SYSTEMATIC REVIEW

published: 24 June 2022

doi: 10.3389/fendo.2022.800257

Effect of Hyperthyroidism Control

During Pregnancy on Maternal and
Fetal Outcome: A Systematic
Review and Meta-Analysis
Jose Mario Alves Junior 1*, Wanderley Marques Bernardo 2,3, Laura Sterian Ward 4
and Danilo Villagelin 1,5
1 Postgraduate Course Internal Medicine, Campinas State University, Campinas, Brazil, 2 School of Medicine, University of

São Paulo, São Paulo, Brazil, 3 Department of Evidence-Based Medicine, University of São Paulo,
São Paulo, Brazil, 4 Laboratory of Cancer Molecular Genetics, School of Medicine Sciences, Campinas State University,
Campinas, Brazil, 5 Endocrinology and Metabolism, Hospital of the Pontifical Catholic University of Campinas
Edited by: (PUC-Campinas), Campinas, Brazil
Alessandro Antonelli,
University of Pisa, Italy

Reviewed by: Context: Although the overt hyperthyroidism treatment during pregnancy is mandatory,
Marco Centanni, unfortunately, few studies have evaluated the impact of treatment on reducing maternal
Sapienza University of Rome, Italy
Francisco Eduardo Prota,
and fetal outcomes.
Pontifical Catholic University of Objective: This study aimed to demonstrate whether treatment to control hyperthyroidism
Campinas, Brazil
Gabriela Brenta,
manifested during pregnancy can potentially reduce maternal-fetal effects compared with
Dr. César Milstein Care Unit, Argentina euthyroid pregnancies through a systematic review with meta-analysis.
*Correspondence:
Data Source: MEDLINE (PubMed), Embase, Cochrane Library Central, LILACS/BIREME
Jose Mario Alves Junior
jmalvesj@gmail.com until May 2021.
Study Selection: Studies that compared, during the gestational period, treated women
Specialty section:
This article was submitted to
with hyperthyroidism versus euthyroid women. The following outcomes of this
Thyroid Endocrinology, comparison were: pre-eclampsia, abruptio placentae, fetal growth retardation,
a section of the journal
gestational diabetes, postpartum hemorrhage, low birth weight, stillbirth, spontaneous
Frontiers in Endocrinology
abortions, premature birth.
Received: 22 October 2021
Accepted: 27 April 2022 Data Extraction: Two independent reviewers extracted data and performed quality
Published: 24 June 2022
assessments. Dichotomous data were analyzed by calculating risk differences (DR) with
Citation:
Alves Junior JM, Bernardo WM,
fixed and random effect models according to the level of heterogeneity.
Ward LS and Villagelin D (2022)
Data Synthesis: Seven cohort studies were included. The results of the meta-analysis
Effect of Hyperthyroidism Control
During Pregnancy on Maternal and indicated that there was a lower incidence of preeclampsia (p=0.01), low birth weight
Fetal Outcome: A Systematic (p=0.03), spontaneous abortion (p<0.00001) and preterm birth (p=0.001) favouring the
Review and Meta-Analysis.
Front. Endocrinol. 13:800257.
euthyroid pregnant group when compared to those who treated hyperthyroidism during
doi: 10.3389/fendo.2022.800257 pregnancy. However, no statistically significant differences were observed in the

Frontiers in Endocrinology | www.frontiersin.org 1 June 2022 | Volume 13 | Article 800257

Alves Junior et al. Hyperthyroidism Control During Pregnancy

outcomes: abruptio placentae, fetal growth retardation, gestational diabetes mellitus,

postpartum hemorrhage, and stillbirth.
Conclusions: Our findings demonstrated that treating overt hyperthyroidism in
pregnancy is mandatory and appears to reduce some potential maternal-fetal
complications, despite there still being a residual risk of negative outcomes.
Keywords: hyperthyroidism, pregnancy, treatment, meta-analysis, maternal, fetal

