1. Antenatal screening for Hypothyroidism: Jordanian study (Part I)
Omymah Zain Alddin AlRajabi,RN,MSN
Rufaida College for Nursing, Midwifery & Paramedical
MOH-Jordan
Dr. Lourance Al Hadid, RN, MSN, CCNS, Ph.D.
Al-Ghad International College for Applied Medical Sciences
Head of Nursing Department, Tabouk Campus- Male, KSA

2. Background
Hypothyroidism (Overt – Subclinical - Isolated hypothyroxinaemia)
It is the 2nd most common health problem among maternal age women.
Prevalence of normal iodized pregnancies is only 2.5% in countries like the USA; we don’t have accurate figures in Jordan.
Prevention of hypothyroidism through early detection of is crucial to prevent complications like:
Still birth, fetal brain damage, congenital malformation,
Cognitive impairment , mental retardation & Autism??? Mainly….. Isolated hypothyroxinaemia complications
Pre-eclampsia, infertility, miscarriage, and preterm delivery

3. Background Jordanian literature lacks studies on this topic.
Therefore, this study explores the prevalence of hypothyroidism among pregnant women in Jordan.
It also aims to conduct health screening related to the early detection of hypothyroidism .

4. Study objectives
Estimate the prevalence of hypothyroidism among Jordanian pregnant women. Identify pregnant women at risk of developing hypothyroidism. Explore the significance of early screening of TSH in the 1st trimester of pregnancy. Develop recommendations to promote better healthcare policies concerning antenatal screening for Gestational Maternal Hypothyroidism.

5. Data Collection & Ethical Considerations
This is part one of a larger multi-step study that includes all geographical regions of Jordan.
This report though addresses only one city.
Data were collected over 4 months using the modified pregnancy and thyroid survey (Vaidya et al., 2012).
The approval to use this survey questionnaire has been granted from the authorized author through e mail request.

6. Data Collection &Ethical consideration, cont.
Participation is voluntary, anonymous, and data collected were used by the researchers for research purposes only.
Cover letter was attached to the study questionnaire explaining the purpose, significance and procedure of the study.
The researchers explained all questions posed by the candidates.

7. Instrument
Modified European Survey Questionnaire (Vaidya et al., 2012).
It is composed of two parts:
Part One:
Demographic data, biophysical tests and measurements (BP, Pulse, Ht, Wt, BMI, Hgb, urine test for protein, and TSH level.
Part Two:
Screening items for the risk factors associated with hypothyroidism.

8. Definition of terms Isolated hypothyroxinemia:
Normal maternal TSH concentration with low FT4 in the lower 5th or 10th percentile of the pregnancy reference range.
Overt hypothyroidism(OH):
Elevated TSH (>2.5mIU/L) with decreased FT4 according to pregnancy reference range;
Women with TSH of 10.0mlU/L or more, irrespective of their FT4 considered OH.
Subclinical hypothyroidism (SCH):
Elevated TSH between (2.51st trimester, 3 in 2nd, & 3rd trimester up to 10 mIU/L) with normal FT4.

9. Study Guidelines
This study adopts the American Thyroid Association (2011) guidelines:
Pregnancy reference range for TSH….and FT4
1ST trimester TSH: mlU/L, FT4: Pmol/L
2nd trimester TSH:0.2-3 mlU/L, FT4: Pmol/L
3rd trimester TSH: mlU/L FT4: Pmol/L
In Jordan, there are NO PREGNANCY REFRENCE RANGES
ONLY adult reference range:
TSH: mIU/L
FT4: Pmol

10. Methods Design Sample Data collected
A descriptive, correlational, cross-sectional was used.
All detected cases were referred for treatment.
Sample
Purposive sample of 153 Jordanian pregnant women.
Settings included one central hospital and one comprehensive health center at Al Rusyfa.
Data collected
Structured interview, antenatal routine lab tests, physical measurements and thyroid function tests.

11. Findings

12. Ch.ch of the respondents
Minim
Maxim
Mean SD
Age
16.00
45.00
28.222
6.397
No. of Preg.
1.00
11.00
3.739
2.194
Abortions
.00
4.00
.712
1.030
No. of Deliveries
7.00
2.046
1.793 Ht
124.00
190.00
8.094 Wt
44.00
159.00
68.670
16.700
Hgb
8.00
120.00
12.074
8.887
FT4
27.02
12.934
2.685
BMI
17.30
51.42
26.961
5.560
TSH
.01
10.50
2.536
1.814

16. Trimester
Frequency
Percent
Cumulative Percent
First 66
43.1
Second 32
20.9
64.1
Third 55
35.9
100.0

17. Prevalence of Hypothyroidism during Pregnancy (%)
Thyroid Dysfunction
National Adult Reference
(trimester)
Pregnancy Trimester Reference (trimester)
1st
2nd
3rd
Total OH
3.27
3.9
Subclinical
1.31
7.85
5.23
9.15
18.3
Isolated Hypothyroxinimia
3.92
1.96
7.19
3.33
3.2
9.8
11.11
2.62
18.31
13.73
11.76 32
Confirmed OH on RX
11.11%

18. Prevalence of hypothyroidism during pregnancy
According to Pregnancy Trimester Reference
Nearly 1/3 were found to have one form of hypothyroidism, mainly SUBCLINICAL hypothyroidism (18.3%).
According to National Adult Reference
Nealry 1/5 were found to have one form of hypothyroidism.
Comparison between both references went as follows:
(Pregnancy Reference)
7.19% had % pregnancy reference)
.(18.3% subclinical )

19. Condition
Adult reference
Pregnancy reference
Clinical hypothyroidism
(Overt)
3.27 %
3.9 %
Isolated hypothyroxinemia
7.19 %
9.8 %
Subclinical hypothyroidism
7.85 %
18.3 %

20. Correlations Data were tested for normality.
Skweness and kurtosis were within the normal bounds.
The study revealed the following correlational results:
No correlation between TSH and BMI.
No significant correlation between TSH and Hgb.
No significant correlation between FT4 and Hgb.
No correlation between TSH, FT4 and diet habits or iodinated salt

21. Slightly negative correlation between FT4 and BMI
Pearson Correlation
- .190*
Sig. (2-tailed)
.019 N
153
* Correlation is significant at the 0.05 level (2-tailed).

