1
13rd Department of Medicine, General University Hospital and 1st Faculty of Medicine,
Charles University in Prague, Czech Republic
2Institute of Clinical Biochemistry and Laboratory Diagnostics,

General University Hospital, Prague,

Czech Republic

1. Introduction
The role of the thyroid gland in pregnancy and the impact of thyroid disorders on the
course of pregnancy and development of the offspring have drawn a considerable interest in
the recent years, both in the medical and in the general society. About 10% of pregnant
women are positive for autoantibodies against thyroperoxidase (TPOAb) (Glinoer 2007,
Lazarus and Kokandi 2000, Springer 2009) and between 2 and 4% suffer subclinical or overt
hypothyroidism (Casey 2005; Vaidya 2007, Springer 2009). Dysfunction of the maternal
thyroid in pregnancy adversely affects the course of pregnancy and the psychomotor
development of the offspring (Haddow 1999, Morreale de Escobar 2004). According to
recent findings, even the mere positivity of TPOAb without concomitant thyroid
dysfunction in pregnant women may have a negative impact on the psychomotor
development of the child (Li 2010). Furthermore, up to one half of the TPOAb-positive
(TPOAb+) pregnant women develop postpartum thyroiditis (PPT) which can lead to
persistent hypothyroidism in about one third of women (Lazarus and Premawardhana
2008). According to recent findings of Stagnaro-Green, this proportion may be even much
higher and persistent hypothyroidism may affect up to one-half of women with history of
PPT (Stagnaro-Green 2011b). If unrecognised and untreated, late postpartum thyroid
dysfunction, in most cases subclinical (SH) or overt hypothyroidism (OH) may have a long-
term negative effect not only on the mother´s health, but also on the next pregnancies.
Since 2006, repeated attempts to implement a universal screening programme for thyroid
disorders in the first trimester of pregnancy have been made in the Czech Republic.
Moreover, the Czech Endocrine Society initiated a wide informational campaign concerning
the importance of correct thyroid function in pregnancy in the media, including TV
discussions, seminars and lectures for both the general population and the health
professionals. Members of the Czech Endocrine Society together with colleagues from the
Czech Society of Biochemistry have initiated several studies focused on various aspects of
thyroid disorders among Czech pregnant women. In this review article, we present an
overview of the data obtained in the recent years.

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148 A New Look at Hypothyroidism

Impact of thyroid dysfunction on pregnancy and foetal health

The developing foetus is dependent upon the maternal thyroid hormone synthesis up to the
14th to 16th gestational weeks. Afterwards, its´ own thyroid gland starts to synthesise thyroid
hormones, albeit in insufficient quantities. Thus, the first trimester of pregnancy is crucial in
terms of adequate supply of maternal thyroid hormones to the embryo. Numerous
retrospective and case-controlled studies confirmed detrimental effects of maternal overt
hypothyroidism (OH) on the course of pregnancy and on foetal health.
Severe deficit of thyroid hormones leads to irreversible changes in foetal development.
Impairment of neuronal differentiation leads to inadequate development of the central
nervous system with resulting mental retardation. It may also lead to somatic defects
including congenital cardiac defects and disrupted bone growth. These changes are most
prominent in untreated congenital hypothyroidism (cretinism). Moderate thyroid hormone
deficit may lead to less pronounced neurocognitive dysfunction. As Haddow et al. have
shown in their well-cited study, children of untreated hypothyroid pregnant women had at
age 7 to 9 years IQ below 85 points in 19% of cases in comparison with 5% of children of
euthyroid or substituted mothers. The average IQ was 7 points lower in children of
hypothyroid untreated mothers than in children of hypothyroid mothers substituted by
levothyroxine (LT4) (Haddow 1999). Furthermore, iodine-deficient pregnant women are
prone to hypothyroxinaemia. As Morreale de Escobar has shown, up to 70 % of children of
iodine-deficient mothers may suffer from attention deficit hyperactive disorder (Morreale de
Escobar 2004a,b).
Apart from neurocognitive foetal impairment, maternal untreated OH is associated with the
risk of foetal loss in up to 60% (Abalovich 2002) and the risk of gestational hypertension in
22 % (Leung 1993), which was higher than in euthyroid women of women with subclinical
hypothyroidism. According to Allan et al, women with OH have also an increased risk of
foetal death (Allan 2000). Thus, it is of no doubt that untreated maternal OH may be
detrimental for the maternal-foetal unit in the short-term and in the long-term sense.
Pros and cons of universal screening for thyroid disorders in pregnancy
Although maternal autoimmune thyroid disorders (AITD) fulfil many criteria used for
identification of diseases subject to universal screening, this issue has been highly
controversial. The main arguments for implementation of universal screening are the
following: a) the impact of maternal hypothyroidism on the course of pregnancy and the
health of offspring has been well described and the treatment is effective and simple; b) the
prevalence of hypothyroidism in pregnancy is comparable with other universally screened
diseases; c) the method of screening (laboratory measurement of thyroid parameters) is
relatively simple and inexpensive – the financial costs depending on the choice of thyroid
parameters screened; d) it is cost-effective (on condition that not only OH, but also SH
decreases the offspring´s IQ (Dosiou 2008, Thung 2009); e) the risk-benefit ratio of the
screening for each individual is acceptable. In the past, some authorities recommended
universal screening but not the American Thyroid Association or the Association of
American Obstetricians and Gynaecologists, who have consistently advocated a case-
finding screening strategy focused on high-risk women (Abalovich 2007, Stagnaro-Green
2011) (Table 1).