INTRODUCTION published in English or Portuguese without time limits. The

research was developed following the PICO strategy, as follows:
Hyperthyroidism, considering all causes, occurs in 0.2 to 1.3% of (P) women with hyperthyroidism during pregnancy; (I)
the population in countries where iodine intake is sufficient. antithyroid drugs; (C) euthyroid pregnancies and (O): pre-
Graves’ disease (GD) is the most frequent cause and has a high eclampsia, abruptio placentae, fetal growth retardation,
prevalence in women who often appear in reproductive age (1, 2). gestational diabetes, postpartum hemorrhage, low birth weight,
Thyrotoxicosis can manifest in pregnancy in three forms: stillbirth, spontaneous abortions, premature birth. Only
gestational thyrotoxicosis, subclinical hyperthyroidism, and publications with complete data were included, and the last
overt hyperthyroidism. Gestational hyperthyroidism is a short search was conducted in May 2021. Literature searches were
form of thyrotoxicosis caused by hCG’s excessive stimulation of performed in PubMed as follows: (Pregnant Women OR
the thyroid gland. It is usually limited to the first trimester of Pregnant Woman OR Pregnancy OR Pregnacies OR Gestation
pregnancy. It affects 1-3% of all pregnancies, especially in women OR Gravidity) AND (Hyperthyroidism OR Hyperthyroid OR
with hyperemesis gravidarum and multiple gestations (3). Hyperthyroids OR Primary Hyperthyroidism OR Thyrotoxicosis
Subclinical hyperthyroidism is defined by TSH under the OR Thyrotoxicosis OR Graves disease OR Basedow Disease OR
standard limit with average T4/T3 values, respecting the TSH Graves’ Disease OR Exophthalmic Goiter OR Exophthalmic
and T4/T3 pregnancy reference values by trimester (1, 3). Overt Goiters OR Hyperthyroidism, Autoimmune OR Basedow’s
hyperthyroidism is rare, occurring in only 0.2% of pregnancies, Disease OR Basedows Disease) AND (Abortion OR
and GD is its most common cause (3, 4). Spontaneous Abortions OR Early Pregnancy Loss OR Early
Although there is consensus on the need for treatment of Pregnancy Losses OR Miscarriage OR Miscarriages OR Tubal
overt hyperthyroidism during pregnancy, only a few studies Abortions OR Pre-Eclampsia OR Pre Eclampsia OR
evaluated the impact of this treatment on maternal and fetal Preeclampsia OR Pregnancy Toxemias OR Pregnancy Toxemia
endpoints (3, 5–11). Most data are conflicting regarding OR Edema-Proteinuria-Hypertension Gestosis OR Edema
pregnancy outcomes such as pre-eclampsia, growth restriction, Proteinuria Hypertension Gestosis OR Hypertension-Edema-
low birth weight, miscarriage, and premature birth. Hence, we Proteinuria Gestosis OR Hypertension Edema Proteinuria
aimed to understand better the maternal-fetal effects of treating Gestosis OR Toxemia Of Pregnancy OR Toxemia Of
overt hyperthyroidism with anti-thyroid drugs (ATD) Pregnancies OR EPH Complex OR EPH Toxemias OR EPH
(methimazole and propylthiouracil) during pregnancy, Toxemia OR Preeclampsia Eclampsia 1 OR Preeclampsia
reducing adverse outcomes. The well-known teratogenic effects Eclampsia 1s OR Proteinuria-Edema-Hypertension Gestosis
of ATD are beyond the scope of this review. OR Proteinuria Edema Hypertension Gestosis OR Premature
Birth OR Premature Births OR Preterm Birth OR Preterm Births
OR Premature Infant OR Preterm Infants OR Preterm Infant OR
METHODS Premature Infants OR Neonatal Prematurity OR Premature
Obstetric Labor OR Premature Labor OR Preterm Labor OR
This study was conducted following the PRISMA statement (12). Premature Obstetric Labor OR Abruptio Placentae OR Placental
The research protocol was registered in the International Abruption OR Placental Abruptions OR Fetal Growth
Prospective Register of Systematic Reviews (http://www.crd. Retardation OR Intrauterine Growth Retardation OR
york.ac.uk/PROSPERO) under CRD42021242704. Intrauterine Growth Restriction OR Fetal Growth Restriction
OR Diabetes, Gestational OR Pregnancy-Induced Diabetes OR
Database Search Gestational Diabetes OR Gestational Diabetes Mellitus OR
The research was exclusively carried out using electronic Postpartum Hemorrhage OR Immediate Postpartum
databases [Medline (https://pubmed.ncbi.nlm.nih.gov/), Hemorrhage OR Delayed Postpartum Hemorrhage OR
EMBASE (https://www.embase.com/), Cochrane Library Stillbirth OR Stillbirths OR Low-Birth-Weight Infant OR Low
(https://www.cochranelibrary.com/), and Lilacs/Bireme (https:// Birth Weight Infant OR Low-Birth-Weight Infants OR Low
lilacs.bvsalud.org/)]. Searches for randomized controlled trials Birth Weight OR Low Birth Weights). The same medical
(RCTs), non-randomized trials (NRS), prospective or subject headings (MeSH) and keywords in various
retrospective cohort studies were restricted to articles combinations were used in the mentioned electronic databases.

