妊娠與產後甲狀腺疾病臨床診治手冊

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

ަყ‫ݳ‬΢Ϝ๽Җ୾ϲϸ‫ݫ‬Ᏹཽ!ಒΫή۪౪ᆀ‫ٲ‬ ౪ ‫ߞ ٲ‬Ȉ෇߈। ளଡ଼౪‫ٲ‬Ȉе‫ڄ‬Нȃጿջང ౪ȁȁ‫ٲ‬Ȉе‫ݾ‬ϰȃ؄߫቉ȃ஼ኋ‫܇‬ȃചࡧႁ ചో਷ȃ༂Љಉȃဩਐᖑȃᙐም‫ع‬ ளଡ଼ᆀ‫ٲ‬Ȉ‫ݔ‬ϧ኉ ᆀȁȁ‫ٲ‬Ȉ‫׊ݔ‬ႁȃ஼Љ໚ બ ਫ ߞȈቔቄ࣏ ୚બਫߞȈ֕ஏᆋȃߚ୊ઊȃងีྶ

ަყ‫ݳ‬΢Ϝ๽Җ୾ϲϸ‫ݫ‬ᄳᑦ‫੿׎‬Ᏹཽ!ጢᒯя‫ېޏ‬সཽ л Ӊ ‫ ې‬সȈ஼Љ໚ ୚лӉ‫ې‬সȈചఽֆ ‫ې‬ȁȁȁসȈചᄹᆌȃ྇୊ിȃᙐም‫ع‬

ަყ‫ݳ‬΢Ϝ๽Җ୾ϲϸ‫ݫ‬Ᏹཽ!ҧ‫ޒ‬သ‫ې‬সཽ лӉ‫ې‬সȈചࡧႁ ‫ې‬ȁȁসȈе‫ڄ‬Нȃе‫ݾ‬ϰȃ‫ݔ‬ϧ኉ȃ‫׊ݔ‬ႁȃ஼Љ໚ ஼ኋ‫܇‬ȃചో਷ȃ෇߈।ȃ༂Љಉȃဩਐᖑ

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

ҭ ᓄ I.‫ ז‬.......................................................................................................................... 1 ަყ‫ݳ‬΢Ϝ๽Җ୾ϲϸ‫ݫ‬Ᏹཽ౪‫߈෇ ߞٲ‬। II.Жّ......................................................................................... ............................ 2 ަყ‫ݳ‬΢Ϝ๽Җ୾ϲϸ‫ݫ‬Ᏹཽ ҧ‫ޒ‬သ‫ې‬সཽлӉ‫ې‬স ചࡧႁ III.ҧ‫ޒ‬သѓ૗ᔯᡜᇅׂ৓.................................................................................... 3 ‫ݔ‬πߞ۹ख‫܉‬ᚃଲ ‫ݔ‬ᐚᆌ IV.࿩‫ޒ‬ᄙ‫ڸ‬ᕋᎵ..................... ............................................................................. 10 ‫ݔ‬πߞ۹ख‫܉‬ᚃଲ ؄ਥᄹ V. ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ‫ׂڸ‬৓‫ ઀ึڂ‬.......................................................................... 21 ᇄіᄹҖᖃᚃଲ ༂֘ᆃ VI.ҧ‫ޒ‬သ੾੿ᄈϛѺ઀‫ڸ‬ህֆҢ෦‫ޠ‬ኈ៫ ..................................................... 28 ήॗᖃᚃଲ ֗Ϯ๽ VII.ҧ‫ޒ‬သѓ૗մίᇅׂ৓ ................................................................................ 39 ଼୎ख‫܉‬ᚃଲ ቔ‫ݙ‬ᑹ VIII. ׂ৓ਣ‫ޠ‬ҧ‫ޒ‬သѓ૗Ϧໍ.......................................................................... 45 ᇄτᚃଲ ࢋ๣ᇉ IX ׂ৓෉໣ҧ‫ޒ‬သ๗࿾Іҧ‫ޒ‬သᕝ೏౪ ......................................................... 58 ᇄϜᄹҖᖃᚃଲ ؄ԈⰩ X.फ‫ڌ‬ᇅུҢ‫ڌ‬ϟྲៗ‫ٲ‬໷............................................................................... 70 ୾੏ᆤӬᚃଲ ༂ೈෙ XI.ҧ‫ޒ‬သ੾੿‫ڸ‬঴‫ ٱ‬......................................................................................... 74 ା໱ߞ۹ख‫܉‬ᚃଲ ‫ڻ‬ਐസ XII.౱ࡤҧ‫ޒ‬သ‫ ވ‬................................................................................................ 79 ା໱ᚃᏱτᏱߤ೪ᚃଲ ࠻‫ְڸ‬ ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

XIII.ׂ৓ࠊ‫ׂܗ‬৓෉໣ҧ‫ޒ‬သѓ૗‫ޠ‬ᑣᔯ....................................................... 86 ᄕϾஆ࿝ఁᚃଲ е๳቉ XIV.ᇄᢋӵୣӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀‫ུޠ‬Ң‫ڌ‬ᑣᔯ...................... ..................... 92 ᇄτ‫่ڌ‬ᚃଲ ጿНЅ XV.ׂ৓෉ҧ‫ޒ‬သ੾੿ྲៗ‫ޠ‬ஐ౱ऌᢏᘉ ........................................................ 97 ᇄіߞ۹ख‫܉‬ᚃଲ ‫ⷔܜ׉‬ȃࢺ੏‫ڸ‬ XVI.ጢࡤᇮ ........................................................................................................ 105 ަყ‫ݳ‬΢Ϝ๽Җ୾ϲϸ‫ݫ‬Ᏹཽબਫߞ ቔቄ࣏

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

‫ז‬ Ϝ๽Җ୾ϲϸ‫ݫ‬Ᏹཽпᖓᛯӓ୾өϵ‫ؾ‬ҴᚃଲІः‫ف‬ᐡᄻ௄‫ٲ‬ϲϸ‫ݫ‬Ң ౪І੾੿ϟः‫ف‬ȃߵໍϲϸ‫ݫ‬ϟᏱ೛ึ৥Іᔗңȃђ஽ᄈ୾ርϲϸ‫ݫ‬Ᏹཽϟ һࢻІ஽Ͼ୾Җϟୋஷ࣐ۡԠȄҐᏱཽϟӉଡ଼࣐ : ߵໍϲϸ‫ݫ‬Ᏹϟः‫ف‬ᇅᔗ ңȃᖟᒳᏱ೛ᅌᗀІଇ፤ཽȃึߓᏱ೛፤Н‫ܗ‬я‫ޏ‬Ᏹ೛ᚖᇭІё‫ޑ‬ȃྜྷ೾ӓ ୾ϵ‫ؾ‬ҴᚃᕜІः‫ف‬ᐡᄻϟϲϸ‫ݫ‬ऌᏱึ৥ȃђ஽୾ርϲϸ‫ݫ‬Ᏹཽϟһࢻȃ ߵໍӓҖୋஷȄҐᏱཽܼ 2018 Ԓ 3 Уя‫ޏ‬ϟȶҧ‫ޒ‬သ๗࿾ІϸϾ࠯ᕝᖞ‫ט‬К ьȷȂ྄‫ڏ‬ᖞ‫ט‬ᄃңІ୥ՄቌঅȂ౐ᕖཽস޼ۢȄ ҐᏱཽܼ 2019 Ԓ 3 Уя‫ޏ‬ȶׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬КьȷȂҐ ਫӶҧ‫ޒ‬သ‫ې‬সཽചࡧႁлӉ‫ې‬সІቔቄ࣏બਫߞ‫ޠ‬೤დίȂϸ࣐ȶҧ‫ޒ‬သ ѓ૗ᔯᡜᇅׂ৓ȷȃȶ࿩‫ޒ‬ᄙ‫ڸ‬ᕋᎵȷȃȶ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ‫ׂڸ‬৓‫઀ึڂ‬ȷȃ ȶҧ‫ޒ‬သ੾੿ᄈϛѺ઀‫ڸ‬ህֆҢ෦‫ޠ‬ኈ៫ȷȃȶҧ‫ޒ‬သѓ૗մίᇅׂ৓ȷȃ ȶׂ৓ਣ‫ޠ‬ҧ‫ޒ‬သѓ૗Ϧໍȷȃȶׂ৓෉໣ҧ‫ޒ‬သ๗࿾Іҧ‫ޒ‬သᕝ೏౪ȷȃ ȶफ‫ڌ‬ᇅུҢ‫ڌ‬ϟྲៗ‫ٲ‬໷ȷȃȶҧ‫ޒ‬သ੾੿‫ڸ‬঴‫ٱ‬ȷȃȶ౱ࡤҧ‫ޒ‬သ ‫ވ‬ȷȃȶׂ৓ࠊ‫ׂܗ‬৓෉໣ҧ‫ޒ‬သѓ૗‫ޠ‬ᑣᔯȷ๊ത࿾Ȃᗝ፝‫ݔ‬ᐚᆌᚃ৲ȃ ؄ਥᄹᚃ৲ȃ༂֘ᆃᚃ৲ȃ֗Ϯ๽ᚃ৲ȃቔ‫ݙ‬ᑹᚃ৲ȃࢋ๣ᇉᚃ৲ȃ؄ԈⰩ ᚃ৲ȃ༂ೈෙᚃ৲ȃ‫ڻ‬ਐസᚃ৲ȃ࠻‫ְڸ‬ᚃ৲ȃе๳቉ᚃ৲п2017Ԓज୾ҧ ‫ޒ‬သᏱཽ‫ݾ‬ᕜྦࠍ(ATA guideline)‫ޠ‬ୱᇅ๏࣐ᙣҐȂᒋӬѯᢋᖞ‫ޠט‬౫‫ݸ‬І Ґρၦਠђпಜᐍȇ‫ٯ‬ᗝ፝ϲϸ‫ݫ‬Ᏹཽ౪ᆀ‫ݔٲ‬ϧ኉ఁ௳ȃ‫׊ݔ‬ႁఁ௳ȃဩ ਐᖑఁ௳ȃ؄߫቉лӉȃᙐም‫ع‬ఁ௳ȃചࡧႁлӉȃചో਷ఁ௳ȃ༂Љಉఁ ௳ȃጿջངఁ௳ȃе‫ݾ‬ϰ୚ఁ௳ȃе‫ڄ‬Нఁ௳Іеᖆ෡ᚃ৲ਯᎨІᏳ᠟ȇѫ ѵᗝ፝Πϊ‫ڌ‬ऌጿНЅఁ௳Іஐ౱ऌࢺ੏‫ڸ‬ᚃ৲ණ‫ٽ‬ȶᇄᢋӵୣӒЉ‫ܓ‬ҧ‫ޒ‬ သմ૗઀‫ུޠ‬Ң‫ڌ‬ᑣᔯȷІȶׂ৓෉ҧ‫ޒ‬သ੾੿ྲៗ‫ޠ‬ஐ౱ऌᢏᘉȷ஠ঢ়ཏ ُȂϲৡᆡீᙵ൳ȄҐਫϟ‫׈‬ԚȂӊфϲϸ‫ݫ‬Ᏹࣩ‫ޠ‬ထ๋ထΩпІϛӤऌր ஠ঢ়‫ڟޠ‬ֆȄᙲԫདᗃ‫ܛ‬ԥ୥ϡ‫ޠ‬஠ঢ়Ᏹ޲ȃചࡧႁл‫ې‬ȃቔቄ࣏બਫߞІ બਫ೏Ӥϧ‫ޠ‬ряȂη्੬րདᗃ஼Љ໚ఁ௳‫ࡍޠ‬८೪ॏᇅඩฬȂᡲҐਫ‫؂‬ ᡘቌঅȄ ަყ‫ݳ‬΢Ϝ๽Җ୾ϲϸ‫ݫ‬Ᏹཽ ౪‫ߞٲ‬