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Universal Screening for Thyroid Disorders in Pregnancy: Experience of the Czech Republic 149

Authority Year Recommendation

American Association of Clinical Endocrinologists 2002 Universal screening
Expert panel of American Thyroid Association, Case-finding
American Association of Clinical Endocrinologists and 2004 screening
The Endocrine Society
Second panel of American Thyroid Association, Universal screening
American Association of Clinical Endocrinologists and 2005
The Endocrine Society
British Thyroid Association, Association of Clinical Case-finding
Biochemists, British Thyroid Foundation. UK 2006 screening
guidelines for the Use of thyroid Function Tests
Case-finding
American College of Obstetrics and Gynecology 2007
screening
Case-finding
The Endocrine Society 2007
screening
Case-finding
American Thyroid Association 2011
screening
Table 1. Overview of recommendations for screening for thyropathy in pregnancy.

The main argument of the opponents to universal screening is the lack of randomised
controlled trials demonstrating that treatment by LT4 of pregnant women with subclinical
hypothyroidism increases the offspring´s IQ. Preliminary results of the first major study
“The Control Antenatal Thyroid Screening Study” presented on ITC in Paris 2010 were
rather disappointing (Lazarus 2010). The authors found only a non-significant difference in
the prevalence of three-year-old children with IQ<85 of women unscreened vs. mothers
screened and treated in case of SH in pregnancy (15% vs. 11.5%, p=0.09). However, the
major drawback of this study is that pregnant women up to the 16th gestation week were
included. Thus, we may suspect that in some women the treatment started too late, after the
crucial changes in the embryonic/foetal brain have occurred. Another multicenter
randomized placebo-controlled clinical trial is at present being conducted by the Maternal
Fetal Medicine Unit of the National Institutes of Health in the USA. The primary outcome
will be child IQ at 5 years of age. Results of this study should be available in 2015 and they
may give a final answer to the question of universal screening for thyroid disorders in
pregnancy.
The case-finding screening strategy
Due to the above-mentioned facts, the latest guidelines of the American Thyroid Association
(ATA) recommend a case-finding screening targeted at women at high-risk for
hypothyroidism in pregnancy (Stagnaro-Green 2011a). The new guidelines introduce age
over 30 years and body-mass index over 40 kg/m2 among the risk factors. The other risk
factors include: history of thyroid dysfunction or prior thyroid surgery, symptoms of
thyroid dysfunction or the presence of goitre, TPOAb positivity, diabetes type 1 or other
autoimmune diseases in history, history of miscarriage or preterm delivery, history of head
of neck radiation, family history of thyroid dysfunction, use of amiodarone/lithium or
recent administration of iodinated radiologic contrast, infertility and residence in an area of

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150 A New Look at Hypothyroidism

known moderate to severe iodine insufficiency. Thus, according to ATA, the first physician
dealing with newly pregnant women should consider 12 different risk factors. If any of them
were positive, he should order a blood test for thyroid-stimulating hormone (TSH). In our
opinion, this form of screening is likely to be neglected due to practical reasons. It has been
shown that the case-finding approach may miss up to one half of pregnant women in
comparison with universal screening (Vaidya 2007, Horacek 2010, Jiskra 2011a); and it may
be difficult to implement in the routine practice (Vaidya 2002). Moreover, in our view,
assessment of only TSH is insufficient due to the above-mentioned risks carried by isolated
hypothyroxinemia and TPOAb positivity.