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Alves Junior et al. Hyperthyroidism Control During Pregnancy

Study Selection (Table 1). Due to the high score, all studies were included in
Two reviewers performed independent eligibility assessments to the systematic review and meta-analysis.
select the studies using predefined inclusion and exclusion
criteria. Any divergence was resolved by consensus or Studies Characteristics
consulting a third reviewer. The inclusion criteria were (I) All included studies were based on a retrospective cohort
pregnant women who have been diagnosed and treated with conducted in India, Hungary, Thailand, Israel, Finland, and
hyperthyroidism during pregnancy and for whom at least one Denmark. The sample sizes ranged from 400 to 1,062,862, and
pregnancy outcome has been assessed and (II) randomized the mean age of studies ranged from 25.5 to 30. The definition of
controlled trials (RCTs) or non-randomized trials (NRS) or hyperthyroidism during pregnancy varied among the included
prospective or retrospective cohort studies with ATD studies, but the studies clearly expressed the treatment of these
treatment in one comparison arm regardless of the patients’ women with antithyroid drugs (Table 2).
number. The exclusion criteria were: (I) non-human studies, (II)
letters, reviews, case reports, editorials, (III) studies without full Study Findings
text, and (IV) studies from which the necessary data could not be No study included the assessment of all eligible outcomes. Data
extracted from the pooled results. describing the presence of pre-eclampsia cases were available in six
out of the seven eligible trials studies; data on gestational diabetes
Quality Assessment mellitus in five studies; fetal growth retardation, stillbirth, and
Study quality was assessed using the Newcastle-Ottawa scale to premature birth in four studies; abruptio placentae data were
assess the quality of non-randomized studies in meta-analyses, available in three studies and spontaneous abortion, postpartum
and certainty assessment was performed using GRADE (13, 14). hemorrhage, and low birth weight in only two studies.
Disagreements were discussed between the investigators until a
consensus was reached. Meta-Analysis of Selected Studies
Among all outcomes evaluated, only preeclampsia, low birth
Data Extraction weight, miscarriage and preterm delivery showed a statistically
One reviewer extracted all relevant information from acceptable significant difference. The pooled data from the network meta-
studies, including design, sample size, population details, analysis showed that euthyroid pregnant women, compared to
recruitment process, hyperthyroidism exposure, method of pregnant women who underwent treatment for hyperthyroidism
treatment, and outcomes. If data were reported in separate during pregnancy, had a lower incidence of preeclampsia: 4.3%
metrics, extracted outcome data were converted to a standard vs. 10.2% (RD=0.04; 95% CI: 0.01 to 0.08; I2 = 66%; p=0.01)
metric to estimate treatment effects. (Figure 2); low birth weight fetuses: 10.6% vs. 26.4% (RD=0.08;
95% CI: 0.01 to 0.16; I2 = 0%; p=0.03) (Figure 3); spontaneous
Statistical Analysis abortions: 13.6% vs. 16% (RD=0.03; 95% CI: 0.02 to 0.04; I2 = 0%;
Statistical analyses were performed using the Review Manager p< 0.00001) (Figure 4) and, premature birth: 4.0% vs. 9.8%
software, version 5.4 (RevMan 5.4; Cochrane Collaboration, (RD=0.03; 95% CI: 0.01 to 0.05; I2 = 38%; p=0.001) (Figure 5).
Oxford, UK). Dichotomous data were analyzed by computing Random-effects analysis method was used to adjust for inter-
risk differences (RD) with fixed- and random-effect models study heterogeneity and certainty assessment was very low for all
employed according to the level of heterogeneity. Sensitivity outcomes (Table 3).
analysis with funnel plot for ≥50% heterogeneity was not For the other outcomes evaluated, the pooled data of the
performed because, as a rule of thumb, tests for funnel plot network meta-analysis did not show statistically significant
asymmetry should be used only when at least ten studies are difference between the groups, as follows: abruptio placentae
included in the meta-analysis. Also, the power of the tests is low (RD=0.00; 95% CI: -0.01 to 0.01; I2 = 0%; p=0.94), fetal growth
when there are fewer studies. retardation (RD=0.02; 95% CI: -0.05 to 0.09; I2 = 67%; p=0.61),
gestational diabetes mellitus (RD=0.02; 95% CI: -0.00 to 0.03; I2 =
13%; p=0.08), postpartum hemorrhage (RD=-0.00; 95% CI: -0.03
to 0.03; I2 = 0%; p=0.95) and stillbirth (RD=-0.00; 95% CI: -0.00 to
RESULTS
0.00; I2 = 0%; p=0.34). Random-effects analysis method was used
Study Selection to adjust for inter-study heterogeneity when necessary and
After searching five databases and exploring reference lists, 1,225 certainty assessment was also very low for all outcomes (Table 3).
potential studies were identified. The studies were uploaded to
Endnote, where duplicates were excluded. After the exclusions,
seven studies contained enough data to be included in a meta- DISCUSSION
analysis (Figure 1).
According to the 2017 ATA guidelines, poor control of
Quality Assessment thyrotoxicosis is associated with pregnancy loss, pregnancy-
All seven studies were considered as high quality by the induced hypertension, prematurity, low birth weight,
Newcastle-Ottawa scale, as they scored between 7 and 8 intrauterine growth restriction, stillbirth, thyroid storm, and

