If nicotine replacement therapy is used, it should be with the clear resolve of the patient to quit smoking. England LJ, Tong VT, Koblitz A, Kish-Doto J, Lynch MM, Southwell BG. No. 1. Obstet Gynecol. 37. American Thyroid Association Taskforce on Thyroid Disease During Pregnancy and Postpartum. Grana R, Benowitz N, Glantz SA. Vuillard E, Di Gianantonio E, Tinelli A, Because of the rapid growth of the literature relating to this topic, plans for revising the guidelines within ∼4–5 years of publication were made at the inception of the project. There also is concern about the effect of overt maternal thyroid disease … Postpartum thyroiditis and autoimmune thyroiditis in women of childbearing age: recent insights and consequences for antenatal and postnatal care. To understand abnormal thyroid function in pregnancy, a review of normal physiologic changes is warranted (Table 1).4 Because of the estrogen-mediated increase in thyroid-binding globulin, the increased volume of distribution of thyroid hormone, and the placental metabolism and transport of maternal thyroxine, there is a 20% to 40% increase in the thyroid hormone requirement as early as the fourth week of gestation.5. Hypothyroidism and chronic autoimmune thyroiditis in the pregnant state: maternal aspects. Lessons learned about predictors, interventions, and gaps in our accumulated knowledge. Sieiro Netto L, Maternal and grandmaternal smoking patterns are associated with early childhood asthma. Hyattsville, MD: National Center for Health Statistics; 2018. American College of Obstetricians and Gynecologists. 24. Available at: National Library of Medicine. ACOG Committee Opinion No. Gismondi R, This document will review the thyroid-related pathophysiologic changes created by pregnancy and the maternal-fetal impact of thyroid disease. Value of combined clinical information and thyroid peroxidase antibodies in pregnancy for the prediction of postpartum thyroid dysfunction. American College of Obstetricians and Gynecologists 409 12th Street SW, Washington, DC 20024-2188. 10. Thyroid disease in pregnancy. Nicotine withdrawal syndrome in a newborn baby after maternal use of oral applied moist tobacco (snus), should result in greater awareness to the use of snus among pregnant women. Smoking cessation in pregnancy: an update for maternity care practitioners. Want to use this article elsewhere? Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society clinical practice guideline. Overt hyperthyroidism and hypothyroidism during pregnancy. Trials studying the use of nicotine replacement therapy in pregnancy have been attempted, but many of those conducted in the United States have been stopped by data and safety monitoring committees because of either adverse pregnancy effects or failure to demonstrate effectiveness 42 63 64. Int J Technol Assess Health Care 2004;20:469–74. White AR, Rampes H, Liu JP, Stead LF, Campbell J. Acupuncture and related interventions for smoking cessation. Pregnant women exposed to family members or coworkers who smoke should be given advice on how to address these situations and avoid exposure. Table 2. Pregnancy and dental work questions are common for expecting moms. Encouraging close follow-up, promotion of postpartum health and overall well-being, review of tobacco use prevention strategies, recognition of psychosocial challenges, and identification of social support systems in the third trimester and postpartum are helpful in decreasing recidivism 59 61. von Kries R, Toschke AM, Koletzko B, Slikker WJr. Pouta A, The American College of Obstetricians and Gynecologists makes the following recommendations and conclusions: Obstetrician–gynecologists and other obstetric care professionals should inquire about all types of tobacco or nicotine use, including cigarette smoking, use of e-cigarettes or vaping products, hookahs, snus, lozenges, patches, and gum, during the prepregnancy, pregnancy, and postpartum periods. By mid-pregnancy, the baby’s thyroid begins to produce thyroid hormone on its own. Please try reloading page. American College of Obstetricians and Gynecologists. Nicotine Tob Res 2017;19:797–803. For current and former tobacco and nicotine users, use status should be monitored and recorded throughout pregnancy, providing opportunities to congratulate and support success, reinforce steps taken towards quitting, and encourage those still considering a cessation attempt. Mestman JH, Dashe JS, Information for healthcare professionals: varenicline (marketed as Chantix) and bupropion (marketed as Zyban, Wellbutrin, and generics) . J Clin Endocrinol Metab. Blatt K, Moore