European Journal of Obstetrics & Gynecology and Reproductive Biology 177 (2014) 89–93

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European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Risk factors for neonatal thyroid dysfunction in pregnancies

complicated by Graves’ disease
Mizuki Uenaka a, Kenji Tanimura a, Shinya Tairaku a, Ichiro Morioka b,
Yasuhiko Ebina a, Hideto Yamada a,*
a
Department of Obstetrics and Gynecology, Kobe University Graduate School of Medicine, Kobe, Japan
b
Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To determine the factors related to adverse pregnancy outcomes and neonatal thyroid
Received 25 November 2013 dysfunction in pregnancies complicated by Graves’ disease.
Received in revised form 24 February 2014 Study design: Thirty-five pregnancies complicated by Graves’ disease were divided into two groups:
Accepted 5 March 2014
adverse pregnancy outcome (n = 15) and no adverse pregnancy outcome (n = 20). Adverse pregnancy
outcomes included spontaneous abortion, stillbirth, premature delivery, fetal growth restriction, and
Keywords: pregnancy-induced hypertension. The 31 pregnancies resulting in live births were also divided into two
Antithyroid medication
groups: neonatal thyroid dysfunction (n = 9) and normal neonatal thyroid function (n = 22). Serum levels
Graves’ disease
Neonatal thyroid dysfunction
of thyroid-stimulating hormone (TSH), free thyroxine (FT4), TSH-receptor antibody (TRAb), the duration
Outcome of hyperthyroidism in pregnancy, doses of antithyroid medication, and the duration of maternal
antithyroid medication throughout pregnancy were compared.
Results: There were no significant differences in these factors between pregnancies with an adverse
pregnancy outcome and those with no adverse pregnancy outcome. However, serum levels of FT4, TRAb,
the duration of hyperthyroidism in pregnancy, the maximum daily dose of antithyroid medication, and
the total dose of antithyroid medication were significantly different between pregnancies with neonatal
thyroid dysfunction and those with normal neonatal thyroid function. Multivariate logistic regression
analysis showed that the FT4 level in mothers was a significant factor related to the development of
neonatal thyroid dysfunction (odds ratio 28.84, 95% confidence interval 1.65–503.62, p < 0.05).
Conclusion: Graves’ disease activity in women of childbearing age should be well controlled prior to
conception.
ß 2014 Elsevier Ireland Ltd. All rights reserved.

1. Introduction with euthyroidism throughout pregnancy [4]. The duration of

The prevalence of hyperthyroidism during pregnancy is
estimated to be 0.1–0.4%. Graves’ disease accounts for 85% of
pregnancies complicated by hyperthyroidism [1]. Pregnant wom-
en with hyperthyroidism have an increased risk of adverse
pregnancy outcomes, including spontaneous abortion, stillbirth,
premature delivery (PD), fetal growth restriction (FGR), and
pregnancy-induced hypertension (PIH) [2,3]. Millar et al. found
that women with hyperthyroidism during the first and second
trimesters, in spite of being euthyroid in the third trimester, had an
increased frequency of PD, FGR, and PIH compared with women
* Corresponding author. Tel.: +81 78 382 6000; fax: +81 78 382 5756.
E-mail address: yhideto@med.kobe-u.ac.jp (H. Yamada).
hyperthyroidism in pregnancy is also associated with FGR [5].
Additionally, pregnant women with Graves’ disease have a risk of
having a baby with neonatal thyroid dysfunction, which appears in
2–5% of their neonates [1]. Previous reports have shown that
maternal serum thyroid-stimulating hormone receptor antibody
(TRAb) levels are related to neonatal thyroid dysfunction [6].
Additionally, TRAb in the latter half of pregnancy is useful for the
prediction of neonatal hyperthyroidism [7]. Another report
showed a strong correlation between fetal free thyroxine (FT4)
and maternal FT4 levels at the time of delivery [8]. The incidence of
neonatal thyroid dysfunction is correlated with the duration of
hyperthyroidism in pregnancy and the total dose of maternal
antithyroid medication during pregnancy [5]. A high dose of
maternal antithyroid medication increases the risk of neonatal
transient hypothyroidism [9], whereas antithyroid medication to