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Alves Junior et al. Hyperthyroidism Control During Pregnancy

FIGURE 1 | Prisma Flow Diagram of Study Selection.

maternal congestive heart failure (3). Unfortunately, there are little placental abruption, delayed fetal growth, gestational diabetes,
data on the effect of controlling thyrotoxicosis during pregnancy on postpartum hemorrhage, stillbirth.
maternal outcomes. Moreover, the risk for adverse maternal Pre-eclampsia is a pregnancy complication characterized by high
outcomes in women who had overt hyperthyroidism treated blood pressure and signs of damage to another organ system, most
with ATD during pregnancy differs in various studies, which often the liver and kidneys. Pre-eclampsia incidence range from 2 -
may be due to differences in inclusion criteria, sample size, and 7,5%; some risk factors are hypertension, obesity, diabetes mellitus,
study design (5–11). age, and race (15, 16). Hyperthyroidism is a well-known risk factor
The present meta-analysis compared almost 6,000 pregnant for pre-eclampsia, especially poorly controlled (5, 17). In addition,
women treated for hyperthyroidism with 1.3 million euthyroid hyperthyroidism could aggravate a preexisting condition (e.g.,
pregnant women, demonstrating that the treatment for hypertension) by predisposing to pre-eclampsia, or it can even
hyperthyroidism and restoration of the euthyroid state can trigger pre-eclampsia. Our data show that the development of
supposedly reduce the incidence of five essential outcomes: preeclampsia was 4% lower in the pregnancies of euthyroid women.

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Alves Junior et al.

TABLE 1 | Newcastle-Ottawa quality assessment scale.

Author Year Country Design Founding Participants (Database) Mean Study Intervention N Control N Folow-up Hypertireoidism During
Source (age) Size (n) Groups Groups (years) Pregnancy (Definition)

Ajmani 2014 India Prospective Not declared Department of obstetrics and 27,53 400 Hyperthyroidism 2 Euthyroidism 347 01 High Free T4 ([2.0 ng/dl) with
SN et al. Cohort gynecology at Kasturba treated decreased TSH (\0.2 lIU/l)
(5) Hospital
Bá nhindy 2011 Hungary Retrospective Both Hungarian Congenital 25.5 60,994 Hyperthyroidism 187 Euthyroidism 60.807 16 Thyrotoxicosis with diffuse
F et al. (6) Cohort nonindustrial Abnormality Registry (HCAR) treated goitre [Graves’ disease, toxic
and industrial diffuse goitre], Thyrotoxicosis
with toxic single thyroid
nodule, and Thyrotoxicosis
with toxic multinodular goitre
Luewan S 2011 Thailand Retrospective None Maternal– Fetal Medicine Unit, 28.98 563 Hyperthyroidism 180 Euthyroidism 360 14 Pregnant women diagnosed
et al. (7) Cohort Chiang Mai University and treated for hyperthyroidism by
medical records of the patients. endocrinologist based on the
clinical manifestations and
endocrine laboratory
confirmation
Pillar N 2010 Israel Retrospective None Soroka University Medical 26.5 185,825 Hyperthyroidism 189 Euthyroidism 185.636 19 Overactive thyroid gland,
et al. (8) Cohort Cente treated resulting in the overproduction
and, thus, excess of
circulating free thyroid
hormones (triiodothyronine,
thyroxine, or both)
Sahu MT 2010 India Prospective None King George Medical University, 26.0 633 Hyperthyroidism 5 Euthyroidism 552 03 Elevation in free T4 with an
5