2. Prevalence of thyroid disorders in pregnant Czech women

The Czech Endocrine Society together with the Czech Society of Biochemistry has
repeatedly attempted to implement universal screening for AITD in the first trimester of
pregnancy. In order to gain data on thyroid disorders in Czech pregnant women, two large
studies including nearly 8 000 consecutive pregnant women (Springer 2009, Limanova
2011), have been conducted in the Czech Republic in the last years.
The first study by Springer et al. was performed between 2006 and 2008 and examined 5520
consecutive asymptomatic pregnant women in the 9th-11th gestational week. The aim of
this study was to evaluate the prevalence of thyroid disorders in pregnant Czech women
and to identify optimal reference intervals in evaluation of maternal thyroid function during
the first trimester of pregnancy. The screening consisted of laboratory assessment of serum
thyroid stimulating hormone (TSH), free thyroxine (FT4, only in those with pathological
TSH/TPOAb) and autoantibodies against thyroperoxidase (TPOAb). All measurements
were performed by chemiluminometric immunoanalysis on an ADVIA Centaur system
(Siemens, Healthcare Diagnostics Inc, Tarrytown, NY, USA) in one centre (Institute of
Clinical Biochemistry and Laboratory Diagnostics, General University Hospital in Prague).
Women with positive screening result were advised to visit an endocrinologist within a few
days. Based on the results obtained, Springer et al. set normal limits for TSH and TPOAb in
pregnancy as following: TSH 0.06-3.67 mU/l; TPOAb <143 kU/l; the study did not attempt
to set new reference ranges for FT4. In this cohort of pregnant women, 822 (14.9%) had at
least one of the parameters outside of the normal range. Suppressed TSH was found in 141
(2.55%) women, while 299 (5.42%) had TSH over the reference interval; elevation of TPOAb
was present in 549 (9.95%) women (Jiskra 2011a). The data are shown in detail in Table 2.
Thus, in this study, there was a higher prevalence of pregnant women with TSH elevation
(4.48%) as compared to other iodine-sufficient countries, where the prevalence of
pregnant women with TSH elevation reaches 2-3% (Casey 2005; Allan 2000; Vaidya 2007).
Obviously, these numbers depend on the TSH upper limit of reference range used. In the
Czech studies, the cut-off at 3.67 mU/l was used (Springer 2009). This value was
determined as the 97.5th percentile of TSH values of 4337 women in the first trimester of
pregnancy with no history of thyroid disease, anti-TPO level lower than 60 kU/l
(=negative) and free bhCG lower than triple that of the median (56.6 mg/l). It is
interesting to note that the 97.5th percentile in unselected women was higher (Table 3). At
present, world authorities recommend to use the upper cut-off at 2.5 mUl (Stagnaro-Green
2011). Therefore, for the Czech population, this cut-off lies either too low; or there is a

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Universal Screening for Thyroid Disorders in Pregnancy: Experience of the Czech Republic 151

higher prevalence of hypothyroidism among Czech pregnant women; or our analytical

method used for TSH measurements gives higher numbers than methods used by others.
However, our analysis was performed using a well-established and widely used analyser
(Advia Centaur, Siemens). Apparently, the cut-off at 2.5 mU/l would lead to large
numbers of pregnant women positive in screening.

