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GuidelinesoftheAmericanThyroidAssociationfortheDiagnosisandManagementofThyroidDiseaseDuringPregnancyandPostpartumTheAmericanThyroidAssociationTaskforceonThyroidDiseaseDuringPregnancyandPostpartumAlexStagnaro-Green(Chair),1MarcosAbalovich,2ErikAlexander,3FereidounAzizi,4JorgeMestman,5RobertoNegro,6AngelitaNixon,7ElizabethN.Pearce,8OffieP.Soldin,9ScottSullivan,10andWilmarWiersinga11INTRODUCTIONPregnancyhasaprofoundimpactonthethyroidglandandthyroidfunction.Theglandincreases10%insizeduringpregnancyiniodine-repletecountriesandby20%–40%inareasofiodinedeficiency.Productionofthyroxine(T4)andtriiodothyronine(T3)increasesby50%,alongwitha50%increaseinthedailyiodinerequirement.Thesephysi-ologicalchangesmayresultinhypothyroidisminthelaterstagesofpregnancyiniodine-deficientwomenwhowereeuthyroidinthefirsttrimester.Therangeofthyrotropin(TSH),undertheimpactofplacentalhumanchorionicgo-nadotropin(hCG),isdecreasedthroughoutpregnancywiththelowernormalTSHlevelinthefirsttrimesterbeingpoorlydefinedandanupperlimitof2.5mIU/L.Tenpercentto20%ofallpregnantwomeninthefirsttrimesterofpregnancyarethyroidperoxidase(TPO)orthyroglobulin(Tg)antibodypositiveandeuthyroid.SixteenpercentofthewomenwhoareeuthyroidandpositiveforTPOorTgan-tibodyinthefirsttrimesterwilldevelopaTSHthatexceeds4.0mIU/Lbythethirdtrimester,and33%–50%ofwomenwhoarepositiveforTPOorTgantibodyinthefirsttri-mesterwilldeveloppostpartumthyroiditis.Inessence,pregnancyisastresstestforthethyroid,resultinginhy-pothyroidisminwomenwithlimitedthyroidalreserveoriodinedeficiency,andpostpartumthyroiditisinwomenwithunderlyingHashimoto’sdiseasewhowereeuthyroidpriortoconception.Knowledgeregardingtheinteractionbetweenthethyroidandpregnancy/thepostpartumperiodisadvancingatarapidpace.OnlyrecentlyhasaTSHof2.5mIU/Lbeenac-ceptedastheupperlimitofnormalforTSHinthefirsttri-mester.Thishasimportantimplicationsinregardstointerpretationoftheliteratureaswellasacriticalimpactfortheclinicaldiagnosisofhypothyroidism.Althoughitiswellacceptedthatoverthypothyroidismandoverthyperthy-roidismhaveadeleteriousimpactonpregnancy,studiesarenowfocusingonthepotentialimpactofsubclinicalhypo-thyroidismandsubclinicalhyperthyroidismonmaternalandfetalhealth,theassociationbetweenmiscarriageandpretermdeliveryineuthyroidwomenpositiveforTPOand/orTgantibody,andtheprevalenceandlong-termimpactofpost-partumthyroiditis.Recentlycompletedprospectiveran-domizedstudieshavebeguntoproducecriticallyneededdataontheimpactoftreatingthyroiddiseaseonthemother,fetus,andthefutureintellectoftheunbornchild.ItisinthiscontextthattheAmericanThyroidAssociation(ATA)chargedataskforcewithdevelopingclinicalguide-linesonthediagnosisandtreatmentofthyroiddiseaseduringpregnancyandthepostpartum.Thetaskforceconsistedofinternationalexpertsinthefieldofthyroiddiseaseandpregnancy,andincludedrepresentativesfromtheATA,AsiaandOceaniaThyroidAssociation,LatinAmericanThyroidSociety,AmericanCollegeofObstetriciansandGynecolo-gists,andtheMidwivesAllianceofNorthAmerica.Inclusionofthyroidologists,obstetricians,andmidwivesonthetask1DepartmentsofMedicineandObstetrics/Gynecology,GeorgeWashingtonUniversitySchoolofMedicineandHealthSciences,Wa-shington,DistrictofColumbia.2EndocrinologyDivision,DurandHospital,FavaloroUniversity,BuenosAires,Argentina.3DivisionofEndocrinology,Diabetes,andHypertension,Brigham&Women’sHospital,HarvardMedicalSchool,Boston,Massachusetts.4InternalMedicineandEndocrinology,ResearchInstituteforEndocrineSciences,ShahidBeheshtiUniversityofMedicineSciences,Tehran,Iran.5DepartmentofMedicineandObstetricsandGynecology,KeckSchoolofMedicine,UniversityofSouthernCalifornia,LosAngeles,California.6DivisionofEndocrinology,V.FazziHospital,Lecce,Italy.7AngelitaNixon,CNM,LLC,ScottDepot,WestVirginia.8SectionofEndocrinology,Diabetes,andNutrition,BostonUniversitySchoolofMedicine,Boston,Massachusetts.9DepartmentsofMedicine,Oncology,ObstetricsandGynecology,GeorgetownUniversityMedicalCenter,Washington,DistrictofCo-lumbia.10DepartmentofObstetrics/Gynecology,MedicalUniversityofSouthCarolina,Charleston,SouthCarolina.11Endocrinology,AcademicMedicalCenter,UniversityofAmsterdam,Amsterdam,TheNetherlands.THYROIDVolume21,Number10,2011ªMaryAnnLiebert,Inc.DOI:10.1089/thy.2011.00871forcewasessentialtoensuringwidespreadacceptanceandadoptionofthedevelopedguidelines.Theclinicalguidelinestaskforcecommenceditsactivitiesinlate2009.Theguidelinesaredividedintothefollowingnineareas:1)thyroidfunctiontests,2)hypothyroidism,3)thyrotoxicosis,4)iodine,5)anti-thyroidantibodiesandmiscarriage/pretermdelivery,6)thyroidnodulesandcancer,7)postpartumthyroiditis,8)recommendationsonscreeningforthyroiddiseaseduringpregnancy,and9)areasforfutureresearch.Eachsectionconsistsofaseriesofquestionsger-manetotheclinician,followedbyadiscussionoftheques-tionsandconcludingwithrecommendations.Literaturereviewforeachsectionincludedananalysisofallprimarypapersintheareapublishedsince1990andse-lectivereviewoftheprimaryliteraturepublishedpriorto1990thatwasseminalinthefield.Inthepast15yearstherehavebeenanumberofrecommendationsandguidelinestatementsrelatin