et al. (9) Cohort and all India Institute of Medical treated undetectable serum TSH
Sciences
Turunen 2020 Finland Retrospective None Medical Birth Register (MBR) 27,5 571,785 Hyperthyroidism 580 Euthyroidism 550.860 09 The ICD-10 code E05 (all
S et al. Cohort and supplemented with treated digits) and the ICD-9/ICD-8
(10) information from the code both 242
Prescription Register, the
Hospital Discharge Register
and the Register on Congenital
Malformations.
Andersen 2014 Denmark Retrospective None Danish nationwide registers 30.0 1,062,862 Hyperthyroidism 5.229 Euthyroidism 836.905 11 ICD-8: 242.00–242.29 and
SL et al. Cohort treated ICD-10: E05.0–E05.9
(11) [excluding thyrotoxicosis
factitia (E05.4),

Hyperthyroidism Control During Pregnancy

overproduction of TSH
June 2022 | Volume 13 | Article 800257

(E05.8A) and thyrotoxic heart

disease (E05.9A)].
Alves Junior et al. Hyperthyroidism Control During Pregnancy

Quality Gestational diabetes mellitus is also an important outcome

High

High

High

High

High

High

High
with several impacts on maternal health. Obesity is the major risk
factor for diabetes mellitus (15, 16, 18). Also, hyperthyroidism is
TOTAL
(0 – 9)

a well-known cause of increased insulin resistance and glucose

8

7
levels. Both hormonal and immunologic conditions are related to
this phenomenon (19). This meta-analysis suggests that overt
Adequacy of
follow-up of

hyperthyroidism treatment mitigates the deleterious effect of

cohorts

excessive thyroid hormone on glucose metabolism, preventing

*

*
an increased risk of gestational diabetes mellitus (5, 6, 8–10).
Spontaneous abortion is a tragic situation during pregnancy.
Chromosomal abnormality is the single most common cause
Follow-up for enough

involved in approximately half of all cases of early spontaneous

form outcome to
Outcome

abortion and is also related to stillbirth (20). In addition,

occour

uncontrolled hyperthyroidism during pregnancy is a risk

*

*
factor, although the molecular mechanism underlying this
association is still not well understood (3). Although small but
significant, our results showed that euthyroid pregnant women
had 3% fewer events of spontaneous abortions.
Assessment
of outcome

One of the critical consequences of uncontrolled

*

hyperthyroidism during pregnancy is low birth weight, which

may be directly or indirectly related to maternal hyperthyroidism
(21). Maternal hyperthyroidism may reduce fetal nutrition or act
importantfactor or

as a predisposing factor for other conditions that will cause these

additional factor
Comparability

outcomes, similar to pregnancy-induced hypertension and

Control for

maternal congestive heart failure (22). In women with GD,

*

maternal TRAb passage to the placenta can induce low birth

weight (3). Although overt hyperthyroidism was medicated with
ATD, and presumably it was controlled; euthyroid pregnant
women had 8% lower occurrence of low birth weight.
not present at start of
Outcome of interest

Placental abruption is the early separation of the placenta

from the lining of the uterus before completing the second stage
study

of labor (23). The primary cause is impairment of the vascular

*

The symbol "*" in each spot means that the characteristic's answer was present in the evaluated article.

structures that support the placenta (24). Hyperthyroidism can

predispose to hypertension, one of the most critical risk factors of
placental abruption (3). Correcting hyperthyroidism during
pregnancy attenuates this predisposition, resulting in no
Ascertainment
of exposure

differences between hyperthyroid-treated women and

euthyroid controls (5, 8, 10).
*

Postpartum hemorrhage is the most common cause of

Selection

maternal mortality worldwide, and the hyperthyroid state

contributes to coagulation disorders, acting directly on the
Selection of the

gene transcription of coagulation proteins and altering the

nonexposed

clot’s structure (25, 26). In addition, hyperthyroidism may

cohort

cause a hyper-dynamic state and favor bleeding. Our data

demonstrated that controlling hyperthyroidism equals the risk
of postpartum hemorrhage compared to the control group (5, 7).
TABLE 2 | Baseline studies characteristics.