Number of women screened

Total 5520

Positive in screening (at least one parameter) 822 (14.89%)

Hypothyroidism 299 (5.42 %)
Overt hypothyroidism 49 (0.89 %)
Subclinical hypothyroidism 250 (4.53 %)
TPOAb+ hypothyroidism 144 (2.61 %)
TPOAb- hypothyroidism 155 (2.81 %)
Transient gestational hyperthyroidism 99 (1.8 %)
Hyperthyroidism 141 (2.55 %)
Overt hyperthyroidism 19 (0.34 %)
Subclinical hyperthyroidism 122 (2.21 %)
TPOAb+ hyperthyroidism 23 (0.42 %)
TPOAb- hyperthyroidism 118 (2.14 %)
TPOAb positivity (>143 kIU/l) 549 (9.95 %)
Euthyroid TPOAb+ 376 (6.81 %)
TPOAb+, normal TSH, decreased FT4 5 (0.09 %)
TPOAb+, normal TSH, elevated FT4 1 (0.02 %)
Hypothyroidism was defined as TSH >3.67 mIU/l (overt with decreased FT4 and subclinical with TSH
>3.67 mIU/l and normal FT4). Hyperthyroidism was defined as decreased TSH <0.06 mIU/l (overt with
TSH <0.06 mIU/l and FT4 >23.0 pmol/l and subclinical with TSH<0.06 mIU/l and normal FT4.
Table 2. Results of universal screening for thyroid disorders among Czech pregnant women
in the 9th to 11th gestational weeks.

2.5th 5th 95th 97.5th

TSH mU/l N Median Minimum Maximum
percentile percentile percentile percentile

Non-
5520 1.280 0 411.874 0.048 0.147 3.713 4.796
selected
Selected
4337 1.213 0 11.534 0.062 0.154 3.144 3.670
group

Selected group: pregnant women with no history of thyroid disease, anti-TPO level lower than 60 kU/l
and free bhCG lower than triple that of the median (56.6 mg/l).
Table 3. Reference ranges for TSH in the 9th to 11th gestational weeks in Czech pregnant women.

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152 A New Look at Hypothyroidism

After two years of preparations, a joint “Pilot Project” of the Czech Society of Endocrinology,
the Society of Clinical Biochemistry and the General Insurance Company of the Czech
Republic started in 2009 (Limanova 2011). The Pilot Project was supported by the General
Insurance Company. The aim of the Pilot Project was to ascertain the optimal combination and
economic feasibility of diagnostic tests, the timing of the blood test and the possibility of
connecting the test with genetic-disorder screening in the first trimester of pregnancy. The
purpose of the study was also to provide information about cooperation among
gynaecologists, laboratories and endocrinologists. In the Pilot Project, TSH, FT4 and TPOAb
were measured in 2937 consecutive pregnant women from 13 Czech regions with good
laboratory background and cooperative endocrinologists. Contrary to the previous study,
measurements were performed in regional laboratories and the reference ranges differed
according to each laboratory. In this cohort, 569 (19.4%) woman were screened as positive.
Abnormalities of TSH were found in 11% of women: elevation in 7.8% and suppression in
3.2%. Only 15 (0.5%) women with TSH suppression were diagnosed with true
hyperthyroidism. Hypothyroxinemia was found in 3.7% and TPOAb positivity in 262 (8.9%)
women. One hundred fifty-eight women (5.37%) had positive TPOAb with normal thyroid
function. Thus, in this second study, we found an even higher prevalence of abnormally high
TSH among pregnant women than in the study of Springer et al. However, due to the different
analytical methods, these results cannot be directly compared. Cooperation with
gynaecologists wasn´t always optimal despite the fact that they were provided with all
necessary information well in advance. On the other hand, laboratories analysed the samples
promptly, and many of them took part in providing publicity and further information to other
cooperating health care professionals. In conclusion, the Pilot Project study showed that
implementation of universal screening for thyroid disorders in pregnancy would be feasible in
the Czech Republic, although the general knowledge on importance of correct thyroid function
in pregnancy needs to be improved among practical gynaecologists.
The attempts to implement a universal screening programme for AITD in pregnancy in the
Czech Republic have suffered a major blow due to the world financial crisis starting in 2009.
In the future years, we will probably have to concentrate on implementation of the case-
finding approach years among the official risk factors.

