CME INDIA Case Presentation by Dr. Sunetha, Gynaecologist, Coimbatore.
CME INDIA Case Study

Question asked in CME INDIA Group
- 29 year-old-female in early pregnancy, weight-72 kg
- On Thyroxine 75,
- TSH 9.8,
- Anti-TPO >1000
- Are steroids needed?
CME INDIA Discussion
Dr. Murugananth, Coimbatore:
- Is it new onset hypothyroidism or pre-existent Madam?
Dr. Sunetha, S DGO, Coimbatore:
- Pre-Existing.
Dr Vivek Ranjan Gupta, Surat:
- Anti-TPO antibody is the autoimmunity marker. It determines whether there is autoimmune thyroiditis in the thyroid gland; this is important in pregnancy. In pregnancy if there is subclinical hypothyroidism, and TSH is in the range of 5–9miU/L, but the TPO antibody is positive, treatment is required. In pregnancy if TPO is positive and there is a slight elevation of TSH (more than 4mIU/L), treatment is required.
- Increase dose of thyroxine to 125 to maintain TSH below 2.5 (Remember for pregnancy normal is not less than 5 but it should be less than 2.5 in first trimester).
- Anti tpo antibody comes positive in both hypo and hyperthyroidism.
- So, if the presentation is thyroiditis or sub-acute thyroiditis then we can think of steroids and other options. But in this case, it is hypothyroidism.

Dr. N. K. Singh:
- ATS 2019 is most commonly followed.
- Treatment of subclinical hypothyroidism is recommended for TPO (thyroid peroxidase)- positive women with thyrotropin levels greater than the pregnancy-specific range and TPO-negative women with thyrotropin levels greater than 10 mIU/L and can be considered for women with lower thyrotropin.
Dr. Om Lakhani, DNB Endo, Ahmedabad:
- No indication for steroids.
- Increase dose of LT4 to 125 mcg… make sure the timing and compliance of medications is correct.
- Repeat thyroid function after 1 month.
- Anti-TPO is a widely-misused test.
- It has very limited indications and it’s use in clinical decision making is declining.
- For example, in this patient there is no indication for Anti TPO since the patient is already having established hypothyroidism. Anti-TPO is not going to change the management in this case. So, the test was not indicated.
- See these experts from https://endocrinology.co.in/FOR+DOCTORS/THYROID/Thyroid+disorders+in+Pregnancy/2.+Hypothyroidism+in+pregnancy

