Prediction of post partum thyroid dysfunction: can it be improved?
Prediction of post partum thyroid dysfunction: can it be improved?
复制标题
产后甲状腺功能障碍的预测：可以改善吗？
DOI：
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发表时间：
1998
影响因子：
5.8
通讯作者：
W. Wiersinga
中科院分区：
文献类型：
--
作者：
J. Kuijpens;V. Pop;H. Vader;H. Drexhage;W. Wiersinga
背景
筛查孕妇甲状腺过氧化物酶抗体（TPOAb），以确定那些在产后甲状腺功能障碍（PPTD）的风险是有争议的，主要是因为低阳性预测值（PPV）的TPOAb。
目标
评估TPOAb的ppv是否可以增强，无论是考虑TPOAb检测的时间，还是将该参数与其他假定的PPTD决定因素（如吸烟、家族史或其他自身免疫性疾病）相结合。
方法
在Kempenland地区（荷兰东南部）进行了一项前瞻性研究。在妊娠12和32周以及产后4、12、20、28和36周对310名孕妇进行了访问。进行系列促甲状腺激素（TSH）、游离甲状腺素（fT 4）和TPOAb检测。甲状腺功能障碍（TD）定义为TSH异常伴fT 4异常（显性TD）或无fT 4异常（亚临床TD）。PPTD定义为产后明显TD。进行多因素回归分析以确定PPTD的独立危险因素。计算TPOAb在不同时间点和不同浓度下的敏感性和特异性，并将其呈现在受试者工作特征（ROC）曲线中。对经历过PPTD的女性进行了2.5-3年的随访。
结果
291名妇女的数据可供分析。妊娠期间血清fT 4下降，产后恢复至基线值。23例（7.9%）妊娠期TD：13例（6例有明显的妊娠期甲状腺毒症（2.1%））血清TSH一过性降低，10例（2例有TPOAb）升高。TPOAb的点患病率和浓度在妊娠期间下降，并在产后12周内恢复到基线水平。产后TD 36例（12.4%），其中亚临床TD 21例，显性TD 15例。在15名明显TD的女性中（PPTD的发生率：5.2%），10名TPOAb阳性（TPOAb+）：9名甲状腺毒症（4名TPOAb+），5名甲状腺功能减退症（5名TPOAb+）和1名甲状腺毒症继发甲状腺功能减退症（TPOAb+）。PPTD的独立危险因素是TPOAb（相对危险度（RR）= 2 7.2），奶瓶喂养（RR = 11.1）和吸烟习惯（曾经吸烟：RR = 3.1; PPTD女性吸烟时间更长）。妊娠12周时TPOAb检测的敏感性最高（0.67）。TPOAb的ppv为0.31-0.75（取决于测试时间和浓度），当与奶瓶喂养或吸烟习惯结合时，略微增加至0.38-0.80。在2/3的病例中似乎存在自身免疫形式的PPTD和非自身免疫形式;具有自身免疫形式的女性有发生永久性甲状腺功能减退症的风险。
结论
最多2/3的PPTD病例可以从TPOAb的存在预测，因为1/3的TPOAb保持阴性。TPOAb测试的最佳时间是在怀孕的前三个月。TPOAb检测与PPTD的记忆决定因素相结合不会显著增加PPV。
BACKGROUND
Screening pregnant women for thyroid peroxidase antibodies (TPOAb) to identify those at risk for post partum thyroid dysfunction (PPTD) is controversial, mainly because of the low positive predictive value (ppv) of TPOAb.
OBJECTIVES
To evaluate if the ppv of TPOAb can be enhanced, either by taking into account the time of TPOAb testing, or by combining this parameter with other putative determinants of PPTD such as smoking, family history or other autoimmune diseases.
METHODS
A prospective study was performed in the Kempenland region (southeastern Netherlands). Three hundred and ten unselected women were visited at 12 and 32 weeks gestation and 4, 12, 20, 28 and 36 weeks post partum. Serial thyroid stimulating hormone (TSH), free thyroxine (fT4) and TPOAb testing was performed. Thyroid dysfunction (TD) was defined as abnormal TSH either in combination with abnormal fT4 (overt TD) or without abnormal fT4 (subclinical TD). PPTD was defined as overt TD post partum. Multivariate regression analysis was performed for determining independent risk factors for PPTD. The sensitivity and specificity of TPOAb at different time points and at different concentrations were calculated and presented in receiver operating characteristic (ROC) curves. Women who had experienced PPTD were followed for 2.5-3 years.
RESULTS
Data from 291 women were available for analysis. Serum fT4 declined during pregnancy and returned to baseline values post partum. TD in gestation was present in 23 women (7.9%): serum TSH was transiently decreased in 13 (6 had overt gestational thyrotoxicosis (2.1%)) and increased in 10 (2 had TPOAb). Both point prevalence and concentration of TPOAb decreased during gestation and returned to baseline levels within 12 weeks post partum. TD in post partum was present in 36 women (12.4%): 21 had subclinical and 15 overt TD. Out of the 15 women with overt TD (incidence of PPTD: 5.2%) 10 were positive for TPOAb (TPOAb+): 9 had thyrotoxicosis (4 TPOAb+), 5 hypothyroidism (5 TPOAb+) and 1 thyrotoxicosis followed by hypothyroidism (TPOAb+). Independent risk factors for PPTD were TPOAb (relative risk (RR) = 2 7.2), bottle feeding (RR = 11.1) and smoking habits (ever smoked: RR = 3.1; women with PPTD had smoked more cigarettes for a longer period of time). The sensitivity of TPOAb testing was highest at 12 weeks gestation (0.67). The ppv of TPOAb was 0.31-0.75 (depending on time of testing and concentration), increasing slightly to 0.38-0.80 when combined with bottle feeding or smoking habits. There appeared to be an autoimmune form of PPTD in 2/3 of cases and a non-autoimmune form; women with the autoimmune form were at risk for developing permanent hypothyroidism.
CONCLUSIONS
A maximum of 2/3 of PPTD cases can be predicted from the presence of TPOAb because 1/3 remained negative for TPOAb. The most appropriate time for TPOAb testing is in the first trimester of pregnancy. The combination of TPOAb testing with anamnestic determinants of PPTD does not increase ppv substantially.
DOI：
10.1210/jcem.74.3.1740500
发表时间：
1992-03
期刊：
The Journal of clinical endocrinology and metabolism
影响因子：
--
作者：
A. Stagnaro-Ǵreen;S. Roman;R. Cobin;Essam El-Harazy;S. Wallenstein;T. Davies
通讯作者：
A. Stagnaro-Ǵreen;S. Roman;R. Cobin;Essam El-Harazy;S. Wallenstein;T. Davies