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ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь ‫ז‬

Жġġّ ҧ‫ޒ‬သ੾੿࢑ᖞ‫ט‬ഷளႅ‫ޠژ‬ϲϸ‫੿੾ݫ‬ȂΚૢளُӱѓ૗‫ܓ‬ሬᛥ‫ܗ‬๗ ࿾‫ܓ‬လድആԚᖞ‫ޒ઀ט‬ȇ‫ڐ‬ϜՍᡞռ࣬ҧ‫ޒ‬သ‫ވ‬ԂึܼԒሇυ‫ܓ‬ȂйளளҦ ԫोҢ‫ڨ‬Ѻȃׂ৓І౱ࡤྲៗα‫ޠ‬ឋᚡȄ੿ொ‫ܗ‬ᖞ‫ט‬ᚃ৲Ԅ‫ݏ‬ᄈᛅѺႇโ‫ܗ‬ ౱ࡤࣻᜱҧ‫ޒ‬သ੾੿ϛࣦΠ၍Ȃ൸྄Ѡ૗ӱԫ౱Ң፞ԄϛѺȃࢻ౱ȃ࿍फȃ ུҢ‫ڌ‬ҧ‫ޒ‬သလτ‫ܗ‬ѓ૗౵ளȃࣦՎܼӡІѺ౱ஐୋஷ๊ୱᚡȄҦܼ೼‫ٳ‬ឋ ᚡϛѬ౟ਗ਼‫ژ‬ஐ౱ऌІϊ‫ڌ‬ऌᚃ৲Ȃ੿ொ‫ྲ෉ߞޠ‬ៗ‫؂‬ሰ्ϲϸ‫ུݫ‬ചхᗃ ऌᚃ৲‫ޠ‬ӓโ୥ᇅȇดՅ೩ӼࣻᜱឋᚡΚ޲ҦܼਣޫᡑϾᢏ‫׾܉‬ᡑȂӕ޲Ҧ ܼુнτ࠯ᖞ‫ט‬ၑᡜէᜍȂҭࠊϬณӔᜌȄӱԫȂᏱཽӶ෇߈।౪‫ဵޠߞٲ‬ ѣίȂᗝ໲୾ϲࣻᜱስ஀஠ঢ়Ȃ୥Մ2017Ԓ‫ޏ‬ज୾ҧ‫ޒ‬သᏱཽຩᘟІ೏ဋׂ ৓І౱ࡤҧ‫ޒ‬သ੾੿ࡿЖІ୾ϲѵࣻᜱ፤НȂཋᐍጢ᝹Ԛȶׂ৓ᇅ౱ࡤҧ‫ޒ‬ သ੾੿ຩ‫ݾ‬КьȷȂп‫ཽٽ‬স୥ՄȄ ҐਫӔϸΫΚത࿾ȂҦ୾ϲөτᚃᏱϜЗϲϸ‫ݫ‬஠ঢ়உ์ȂᆤӬᐍ౪୾ ϲѵࣻᜱ፤НȂᗷดл्୥ՄЖң2017Ԓ‫ޏ‬ज୾ҧ‫ޒ‬သᏱཽࡿЖȂկηᙥᐡ Ӳ៬୾ϲࣻᜱः‫ف‬Ȃ‫ٯ‬စҦၦ౐Ᏹ޲஠ঢ়ᘉຠȂ२ᘉᏳ᠟ȄਫϜోࢃׂ৓෉ ໣๘Ъጱᐮષᄈܼҧ‫ޒ‬သѓ૗‫ޠ‬ኈ៫ȃᛅѺ෉໣࿩ᕋᎵ‫ޠ‬२्‫ܓ‬ȃՍᡞռ࣬ ҧ‫ޒ‬သ‫ވ‬ᇅϛѺ઀ϟᜱᖓȃׂ৓෉໣ҧ‫ޒ‬သѓ૗౵ளᇅ๗࿾‫ޠ‬ຩᘟᇅ‫ݾ‬ᕜȃ ΞՎܼ౱ࡤ঴‫ٱ‬ᄈུҢ‫ڌ‬І౱ஐୋஷ‫ޠ‬ኈ៫І౱ࡤҧ‫ޒ‬သ‫๊ވ‬ȂѠᒞ८८঎ ‫ژ‬Ȃ౐Τ఼яȄҐਫഷࡤ‫؂‬Ωᗝϊ‫ڌ‬ऌጿНЅఁ௳Іஐ౱ऌࢺ੏‫ڸ‬лӉ൸ѯ ᢋҭࠊུҢ‫ڌ‬ᑣᔯІѺ౱ஐҧ‫ޒ‬သѓ૗ഌϸձ஠ঢ়ຠ፤Ȃ‫ו‬గ૗ණ‫ཽٽ‬সࣻ ᜱၦଊȇկ४ܼਣ໣ІစຳȂਫϜԄԥӉեᒹᅔ‫ܗ‬ᇳଢ଼Ȃۧ፝ϛ֌ඐϡࡿ ఁȄ ᖞ‫ޠ੿੾ט‬ຩᘟᇅ‫ݾ‬ᕜࡿЖሰ्๗Ӭᖞ‫ט‬ၑᡜໍ՘ࡋᢏಜӬϸ‫ݚ‬Ȃ‫ٯ‬໲ Ӭၯስ஀஠ঢ়Ȃ൸ᜍᐄ઼๊ାմձяᎍ࿌࡛ឋȇᗷดᏱཽϜϛнөঐስ஀‫ޠ‬ ஠ঢ়ȂկҦܼ୾ϲࣻᜱ፤НၷЎȂӶᖆԕ‫ޠ‬СளҢࣁϜη࡟ᜳூᆺ໲өስ஀ ஠ঢ়ӔӤଇ፤Ȃӱԫ෉ࣿᙥҦԫ‫ޏ‬ຩ‫ݾ‬Кь‫ޠ‬яёȂᖄ‫ٻ‬НϜτљЖң୾ѵ ၦਠȂηࣿѠпуύϟҰȂЖᏳяᎍӬ୾௒‫ޠ‬ӔᜌȂ֊߰࢑ҐཽΚೲ‫ߒޠ‬ ଀Ȅ ަყ‫ݳ‬΢Ϝ๽Җ୾ϲϸ‫ݫ‬Ᏹཽ ҧ‫ޒ‬သ‫ې‬সཽлӉ‫ې‬স !