The World Health Organization defines premature birth as

Representativeness
of the exposed

births before 37 completed weeks of gestation (27). Premature

birth rates range from 3 to 14% in low-risk pregnancies.
cohort

Maternal conditions, including hyperthyroidism, and other

conditions such as pre-eclampsia, pre-gestational and
gestational diabetes, and cervical incompetence may increase
this incidence (28, 29). This meta-analysis showed that even with
Cohortstudies

Sahu MT et al.,
et al., 2014 (5)

et al., 2011 (6)

et al., 2011 (7)

the treatment of hyperthyroidism, the occurrence of preterm

Pillar N et al.,

Andersen SL
et al., 2020

et al., 2014
Bá nhindy F
Ajmani SN

Turunen S

birth was 3% lower in euthyroid pregnant women (5, 7, 9, 10).

Luewan S

2010 (8)

2010 (9)

This meta-analysis shows an excess risk of hyperthyroid-

(10)

(11)

treated women in four endpoints (pre-eclampsia, low birth

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Alves Junior et al. Hyperthyroidism Control During Pregnancy

FIGURE 2 | Forest Plot: Pre-eclampsia.

FIGURE 3 | Forest Plot: Low Birth Weight.

FIGURE 4 | Forest Plot: Spontaneous Abortions.

FIGURE 5 | Forest Plot: Premature Birth.

weight, spontaneous abortion, and premature birth) in third-trimester pre-eclampsia, low birth weight, and premature
comparison to euthyroid women. The differences were slight, birth. The mechanisms involved may be several and may be
ranging from 3 to 8%, however significant. The deleterious effect directly or indirectly related to hyperthyroidism, as discussed
of hyperthyroidism affects the three trimesters of gestation, in the above. Also, other causes can be related to these negative
first-trimester spontaneous abortion and during the second and outcomes, such as other autoimmune conditions associated

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Alves Junior et al.

TABLE 3 | GRADE - certainty assessment.

Certainty assessment № of patients Effect Certainty

№ of studies Study Risk of Inconsistency Indirectness Imprecision Other Anti-thyroid No treatment Relative Absolute
design bias considerations drugs (ATD) (95% CI) (95% CI)
Pre-eclampsia
6 observational not not serious not serious seriousa,b none 117/1143 34546/798562 not 40 fewer per ⨁x̂ x̂ x̂
studies serious (10.2%) (4.3%) estimable 1.000
(from 80 fewer to Very low
10 fewer)
Low Birth Weight
2 observational not not serious not serious seriousa none 48/182 (26.4%) 75/707 (10.6%) not 80 fewer per ⨁x̂ x̂ x̂
studies serious estimable 1.000
(from 160 fewer to Very low
10 fewer)
Spontaneous Abortions
2 observational not not serious not serious seriousa none 886/5231 110928/837252 not 30 fewer per ⨁x̂ x̂ x̂
studies serious (16.9%) (13.2%) estimable 1.000
(from 40 fewer to Very low
20 fewer)
Premature Birth
4 observational not not serious not serious seriousa none 74/765 (9.7%) 21704/552035 not 30 fewer per ⨁x̂ x̂ x̂
studies serious (3.9%) estimable 1.000
(from 50 fewer to Very low
10 fewer)
8

Abruptio Placentae
3 observational not not serious not serious seriousa none 15/771 (1.9%) 14373/736843 not 0 fewer per 1.000 ⨁x̂ x̂ x̂
studies serious (2.0%) estimable (from 10 fewer to Very low
10 more)
Fetal Growth Retardation
4 observational not not serious not serious seriousa,b none 30/376 (8.0%) 4951/186895 not 20 fewer per ⨁x̂ x̂ x̂
studies serious (2.6%) estimable 1.000
(from 90 fewer to Very low
50 more)
Gestational Diabetes
5 observational not not serious not serious seriousa none 78/963 (8.1%) 59618/798202 not 20 fewer per ⨁x̂ x̂ x̂
studies serious (7.5%) estimable 1.000
(from 30 fewer to Very low