E, Chen A, Van Hook J, DeFranco EA. Obstetrician-gynecologists and other obstetric care professionals should counsel women about the risks of smoking and the benefits of cessation and discuss the resources available to help with smoking cessation, which may include the use of varenicline and bupropion. Whereas there is an incorrect perception that vaping represents a safer alternative to cigarette smoking because users are not inhaling tobacco combustion products, these products often contain nicotine or nicotine salts. Greer LG, Although smoking of any duration during pregnancy is associated with an increased risk of fetal growth restriction, the risk is reduced the earlier in gestation that cessation occurs 57. 1994;170(1 pt 1):90–95. Burrow G. Nicotine Tob Res 2018;20:665–73. These women often are heavily addicted to nicotine and have greater psychosocial challenges. Key words were thyroid disease and pregnancy. In the middle of the cycle, an egg is released ... history of certain conditions, such as diabetes mellitus, PCOS, gallbladder disease, or thyroid disease: obesity. Tobacco and nicotine cessation during pregnancy. Author disclosure: No relevant financial affiliations. Am J Epidemiol 2002;156:954–61. Adverse effects of prenatal methimazole exposure. E-cigarettes and similar devices. Ito K, 1992;80(3 pt 1):359–364. Negro R, Obstet Gynecol. Treatment seems to reduce the incidence of miscarriage and preterm birth, and to improve fetal intellectual development; however, it has little impact on hypertensive disorders and placental abruption.1. thyroid function (see Thyroid Function Test Brochure). Mitsuda N, Detection of thyroid dysfunction in early pregnancy: universal screening or targeted high-risk case finding? Int J Gynaecol Obstet 1994;47:7–15. Neale DM, Nicotine Tob Res 2016;18:585–9. Encourage the patient to talk about the process of quitting. Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and postpartum. Richardson JL, Stephens S, Yates LM, Diav-Citrin O, Arnon J, Beghin D, et al. Castles A, Adams EK, Melvin CL, Kelsch C, Boulton ML. Optimizing postpartum care. Obstet Gynecol. Rovet JF. Cochrane Database of Systematic Reviews 2017, Issue 2. Hurt RD, Renner CC, Patten CA, Ebbert JO, Offord KP, Schroeder DR, et al. Clinical Practice Guideline. Schaefer C, Rockville, MD: AHRQ; 2015. Eur J Endocrinol. 2014 Feb 15;89(4):273-278. Screening and intervention for alcohol and other drug use are recommended for all pregnant women. | Terms and Conditions of Use. A radioactive iodine uptake scan can help distinguish postpartum thyroiditis from Graves disease, but is contraindicated in breastfeeding women. Electronic nicotine delivery systems are used by smokers who commonly believe that they are a safer and healthier alternative to cigarettes that will aid their smoking cessation efforts 38 39. Serum TSH is a more accurate indicator of maternal thyroid status than alternative FT4 assay methods. Mandel SJ. Tobacco and Nicotine Cessation During Pregnancy, https://www.ahrq.gov/prevention/guidelines/tobacco/index.html, https://www.cdc.gov/nchs/data/databriefs/db305.pdf, https://www.ncbi.nlm.nih.gov/books/NBK179276/pdf/Bookshelf_NBK179276.pdf, https://www.cdc.gov/reproductivehealth/maternalinfanthealth/tobaccousepregnancy/e-cigarettes-pregnancy.htm, https://www.femaflavor.org/safety-regulatory-authority-use-flavors-focus-vaping-products, https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html, https://www.ncbi.nlm.nih.gov/books/NBK321744/, http://wayback.archive-it.org/7993/20170112032419/http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/DrugSafetyInformationforHeathcareProfessionals/ucm169986.htm, https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-revises-description-mental-health-side-effects-stop-smoking, https://www.ncbi.nlm.nih.gov/books/NBK501184/, Alliance for Innovation on Women's Health, Postpartum Contraceptive Access Initiative. Bitzer ZT, Goel R, Reilly SM, Elias RJ, Silakov A, Foulds J, et al. Hartmann‐Boyce J, Chepkin SC, Ye W, Bullen C, Lancaster T. Nicotine replacement therapy versus control for smoking cessation. A randomized trial of a serialized self-help smoking cessation program for pregnant women in an HMO. Clin Perinatol. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. Cochrane Database of Systematic Reviews 2015, Issue 12. Koonings PP, Nishikawa Y, Stagnaro-Green A, Swiss Dent J 2016;126:799–811. 