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ചࡧႁ

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь Ж ّ

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ҧ‫ޒ‬သѓ૗ᔯᡜᇅׂ৓ ‫ݔ‬πߞ۹ख‫܉‬ᚃଲ ‫ݔ‬ᐚᆌ

Κȃҧ‫ޒ‬သѓ૗ӶᛅѺ෉໣‫ޠ‬ᡑϾ࣐եȉ ᇴ݃Ȉ ᛅѺਣ 1) ๬᠛‫ޠ‬࿩௷я໕ཽቩђȂ 2) ҧ‫ޒ‬သષ๗Ӭ౩೗Ҫᐩཽ࡚α ЁȂ3)फዻᇨആ‫ޠ‬΢᜹๘Ъጱߵ‫ܓ‬သᐮષཽ‫ڗ‬ᐮҧ‫ޒ‬သȂ4)ҧ‫ޒ‬သષ ҢԚཽቩђ(შΚ)ȄӱԫȂѺஐ‫ޠ‬ҧ‫ޒ‬သѓ૗‫ޠ‬ҔளঅᇅґᛅѺஐυ ϛӤ(1,2)ȄѫѵȂϛӤఋထ‫ޠ‬TSH‫ڸ‬෭ᚕT4୥ՄঅѠ૗ԥ݃ᡘৰ౵Ȅ ‫ڨ‬ѺࡤȂҧ‫ޒ‬သષ๗Ӭ౩೗Ҫ‫ڸ‬ᖃ T4 ᐩ࡚ӶᛅѺಒ 7 ໋ࠊ֊໡ۗα ЁȂ‫ٯ‬ӶᛅѺङಒ 16 ‫ڻ‬ਣႁ‫ژ‬ା৬অ (3) Ȃดࡤࡼ៊ߴࡼା৬‫ޣ‬Վϸ ৕ȄӶׂ৓ॷήঐУȂҕᒒ‫ޠ‬΢᜹๘Ъጱߵ‫ܓ‬သᐮષཽ‫ڗ‬ᐮ T S H ‫ڨ‬ ᡞȂՅቩђҧ‫ޒ‬သೊᅮᇍ‫ޠ‬౱ҢȂ‫ٯ‬ᏳयTSHᐩ࡚७մ(2,4)ȄӱԫȂӶ ᛅѺ෉໣Ȃυ‫ޠܓ‬TSHᐩཽ࡚մܼѺࠊȄӶᛅѺ‫ࠊޠ‬ήঐУϜȂӼႁ 15ʦ‫ޠ‬υ‫ڐܓ‬TSHմܼ୥Մঅί४(0.4 mU/L)(5,6)ȄTSH‫ޠښ׼ڨ‬Щ౦ ӶᛅѺϜ෉෶ЎՎङ10ʦȂӶᛅѺࡤ෉෶ЎՎ5ʦ(2)Ȅ τӼ኶ᖞ‫ט‬ᔯᡜࡊ‫ٻ‬ңՍ୞ռ࣬ขۢ‫ݳ‬ข໕෭ᚕT4ᐩ࡚ȂԫР‫ཽݳ‬ӱ ࣐Ѻஐ՗ష‫ޠ‬ҧ‫ޒ‬သષ๗Ӭ౩೗Ҫᐩ࡚ቩђІҪ೗Ҫᐩ࡚७մՅ‫ژڨ‬ ϔᘚ(7,8)Ȅ‫ڐ‬у‫ޣ‬௦ข໕Р‫ݳ‬Ȃ‫پ‬Ԅ҂ᒌഇ‫ݚ‬Ȃົཌྷᘯ‫ܗ‬షࣻՔᜋ/՜ ᖓ፵ᜋข໕Ȃၷϛཽ‫ژڨ‬՗ఽϜ‫ޠ‬೗Ҫ፵ኈ៫Ȃկ࢑೼‫ٳ‬Р‫ݳ‬ၷ࣐݂ ີՅґೞኅ‫ٻހ‬ңȄӱԫȂᔗңՍ୞ռ࣬ขۢ‫ݳ‬пขۢ෭ᚕT4Ϭดೞ ኅ‫ٻހ‬ңȄ‫׳‬яఋထ੬ۢІѺ෉੬ۢ‫ޠ‬෭ᚕT4୥Մঅ࢑၍‫؛‬ԫୱᚡ‫ޠ‬ ഷ‫ٺ‬Р‫ݳ‬Ȅ ѯᢋȈ ґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ ΡȃTSHӶؑঐѺ෉‫ޠ‬୥Մঅ࣐եȉ ᇴ݃Ȉ ᛅѺஐυTSH‫ޠ‬୥ՄঅཽၷߩᛅѺஐυ࣐մȄӶׂ৓ॷήঐУѠᢏᄇ ‫ژ‬ഷᡘ຀‫ޠ‬TSHᐩ࡚७մȂӱ࣐΢᜹๘Ъጱߵ‫ܓ‬သᐮષᐩ࡚Ёାཽ‫ڗ‬ ᐮTSH‫ڨ‬ᡞՅቩђҧ‫ޒ‬သೊᅮᇍ‫ޠ‬౱ҢȞߓΚȟȄ௦຀ȂTSHঅӶׂ ৓ϜήঐУ‫ׂڸ‬৓ҒήঐУཽഃᅛЁାȂկ࢑ϬดմܼґᛅѺஐυ (9,10) ȄӼबफᛅѺ‫ޠ‬΢᜹๘Ъጱߵ‫ܓ‬သᐮષᐩཽ࡚ାܼ൑बफᛅѺȂ ӱԫӼबफᛅѺ‫ޠ‬TSH୥Մঅί७‫࣐؂‬ᡘ຀(8)Ȅ63ӫᛅѺυ‫ޠܓ‬ः‫ف‬ ึ౫ȂԄ‫ݏ‬΢᜹๘Ъጱߵ‫ܓ‬သᐮષᐩ࡚> 200,000 IU/LІ > 400,000 IU/ LȂϸրԥ67ʦІ100ʦ‫ޠ‬υ‫ڐܓ‬TSHཽೞ‫ښ׼‬Վ P8 /(11)ȄTSH୥ Մঅ‫ޠ‬ጃۢηᔗՄኍ࿩ឹ‫ڦ‬໕ȂThyroid peroxidase‫׫‬ᡞ໩‫ܓ‬Ȃٙᡞ፵ ໕ࡿ኶Іᆎఋ‫ޠ‬ӱષȄ ҭࠊ‫ޠ‬ᜍᐄМࡼׂ৓ॷήঐУ‫ޠ‬TSH୥Մঅα४༊ၷґᛅѺஐυเཌྷ 3