Hyperthyroidism Control During Pregnancy

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0 fewer)
Postpartum Hemorrhage
2 observational not not serious not serious seriousa none 4/182 (2.2%) 28/707 (4.0%) not 0 fewer per 1.000 ⨁x̂ x̂ x̂
studies serious estimable (from 30 fewer to Very low
30 more)
Stillbirth
4 observational not not serious not serious seriousa none 19/5991 (0.3%) 4453/1388472 not 0 fewer per 1.000 ⨁x̂ x̂ x̂
(from 0 fewer to studies serious (0.3%) estimable Very low
0 fewer)
“a” means “Type of study design” and “b” means “Heterogeneity > 50%”.
Alves Junior et al. Hyperthyroidism Control During Pregnancy

with GD (30). Also, GD TRAb could have essential participation there is a residual risk of negative results even when overt
in negative outcomes. TRAb passage through the placenta and hyperthyroidism is treated. This information will help doctors
the action in the thyroid fetus` gland also can determine the and patients manage pregnancy, especially those who needed to
increase of these outcomes (31–33), especially in the third treat hyperthyroidism during this process.
trimester. None of the studies evaluated in the meta-analysis
mentioned the TRAb titers during treatment. The control of
hyperthyroidism and the decrease in TRAb titers do not always
present in the same period (34); thus, TRAb can cause fetus’ DATA AVAILABILITY STATEMENT
hyperthyroidism even with maternal thyroid levels normal.
The original contributions presented in the study are included in
Despite our attempts to eliminate potential biases, this
the article/supplementary material. Further inquiries can be
systematic review has limitations. First, because some studies did
directed to the corresponding author.
not specify if hyperthyroidism was treated, we had to exclude many
patients from the final analyses (35–46). Second, it is important to
emphasize that in carrying out this meta-analysis, we only used
studies that showed the treatment of overt hyperthyroidism during AUTHOR CONTRIBUTIONS
pregnancy. Unfortunately, some studies are not specific about the
degree of control of hyperthyroidism, we presumed that an JA: made considerable contributions to the design and
euthyroid state was reached and maintained in all treated postulation of the study, the definition of technical content,
patients. Also, some studies may have started treatment after the literature research, data analysis, statistical analysis, manuscript
first trimester. Third, the quality of evidence evaluated by the preparation, drafting, writing, critical review, and approval of the
GRADE tool showed a very low certainty of the evidence for all manuscript final version for publication. WB: were involved in
outcomes. The main weak point in the quality of evidence was the the data analysis, statistical analysis, manuscript preparation,
type of study design, leading to a high level of imprecision. In writing, drafting, critical review for important intellectual
addition, we were unable to examine data on subclinical content. LW: Manuscript preparation, writing, drafting, critical
hyperthyroidism and gestational thyrotoxicosis, limiting this review for important intellectual content, and approval of the
meta-analysis to overt hypothyroidism. manuscript final version for publication. DV: provided support
No meta-analysis or systematic review has been published on for the entire process of developing and reviewing this systematic
this topic to our knowledge. In conclusion, treatment of overt review and approval of the manuscript final version for
hyperthyroidism in pregnancy is mandatory and appears to publication. All authors contributed to the article and
reduce some potential maternal-fetal complications. However, approved the submitted version.

8. Pillar N, Levy A, Holcberg G, Sheiner E. Pregnancy and Perinatal Outcome in

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Subclinical Hyperthyroidism and Pregnancy Outcomes. Obstet Gynecol (2006) 107 Publisher’s Note: All claims expressed in this article are solely those of the authors
(2 Pt 1):337–41. doi: 10.1097/01.AOG.0000197991.64246.9a and do not necessarily represent those of their affiliated organizations, or those of
32. van Dijk MM, Smits IH, Fliers E, Bisschop PH. Maternal Thyrotropin Receptor the publisher, the editors and the reviewers. Any product that may be evaluated in
Antibody Concentration and the Risk of Fetal and Neonatal Thyrotoxicosis: A this article, or claim that may be made by its manufacturer, is not guaranteed or
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American Thyroid Association Guidelines for Diagnosis and Management of the original author(s) and the copyright owner(s) are credited and that the original
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