3. Ultrasound imaging and risk-assessment of positively screened pregnant

women
Most of the studies on AITD in pregnancy deal only with laboratory parameters and it is not
clear whether the thyroid ultrasound (TUS) image is of any consequence for the clinical
outcomes of the pregnancy. Studies concerning TUS in pregnancy are scarce, mostly aimed
at the assessment of thyroid volume. Therefore, in one of our studies, we focused on the
relationship between TUS, laboratory parameters and the outcome of pregnancy. Between
2006 and 2009, we performed thyroid ultrasound in 186 pregnant women positively
screened for thyroid disorders in the first trimester of pregnancy; i.e. they had abnormal
TSH and/or positivity for TPOAb (Jiskra 2011a). The control group consisted of 67 age-
comparable non-pregnant women with pathological TSH and/or TPOAb levels.
Unexpectedly, we found that these positively screened pregnant women had rather small
thyroid glands with the median volume of 8.5 ml. This is smaller than in age-comparable
non-selected non-pregnant Czech women in the study of Dvorakova et al. (median 11.8 mL

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Universal Screening for Thyroid Disorders in Pregnancy: Experience of the Czech Republic 153

in group of women aged 31-35 years) (Dvorakova 2006). Furthermore, the thyroid volume in
pregnant women did not differ from controls. This is in contrast to the findings of both
Fister and Vila, who showed an increased thyroid volume in pregnancy in iodine-sufficient
(Fister 2009) and iodine-deficient areas (Vila 2008). The finding of small thyroids in pregnant
Czech women is probably linked to the saturation with iodine. Iodine supplementation of
salt has been introduced in Czechoslovakia in 1950. Therefore, the present pregnant women
are already the third generation who live in iodine-sufficient conditions.
In our study, we also found that only 49% of the TPOAb+ pregnant women had
autoimmune pattern on TUS. This was significantly less than in non-pregnant TPOAb+
controls (74 %) (Fig.1). Apparently, alterations of immune system in pregnancy cause a
different manifestation of autoimmunity in the thyroid tissue. Moreover, we found that the
thyroid ultrasound pattern was associated with preterm delivery: TPOAb+ women without
autoimmune pattern in TUS had significantly lower prevalence of preterm delivery than the
TPOAb+ ones with autoimmune pattern (3.1 vs. 15.2 %). Therefore, autoimmune TUS image
in TPOAb+ pregnant women seems to be associated with preterm delivery.
% with autoimmune pattern

100
p<0.001 Pregnant women
p=0.011
80 Controls

60

40

20

0
TPOAb>143 kU/l TPOAb>200 kU/l

Fig. 1. Ultrasound autoimmune pattern in TPOAb-positive pregnant women and controls.

In the next study from 2011, we focused on the relationship between clinical history,
laboratory findings and TUS pattern in positively screened pregnant women (Jiskra 2011b). In
this study, 200 of the positively screened women from the cohort of Springer et al. were
included (Springer 2009). We regarded women as high-risk if they had any of the following
risk factors: family and/or personal history of thyroid disease (including presence of goitre
and signs and symptoms suggestive for thyroid dysfunction), family and/or personal history
for autoimmune disease, history of neck irradiation, previous miscarriages and preterm
deliveries). After exclusion of transient gestational hyperthyroidism, only 74/159 (47 %)
women were classified as high-risk for thyroid disease according to their history. There were
no significant clinical and laboratory differences between the high- vs. low-risk women, except
for higher proportion of FT4 < 75th percentile and a larger thyroid volume in the high-risk
group. These finding were consistent with the results of Horacek et al. (Horacek 2010) who
found that case-finding screening strategy would miss one half of the high-risk women.

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154 A New Look at Hypothyroidism