http://dx.doi.org/10.1016/j.ejogrb.2014.03.007
0301-2115/ß 2014 Elsevier Ireland Ltd. All rights reserved.
90 M. Uenaka et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 177 (2014) 89–93
mothers is not associated with serum thyroid-stimulating
hormone (TSH) levels in their neonates [10]. Therefore, there is
still controversy over maternal factors affecting pregnancy
outcome.
The present study aimed to determine factors related to an
adverse pregnancy outcome and neonatal thyroid dysfunction in
pregnancies complicated by Graves’ disease, using multivariate
logistic regression analyses.
2. Patients and methods
Between January 2007 and December 2012, we encountered 35
pregnancies complicated by Graves’ disease, including 1 twin
pregnancy, at Kobe University Hospital. We managed Graves’
disease-complicated pregnancies to maintain maternal serum
levels of FT4 at the upper limit of the reference range for non-
pregnant women. Thirty-one pregnancies resulted in 32 live births,
while 4 pregnancies ended in spontaneous abortions. All 35
pregnancies were divided into 2 groups: adverse pregnancy
outcome (n = 15) and no adverse pregnancy outcome (n = 20).
Adverse pregnancy outcomes were defined as spontaneous
abortion, stillbirth, PD, FGR, and PIH. The 31 pregnancies involving
live births were also divided into 2 groups: neonatal thyroid
dysfunction (n = 9) and normal neonatal thyroid function (n = 22).
We compared serum levels of minimum TSH and maximum FT4
during pregnancy, second-generation TRAb in the third trimester,
the duration of hyperthyroidism in pregnancy, doses of antithyroid
medication (maximum daily dose, total dose, and an increase in
medication during pregnancy), and the duration of maternal
antithyroid medication during pregnancy between the two groups.
In the four cases with spontaneous abortion, maternal TRAb values
during early pregnancy were used for analysis. Serum levels of TSH
(normal: 0.449–3.809 mU/mL) and FT4 (normal: 0.82–1.22 ng/dL)
in mothers and neonates were measured using the Abbott
ARCHITECT i2000SR Analyzer (Abbott Japan, Tokyo, Japan). The
DYNO test TRAb Human kit (Yamasa, Tokyo, Japan) was used for
TRAb measurement (normal: <1.0 IU/L). In statistical calculations,
values of less than cut-off levels of maternal TSH and TRAb were
considered the same as the cut-off value. The biological potency of
1 mg methimazole was converted to that of 20 mg propylthiouracil
as described previously [11,12].
Differences between the two groups were analyzed by the
Mann–Whitney U test and Fisher’s exact test. Values were
considered statistically significant when p < 0.05. To assess
significant factors, uni- and multi-variate logistic regression
analyses were performed using SAS version 9.1 software (SAS
Institute Inc., Cary, NC, USA).
3. Results
Mothers had a median age of 32.5 years (range, 23–44 years),
and the gestational week (GW) at delivery was 37.9 GW (30–
41 GW). Four pregnancies ended in spontaneous abortion during
5–18 GW. The weight of the neonates was 2827 g (1290–3694 g).
Of the 35 pregnancies complicated by Graves’ disease, adverse
pregnancy outcomes involved 4 spontaneous abortions (11.4%), 7
were PD (20.0%), 4 were FGR (11.4%), and 5 were PIH (14.3%). There
were no significant differences in serum levels of minimum TSH
during pregnancy (median [range], 0.023 [0.003–1.92] vs. 0.004
[0.003–1.79] mU/mL; p = 0.24), maximum FT4 during pregnancy
(1.44 [1.04–2.8] vs. 1.54[1.04–4.58] ng/dL; p = 0.31), TRAb in the
third trimester (1.5 [0.8–26] vs. 2.25 [1.0–512] IU/L; p = 0.37), the
duration of hyperthyroidism in pregnancy(5 [0–37] vs. 13 [0–38]
weeks; p = 0.55), the maximum daily dose of antithyroid medica-
