Miscarriage in early pregnancy may be associated with thyroid abnormalities Wu Min, Department of Endocrinology, Jiangsu Provincial Hospital of Traditional Chinese Medicine
A recent study in China found that the presence of subclinical hypothyroidism or thyroid autoimmune abnormalities or both before 8 weeks of gestation greatly increases the likelihood of miscarriage. The study was conducted by Professors Teng Weiping, Shan Zhongyan and Liu Haixia of the Department of Endocrinology at the First Affiliated Hospital of China Medical University and colleagues. The results were recently published online in the journal Thyroid. In this prospective cohort study, the researchers evaluated 3,315 women attending 13 hospital obstetrics and gynecology departments and six antenatal screening clinics in three cities in China from January to September 2012, and all of whom had lived in iodine-sufficient areas of China for more than five years and had been pregnant for four to six weeks. A growing number of studies have shown that subclinical hypothyroidism (SCH) or thyroid autoimmune abnormalities (TAI) lead to poor pregnancy outcomes, but very few studies have focused on the association between the presence of these two thyroid disorders early in pregnancy and the risk of subsequent miscarriage.
The study included maternal age, gestational age, previous childbirth and miscarriage history, as well as education level, income, smoking, alcohol consumption, family history of thyroid disease, type 1 diabetes and autoimmune disease, and history of head and neck radiation therapy.
All women had their pregnancy confirmed by ultrasound and had monthly ultrasound and thyroid function tests for thyroid stimulating hormone (TSH), free thyroxine (FT4), thyroid peroxidase antibodies (TPOAb), thyroglobulin antibodies (TgAb) and urinary iodine levels during the study. The primary endpoint of the study was sudden onset of miscarriage before 20 weeks of pregnancy.
Based on thyroid function test results, all participants are divided into four groups: normal thyroid function (ET) group, subclinical hypothyroidism alone (SCH) group, thyroid autoimmune abnormalities alone (TAI) group and subclinical hypothyroidism with thyroid autoimmune abnormalities (SCH+TAI) group. patients in the SCH group cohort will also be evaluated based on TSH levels (2.5≤ The SCH cohort was further divided into 2 subgroups: SCH 1 and SCH 2, and the SCH+TAI group was further divided into 2 subgroups: SCH+TAI 1 and SCH+TAI 2, based on TSH levels (2.5≤TSH<5.22 or 5.22≤TSH<10).
The results of the study suggested that the risk of miscarriage for women in the normal thyroid function group was 2.2%, compared with a significantly increased risk of miscarriage in both the SCH and TAI groups, 7.1 (corrected OR=3.40; 95% CI: 1.62-7.15) and 5.7% (corrected OR=2.71; 95% CI: 1.43-5.12), respectively; the risk of miscarriage in the SCH+TAI1 and SCH+TAI2 groups had a higher risk of miscarriage, 10% (corrected OR=4.96; 95% CI: 2.76-8.90) and 15.2% (corrected OR=9.56; 95% CI: 3.76-24.28), respectively.
Among the 110 women who miscarried, the gestational age at miscarriage was 10.47 weeks in those with subclinical hypothyroidism vs. 11.13 weeks in those with normal thyroid function (P=0.024 ). For the SCH 2 subgroup with higher TSH levels and the two subgroups with SCH+TAI, the gestational age at miscarriage was lower, 10.79 weeks vs. 9.7 weeks for the SCH 1 and SCH 2 groups, respectively (P=0.039), and 9.59 weeks vs. 8.88 weeks for the SCH+TAI 1 and SCH+TAI 2 groups, respectively (P=0.031). Subgroup analysis also revealed that high TSH levels were associated with low gestational age at the time of miscarriage, regardless of whether TAI was combined or not.
This study suggests , universal screening for thyroid function in women of childbearing age, especially for thyroid autoimmune antibodies in early pregnancy or in the first trimester.
Chinese medicine has a unique advantage in helping pregnancy and preserving fetus. The Chinese medical diagnosis of subclinical hypothyroidism with thyroid autoimmune abnormalities is mainly kidney deficiency, liver depression, and imbalance of flushing. The research team led by Prof. Wu Min has used Chinese herbal medicine (Yifu Fetus Drink) to intervene in the risk of miscarriage in early pregnancy in subclinical hypothyroidism with thyroid autoimmune abnormalities, and achieved certain efficacy.
Typical cases.
Tian, female, 34 years old March 2011
Initial diagnosis: The patient had been married for 8 years without pregnancy, had four recurrent miscarriages and one unsuccessful artificial insemination.
At the time of initial consultation, she was fatigued and weak, her face was less florid, her body was fat, she was cold, her libido was low, her menstrual flow was low and her cycle was still accurate, she was easily depressed, her memory was diminished, her eyelids were puffy, her stools were dry or unformed, her tongue was light with white greasy coating, and her pulse was string. The thyroid ultrasound showed that the left thyroid gland was 4.3cm×1.9cm×2.1cm and the right thyroid gland was 4.5cm×2.0cm×1.5cm with an isthmus of 0.6cm. The diagnosis was “Hashimoto’s thyroiditis with hypothyroidism”. The Chinese medicine diagnosis was due to a deficiency of spleen and kidney yang and imbalance of the flush.