4. Postpartum follow-up of positively screened women

Between 2009 and 2010, we invited all 822 positively screened women from the first cohort
of 5520 pregnant women screened (the cohort of Springer et al.) for follow-up (Potlukova et
al. 2011, manuscript in preparation). In order to gain as complete a picture of their clinical
state and history as possible, we asked them to fill in a detailed internet-based questionnaire
concerning their personal, family and gynaecological history. Furthermore, we invited them
for a blood test including analysis of TSH, FT4 and TPOAb. The two main aims of the study
were: a) to assess the prevalence of high risk-profile women in this group; b) to evaluate the
postpartum thyroid function in this group with regard to the adequacy of treatment.
Of the 822 women invited, 237 (28.8%) joined the study. This group of positively screened
women differed from the one analysed in our other two recent studies (Jiskra 2011a, b).
The median age of participating women was 31 years at the time of screening in
pregnancy. The median interval between delivery and follow-up reached 21 months. The
analysis of questionnaires brought a major finding: the use of the new guidelines of
American Thyroid Association (Stagnaro-Green 2011) for identification of high-risk
women substantially increased the proportion of high-risk women among the positively
screened. The “old” risk factors could identify only two thirds of the positively screened
women: personal and family history of thyroid disease (only first-degree relatives),
diabetes mellitus type 1, other autoimmune diseases in personal history, infertility and
history of spontaneous abortion. However, if the “new” risk factor, age>30 years (in our
analysis, 31 years and more), was added to the classical ones, 85% of the women could be
classified as “high-risk” (Fig.2). This is a surprisingly high number, especially in the view
of previous studies (Jiskra 2011b, Horacek 2010, Vaidya 2002). However, this effect of age
could be partially due to selection bias, as the majority of women who answered the
questionnaire had good education and therefore they tended to later pregnancies. We also
tried to identify the most important risk factors in order to simplify the decision process
which women should be screened. We found that four risk factor could identify 82% of
the high-risk women: age 31 and more, personal and family history of thyroid disease and
the presence of goitre (Fig.2).
In our follow-up study, we further found that one third of initially euthyroid TPOAb+
pregnant women had TSH outside of normal range at follow-up. In comparison to
pregnancy, median TSH (as well as FT4) significantly increased at follow-up (Fig. 3).
Thirty-eight (33.6%) of 113 initially euthyroid TPOAb+ women had TSH outside of
normal range at follow-up (median 17 months after delivery): 13 (11.5%) had TSH<0,37
mU/l; 18 (15.9%) had TSH >4,0 and <10.0 mU/l (all had normal FT4). Seven (6.2%) had
TSH>10.0 mU/l with three having a hypothyroxinemia. It is important to note that many
of these women were inadequately treated: all of the women with TSH suppression at
follow-up were simply overdosed by LT4; and half of those with TSH elevation at follow-
up were treated by too low doses of LT4. Thus, TPOAb positivity even with normal
thyroid function in pregnancy carries a high risk of hypothyroidism one and half years
postpartum. This is in line with results of Stagnaro-Green, who found that 50% of women
with PPT were hypothyroid one year after delivery (Stagnaro-Green 2011). Our results
also show that monitoring and treatment of women with AITD in the peripartal period is
commonly inadequate.

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Universal Screening for Thyroid Disorders in Pregnancy: Experience of the Czech Republic 155

p=0.004 p= n.s.
100 With risk factor
Without risk factor
80

60
%
40

20

0
Old New Four selected
Risk factors

Fig. 2. Proportion of positively screened pregnant women with at least one risk factor for
hypothyroidism. Old: risk factors according to Guidelines of ATA 2007; New: risk factor
according to Guidelines of ATA 2011; Four selected: age, personal and family history of
thyroid disease and the presence of goitre.

p=0.0015
60 p=0.0004
90 50
60 40
30 30

10
FT4 (pmol/l)
TSH (mU/l)

8 20
6
15
4
2 10
0
5
TSH in pregnancy TSH at follow-up FT4 in pregnancy FT4 at follow-up

A B
Fig. 3. Postpartum development of the thyroid function in initially euthyroid TPOAb+
pregnant women. A: Thyroid Stimulating Hormone (TSH); B: Free Thyroxine (FT4). Median
time between delivery and follow-up was 17 months. Median values of TSH and FT4 are
marked in grey. Reference intervals for non-pregnant women are marked by dotted lines.

5. Financial analysis
Two studies have dealt with the cost-effectiveness of universal screening for thyroid
disorders in pregnancy and both found it cost-effective under condition that subclinical
hypothyroidism decreases IQ of the offspring (Dosiou 2008, Thung 2009). In order to
roughly assess the financial aspects of the universal screening in the Czech conditions, we
performed a simple statistical analysis of the financial costs of the Pilot Project (Telicka

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156 A New Look at Hypothyroidism

2010). The goal of this study was to find out the overall costs of the Pilot Project as compared
to positively-screened tests and simulate the costs in the current situation when the
screening is not paid by the insurances companies. Total costs of both TSH and TPOAb
screening included in the Pilot Project were 1 373 218 CZK (15 280 €) for 2 651 tested women.
The cost of one positive result in any tested parameter (TSH/TPOAb) amounted 2 243 CZK
(91€) and the costs of one positive result for hypothyroidism was 1380 CZK (56€).

