Background: Thyroid disease in pregnancy is a common clinical problem. Since the guidelines for the management of these disorders by the American Thyroid Association (ATA) were first published in 2...

https://www.thyca.org/download/document/486/PregnancyandPostpartum.pdf

2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum

Sponsors asked the IOM's Food and Nutrition Board and the Division of Behavioral and Social Sciences and Education Board on Children, Youth, and Families to review and update the IOM (1990) recommendations for weight gain during pregnancy and recommend ways to encourage their adoption through consumer education, strategies to assist practitioners, and public health strategies.The committee was asked to address the following tasks: 1. Review evidence on the relationship between weight gain patterns before, during, and after pregnancy and maternal and child health outcomes, with particular attention to the prevalence of maternal obesity racial/ethnic and age differences, components of GWG, and implications of weight during pregnancy on postpartum weight retention, maternal and child obesity, and later child health. 2. Within a life-stage framework consider factors in relation to GWG that are associated with maternal health outcomes such as lactation performance, postpartum weight retention, cardiovascular disease, metabolic processes including glucose and insulin-related issues, and risk of other chronic diseases; for infants and children, in addition to low birth weight, consider early developmental impacts and obesity-related consequences (e.g., mental health, diabetes). 3. Recommend revisions to the existing guidelines, where necessary, including the need for specific pregnancy weight guidelines for underweight, normal weight, and overweight and obese women and adolescents and women carrying twins or higher-order multiples. 4. Consider a range of approaches to promote appropriate weight gain, including: individual (behavior), psychosocial, community, health care, and health systems; timing and components of interventions; and ways to enhance awareness and adoption of the guidelines, including interdisciplinary approaches, consumer education to men and women, strategies to assist practitioners to use the guidelines, and public health strategies. 5. Identify gaps in knowledge and recommend research priorities.

/pdf/weight-gain-during-pregnancy-reexamining-the-guidelines-54naat6auf.pdf

Weight Gain During Pregnancy: Reexamining the Guidelines

Pregnancy has a profound impact on the thyroid gland and thyroid function. The gland increases 10% in size during pregnancy in iodine-replete countries and by 20%– 40% in areas of iodine deficiency. Production of thyroxine (T4) and triiodothyronine (T3) increases by 50%, along with a 50% increase in the daily iodine requirement. These physiological changes may result in hypothyroidism in the later stages of pregnancy in iodine-deficient women who were euthyroid in the first trimester. The range of thyrotropin (TSH), under the impact of placental human chorionic gonadotropin (hCG), is decreased throughout pregnancy with the lower normal TSH level in the first trimester being poorly defined and an upper limit of 2.5 mIU/L. Ten percent to 20% of all pregnant women in the first trimester of pregnancy are thyroid peroxidase (TPO) or thyroglobulin (Tg) antibody positive and euthyroid. Sixteen percent of the women who are euthyroid and positive for TPO or Tg antibody in the first trimester will develop a TSH that exceeds 4.0 mIU/L by the third trimester, and 33%–50% of women who are positive for TPO or Tg antibody in the first trimester will develop postpartum thyroiditis. In essence, pregnancy is a stress test for the thyroid, resulting in hypothyroidism in women with limited thyroidal reserve or iodine deficiency, and postpartum thyroiditis in women with underlying Hashimoto’s disease who were euthyroid prior to conception. Knowledge regarding the interaction between the thyroid and pregnancy/the postpartum period is advancing at a rapid pace. Only recently has a TSH of 2.5 mIU/L been accepted as the upper limit of normal for TSH in the first trimester. This has important implications in regards to interpretation of the literature as well as a critical impact for the clinical diagnosis of hypothyroidism. Although it is well accepted that overt hypothyroidism and overt hyperthyroidism have a deleterious impact on pregnancy, studies are now focusing on the potential impact of subclinical hypothyroidism and subclinical hyperthyroidism on maternal and

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Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and Postpartum The American Thyroid Association Taskforce on Thyroid Disease During Pregnancy and Postpartum