22. Previous history of thyroid disease and rheumatoid disease
FT4 Range-Trimester
Pearson Correlation *
Sig. (2-tailed)
.000 N
153
* Correlation is significant at the 0.01 level (2-tailed).

23. Previous history of Rheumatoid disease
Rheumatoid diseases
FT4 Range-Trimester
Pearson Correlation
-.211*
Sig. (2-tailed)
.009 N
153
* Correlation is significant at the 0.01 level (2-tailed).

24. Family history of thyroid disease
FT4 Range-Trimester
Pearson Correlation
- .208*
Sig. (2-tailed)
.010 N
153
* Correlation is significant at the 0.01 level (2-tailed).

25. Previous history of repeated abortions
FT4 Range-Trimester
Pearson Correlation
- .212*
Sig. (2-tailed)
.008 N
153
* Correlation is significant at the 0.01 level (2-tailed).

26. Gestational hypertension
Previous history of Gestational hypertension
Gestational hypertension
FT4 Range-Trimester
Pearson Correlation
- .164*
Sig. (2-tailed)
.043 N
153
*Correlation is significant at the 0.05 level (2-tailed).

27. Post partum hemorrhage
Previous history of Post partum hemorrhage
Post partum hemorrhage
FT4 Range-Trimester
Pearson Correlation
- .279*
Sig. (2-tailed)
.000 N
153
* Correlation is significant at the 0.01 level (2-tailed).

28. Post partum thyroiditis
Previous history of Post partum thyroiditis
Post partum thyroiditis
FT4 Range-Trimester
Pearson Correlation
-.230*
Sig. (2-tailed)
.004 N
153
*Correlation is significant at the 0.01 level (2-tailed).

29. Conclusion
TSH, FT4 adult reference ranges might not apply on pregnant women.
Risky pregnancies and negative obstetrical outcomes may developed 2ndry to undiagnosed or misdiagnosed cases of hypothyroidism.
Antenatal screening for hypothyroidism and trimester-reference range need to be adopted for safe maternal-child health.

30. Conclusion
Women reported consuming iodine-added salt in this study, and yet it did not improve levels of TSH, FT3, and FT4.
We assume that this result is related mainly to inadequate iodine intake.
Thus, we recommend that iodine added to the table salt be improved to suite internationally acceptable levels.
Additionally, other sources of iodine should be explained through educational sources (leaflets, brochures) to pregnant women.

31. Clinically, WHAT SHALL DO?

32. International Recommendations
All pregnant women should be verbally screened at the initial prenatal visit for thyroid dysfunction problem & risk factors.
SCH arising before conception or during gestation should be treated with levothyroxine.
To date, NO study of intervention is available to demonstrate benefit from treating hypothyroxinaemic, but …………

33. it is associated with neuropsychological impairment in children
Levothyroxine therapy may be considered in isolated hypothyroxinaemia detected in the 1st trim -
it is associated with neuropsychological impairment in children
Levothyroxine therapy is not recommended in isolated hypothyroxinaemia detected in the 2nd and 3rd trim.s.
Trimester-specific reference ranges for TSH and T4 (total or free) should be established in each antenatal hospital setting.
Local variations may occur.

34. International recommendations
If TSH trimester-specific reference ranges are not available, the following limits are recommended:
1st trimester:TSH: mU/L
2nd trimester: mU/L
3rd trimester: mU/L
T4 and FT4 assays are both suitable for thyroid function testing in pregnancy.
TSH should be measured at the beginning of pregnancy, if it is elevated.

35. International recommendations
FT 4 and TPOAb should be determined for SCH or overt hypothyroidism to be diagnosed. The daily iodine intake during pregnancy and lactation should be at least 250 μg and should not exceed500 μg. Iodine intake by supplementing euthyroid pregnant and lactating women with formulas containing 150 μg of iodine/day, ideally before conception. Effectiveness and side effects of iodine prophylaxis together with or without levothyroxine Rx in sub clinical hypothyroid women should be assessed.

36. International recommendations
SCH arising before conception or during gestation should be treated with levothyroxine T4 The recommended Rx of maternal hypothyroidism is oral levothyroxine The use of levothyroxine-T3 combinations or desiccated thyroid is not recommended. The goal of levothyroxine Rx is to normalize maternal serum TSH values within the trimester-specific pregnancy reference range.

37. In newly diagnosed women with SCH in pregnancy, a starting dose of 1
In newly diagnosed women with SCH in pregnancy, a starting dose of 1.20 μg/kg.day is advised.
Women with SCH and those with overt hypothyroidism desiring pregnancy should take levothyroxine in a single dose to ensure a TSH level of < 2.5 mU/l. (2S)

38. Thank you for the attendance