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

७մȂ೾ளӶᛅѺಒ7໋ϟࡤ(12)ȄӶႇџȂज୾‫ڸ‬ዊࢹ࡛ឋTSHα४ ୥ՄঅӶׂ৓ॷήঐУ࣐2.5 mU/LȂӶׂ৓ϜήঐУІׂ৓ҒήঐУ ࣐3.0 mU/L(13,14)Ȅկ࢑ӶഷߗȂϜ୾4800ӫѺஐ‫ޠ‬ः‫ف‬ᡘұȂTSHα ४୥Մঅ‫ޠ‬७մึҢӶಒ7-12໋Ȃα४୥Մঅ༊௄5.31เཌྷ७࣐4.34 mU/L(12)Ȅηึ౫Ѭԥ࿌Ѻஐ՗ఽTSHτܼ4.8 mU/LਣϘ૗ᢏᄇ‫ژ‬෭ᚕ T4‫ޠ‬෶ЎȄ ΚϊഌϸҔளᛅѺυ‫ܓ‬Ѡпᢏᄇ‫ژ‬TSHմՎณ‫ݳ‬ขяȞTSH <0.01 mU/ LȟȄঅூ‫ݨ‬ཏ‫ٴ࢑ޠ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗Ϧໍ‫ڸ‬ϛًᛅѺ๗‫ݏ‬ณࣻᜱȄ ӱԫȂҕᡞTSHᐩ࡚७մȂկϬѠขூȂѠ૗ϛ‫ڏ‬ԥᖞ‫ט‬ཏဏ(15)Ȅ ᛅѺ෉໣TSHҔள୥ՄঅԇӶᡘ຀‫ޠ‬ӵ౪‫ڸ‬ᆎఋৰ౵ȂԄߓΚ‫ܛ‬ұȄ կτӼ኶ఋထુн࿌ӵᛅѺஐυөѺ෉஠ԥ‫ޠ‬TSH୥Մঅ(Trimesterspecific TSH references)Ȅҭࠊज୾ҧ‫ޒ‬သᏱཽ࡛ឋӶ‫ء‬ԥ࿌ӵᛅѺஐ υөѺ෉‫ޠ‬TSH୥ՄঅਣȂׂ৓ॷήঐУ‫ ޠ‬TSH୥Մঅα४Ѡ෶Ўङ 0.5 mU/LȂՅ୥Մঅί४෶Ўङ0.4 mU/LȄӱԫȂᄈܼᛅѺԟ෉‫ޠ‬ொ ޲ȂTSHα४୥Մঅᔗ࣐4.0 mU/LȂԫ୥Մঅ೾ளᔗ௄ᛅѺ7-12໋໡ ۗȂӶᛅѺϜ෉‫ڸ‬ఐ෉ȂTSHཽഃᅛαЁՎ௦ߗߩᛅѺ‫ޠ‬TSHጓ൝Ȅ ࡛ឋȈᔗϸ‫ݚ‬࿌ӵᛅѺஐυөѺ෉‫ ޠ‬T S H অȂпᕖூ࿌ӵѺஐ‫ ޠ‬T S H ୥Մ অȄ୥Մঅ‫ޠ‬ጃۢᔗࠂ४ܼϸ‫ݚ‬ณҧ‫ޒ‬သ੾੿Ȃϑԥഷᎍ࿌࿩ឹ‫ڦ‬й Thyroid peroxidase‫׫‬ᡞ࣐ജ‫ޠܓ‬ѺஐȄା࡚࡛ឋȂϜᜍᐄ઼๊ ѯᢋȈґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ ήȃᛅѺ෉໣ᔯขT4‫ޠ‬ഷ‫ٺ‬Р‫࣐ݳ‬եȉ ᇴ݃Ȉ ґᇅ೗Ҫ፵๗Ӭ‫ޠ‬෭ᚕT4ङխᖃT4֥໕‫ޠ‬0.03ʦȄՅѬԥ෭ᚕT4Ѡೞ ಣᙒឹ‫ڦ‬Ȃ‫ڐ‬Ꮈ‫ޠ‬T4ᇅ՗ఽϜ‫ޠ‬೗Ҫ፵๗ӬȂл्࢑ҧ‫ޒ‬သષ๗Ӭ౩ ೗ҪȄӶାᐩ࡚T4ԇӶίข໕෭ᚕT4‫ڏ‬ԥࢆ᏾‫ܓ‬ȂЏ‫࢑ڐ‬Ӷ๗Ӭ೗Ҫ ᐩ࡚‫׾‬ᡑ‫ޠ‬௒‫ݸ‬ίȂ‫پ‬ԄᛅѺȄӤ՞ષไម‫ݳ‬-షࣻՔᜋ/՜ᖓ፵ᜋข ໕ഇ‫ݚ‬షϜ‫ޠ‬T4࢑ᔯข෭ᚕT4‫ޠ‬༂ߝዀྦ(16)ȂկҦܼ቉Ꮳ‫ڸ‬ᐈձԚҐ ା݂Ȃԫข໕‫׭‬೛ҭࠊґኅ‫ٻހ‬ңȄషࣻՔᜋ/՜ᖓ፵ᜋηѠпϸ‫ݚ‬ഇ ‫ݚ‬ష‫ົܗ‬ཌྷᘯషϜ‫ޠ‬෭ᚕT4‫ޠ‬ᐩ࡚Ȃկ೼‫ٳ‬Р‫ݳ‬૊ਣȃ݂ີй೾ளϛ ϹᄃርȄ‫ٻ‬ң‫ޣ‬௦҂ᒌഇ‫ڸݚ‬షࣻՔᜋ/՜ᖓ፵ᜋȂᓎ຀Ѻឮ‫ޠ‬ቩђȂ 95ʦ ෭ᚕT4‫ޠ‬୥Մୣ໣ཽഃᅛ७մȈಒ14໋࣐1.08-1.82 ng/dLȂಒ20 ໋࣐0.86-1.53 ng/dL(17)Ȅ ҭࠊτӼ኶ᖞ‫ט‬ᔯᡜࡊ‫ٻ‬ңռ࣬ขۢ‫ݳ‬ข໕෭ᚕT4ᐩ࡚Ȃл्࢑ӱ࣐ ռ࣬ขۢ‫ݳ‬૗஋ӶՍ୞Ͼ҂ѯα‫ץ‬ഁໍ՘Ȅҭࠊ‫ٻ‬ң‫ޠ‬෭ᚕT4ռ࣬ϸ ‫ݚ‬Ӷ೩Ӽ௒‫ݸ‬ίߓ౫ًԂȂѠпྦጃᡘұҧ‫ޒ‬သೊᅮᇍુнਣԥմᐩ ࡚෭ᚕT4‫ڸ‬ҧ‫ޒ‬သೊᅮᇍႇ໕ਣԥାᐩ࡚෭ᚕT4(18,19)ȄᛅѺਣ෉෭ᚕ T4୥Մୣ໣ӶϛӤขۢၑᏙϟ໣‫ޠ‬ৰ౵࡟τȂӱԫ෭ᚕT4ข໕অ‫ޠ‬ց ᠟ሰ्਴ᐄၑᏙпІᛅѺ෉ր୉ցᘟ(7,8,19)Ȅ෭ᚕT4ၑᏙᇨആ୧೾ள࡛ ҧ‫ޒ‬သѓ૗ᔯᡜᇅׂ৓

4

ឋөᔯᡜࡊ࡛ҴՍϐ‫ޠ‬୥ՄঅȂկԫ࡛ឋ೾ள࢑ϛϹᄃርȂӱ࣐‫ܤ‬༔ ‫ڏ‬ԥ੬ۢ఩ӈȞԄᛅѺȟ‫ڨޠ‬ၑ޲ԥ֩ᜳȄӱԫȂᖞ‫ט‬ᔯᡜࡊ೾ளཽ ௵ңၑᏙᇨആ୧ණ‫ޠٽ‬ᛅѺ෭ᚕT4୥ՄঅȄկ࢑Ѻஐ‫ޠ‬ᖞ‫ט‬੬‫ܓ‬Ȃ࿩ ឹ‫ڦ‬໕пІᆎఋᡲ෭ᚕT4୥ՄঅӶ೼‫ٳ‬ఋထԥ‫ܛ‬ϛӤȄ ௄ᛅѺ7-16໋໡ۗȂᖃT4ᐩཽ࡚ቩђȂഷࡤႁ‫ژ‬ାܼᛅѺࠊЬ҂ङ50 ʦȂดࡤӶᛅѺ෉໣ࡼ៊ᆱࡼӶ೼ঐЬ҂ȄӱԫȂ஡ߩᛅѺα४ණା 50ʦѠॏᆘяᖞ‫ט‬αѠ௦‫ޠڨ‬ᖃT4α४Ȅկ࢑ȂԫզॏѬᎍңܼᛅѺ ಒ16໋пࡤ(3)Ȅഷߗ‫ޠ‬ः‫ف‬ᡘұᖃT4ӶᛅѺࠊ෉(9.8í17.6໋)‫ڸ‬TSH‫ޠ‬ ࣻᜱ‫ܓ‬ϛԄ෭ᚕT4 (20)Ȅ ෭ᚕT4 indexᇅ՗ఽTSH‫ڏ‬ԥЇӪࣻᜱ(21)Ȅ‫ٻ‬ңҧ‫ޒ‬သೊᅮᇍឹ‫ڦ‬ᔯ ᡜȞ‫پ‬Ԅҧ‫ޒ‬သೊᅮᇍ๗ӬЩ౦ȟॏᆘ෭ᚕT4 indexਣȂ୥Մঅᔗ၏ ஡ᛅѺ෉໣ཽቩђ50ʦ‫ޠ‬ҧ‫ޒ‬သષ๗Ӭ౩೗ҪӗΤՄኍȄ ࡛ឋȈ ռ࣬ขۢ‫ݳ‬ขۢ෭ᚕT4‫ྦޠ‬ጃཽ࡚‫ژڨ‬ᛅѺІၑᏙᇨആ୧ϛӤՅԥᡘ ຀ৰ౵Ȅց᠟Ѻஐ‫ޠ‬෭ᚕT4Ȃᔗ୥ྲѺ෉੬ۢІၑᏙ੬ۢ‫ޠ‬෭ᚕT4୥ ՄঅȄା࡚࡛ឋȂϜᜍᐄ઼๊ ࡛ឋȈ ᖃT4࢑զॏᛅѺࡤ෉ҧ‫ޒ‬သೊᅮᇍᐩ࡚‫ޠ‬ѠᎭ‫ޠ‬Р‫ݳ‬Ȟկሰ୥ྲᛅѺ ෉‫ޠ‬୥ՄঅȟȂѠп‫ڦ‬х෭ᚕT4‫ޠ‬ข໕ȇկӶᛅѺࠊ෉ᖃT4Ѡ૗ϛԄ ෭ᚕT4ѠᎭȄ෭ᚕT4 indexѠпᆡጃզॏ෭ᚕT4‫ޠ‬ᐩ࡚Ȅ ା࡚࡛ឋȂϜᜍᐄ઼๊ ѯᢋȈ ґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ შΚȃᛅѺ෉໣ҧ‫ޒ‬သѓ૗‫ޠ‬ҔளҢ౪ᡑϾ (From Korevaar TIM et al. Nat Rev Endocrinol 2017;13:610-622)Ȅ

5

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

ߓΚȃзࣩөӵTSHІ෭ᚕT4ӶᛅѺࠊ෉‫ޠ‬୥Մঅ (Modified from Alexander EK, et al. Thyroid 2017; 27:315-389).