6. Vuillard E, The use of electronic cigarettes in pregnancy: a review of the literature. Cossich MC, Providing continual support and addressing psychosocial stressors in the postpartum period are necessary to ensure continued cessation success. Azizi F. 305 . Poorly controlled thyroid disease is associated with adverse outcomes during pregnancy, and treatment is an essential part of prenatal care to ensure maternal and fetal well-being.1–3, Enlarge 7. 134 . Mangieri T, 17. Di Gianantonio E, ACOG Committee Opinion No. Obstet Gynecol 2020;135:e221–9. Millar LK, This content is owned by the AAFP. Studies demonstrate an increased risk of altered fetal autonomic cardiac regulation and nicotine withdrawal in neonates born to women who used snus during pregnancy, effects that are similar to those found in women who smoke tobacco 32 33. Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society clinical practice guideline. This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice in collaboration with committee member Amy M. Valent, DO, and the American Academy of Family Physicians’ liaison member Beth Choby, MD. Bupropion is an antidepressant with limited data on its use in pregnancy, but there is no known risk of fetal anomalies or adverse pregnancy effects with its use 67 68. After delivery, levothyroxine should be decreased to the prepregnancy dosage over a four-week period, and further adjustment should be guided by TSH levels four to six weeks after delivery.2, Methimazole (Tapazole; preferred agent after first trimester), 10 to 40 mg per day orally in two divided doses, Serum free thyroxine in upper one-third of normal range2, Measurement of serum TSH and free thyroxine every two weeks until on stable medication dosage2,3, Weekly beginning at 32 to 34 weeks' gestation in women with poorly controlled hyperthyroidism; consider testing earlier or more frequently in patients with other indications for testing3,14,15, Propylthiouracil, 100 to 450 mg per day orally in two divided doses, Levothyroxine, 100 to 150 mcg per day orally 2, Measurement of serum TSH at 4 to 6 weeks' gestation, then every 4 to 6 weeks until 20 weeks' gestation and on stable medication dosage, then again at 24 to 28 weeks' and 32 to 34 weeks' gestation2,16, Typically reserved for women with coexisting conditions or obstetric indications, and in patients with other indications for testing15. Anthony S, Available at: Whittington JR, Simmons PM, Phillips AM, Gammill SK, Cen R, Magann EF, et al. Potential adverse fetal effects of antithyroid medications include congenital abnormalities and neonatal hypothyroidism caused by transplacental transfer.2,3 Although radioactive iodine ablation is not associated with long-term consequences on gonadal function, fertility, or pregnancy outcomes, it is customary to wait six months after the therapeutic dose is administered before attempting conception.8 Radioactive ablation and surgery can increase the risk of neonatal goiter and hyperthyroidism because of the absence of maternal antithyroid medication, which crosses the placenta and counteracts the stimulatory effect of thyrotropin receptor antibodies on the fetal thyroid.2,3 The importance of achieving and maintaining euthyroidism before conception should be emphasized, because a significant increase in congenital malformations has been reported when hyperthyroidism is not controlled in the first trimester of pregnancy.10. With the recent CDC advisory and the effects of e-cigarette and vaping product use on offspring health, immediate discontinuation of e-cigarette and vaping products should be advised among all pregnant and postpartum women. Momotani N, Prev Med 2019;118:238–42. Several small studies that evaluated its safety in pregnancy have not shown teratogenicity 65 66 but, overall, data are limited. LEO A. CARNEY, DO, Naval Hospital Pensacola Family Medicine Residency Program, Pensacola, Florida, JEFF D. QUINLAN, MD, Uniformed Services University of the Health Sciences, Bethesda, Maryland, JANET M. WEST, MD, Naval Hospital Pensacola Family Medicine Residency Program, Pensacola, Florida. The occurrence of permanent thyroid failure in patients with subclinical postpartum thyroiditis. Estrogen causes the lining to grow and thicken to prepare the uterus for pregnancy. ASK the patient about all types of tobacco or nicotine use* at the first prenatal visit and follow up with her at subsequent visits. 