tion (50 [0–300] vs. 175 [0–400] mg; p = 0.11), the total dose of
antithyroid medication (8.9 [0–45.1] vs. 18.0 [0–77.0] g; p = 0.21),
Table 1
Results of univariate logistic regression analyses of the factors related to adverse
pregnancy outcomes.
Factors Univariate analysis
p-Value Odds ratio (95% CI)
Serum levels in mothers
Minimum TSH during pregnancy 0.24 2.10 (0.61–7.26)
Maximum FT4 during pregnancy 0.31 0.63 (0.26–1.53)
TRAb in the third trimester 0.37 0.91 (0.75–1.11)
Duration of hyperthyroidism 0.55 0.99 (0.94–1.04)
Antithyroid medication in mothers during pregnancy
Increase in medication 0.27 0.44 (0.10–1.88)
Maximum daily dose 0.11 0.99 (0.99–1.00)
Total dose 0.21 0.98 (0.94–1.01)
Duration of medication 0.32 0.98 (0.94–1.02)
CI, confidence interval; TSH, thyroid-stimulating hormone; FT4, free thyroxine;
TRAb, thyroid-stimulating hormone receptor antibody.
increase in medication (p = 0.27), and the duration of antithyroid
medication (24 [0–37] vs. 31.5 [0–39] weeks; p = 0.32) between
pregnancies with an adverse outcome and those with no adverse
outcome (Table 1).
Of the 31 mothers who had live births, 9 (29.0%) had neonatal
thyroid dysfunction involving 5 neonates with hyperthyroidism, 3
with transient hypothyroidism, and 1 with central hypothyroidism
(Table 2). In neonatal transient hypothyroidism, serum FT4 levels
were transiently low in combination with high TSH levels. In
central (hypothalamic or pituitary) hypothyroidism, FT4 and TSH
levels were low. Graves’ disease was diagnosed during the second
or third trimester for the first time in Case 5 and Case 9. Case 9 was
a woman who was transferred to the hospital because of
premature rupture of the membranes at 30 GW. She complained
of palpitations and perspiration. She was investigated for
hyperthyroidism, and subsequently a cesarean section was
performed before commencement of antithyroid medication.
In 9 mothers with neonatal thyroid dysfunction and 22 with
normal neonatal thyroid function, levels of the maximum FT4
during pregnancy (median [range], 2.8 [1.23–4.58] vs. 1.3 [1.04–
3.23] ng/dL; p < 0.005) (Fig. 1A), TRAb in the third trimester (10.5
[4.0–512] vs. 1.35 [0.8–26] IU/L; p < 0.001) (Fig. 1B), the duration
of hyperthyroidism in pregnancy (30 [1–39] vs. 1 [0–37] weeks;
p < 0.005) (Fig. 1C), the maximum daily dose of antithyroid
medication (200 [0–300] vs. 100 [0–400] mg; p < 0.05) (Fig. 1D),
and the total dose of antithyroid medication (42.3 [0–50.7] vs. 13.0
[0–77.0] g; p < 0.05) (Fig. 1E) were significantly different. There
were no significant differences in serum levels of minimum TSH
during pregnancy (0.004 [0.003–0.007] vs. 0.005 [0.003–1.79] mU/
mL; p = 0.12), increase in medication (p = 0.11), and the duration of
antithyroid medication (32 [0–39] vs. 28 [0–39] weeks; p = 0.37).
Table 3 shows the results of uni- and multi-variate logistic
regression analyses of factors related to neonatal thyroid
dysfunction. Maximum FT4 levels during pregnancy, the duration
of hyperthyroidism in pregnancy, and the maximum daily dose
and total dose of antithyroid medication were found to be
significant factors related to neonatal thyroid dysfunction by
univariate analysis. Multivariate logistic regression analysis
showed that maximum FT4 during pregnancy was the only
significant factor related to neonatal thyroid dysfunction (odds
ratio 28.84, 95% confidence interval1.65–503.62, p < 0.05).
4. Comment
Pregnant women with hyperthyroidism have an increased risk
of spontaneous abortion, stillbirth, PD, FGR, PIH, and maternal
heart failure. Kriplani et al. reported the outcomes of 32
pregnancies complicated by hyperthyroidism, and found that
 M. Uenaka et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 177 (2014) 89–93 91