஠ԥӫມϜऽНᄈྲߓ ҧ‫ޒ‬သષ๗Ӭ౩೗Ҫ

Thyroid-binding globulin

෭ᚕѳ࿩ҧ‫ޒ‬သષ

Free T4

ᖃѳ࿩ҧ‫ޒ‬သષ

Total T4

ׂ৓ॷήঐУ

First trimester

ׂ৓ϜήঐУ

Second trimester

ׂ৓ҒήঐУ

Third trimester

΢᜹๘Ъጱߵ‫ܓ‬သᐮષ

Human chorionic gonadotropin

TSH‫ڨ‬ᡞ

TSH receptor

Ս୞ռ࣬ขۢ‫ݳ‬

Automated immunoassays

҂ᒌഇ‫ݚ‬

Equilibrium dialysis

ົཌྷᘯ

8OWUD¿OWUDWLRQ

షࣻՔᜋ/՜ᖓ፵ᜋ

Liquid chromatography/tandem mass spectrometry (LC/MS/MS)

ٙᡞ፵໕ࡿ኶

Body mass index

Ӥ՞ષไម

Isotope dilution ҧ‫ޒ‬သѓ૗ᔯᡜᇅׂ৓

6

୥ՄНᝧ 1. van Raaij JM, Vermaat-Miedema SH, Schonk CM, Peek ME, Hautvast JG. Energy requirements of pregnancy in The Netherlands. Lancet 1987; 2:953–955.

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Acta Endocrinologica 1982; 101:531.

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Laboratory support for the diagnosis and monitoring of thyroid disease. Thyroid 2003; 13:3– 126.

6ROGLQ 23 7UDFWHQEHUJ 5( +ROORZHOO -* -RQNODDV - -DQLFLF 1 6ROGLQ 6- 7ULPHVWHU VSHFL¿F changes in maternal thyroid hormone, thyrotropin, and thyroglobulin concentrations during gestation: trends and associations across trimesters in iodine sufficiency. Thyroid 2004; 14:1084–1090.

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10. Panesar NS, Li CY, Rogers MS. Reference intervals for thyroid hormones in pregnant Chinese women. Ann Clin Biochem 2001; 38:329–332.

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13. Stagnaro-Green A, Abalovich M, Alexander E, Azizi F, Mestman J, Negro R, Nixon A, Pearce EN, Soldin OP, Sullivan S, Wiersinga W, American Thyroid Association Taskforce on Thyroid Disease During Pregnancy and Postpartum. Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and postpartum. Thyroid 2011; 21:1081–1125.

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ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

14. De Groot L, Abalovich M, Alexander EK, Amino N, Barbour L, Cobin RH, Eastman CJ, Lazarus JH, Luton D, Mandel SJ, Mestman J, Rovet J, Sullivan S. Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2012; 97:2543–2565.

15. Casey BM, Dashe JS, Wells CE, McIntire DD, Leveno KJ, Cunningham FG. Subclinical hyperthyroidism and pregnancy outcomes. Obstet Gynecol 2006; 107:337–341.

16. Thienpont LM, Van Uytfanghe K, Beastall G, Faix JD, Ieiri T, Miller WG, Nelson JC, Ronin C, Ross HA, Thijssen JH, Toussaint B, IFCC Working Group on Standardization of Thyroid Function Tests. Report of the IFCC Working Group for Standardization of Thyroid Function Tests; part 2: free thyroxine and free triiodothyronine. Clin Chem 2010; 56:912–920.

17. Yue B, Rockwood AL, Sandrock T, LaɅulu SL, Kushnir MM, Meikle AW. Free thyroid hormones in serum by direct equilibrium dialysis and online solid-phase extraction–liquid chromatography/tandem mass spectrometry. Clin Chem 2008; 54:642–651.

18. Anckaert E, Poppe K, Van Uytfanghe K, Schiettecatte J, Foulon W, Thienpont LM. FT4 immunoassays may display a pattern during pregnancy similar to the equilibrium dialysis IDLC/tandem MS candidate reference measurement procedure in spite of susceptibility towards binding protein alterations. Clin Chim Acta 2010; 411:1348–1353.

19. Sapin R, dɅHerbomez M. Free thyroxine measured by equilibrium dialysis and nine immunoassays in sera with various serum thyroxine-binding capacities. Clin Chem 2003; 49:1531–1535.

20. Korevaar TI, Chaker L, Medici M, de Rijke YB, Jaddoe VW, Steegers EA, Tiemeier H, Visser TJ, Peeters RP. Maternal total T4 during the first half of pregnancy: physiologic aspects and the risk of adverse outcomes in comparison with free T4. Clin Endocrinol (Oxf) 2016; 85:757763.

21. Lee RH, Spencer CA, Mestman JH, Miller EA, Petrovic I, Braverman LE, Goodwin TM. free 7 LPPXQRDVVD\V DUH ÀDZHG GXULQJ SUHJQDQF\ $P - 2EVWHW *\QHFRO H ± e6.

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8

Ᏻ᠟ ‫ݔ‬πߞ۹ख‫܉‬ᚃଲུചхᗃऌ ‫ݔ‬ϧ኉ఁ௳

Ӊե੾੿ϟຩᘟᇅ‫ݾ‬ᕜȂߩள२्‫ޠ‬Κӈ‫࢑ٲ‬Ҕளঅ ϟණ‫ٽ‬ȄसณҔளঅϟ୥ՄӶຩᘟᇅ‫ݾ‬ᕜ஡ѷџ‫ٸ‬ᐄȄᛅ ѺҐٙӶ΢ᡞཽЖึϲϸ‫قݫ‬ಜೊᅮᇍϸ‫ݫ‬஽੩ϟକӆᡑ ϾȄӱՅȂѠпདྷ჌Κ՞υ‫ܓ‬ӶᛅѺϜҧ‫ޒ‬သೊᅮᇍᡑϾ ࢑ѠႲ෉‫ޠ‬ȄӱԫȂᖞ‫ט‬Ӷຩᘟᇅ‫ݾ‬ᕜҧ‫ޒ‬သөᆎ੾੿Ӷ ᛅѺᇅߩᛅѺொ޲҇໹ԥϛӤϟ୥ՄၦਠȂᏱཽԫԪණ‫ٽ‬ ȶ㥞৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬КьȷΚН஡ණ‫ٽ‬τঢ় Ӷᖞ‫ט‬αಁӼυ‫ܓ‬ᛅѺঐ਱ԥҧ‫ޒ‬သ੾੿ਣ२्ϟ୥Մၦ ଊȄ