Prescription: 28 doses of Astragalus membranaceus, Semen Cuscutae, Radix et Rhizoma mulberry, Chuanjian, Aconite, Radix Angelicae Sinensis, Cornu Cervi Pantotrichum, Rhizoma Atractylodis Macrocephalae, Radix et Rhizoma Huaiyamensis, Poria, Radix et Rhizoma Aromaticae, Radix et Rhizoma Sagittariae. Add Eugenol 25ug. once daily.
2 Diagnosis: After taking the medicine, the patient’s symptoms were relieved, the weakness and chilliness were reduced, there was thirst, irritability and abdominal distension, and the nail function was rechecked: TSH 4.15nIu/mL, TGAb 538.02u/mL, TMAb >1000.00u/mL.
Diagnosis 3: The patient’s weakness and eyelid swelling were relieved, memory improved, and menstrual flow increased. The tongue is light with white greasy coating and the pulse is string. Continue with the original formula for 28 doses.
Repeated A function: TSH 2.15nIu/mL, TGAb,327 .02u/mL, TMAb 761u/mL
4 Diagnosis: The patient has no weakness or swelling, and memory is significantly improved. There may be bad wind. Treatment is to tonify the spleen and kidney and regulate the flushing. She was given 28 doses of roasted Astragalus membranaceus, Semen Cuscutae, Gramophora sinensis, Radix et Rhizoma Sequoiae, Atractylodes Macrocephalae, Fructus Anemarrhenae, Radix et Rhizoma Polygonati, Cornu Cervi Pantotrichum, Poria Cocos, Scutellaria Baicalensis, Fried Jujube Seeds and Radix et Rhizoma Polygonati.
5 Diagnosis: The patient was informed of her pregnancy. The patient was instructed to monitor thyroid function regularly and to adhere to the herbal regimen during pregnancy with homemade fetus benefit drink, made into a cream formula, and with eugenol, 25ug, once a day, until one week before delivery, which resulted in the successful delivery of a male child.
Discussion.
Hashimoto’s thyroiditis (HT) is an autoimmune thyroid disease with enlargement and toughness of the neck as the main clinical manifestation, and most patients also present because of neck discomfort. Laboratory tests often show elevated titers of antithyroglobulin (TgAb) and peroxidase antibodies (TPOAb), and thyroid function tests may show hypothyroidism in half of patients, hyperthyroidism in a few, or normal thyroid function in others.
Increasingly, it has been found that increased titers of TgAb and TPOAb in patients with Hashimoto’s thyroiditis can lead to infertility in women of childbearing age, miscarriage and preterm delivery in pregnant women, and mental retardation and physical weakness in the child.
In 1990, Stagnaro-Green et al. first reported a 1-fold increase in the incidence of miscarriage in women with positive thyroid autoantibodies in the third trimester compared to women with normal pregnancies. Since then, an increasing number of authors have found an association between miscarriage and positive thyroid antibodies (mainly TgAb and TPOAb) in women. In a comparison of 80 patients with recurrent spontaneous abortions and 40 healthy women of childbearing age, Xuan Yinghua et al. found that the TgAb and TPOAb positivity rates were 25.0% and 18.8%, respectively, which were significantly higher than those of 7.5% and 5.0% in the normal control group. Poppe and Janssen et al. found that TPO-Ab and TgAb positivity rates were also much higher in infertile women than in healthy women for different reasons, and Ghafoor et al. evaluated the relationship between pregnancy outcome and TPO-Ab in 1500 pregnancies and found that the preterm birth rate was much higher in TPO-Ab-positive than in TPO-Ab-negative women. preterm birth rate in TPO-Ab-negative pregnant women. The results showed that the offspring of TPO-Ab-positive mothers had significantly lower IQ and motor scores than the control group.
Although a large number of studies have shown an association between these two antibodies and adverse pregnancies, the pathogenesis is unclear. There are three hypotheses: an underlying abnormal thyroid immune function, a subclinical stage or slight deficiency of thyroid hormones, and thyroid antibodies affecting placental function. In view of the adverse effects of antibodies on pregnancy, it is important to regularly monitor thyroid function and antibodies in women who are ready to conceive or are pregnant, and to treat patients with early detection of abnormalities so as to reduce the incidence of adverse pregnancies, and to identify the cause in women with a history of recurrent miscarriages and other adverse pregnancies and those who need assisted reproduction to achieve eugenics.
There is no ideal solution for Hashimoto’s infertility in Western medicine, but Chinese medicine has unique advantages for Hashimoto’s infertility in terms of dialectical medicine, benefiting the kidney and strengthening the spleen, and helping the fetus to conceive, which should be studied in depth.