Dr. S. K. Gupta, MBBS MD (Med) CFM (France), Senior Consultant Physician, Delhi:
- In pregnancy:
- Treat in first TM (Trimester)treat if TSH is more than 4.
- I remember TSH values as 1.5 for First Tm.
- 2.5 for Second TM.
- 3.5 for Third TM.
- (Though actual values are slightly different).
- If TSH value is between 2.5 and 4 than only Anti TPO should be advised if positive these patients may need treatment with low dose thyroxin.
- Steroids not to be used in this case.
- Anti TPO is non-specific marker which can present in number of conditions.
Dr. Ronak Shah, Senior Physician, Anand:
- Also, avoid iron & calcium supplements at the same time with thyroxine.
- TPO is useful in decision making for treatment of subclinical hypothyroidism.
- How TPO is useful in decision making.
- If TPO is significantly high and TSH between 4.5 to 10, we may start treatment.
- If TPO is negative, we may wait.
- This is for the most common cause of primary hypothyroidism i.e. Hashimoto’s thyroiditis.
Dr. Om Lakhani, DNB Endo, Ahmedabad:
- While this is true and accepted notion for a while this concept is now being challenged in the endocrine community.
- For people age less than 70 with TSH between 5 to 7 – Anti TPO can be used for decision making on whether to treat or not
- For people age less than 70 with TSH between 7 to 10 – Anti TPO is not required and treatment must be given since data has suggested that treatment in this group is associated with reduced CV disease.
- But always remember to repeat the thyroid function in non-pregnant individual with subclinical hypothyroidism before taking a decision, it is not uncommon to see lab errors with regards to TSH very commonly.
- A patient is established to have SCH only if she/he has elevated TSH on repeated measurements.
CME INDIA Learning Points
- Antithyroid antibodies, which include thyroid-stimulating hormone receptor antibodies (TRAbs), thyroid peroxidase antibodies (TPOAbs), and thyroid globulin antibodies (TgAbs), are widely known for their tight association with thyroid autoimmune diseases.
- The variation in all three kinds of antibodies also showed different trends during and after pregnancy
- Autoimmunity increases with age and is often commonly evaluated in women of the reproductive age group. Prevalence of thyroid antibodies is common even in euthyroid pregnant women
- Assays for anti–thyroid peroxidase (anti-TPO) and antithyroglobulin (anti-Tg) antibodies may be helpful in determining the etiology of hypothyroidism or in predicting future hypothyroidism.
- However, once a patient has been found to be antibody positive, repeated antibody testing adds little to the clinical picture and thus is not recommended.
- Assays for anti–thyroid peroxidase (anti-TPO) and antithyroglobulin (anti-Tg) antibodies may be helpful in determining the etiology of hypothyroidism or in predicting future hypothyroidism.
- Anti-TPO antibodies have been associated with increased risk of infertility and miscarriage; whether levothyroxine (LT4) treatment can lower this risk is controversial.
CME INDIA Tail Piece
- Thyroid peroxidase (TPO), a membrane-bound enzyme, catalyzes the oxidation of iodide and the iodination of the tyrosyl residues of thyroglobulin.
- TPOAbs can bind to TPO and then damage the thyrocytes and cause hypothyroidism.
- Among the three kinds of antibodies, the TgAb is the earliest-discovered and it is mainly composed of IgG. It mainly attacks different antigenic determinants of thyroglobulin, which is located in the colloid of thyroid follicles.
- TPOAb and TgAb are frequently present in the same individual.

The variation in TPOAbs before, during, and after pregnancy. The curve is a set of data from one patient. The patient suffered from Hashimoto’s thyroiditis. (Courtsey: C.Lie et al.The Clinical Value and Variation of Antithyroid Antibodies during Pregnancy Volume 2020 |Article ID 8871951 | https://doi.org/10.1155/2020/8871951)

- Both the American Thyroid Association (ATA) and American Association of Clinical Endocrinology (AACE) recommend starting levothyroxine therapy under the following scenarios:
- TSH is >10 mIU/l or;
- Presence of hypothyroid symptoms or;
- Presence of cardiovascular risk factors or;
- Positive TPO antibody.
References:
- Levothyroxine in Women with Thyroid Peroxidase Antibodies before Conception.
- N Engl J Med. 2019; 380(14):1316-1325 (ISSN: 1533-4406)
- https://pro.aace.com/sites/default/files/2021-01/AACE%20TRC%20Interpretation%20of%20TFTs%20Part%203-FINAL.pdf
- https://endocrinology.co.in/FOR+DOCTORS/THYROID/Thyroid+disorders+in+Pregnancy/2.+Hypothyroidism+in+pregnancy
- C.Lie et al.The Clinical Value and Variation of Antithyroid Antibodies during Pregnancy Volume 2020 |Article ID 8871951 | https://doi.org/10.1155/2020/8871951
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In a patient with already diagnosed & established hypothyroidism on Thyroxine ,why should u do anti TP O antibody assessment . how does it help in management of the case ?
Yes, in this case, no need of doing Anti TPO
increase the dose to 100-125 mcg and keep TSH around 2.5 for best pregnancy outcome.Monitor TSH and T4 every 4 weeks until delivery. TPO abs indicate auto immune etiology and generally useful in subclinical hypo to determine whether they need thyroxine or not
I have tpo antibody 148. tsh 3.84.can i get a successful pregnancy?in this case have any proper treatment and medicine for achieving mother hood?