9

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

࿩‫ޒ‬ᄙ‫ڸ‬ᕋᎵ ‫ݔ‬πߞ۹ख‫܉‬ᚃଲ ؄ਥᄹ ࠊّȈ ӶᛅѺ෉໣ȂҦܼҧ‫ޒ‬သೊᅮᇍҢԚቩђȃ๬᠛௷я࿩‫ޠ‬໕ቩђпІ फ‫ڌ‬࿩ሰؒαЁȂӱԫѺஐӶ໾ॶϜ‫ޠ‬࿩ሰؒ໕ཽାܼߩᛅѺ‫ޠ‬Ԛ΢ (1) ȄᛅѺࠊ‫ڸ‬ᛅѺ෉໣ԥᎍ໕࿩ឹ‫ޠڦ‬υ‫ܓ‬Ȃҧ‫ޒ‬သϲԥ٘໕‫ޠ‬࿩ᓾ ԇȂ‫ٽٿ‬ᔗᛅѺ෉໣ҧ‫ޒ‬သೊᅮᇍᇨആቩђ‫ޠ‬ሰؒȂ‫ٻ‬ѺஐӶᛅѺ෉ ໣ߴࡼᛨۢ‫ޠ‬ӓٙ࿩֥໕ȄดՅӶሇ࡚ՎϜ࡚࿩ુн‫ޠ‬ӵୣȂп‫׎‬࿩ Ї࢏‫ޠ‬ᡞϲ࿩ຮԇȂ௄first trimester‫ژ‬third trimesterཽഃᅛί७(2)ȄӶ Ң౱‫ࡤ׈‬Ȃᔊ‫ڌ‬ᕋᎵ‫ܛ‬ሰ‫ޠ‬࿩࢑௄ҕ‫ٱ‬ϜᕖூȂӱԫ঴‫ٱ‬Ϝ‫ޠ‬ஐυ໾ ॶϜ࿩‫ޠ‬ሰؒηཽၮ຀ቩђȄ‫׎‬࿩ᐩ࡚࢑ҭࠊഷளңܼຠզᐍᡞఋထ ‫ޠ‬࿩‫ޒ‬ᄙȂկҦܼΚСϟϜᇅؑС‫׎ޠ‬࿩௷я໕ԥ݃ᡘৰ౵Ȃӱԫ‫׎‬ ࿩ᐩ࡚ϛ૗‫׈‬ӓጃۢঐ΢‫ޠ‬࿩‫ޒ‬ᄙ(3,4)Ȅ ࡛ឋȈ ‫׎‬࿩ᐩ࡚‫ޠ‬Ϝ՞኶Ѡпңܼຠզᐍᡞఋထ‫ޠ‬࿩‫ޒ‬ᄙȂկ൑Ԫ‫ܗ‬24ϊਣ ‫׎‬࿩ᐩ࡚ࠔϛ૗࡟ྦጃӵң‫ٿ‬ຠզঐ΢‫ޠ‬࿩ᕋᎵ‫ݸޒ‬Ȅ ା࡚࡛ឋȂାᜍᐄ઼๊ ѯᢋȈ ѯᢋܼߗԒȞ2016ȟԥึߓп‫׎‬࿩ᐩ࡚‫ޠ‬Ϝ՞኶‫ٿ‬ຠզ2005-2008Ԓѯ ᢋԚԒ΢࿩ᕋᎵ‫ޒ‬ᄙȂ‫׎‬࿩ᐩ࡚‫ޠ‬Ϝ՞኶࣐100 ȝ g/LȂ‫ڐ‬๗‫ݏ‬ᡘұԥ ഌϸఋထ‫ޠ‬΢Ѡ૗ԥ࿩ુнȂ੬ր࢑Ԓखτܼ60ྒ‫ޠ‬ၷՃԚ΢ȃ۩՟ Ӷύୣ‫ޠ‬ҖಁᇅԒखϮܼ19-44ྒ‫ޠ‬ᛅѺஐυ(5)ȄଷԫϟѵȂӶ‫؂‬ԟ‫ٳ‬ ԒȞ2014ȟึߓѯᢋη෇п‫׎‬࿩ᐩ࡚‫ޠ‬Ϝ՞኶‫ٿ‬ຠզ2001-2002Ԓ໣ѯ ᢋᏱ่Ӷ୾ঢ়ॶᢅђ࿩࢈๋ᡑ‫ޠࠊ؂‬࿩ᕋᎵ‫ݸޒ‬ȞѯᢋՍ1967Ԓ໡ۗ ஽‫ښ‬ᄃࢋӓѯॶᢅђ࿩Ȃ1990Ԓѯᢋᇨᢅኆ໡ۗӤਣҢ౱ђ࿩ᢅ‫ڸ‬ϛ ђ࿩ᢅȂ‫ژ‬Π2003Ԓӱ࣐ђΤWTOȂ໡ܺѵ୾ᢅໍπȂԥ‫ໍٳ‬πᢅ࢑ ϛђ࿩ᢅȄȟ‫ڐ‬๗‫ݏ‬ᡘұ਴ᐄзࣩፐҢಣᙒዀྦȂӶ2001-2002Ԓਣѯ ᢋ࿩ᕋᎵ‫٘࢑ݸޒ‬஋‫(ޠ‬6)ȄՅӶ‫ي‬ឮ෉υ‫ޠܓ‬࿩ᕋᎵ‫ݸޒ‬Р८Ȃ20052008Ԓः‫ف‬Ϝ19-44ྒ‫ي‬ឮ෉υ‫׎ޠܓ‬࿩Ϝ՞኶࣐103 ȝ g/L(5)Ȃ2013Ԓ ः‫࣐ࠍف‬124 ȝ g/L (7)ȄᗷดпԚԒ΢ዀྦ(‫׎‬࿩Ϝ՞኶100-199 ȝ g/L)࣐ ҔளȂկसԃউໍΤᛅѺȂ೼ኻ‫ޠ‬኶অӶᛅѺυ‫࢑ܓ‬឵ϛ٘‫(ޠ‬ᛅѺυ ‫׎ܓ‬࿩Ϝ՞኶Ҕளዀྦ࣐150-249 ȝg/L)Ȅ Κȃᝓ२࿩ુнᄈҕᒒȃफ‫ޠ่ڌڸڌ‬ኈ៫࣐եȉ ᇴ݃Ȉ ҕᒒ‫ޠ‬໾ॶϜ࿩ુнཽᏳयҕᒒ‫ڸ‬फ‫ޠڌ‬ҧ‫ޒ‬သೊᅮᇍҢԚ‫཭ڨ‬Ȅ՗ Ϝҧ‫ޒ‬သೊᅮᇍմίཽ‫ڗ‬ᐮဟί࠮ᡞTSHҢԚȂՅTSHᐩ࡚ቩђཽ‫ڗ‬ ᐮҧ‫ޒ‬သҢߞໍՅᏳयҕᒒІफ‫ڌ‬я౫ҧ‫ޒ‬သလ(8)ȄӶᝓ२࿩ુн‫ޠ‬ ӵୣȂԥӼႁ30%‫ޠ‬Ѻஐཽԥҧ‫ޒ‬သ๗࿾Ȅᝓ२࿩ુнѺஐԥၷାᐡ ࿩‫ޒ‬ᄙ‫ڸ‬ᕋᎵ

10

౦ึҢࢻ౱ȃԬ౱Іᔊ‫ڌ‬Ԭκ(9)Ȅ Ҕளᐩ࡚‫ޠ‬ҧ‫ޒ‬သೊᅮᇍᄈઢစϰ‫ם‬Ԛȃᡝᓚ‫ם‬Ԛ‫ڸ‬फ‫ڌ‬τဟ‫ޠ‬๗ᄻ ึ‫྄࣐ي‬२्ȄӶᐍঐᛅѺ෉໣എሰ्ҧ‫ޒ‬သೊᅮᇍȂ࿩ુнཽኈ៫ ҕᒒ‫ڸ‬फ‫ޠڌ‬ҧ‫ޒ‬သೊᅮᇍ౱ҢȄᛅѺ෉໣ҕᒒ‫ڸ‬फ‫ڌ‬࿩ુнཽᄈफ ‫ޠڌ‬ᇰ‫ޤ‬ѓ૗ึ‫ي‬ԥϛًኈ៫(10-13)ȄҕᒒӶᛅѺ෉໣ԥᝓ२࿩ુн‫ޠ‬ ‫่ڌ‬Ѡ૗ึҢ֓ϊ઀Ȃ‫ڐ‬੬ኊ࢑ᝓ२‫ޠ‬හΩሬᛥȃՇ᠙‫ڸ‬ၽ୞ቋ฾Ȅ ࿩ુн࢑ӓзࣩആԚහΩુട‫ޠ‬л्঩ӱկ೼ࠔ࢑ѠпԥਞႲ٪‫ޠ‬Ȅ ӓ८‫ॶޠܓ‬ᢅђ࿩࢑ഷ‫ڏ‬ԚҐਞઊ‫ޠ‬࿩၅щРԓȂѠп‫׾‬๢Ѻ౱ஐ‫ڸ‬ ᔊ‫ڌ‬ୋஷ(14)Ȅ ѯᢋȈ ґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ Ρȃሇ࡚ՎϜ࡚࿩ુнᄈҕᒒȃफ‫ޠ่ڌڸڌ‬ኈ៫࣐եȉ ᇴ݃Ȉ‫׎‬࿩ᐩ࡚Ϝ՞኶࣐ 50-150 ȝ g/L ‫ޠ‬Ѻஐఋထೞۢဏ࣐ሇ࡚ՎϜ࡚࿩ુ нȄᛅѺ෉໣ሇ࡚ՎϜ࡚࿩ુн‫ޠ‬ஐυԥၷାॴᓏึҢҧ‫ޒ‬သလ(8)п Іҧ‫ޒ‬သ੾੿(15)ȄᛅѺ෉໣ҕᒒԥմ‫׎‬࿩ᐩ࡚ᇅफዻ२໕෶ሇІུҢ ‫ڌ‬ᓟ൝෶ЎԥࣻᜱȄӶ࿩ឹ‫ڦ‬໕щ٘‫ޠ‬ӵୣȂҕᒒ‫׎‬࿩ᐩ࡚‫ޠ‬ᡑ౵ᄈ फ‫ڌ‬ٙᡞึ‫ޠي‬ኈ៫ԥ४(16)Ȅሇ࡚ՎϜ࡚‫ޠ‬ҕᒒ࿩ુнᇅ‫ݨޠ่ڌ‬ཏ Ωુടȃႇ୞Іᇰ‫ޤ‬ѓ૗‫ࣻ཭ڨ‬ᜱ(17-19)ȄӶ࿩ુнӵୣȂᛅѺࠊॶᢅ ђ࿩ጃᄃ‫׾‬๢Πҕᒒҧ‫ޒ‬သѓ૗ȂηѠ૗‫׾‬๢‫่ڌ‬ઢစึ‫(ي‬20,21)Ȅ ѯᢋȈґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ ήȃӓзࣩѺஐ‫ڸ‬঴‫෉ٱ‬ஐυ‫ޠ‬࿩ᕋᎵ‫ޒ‬ᄙԄեȉ ᇴ݃ȈՍ1990Ԓп‫ٿ‬Ȃӓ౩‫ٻ‬ңॶᢅђ࿩‫ޠ‬ঢ়৴኶໕௄ϛ‫ژ‬20%ቩђ‫ົژ‬ႇ 70%(22,23)ȂᏒᆔԥ೼ኻ‫׾ޠ‬๢ȂϬԥ30ঐ୾ঢ়ુ࿩Ȃ࿩ુнϬด࢑ӓ зࣩѠႲ٪‫ޠ‬හΩુട‫ޠ‬л्঩ӱ(12)Ȅഷߗ‫ޠ‬ൣ֚ᡘұॶᢅђ࿩‫׾‬๢ ΠӠ࡚‫ુޠ‬࿩‫ޒ‬ᄙȂկᗚ࢑ԥНᝧࡿяӠ࡚Ϭ࢑࿩ᕋᎵુн‫ޠ‬ӵୣ (24) Ȅ۞ђ‫ܝ‬ၼ؇ӵୣѬԥ 6% ‫ޠ‬Ѻஐ‫׎‬࿩ᐩ࡚ၷմȂՅВஆල‫ࠍۅ‬ԥ 80%‫ޠ‬Ѻஐ‫׎‬࿩ᐩ࡚ၷմȄӶα੖ȂΚഌϸѺஐԥ࿩ુнȂՅᘮ໩Ҁ ࠍԥ࿩ႇ໕(25)ȂᏳय‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մί‫੿ޠ‬΢ቩђȄᗻ୾‫ޠ‬࿩ᕋ Ꮅ‫ޒ‬ᄙ࣐ႇ໕Ȟ‫׎‬࿩ᐩ࡚Ϝ՞኶࣐427 ȝ g/Lȟ(26)ȄСҐ‫ޠ‬࿩ᕋᎵ‫ޒ‬ᄙ η࢑ႇ໕Ȟ‫׎‬࿩ᐩ࡚Ϝ՞኶ 328 ȝ g/Lȟ(27)ȄӶߩࢹτഛȂѼСᅮᇅ৆ ༭߽Щ‫ޠٴ‬ᛅѺஐυ࿩ᕋᎵ‫ޒ‬ᄙ࣐ϛ٘(28,29)ȄӁਮ‫ޠ‬࿩ᕋᎵщ٘(30)Ȅ ӶВ՚Ȃ‫׎‬࿩ᐩ࡚Ϝ՞኶࣐138 ȝ g/LȂѠ૗࢑ҦܼॶᢅϜ࿩ᐩ࡚७մ (31) ȄӶዊࢹȂєࢃЩւਣȃ௧ջӔ‫୾ڸ‬ȃϞബȃ‫୾ݳ‬ȃ‫ܝ‬಴ᆱ‫ٴ‬ȃਙ ࡅȃ՚ੳв‫ڸ‬ऽ୾Ӷϲ‫ޠ‬೩Ӽ୾ঢ়‫ޠ‬ѺஐϬԥᝓ२ુ࿩‫ޠ‬௒‫(ݸ‬32-38)Ȅ ѯᢋȈ ႇџ෇ԥϊ೤ዂϟѺஐ࿩ᕋᎵ።ࢦȂ‫׎‬࿩Ϝ՞኶‫ٯ‬ґႁ150 ȝ g/LϟҔ ளጓ൝ (39)ȇҭࠊϬԥѺஐ࿩ᕋᎵः‫ف‬ҔӶໍ՘ϜȄ