Number of drugs per 100 population 4 Total number of drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . 400.3 604.3 321.1 502.1 475.6 701.9 Antidepressants (depression and related disorders). . . . . . . 13.8 30.2 9.1 20.0 18.2 40.0 NSAID 6 (pain relief) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.9 30.1 16.0 25.4 23.7 34.7 Antiasthmatics/bronchodilators (asthma, breathing) . . . . . . . 13.0 24.7 11.7 21.4 14.3 27.9 Hyperlipidemia (high cholesterol) . . . . . . . . . . . . . . . . . . . . 5.4 23.7 5.4 24.0 5.4 23.4 Hypertension control drugs, not otherwise specified (high blood pressure) . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.0 23.6 4.1 20.5 7.8 26.6 Nonnarcotic analgesics (pain relief) . . . . . . . . . . . . . . . . . . 14.4 23.6 13.0 21.9 15.7 25.3 Antihistamines (allergies) . . . . . . . . . . . . . . . . . . . . . . . . . 13.7 22.7 10.8 17.3 16.4 27.9 Acid/peptic disorders (gastrointestinal reflux, ulcers). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.0 21.4 9.8 18.3 14.1 24.3 Blood glucose/sugar regulators (diabetes) . . . . . . . . . . . . . 9.5 19.8 8.6 19.1 10.4 20.6 Vitamins/minerals (dietary supplements) . . . . . . . . . . . . . . . 9.2 16.8 3.4 10.3 14.8 23.1 ACE inhibitors (high blood pressure, heart disease). . . . . . . 9.6 16.8 9.0 16.5 10.2 17.0 Narcotic analgesics (pain relief) . . . . . . . . . . . . . . . . . . . . . 11.2 16.7 10.3 13.4 12.2 19.9 Diuretics (high blood pressure, heart disease). . . . . . . . . . . 10.2 16.6 7.8 13.4 12.6 19.6 Penicillins (bacterial infections) . . . . . . . . . . . . . . . . . . . . . 16.6 13.1 15.5 12.6 17.7 13.6 Estrogens/progestins (menopause, hot flashes) . . . . . . . . . . . . . . . . . . . . . 19.8 14.9

/pdf/health-united-states-2005-with-chartbook-on-trends-in-the-33t2w1py7x.pdf

Health, United States, 2005; with chartbook on trends in the health of Americans

The prevalence of smoking during pregnancy varies markedly across countries. In many industrialized countries, prevalence rates appear to have peaked and begun to decline, whereas in other countries smoking is becoming increasingly common among young women. Randomized controlled trials have shown that smoking interventions during pregnancy have had limited success. Smoking during pregnancy is in many countries recognized as the most important preventable risk factor for an unsuccessful pregnancy outcome. Smoking is causally associated with fetal growth restriction, and increasing evidence also suggests that smoking may cause stillbirth, preterm birth, placental abruption, and possibly also sudden infant death syndrome. Smoking during pregnancy also is generally associated with increased risks of spontaneous abortions, ectopic pregnancies, and placenta previa and may increase risks of behavioral disorders in childhood. Smoking during pregnancy will continue to be an important risk factor for maternal and fetal outcomes during pregnancy.

/pdf/the-epidemiology-of-smoking-during-pregnancy-smoking-krht7ugr9z.pdf

The epidemiology of smoking during pregnancy: smoking prevalence, maternal characteristics, and pregnancy outcomes.

https://www.perinatology.theclinics.com/article/S0095-5108(08)00022-5/pdf

Cesarean Birth in the United States: Epidemiology, Trends, and Outcomes

The crude birth rate in 2004 was 14.0 births per 1000 population, the second lowest ever reported for the United States. The number of births and the fertility rate (66.3) increased slightly (by <1%) from 2003 to 2004. Fertility rates were highest for Hispanic women (97.7), followed by Asian or Pacific Islander (67.2), non-Hispanic black (66.7), Native American (58.9), and non-Hispanic white (58.5) women. The birth rate for teen mothers continued to fall, dropping 1% from 2003 to 2004 to 41.2 births per 1000 women aged 15 to 19 years, which is another record low. The teen birth rate has fallen 33% since 1991; declines were more rapid for younger teens aged 15 to 17 (43%) than for older teens aged 18 to 19 (26%). The proportion of all births to unmarried women is now slightly higher than one third. Smoking during pregnancy declined slightly from 2003 to 2004. In 2004, 29.1% of births were delivered by cesarean delivery, up 6% since 2003 and 41% since 1996 (20.7%). The primary cesarean delivery rate has risen 41% since 1996, whereas the rate of vaginal birth after a previous cesarean delivery has fallen 67%. The use of timely prenatal care was 84.0% in both 2003 and 2004. The percentage of preterm births rose to 12.5% in 2004 from 10.6% in 1990 and 9.4% in 1981. The percentage of low birth weight births also increased to 8.1% in 2004, up from 6.7% in 1984. Twin birth rate and triplet/+ birth rates increased by 1% and <1%, respectively, from 2002 to 2003. Multiple births accounted for 3.3% of all births in 2003. The infant mortality rate was 7.0 per 1000 live births in 2002 compared with 6.8 in 2001. The ratio of the infant mortality rate among non-Hispanic black infants to that for non-Hispanic white infants was 2.4 in 2002, the same as in 2001. The United States continues to rank poorly in international comparisons of infant mortality. Expectation of life at birth reached a record high of 77.6 years for all gender and race groups combined. Death rates in the United States continue to decline, with death rates decreasing for 8 of the 15 leading causes. Death rates for children < or =19 years of age declined for 7 of the 10 leading causes in 2003. The death rates did not increase for any cause, and rates for heart disease, influenza, and pneumonia and septicemia did not change significantly for children as a group. A large proportion of childhood deaths, however, continue to occur as a result of preventable injuries.

