Intended for healthcare professionals

Clinical Review State of the Art Review

Diagnosis and management of subclinical hypothyroidism in pregnancy

BMJ 2014; 349 doi: (Published 06 October 2014) Cite this as: BMJ 2014;349:g4929
  1. Roberto Negro, division head1,
  2. Alex Stagnaro-Green, regional dean 2
  1. 1Division of Endocrinology, Department of Internal Medicine, “V Fazzi” Hospital, Lecce, 73100, Italy
  2. 2University of Illinois-College of Medicine at Rockford, Rockford, IL, USA
  1. Correspondence to: N Roberto dr.negro{at}


In prospective studies, the prevalence of undiagnosed subclinical hypothyroidism in pregnant women ranges from 3% to 15%. Subclinical hypothyroidism is associated with multiple adverse outcomes in the mother and fetus, including spontaneous abortion, pre-eclampsia, gestational hypertension, gestational diabetes, preterm delivery, and decreased IQ in the offspring. Only two prospective studies have evaluated the impact of levothyroxine therapy in pregnant women with subclinical hypothyroidism, and the results were mixed. Subclinical hypothyroidism is defined as raised thyrotropin combined with a normal serum free thyroxine level. The normal range of thyrotropin varies according to geographic region and ethnic background. In the absence of local normative data, the recommended upper limit of thyrotropin in the first trimester of pregnancy is 2.5 mIU/L, and 3.0 mIU/L in the second and third trimester. The thyroid gland needs to produce 50% more thyroid hormone during pregnancy to maintain a euthyroid state. Consequently, most women on levothyroxine therapy before pregnancy require an increase in dose when pregnant to maintain euthyroidism. Ongoing prospective trials that are evaluating the impact of levothyroxine therapy on adverse outcomes in the mother and fetus in women with subclinical hypothyroidism will provide crucial data on the role of thyroid hormone replacement in pregnancy.


  • Contributors: RN and AS-G contributed equally to the writing of this article and are both guarantors.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: none.

  • Provenance and peer review: Commissioned; externally peer reviewed.

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