TSH, thyroid-stimulating hormone; FT4, free thyroxine; TRAb, thyroid-stimulating hormone receptor antibody; PIH, pregnancy-induced hypertension; PD, premature delivery; Hyper-, hyperthyroidism; Trans. hypo-, transient
25% of them had PD, 13% had FGR, and 22% had PIH [2]. Momotani

Neonatal thyroid
et al. showed that the incidence of spontaneous abortion is 25.7% in

Central hypo-
mothers with hyperthyroidism at the time of conception compared

Trans. hypo-
Trans. hypo-
Trans. hypo-
dysfunction
with 12.8% in euthyroid mothers [3]. In the present study, the

Hyper-
Hyper-
Hyper-
Hyper-
Hyper-
incidence of spontaneous abortion was 11.4%, PD was 20.0%, FGR
was 11.4%, and PIH was 14.3% in pregnancies complicated by
Graves’ disease. The incidence of PD, FGR, and PIH in women with
FT4 (ng/dL)

A 2.69/0.71
B 2.17/0.58
Graves’ disease in our study was higher than that in those with a

3.46/1.62

2.34/2.14
2.58/1.44
1.98/1.08
0.75/1.34
0.93/1.42
0.44/1.52
3.80/0.98
normal pregnancy, in which the incidence of spontaneous abortion
Serum levels in neonates

is 8–15%, PD is 5%, FGR is 7%, and PIH is 7–10% in Japan. The

(at birth/in the month

incidence of PD, FGR, and PIH in our study is not reflective of the
general population of pregnant women. No significant factor for

B <0.004/0.097
A 0.005/0.062
TSH (mU/mL)

these adverse pregnancy outcomes was determined in our

24.23/1.365
0.497/0.045
0.214/0.058
0.035/0.023
0.041/0.120
0.223/0.004
after birth)

336/1.822
15.6/2.19
analyses. The reason for this lack of finding of a significant factor
might be because the disease activity of women in our study was
relatively well controlled. Therefore, the incidence of an adverse
pregnancy outcome was not high in the present study compared
Birth-weight

with previous reports.

Maternal thyroid function at the time of delivery is thought to
A 1312
B 1440
2396
2688

2848
2968
2966
2822
2568

affect neonatal thyroid function [8]. In our study, however, thyroid

3430
(g)

function in women with Grave’s disease was relatively well

controlled at the time of delivery. Serum levels of TSH and FT4 in
Gestational

the third trimester were not significantly different between

weeks at
delivery

pregnancies with neonatal thyroid dysfunction and those with

normal thyroid function. Furthermore, 66.7% (6/9) of the mothers
35
37
39
39
39

41
37
40

30

with neonatal thyroid dysfunction and 22.7% (5/22) of the mothers

pregnancy

without neonatal thyroid dysfunction had uncontrolled hyperthy-

outcome
Adverse

PIH, PD

PIH, PD

roidism at the time of delivery. Therefore, we selected the

minimum TSH and the maximum FT4 levels during pregnancy,
–
–
–
–
–
–
–

but not TSH and FT4 levels at the time of delivery, as predictive
medication

factors for neonatal thyroid dysfunction.

Increase in

In our study, nine mothers had neonatal thyroid dysfunction

Antithyroid medication during pregnancy

involving five neonates with hyperthyroidism, three with transient

Yes
Yes

Yes
Yes
Yes

Yes
–

hypothyroidism, and one with central hypothyroidism. Maximum

FT4 levels during pregnancy, TRAb levels in the third trimester, the
Total dose (g)

maximum daily dose, and the total dose of antithyroid medication

in mothers with neonatal thyroid dysfunction were significantly
higher, and the duration of hyperthyroidism in pregnancy was
42.3

42.7
25.2
19.6
49.7

44.8
29.0

50.7

significantly longer than those in mothers with normal neonatal

thyroid dysfunction. These factors appeared to be closely
Maximum daily

associated with Graves’ disease activity during pregnancy.

Multivariate logistic regression analysis showed that maximum
dose (mg)

FT4 levels during pregnancy were a significant factor related to

250
300

200
200
300
200
200
300

neonatal thyroid dysfunction.

0

Generally, women with more severe hyperthyroidism require

Characteristics of nine pregnancies with neonatal thyroid dysfunction.

higher doses and larger amounts of antithyroid medication during

TRAb (IU/L)

pregnancy. If a mother is appropriately treated with antithyroid

medication to control disease activity, her fetus benefits from the
71.1
46.8
80.1

10.5
10.0
512
9.2

5.3
4.0

maternal therapy. However, the protective effect of antithyroid

medication on the fetus is lost after delivery, and neonatal clinical
hypothyroidism; Central hypo-, central hypothyroidism.
FT4 (ng/dL)

hyperthyroidism may develop within a few days of birth [13].

Serum levels in mothers

Antithyroid medication given to mothers can cross the placenta.

