(三)筛查
就目前而言,并无证据支持在所有女性人群中筛查PPT,因为TPOAb对PPT的阳性预测值比较低,仅50%TPOAb阳性的女性真正发生PPT,而且PPT是自限性疾病,且无有效的预防方法。
在产后3~6个月应对PPT的高危妇女检测甲状腺功能。这些高危因素包括:①1型糖尿病。②既往有PPT的病史。③妊娠前TPOAb阳性者。④有症状的妇女。⑤有PPT的临床表现。⑥产后抑郁(产后抑郁和产后甲减潜在相关,而甲减是抑郁症可逆转的病因)。由于TPOAb阳性的人群中PPT的发生率明显升高,因此TPOAb阳性的女性应该在产后的6~12周及6个月左右,监测TSH水平。TPOAb阳性第一次产后未发生甲状腺功能异常者发生PPT的风险在25%。总之,在妊娠早期10%女性TPOAb阳性,其中50%发生PPT。此外,30%TPOAb阳性的女性在产后将发生抑郁症状(独立于甲状腺功能),而抗体阴性者仅20%。甲状腺功能异常和抑郁相关症状提示应该用TPOAb筛查产后甲状腺疾病,例如,在妊娠早期检测甲状腺抗体可能提醒临床医生警惕产后发生PPT,并且早期治疗。
参考文献
[1] 李晨阳,关海霞,李玉姝,等.产后甲状腺炎的前瞻性临床流行病学调查[J].中华内分泌代谢杂志,2005,21(2):99-102.
[2] ROBERTSON H E.Lassitude, coldness, and hair changes following pregnancy, and their response to treatment with thyroid extract[J].Br Med J,1948,Au;2(4573):93.
[3] Zaletel K, Krhin B, Gaberscek S, et al.Association of CT60 cytotoxic T lymphocyte antigen-4 gene polymorphism with thyroid autoantibody production in patients with Hashimoto's and postpartum thyroiditis[J].Clin Exp Immunol,2010,161(1):41-47.
[4] Shi X, Li C, Li Y, et al.Circulating lymphocyte subsets and regulatory T cells in patients with postpartum thyroiditis during the first postpartum year[J].Clin Exp Med,2009,Dec;9(4):263-267.
[5] 李晨阳,李玉姝,关海霞,等.产后甲状腺炎患者循环Thl、Th2 细胞因子的动态变化[J].中华内科杂志,2006,45(6):448-451.
[6] Teng D,Li C,Teng Y,et al.Dynamic changes of IgG subtypes of thyroid peroxidase antibody in patients with postpartum thyroiditis[J].Gynecol Obstet Invest, 2010,69(1):24-29.(https://www.daowen.com)
[7] Okosieme O E, Parkes A B, McCullough B, et al.Complement activation in postpartum thyroiditis[J].QJM,2002,95(3):173-179.
[8] 李晨阳,单忠艳,关海霞,等.碘摄入量对产后甲状腺炎发生、发展的影响[J].中华内分泌代谢杂志,2005,21(2):103-105.
[9] 郭慧玲,李晨阳,李玉姝,等.血清瘦素水平与产后甲状腺炎相关性的病例对照研究[J].中华内分泌代谢杂志,2014,30(1):31-34.
[10] Ando T, Davies T F.Clinical Review 160: Postpartum autoimmune thyroid disease: the potential role of fetal microchimerism[J].J Clin Endocrinol Metab,2003,88(7):2965-2971.
[11] Pearce E N, Farwell A P, Braverman L E.Thyroiditis[J].N Engl J Med,2003,348(26):2646-2655.
[12] Kent G N, Stuckey B G, Allen J R, et al.Postpartum thyroid dysfunction: clinical assessment and relationship to psychiatric affective morbidity[J].Clin Endocrinol(Oxf),1999,51(4):429-438.
[13] 李晨阳,关海霞,李玉姝,等.58例产后甲状腺炎患者的2年随访研究[J].中华内分泌代谢杂志,2015,28(5):372-376.[
14] Negro R, Greco G, Mangieri T, et al.The influence of selenium supplementation on postpartum thyroid status in pregnant women with thyroid peroxidase autoantibodies[J].J Clin Endocrinol Metab,2007,92(4):1263-1268.