Annual Summary of Vital Statistics: 2004

Cesarean delivery: background, trends, and epidemiology.

Objectives This report presents 2002 period infant mortality statistics from the linked birth/infant death data file by a variety of maternal and infant characteristics. The linked file differs from the mortality file, which is based entirely on death certificate data. Methods Descriptive tabulations of data are presented and interpreted. Results The U.S. infant mortality rate increased from 6.8 infant deaths per 1000 live births in 2001 to 7.0 in 2002. The rate for infants of non-Hispanic white mothers was 5.7 in 2001 compared with 5.8 in 2002. The rate for infants of non-Hispanic black mothers was 13.5 in 2001 compared with 13.9 in 2002. Neither of the changes for non-Hispanic white nor non-Hispanic black was significant. Between 2001 and 2002, overall cause-specific rates increased 5 percent for low birthweight and 14 percent for maternal complications. The rate rose significantly for infants of mothers who smoked, 10.5 to 11.1. It also increased significantly from 10.7 to 11.5 for infants of mothers aged 15-17 years. The rate dropped significantly for triplet births, 71.4 to 60.1. Infant mortality rates ranged from 3.0 per 1000 live births for Chinese mothers to 13.9 for non-Hispanic black mothers. Among Hispanics, rates ranged from 3.7 for Cuban mothers to 8.2 for Puerto Rican mothers. Infant mortality rates were higher for those infants whose mothers were born in the 50 States and the District of Columbia, were unmarried, or smoked during pregnancy. Infant mortality was also higher for male infants, multiple births, and infants born preterm or at low birthweight. The three leading causes of infant death-Congenital malformations, low birthweight, and Sudden infant death syndrome (SIDS)-taken together accounted for 45 percent of all infant deaths. For infants of non-Hispanic black mothers, the cause-specific infant mortality rate for low birthweight was nearly four times that for infants of non-Hispanic white mothers. For infants of non-Hispanic black and American Indian mothers, the SIDS rates were at least double the rate for non-Hispanic white mothers. A more intensive analysis of the rise in the infant mortality rate utilizing information on maternal and infant health risk factors available in the linked birth/infant death and fetal death data files is forthcoming.

https://www.cdc.gov/nchs/data/nvsr/nvsr53/nvsr53_10.pdf

Infant mortality statistics from the 2002 period: linked birth/infant death data set.

Background: The percentage of United States' births delivered by cesarean section has increased rapidly in recent years, even for women considered to be at low risk for a cesarean section. The purpose of this paper is to examine infant and neonatal mortality risks associated with primary cesarean section compared with vaginal delivery for singleton full-term (37-41 weeks' gestation) women with no indicated medical risks or complications. Methods: National linked birth and infant death data for the 1998-2001 birth cohorts (5,762,037 live births and 11,897 infant deaths) were analyzed to assess the risk of infant and neonatal mortality for women with no indicated risk by method of delivery and cause of death. Multivariable logistic regression was used to model neonatal survival probabilities as a function of delivery method, and sociodemographic and medical risk factors. Results: Neonatal mortality rates were higher among infants delivered by cesarean section (1.77 per 1,000 live births) than for those delivered vaginally (0.62). The magnitude of this difference was reduced only moderately on statistical adjustment for demographic and medical factors, and when deaths due to congenital malformations and events with Apgar scores less than 4 were excluded. The cesarean/vaginal mortality differential was widespread, and not confined to a few causes of death. Conclusions: Understanding the causes of these differentials is important, given the rapid growth in the number of primary cesareans without a reported medical indication. (BIRTH 33:3 September 2006)

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Fay Menacker

Papers

Cesarean Birth in the United States: Epidemiology, Trends, and Outcomes

Annual Summary of Vital Statistics: 2004

Cesarean delivery: background, trends, and epidemiology.

Infant mortality statistics from the 2002 period: linked birth/infant death data set.

Infant and neonatal mortality for primary cesarean and vaginal births to women with "no indicated risk," United States, 1998-2001 birth cohorts.