2.96
1.58
3.89
4.58
1.23
1.96
2.60

2.80
2.80

Antithyroid medication can expose the fetus to the risk of neonatal

transient hypothyroidism [10], and in 25% of neonates with
TSH (mU/mL)

transient hypothyroidism the condition is caused by maternal

antithyroid medication [14]. Although the present study showed
<0.004
<0.004
<0.004
<0.003
<0.004
<0.004
<0.004

that five neonates had hyperthyroidism and three had transient

0.007
0.004

hypothyroidism, no differences in maternal factors between these

two groups were found.
Age (y)

Neonatal central (hypothalamic or pituitary) hypothyroidism

can be caused by insufficient treatment for maternal hyperthyroid-
37
33
27
23
31
29
41
30
30

ism during pregnancy. High levels of serum thyroxine in the

maternal circulation cross the placenta and affect the pituitary, with
Case no.

suppression of TSH levels in fetuses [13]. Higuchi et al. suggested

Table 2

that passage of thyroid hormones occurs from a thyrotoxic mother to

1
2
3
4
5
6
7
8
9

the fetus and that a gestational period earlier than 32 GW may be the
[(Fig._1)TD$IG]
92 M. Uenaka et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 177 (2014) 89–93

A B
p<0.005 p<0.001
8 600

7 525

6 450

Maternal TRAblevels
Maternal FT4 levels

5 375

4 300
(ng/dL)

(IU/L)
3 225

2 150

1 75

0 0
Neonatal Normal neonatal Neonatal Normal neonatal
thyroid dysfunction thyroid function thyroid dysfunction thyroid function

C p<0.005 D p<0.05
40 400

Maximum daily dose of antithyroid medication

35 350
Duration of hyperthyroidism in pregnancy

30 300

25 250

20 200
(weeks)

(mg/d)

15 150

10 100

5 50

0 0
Neonatal Normal neonatal Neonatal Normal neonatal
thyroid dysfunction thyroid function thyroid dysfunction thyroid function

E P<0.05
100
90
Total dose of antithyroid medication(g)

80
70
60
50
40
30
20
10
0
Neonatal Normal neonatal
thyroid dysfunction thyroid function

Fig. 1. (A) Maternal levels of FT4 and neonatal thyroid function. (B) Maternal levels of TRAb and neonatal thyroid function. (C) Duration of hyperthyroidism in pregnancy. (D)
Maximum daily dose of antithyroid medication and neonatal thyroid function. (E) Total dose of antithyroid medication and neonatal thyroid function. Individual data of
pregnant women with neonatal thyroid dysfunction (n = 9) were compared with those of pregnant women with normal neonatal thyroid function (n = 22) (open circles).
Neonatal thyroid dysfunction included hyperthyroidism (n = 5) (gray circles), transient hypothyroidism (n = 3) (closed circles), and central hypothyroidism (n = 1) (banded
circle). Horizontal bars indicate median values in each group. In terms of the doses of antithyroid medication, the biological potency of 1 mg methimazole was converted into
that of 20 mg propylthiouracil. Differences were analyzed by the Mann–Whitney U test.

critical time for development of central hypothyroidism [15]. In the Multivariate analysis showed that a high level of serum FT4 in
present study, Case 9 (Table 2), who underwent a cesarean section at mothers was a factor for the development of neonatal thyroid
30 GW before commencement of antithyroid medication, developed dysfunction. Therefore, Graves’ disease activity in women of
neonatal central hypothyroidism. childbearing age should be well controlled prior to conception.
 M. Uenaka et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 177 (2014) 89–93 93

Table 3
Results of uni- and multivariate logistic regression analyses of the factors related to neonatal thyroid dysfunction.

Factors Univariate analysis Multivariate analysis

p-Value Odds ratio (95% CI) p-Value Odds ratio (95% CI)

Serum levels in mothers

Minimum TSH during pregnancy 0.59 <0.001 (<0.001–>999.999)
Maximum FT4 during pregnancy 0.0076 6.57 (1.65–26.20) 0.021 28.84 (1.65–503.62)
TRAb in the third trimester 0.11 1.17 (0.97–1.41)
Duration of hyperthyroidism 0.0088 1.09 (1.02–1.17) 0.211 1.07 (0.96–1.19)
Antithyroid medication in mothers during pregnancy
Increase in medication 0.084 4.29 (0.82–22.34)
Maximum daily dose 0.033 1.01 (1.00–1.02) 0.197 0.98 (0.95–1.01)
Total dose 0.047 1.05 (1.00–1.10) 0.158 1.10 (0.96–1.26)
Duration of medication 0.34 1.03 (0.97–1.10)

CI, confidence interval; TSH, thyroid-stimulating hormone; FT4, free thyroxine; TRAb, thyroid-stimulating hormone receptor antibody.

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