6. Conclusions
We have shown that the prevalence of thyroid disorders is relatively high among the Czech
pregnant women in comparison with other developed iodine-sufficient countries. About one
tenth of pregnant women are TPOAb+ and more than 4% have subclinical or overt
hypothyroidism in the first trimester of pregnancy. We have also shown that one third of
initially euthyroid TPOAb+ pregnant women have TSH outside of normal range one and
half years after delivery. This was due to postpartum thyroiditis and in many cases
inadequate treatment. Thus, TPOAb positivity may endanger not only the current, but also
the next pregnancies.
Based on the ultrasound findings in the positively screened women, we can furthermore
conclude that pregnant TPOAb positive women have less pronounced TUS changes than
non-pregnant controls. Thus, sonography may only be a part of a more complex diagnostic
procedure in the screening for thyroid disorders in pregnancy. However, it seems that
pregnant women with autoimmune pattern in thyroid ultrasound have an increased risk of
preterm delivery.
Moreover, in our studies we confirmed that targeted case-finding screening programme
based on the “old” risk factors (Abalovich 2007) would miss one-half of pregnant women
with thyroid disease. Also, high- and low-risk pregnant women have similar clinical and
laboratory characteristics. However, these findings change if “new” risk factors including
age over 30 years (Stagnaro-Green 2011) are used for identification of high-risk women. Age
over 30 years increases the proportion of positively screened pregnant women with at least
one risk factor to 85%; however, this may be an effect of selection bias.
Finally, the financial analysis showed that the costs of the screening for thyroid dysfunction
in pregnancy are not high enough to rend the financial issue a main obstacle in an
implementation of universal screening. Both TSH and TPOAb should be included in any
screening programme.
The awareness on the thyroid problematics in pregnancy has improved in the general
population thanks to the activities of the Czech Society of Endocrinology in the recent;
however, some health care professionals dealing with pregnant women show lack of interest
in this topic. In conclusion, our data provide a contribution to the published guidelines for
management of thyroid disease in pregnancy and present a basis for a world-wide discussion.

7. Acknowledgements
These studies were supported by the grants of the Czech Health Ministry IGA NS 10662-3
and 10595-3.

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Universal Screening for Thyroid Disorders in Pregnancy: Experience of the Czech Republic 157

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 A New Look at Hypothyroidism
Edited by Dr. Drahomira Springer

ISBN 978-953-51-0020-1
Hard cover, 256 pages
Publisher InTech
Published online 17, February, 2012
Published in print edition February, 2012

Hypothyroidism is the most common thyroid disorder. It can cause a variety of changes in women's menstrual
periods, reduce their chances of becoming pregnant, as well as affect both the course of pregnancy and the
neuropsychological development of babies. During pregnancy there is a substantially increased need for
thyroid hormones and a substantial risk that a previously unnoticed, subclinical or latent hypothyroidism will
turn into overt hypothyroidism. The thyroid inflammation caused by the patient's own immune system may
form autoimmune thyroiditis (Hashimoto's thyroiditis). Congenital hypothyroidism (CH) occurs in approximately
1:2,000 to 1:4,000 newborns. Nearly all of the developed world countries currently practice newborn screening
to detect and treat congenital hypothyroidism in the first weeks of life. "A New Look at Hypothyroidism"
contains many important specifications and innovations for endocrine practice.

How to reference
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Eliska Potlukova, Jan Jiskra, Zdenek Telicka, Drahomira Springer and Zdenka Limanova (2012). Universal
Screening for Thyroid Disorders in Pregnancy: Experience of the Czech Republic, A New Look at
Hypothyroidism, Dr. Drahomira Springer (Ed.), ISBN: 978-953-51-0020-1, InTech, Available from:
http://www.intechopen.com/books/a-new-look-at-hypothyroidism/universal-screening-for-thyroid-disorders-in-
pregnancy-experience-of-the-czech-republic

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