11

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

ѳȃᛅѺ‫ڸ‬঴‫෉ٱ‬၅щ࿩࢑֐૗‫׾‬๢ᝓ२ુ࿩‫ݏࡤޠ‬ȉ ᇴ݃ȈӶᝓ२ુ࿩‫ޠ‬ӵୣȂҕᒒӶᛅѺࠊ‫ܗ‬ᛅѺߒ෉၅щ࿩ཽ‫׾‬๢‫ޠ่ڌ‬ᇰ ‫ޤ‬૗Ω(40)Ȃӱԫ֓ϊ઀‫ڐڸ‬уᝓ२ઢစ‫ق‬ಜ౵ள‫ޠ‬ᑰ੿౦ཽԥᡘ຀७ մ(41)Ȃηཽ७մԬ౱౦ȃІུҢ‫ڸڌ‬ᔊ‫ڌ‬Ԭκ౦(42,43)ȄӶഌϸӵୣп π݉࿩‫ݷ‬РԓϛկѠᕥҔ࿩ુнȂᔊ‫ڌ‬яҢᡞ२η֖౫αЁ(44)Ȅ ഷߗ‫ޠ‬Κ໷ᓎᐡᖞ‫ט‬ၑᡜึ౫ȂӶ‫ء‬ԥॶᢅђ࿩‫ޠ‬Ϝ࡚Վ२࡚ુ࿩ӵ ୣȂϸ৕ࡤ௦‫ڨ‬ΚᏙ400రջπ݉ђ࿩‫ޠݷ‬঴‫ٱ‬ஐυѠпഇႇҕ‫ٱ‬๞ ϡᔊ‫٘ڌ‬஋‫ޠ‬࿩ՎЎ6ঐУȂկ‫ޣ‬௦๞ᔊ‫ڌ‬࿩၅щᏙӶ‫׾‬๢ᔊ‫ڌ‬࿩ᕋ Ꮅ‫ޒ‬ᄙ‫ޠ‬ਞ‫ࠍݏ‬ၷৰ(45)Ȅ ѯᢋȈґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ ϥȃᛅѺ‫ڸ‬঴‫෉ٱ‬၅щ࿩࢑֐Ѡп‫׾‬๢ሇ࡚ՎϜ࡚࿩ુнஐυ‫ޠ‬Ⴒࡤȉ ᇴ݃ȈҭࠊϑစึߓΠ8ঐᄈሇ࡚ՎϜ࡚࿩ુн‫ޠ‬ዊࢹѺஐ၅щ࿩‫ޠ‬ᖞ‫ט‬ၑᡜ (46-53) ȂᏒᆔ࿩၅щ‫ޠ‬Ꮩ໕‫ڸ‬ਣ໣ϛӤȂՅй‫ڐ‬ϜѬԥ‫ڎ‬ঐၑᡜԥः‫ف‬ ᄈίΚхึ‫ޠي‬ኈ៫ȄᄈϜ࡚࿩ુн‫ޠ‬Ѻஐ၅щ࿩ᡘұѠп७մҕᒒ ᇅུҢ‫ڌ‬ҧ‫ޒ‬သᡞᑗ‫ڸ‬ҧ‫ޒ‬သ౩೗ҪȞTgȟȄดՅᄈҕᒒҧ‫ޒ‬သѓ૗ ‫ޠ‬ኈ៫ࠔ࢑ϛΚय‫ޠ‬Ȃ8ঐϑึߓ‫ޠ‬ၑᡜϜԥ4ঐᡘұҕᒒ՗ϜTSH݃ ᡘ෶ЎȂՅѬԥ‫ڎ‬ঐၑᡜᡘұҕᒒT4‫ܗ‬free T4ቩђȄᙞழ՗ϜTSH‫ޠ‬ ෶ЎηᜍᄃᛅѺਣ࿩‫ޒ‬ᄙԥ‫׾ܛ‬๢(54)Ȅ Ӷሇ࡚‫ژ‬Ϝ࡚࿩ુн‫ޠ‬ӵୣȂԥ‫ڎ‬໷ߩᓎᐡः‫ف‬๗‫ݏ‬ᡘұѺஐԄӶᛅ Ѻ෉໣௦‫ڨ‬࿩‫ޠ‬၅щȂ‫ޠ่ࡇڐ‬ઢစึ‫ي‬ԥ‫׾ܛ‬๢ȇดՅѫΚ໷ः‫ف‬ ࠍᡘұȂᗷดӶᛅѺ෉໣௦‫ڨ‬࿩‫ޠ‬၅щȂկ‫ࡇڐ‬φܼ16ঐУτਣઢစ З౪‫ޒ‬ᄙ‫ٯ‬ณ݃ᡘ‫׾‬๢(55)Ȅ೼‫ٳ‬ϛΚय‫ޠ‬ः‫ف‬๗‫ཱུݏ‬ұ࿩၅щ‫ޠ‬ਣᐡ Ѡ૗྄࣐२्Ȃӱ࣐Ԅ‫ݏ‬ӶᛅѺ10-20 ໋ࡤϘ໡ۗ၅щȂ࿩ᄈίΚх ึ‫ޠي‬ਞઊծо൸ཽോѷȄԄ‫ݏ‬ӶᛅѺࠊ֊໡ۗ၅щ࿩Ȃҕᒒ‫ޠ‬ҧ‫ޒ‬ သѓ૗൸ѠпӒᕖூ‫׾‬๢;ӱԫ௦‫ڨ‬࿩၅щ‫ޠ‬Ꮩ໕‫ڸ‬໡ۗਣ໣ཽኈ៫๗ ‫ݏ‬ȄԥΚঐಜӬϸ‫ݚ‬ᡘұ࿩၅щѠп‫׾‬๢ҕᒒҧ‫ޒ‬သѓ૗ࡿ኶Ȃ‫ٯ‬Ѡ ૗ԥઊܼᏱឮ‫ޠ่ڌ‬ᇰ‫ޤ‬ѓ૗Ȃ֊‫࢑ٻ‬Ӷሇཌྷ࿩ુн‫ޠ‬ӵୣη࢑(56)Ȅ ᄈܼӶሇ࡚ՎϜ࡚࿩ુн‫ޠ‬ӵୣໍ՘࿩၅щ‫ޠ‬ᓎᐡᖞ‫ט‬ၑᡜ࢑֐Ӭо ၿ኉Ϭԥ‫ލ‬ឋȂӱ࣐ᄈܼϑစ۩՟Ӷુ࿩ӵୣ‫ޠ‬ҖಁՅّȂ‫ڐ‬௦‫ڨ‬࿩ ၅щ‫࢑ܓ्҇ޠ‬Ӭ౪ԇӶ‫ޠ‬Ȃ‫ܛ‬п٠ϭ࣐ЦȂϬ‫ء‬ԥᓎᐡᖞ‫ט‬ၑᡜџ ः‫ܼف‬ሇ࡚ՎϜ࡚࿩ુнӵୣ‫ޠ‬঴‫ٱ‬ஐυ၅щ࿩‫ޠ‬ኈ៫Ȅ ѯᢋȈґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ ϳȃॏდᛅѺ‫ޠ‬ஐυȃѺஐ‫ڸ‬঴‫ٱ‬ஐυ‫ؑޠ‬С࿩ឹΤ໕ᔗ࢑ӼЎȉ ᇴ݃Ȉ ࿩࢑ҧ‫ޒ‬သೊᅮᇍҢԚ‫҇ܛ‬ሰ‫ޠ‬ϰષȂл्‫ٿ‬Ս໾ॶ‫ڸ‬ᇅΚ‫ٳ‬ᆱҢષ/ ᝫ‫ޑ‬፵ᇨᏙȄThe U.S. Institute of MedicineȞज୾ᚃᏱः‫ܛف‬ȟ࡛ឋॏ