5. Postpartum thyroiditis is the most common form of postpartum thyroid dysfunction and may present as hyper- or hypothyroidism. J Epidemiol Community Health 2009;63:474–80. / Journals Drexhage HA, ACOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Thyroid disease in pregnancy. Although much of the data on nicotine-delivery in pregnancy are derived primarily from animal studies, e-cigarettes appear to have similar effects on lung development and offspring lung health when compared with cigarette smoking 22. Transient hyperthyroidism may also be associated with hyperemesis gravidarum and gestational transient thyrotoxicity, most likely resulting from the stimulatory effect of human chorionic gonadotropin on the thyroid.11 Although the radioactive iodine uptake scan used in the diagnosis of hyperthyroidism is contra-indicated during pregnancy, testing for the presence of antithyroid antibodies can be diagnostically useful. Pediatrics 2019;143:e20183652. Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society clinical practice guideline. As the condition progresses, signs of anemia in pregnancy may include: 2010;(7):CD007752.... 2. Clinicians should individualize care by offering psychosocial, behavioral, and pharmacotherapy interventions. Antepartum fetal surveillance. Nicotine Tob Res 2019;21:1151–61. Obstet Gynecol 2020; 135:e261. Chamberlain C, O’Mara‐Eves A, Porter J, Coleman T, Perlen SM, Thomas J, et al. 2010;15(2 pt 1):387]. Don't miss a single issue. In pregnant women who are being treated for hyperthyroidism, serum TSH and FT4 should be measured every two weeks until the patient is on a stable medication dosage. Two counseling techniques with positive effects on smoking and nicotine cessation in pregnant women include motivational interviewing and cognitive behavioral therapy. Rockville (MD: FDA; 2009. Vaidya B, et al. E. I use tobacco or nicotine regularly now, about the same as before I found out I was pregnant. Tanizawa O. ACOG practice bulletin no. Retrieved November 7, 2019; and data from (for supplemental information in number 1) Ershoff DH, Mullen PD, Quinn VP. 2001;22(5):605–630. Am J Public Health 1989;79:182–7. MMWR Surveill Summ 2013;62(SS-6):1–19. Thyroid Disease in Pregnancy. Middleton P, Available at: Safety of smoking cessation drugs. 14. Further, health care professionals should advise cessation of tobacco products used in any form and provide motivational feedback. 2002;100(2):388. This document reviews the thyroid-related pathophysiologic changes that occur during pregnancy and the effects of overt and subclinical maternal thyroid disease on maternal and fetal outcomes. Maternal smoking during pregnancy and childhood obesity. QuickStats: cigarette smoking status among current adult e-cigarette users, by age group—National Health Interview Survey, United States, 2015. In: Program and abstracts from the 76th annual meeting of the American Thyroid Association; September 30 – October 3, 2004; Vancouver, British Columbia. An expert commentary on ACOG Practice Bulletin Number 148: Thyroid disease in pregnancy. Referral to a tobacco quit line may further benefit the patient. Electronic cigarettes: one size does not fit all. Number 9, October 1999 (replaces Technical Bulletin Number 188, January 1994). Nicotine Tob Res 2019;21:1001–10. Thyroid disease in pregnancy. Depending on the tobacco services provided, the counseling may merit a separate code or time-based evaluation and management service code. Vääräsmäki M, Coeli CM, Treating tobacco use and dependence: 2008 update. Postterm pregnancy is when a woman has not yet delivered her baby after 42 weeks of gestation, two weeks beyond the typical 40 week duration of pregnancy. E-cigarettes: a scientific review. Number 9, October 1999 (replaces Technical Bulletin Number 188, January 1994). 13. Health care professionals are encouraged to consult coding manuals regarding billing and reimbursement variation from insurance carriers. A report of the Surgeon General . Männistö T, Still, smoking cessation at any point in gestation benefits the pregnant woman and her fetus. Address correspondence to Leo A. Carney, DO, Naval Hospital Pensacola, 6000 W. Hwy 98, Pensacola, FL 32512 (e-mail: Reid SM, Committee on Practice Bulletins-Obstetrics ACOG Practice Bulletin Number 148: Thyroid disease in pregnancy, April 2015. The patient should choose the statement that best describes her tobacco or nicotine use status: A. I have never used tobacco or nicotine or have minimal amounts of tobacco or nicotine in my lifetime (for example, less than 100 cigarettes in my lifetime). Available at: Motivational interviewing: a tool for behavior change. Maglione MA, Maher AR, Ewing B, Colaiaco B, Newberry S, Kandrack R, et al. The U.S. Food and Drug Administration (FDA) mandated a product warning about the risk of psychiatric symptoms and suicide associated with varenicline and bupropion in 2015; however, a December 2016 update removed the boxed warning 69 70 71.
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