࿩‫ޒ‬ᄙ‫ڸ‬ᕋᎵ

12

დᛅѺ‫ޠ‬υ‫ؑܓ‬Сᖃ࿩ឹΤ໕Ȟ໾ॶ‫ڸ‬၅щᏙȟ‫ޠ‬ҭዀ࣐150 ȝ g/dȃ Ѻஐ࣐220 ȝ g/dȂՅᗾҕ‫ٱ‬ஐυ࣐290 ȝ g/d(57)ȄзࣩፐҢಣᙒ࡛ឋѺஐ ‫ڸ‬঴‫෉ٱ‬ஐυؑС࿩ឹ‫ڦ‬໕࣐250 ȝ g/d(8)Ȅ೼ঐ࡛ឋ‫ޠ‬኶অூ‫ژ‬ΠΚ໷ ᄈົႇ7000ӫϜ୾Ѻஐ‫ޠ‬ः‫ف‬МࡼȂ‫ڐ‬Ϝึ౫‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մί ‫ڸ‬ҧ‫ޒ‬သѓ૗մίӶ‫׎‬࿩ጓ൝150-249 ȝ g/LਣഷϛளُȂկѬ्‫׎‬࿩ ᐩ࡚մܼ‫ܗ‬ାܼ೼ጓ൝Ȃ൸ԥѠ૗ึҢ‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մί‫ܗ‬ҧ‫ޒ‬ သѓ૗մί(25)Ȅ໾ॶϜ‫ޠ‬࿩‫ྜٿ‬ӱӵୣՅ౵Ȃज୾໾ॶϜ‫ޠ‬࿩‫࡟ྜٿ‬ ᜳጃۢȂഌϸ঩ӱ࢑ӱ࣐ԥөԓөኻ‫ޠ‬዗Ӷ‫ྜٿ‬йॶࠣϜ‫ޠ‬࿩֥໕ԥ ਣ‫ءٯ‬ԥചӗӶє၇αȄђ࿩ᢅϬด࢑ӓзࣩ੒ଷ࿩ુн઀‫ޠ‬л्Р ԓȂ֊‫ٻ‬ԄԫȂज୾௄ґ஽‫ॶ्ؒښ‬ᢅђ࿩ȂӶज୾༊ङ50ʦॶᢅԥ ђ࿩ȄӶज୾Ȃ‫ٱ‬ᇨࠣ࢑ѫΚᆎ२्‫ޠ‬໾ॶ࿩‫ྜٿ‬Ȃӱ࣐гႸਠϜ‫ޠ‬ ࿩‫ٱڸ‬ᇨࠣ՘ཿ‫ٻ‬ң֥࿩੒ࢴᏙȇଷԫϟѵȂҦܼ‫ٻ‬ң֥࿩ሗᢅឩє ።౪ᏙȂ୧ཿ੦ฏ‫ޠ‬ឩєӶज୾ࠍ࢑ѫΚᆎл्‫ޠ‬࿩‫ྜٿ‬ȄดՅȂӶ ႇџ‫ޠ‬ංΫԒϜȂ࿩ሗᢅឩє።౪Ꮩ‫ٻޠ‬ңϑစ෶ЎȂࣻၷϟίȂज ୾໾ॶϜ‫ڐޠ‬ул्࿩‫࢑ྜٿ‬Ѡ૗࢑੖ᘁȃᚙ೗ȃՉ᜹‫ڸ‬ঢ়࿴Ȅ੖ࢸ ॶ‫ޑ‬೾ள֥ԥାᐩ࡚‫ޠ‬࿩Ȃӱ࣐੖ࢸ୞‫ཽޑ‬௄੖ЬϜᐩᕼ࿩ȂดՅϛ Ӥ‫ޠ‬ന᜹ᇅϮٕ᜹࿩֥໕ৰ౵࡟τȄ Ӷज୾Ȃณ፤࢑೾ႇொ޲੿ѭᗚ࢑೾ႇӉեᄃᡜࡊข໕Ȃഎณ‫ݳ‬ѠᎭ ӵጃۢΚঐ΢‫ޠ‬໾ॶ࿩ឹΤ໕ȄҦܼᐋЗΚഌϸᛅѺ‫ޠ‬ज୾υ‫ܓ‬Ѡ૗ ԥሇ࡚ՎϜ࡚࿩ુнȂज୾ҧ‫ޒ‬သᏱཽȞATAȟϟࠊ൸ϑ࡛ឋ‫ܛ‬ԥі जѺஐ‫ܗ‬঴‫෉ٱ‬ஐυؑЉ‫ٻ‬ң֥150 ȝ g࿩‫ޠ‬၅щᏙȄഷߗȂϲϸ‫ݫ‬Ᏹ ཽȃ࿍‫ם‬Ᏹཽ‫ڸ‬ज୾‫ڌ‬ऌᚃᏱཽηණএ࣐Ѻஐ‫ڸ‬঴‫෉ٱ‬ज୾ஐυ၅щ ࿩Ȅ‫ڐ‬ҭዀ࢑၅щ໾ॶϜ‫ޠ‬࿩ឹ‫ڦ‬ȂՅߩ‫׈‬ӓ‫ڦ‬хȄկѠ૗ሰ्੬ր ‫ݨ‬ཏ‫࢑ޠ‬Ȃ٦‫ٳ‬໾ॶαԥ४‫ޠښ‬΢Ȟ‫پ‬Ԅ:‫ٱ‬ᑦϛट઀ȃᏌ፵ϛट‫ڨ‬ȃ մᆈЬϾӬ‫ܗޑ‬હષॶ޲ȟȂӱ࣐೼‫ٳ‬΢൸Ѡ૗्ԥ᚟ѵ‫ޠ‬࿩ᇨᏙ‫ٿ‬ ੬ր၅щȄ ดՅӶNHANES 2001-2006Ԓ‫ޠ‬኶ᐄϜȂѬԥ20%‫ޠ‬Ѻஐ‫ڸ‬15%‫ޠ‬঴‫ٱ‬ ஐυԥ‫ٻ‬ң֥࿩၅щᏙȄӶ2009ԒຠզਣȂӶज୾ԥ223ᆎ౱ࠊᆤӬ ᆱҢષϜȂѬԥ51%֥ԥ࿩ȄดՅ೼ঐ௒‫ݸ‬ϑစԥ‫׾ٳ‬ᡑȂӶ2015Ԓ ज୾၅щᏙᕋᎵ‫ې‬সཽ࡛ឋ‫ܛ‬ԥ౱ࠊᆤӬᆱҢષᇨᏙϜሰђΤ150 ȝ g ‫ޠ‬࿩Ȃज୾౱ࠊӼᆎᆱҢષϜ‫ޠ‬࿩೾ள‫ٿ‬Ս࿩Ͼ႖‫ٿܗ‬Ս੖᝾ȂҦܼ ੖ழ࿩֥໕‫ޠ‬ϛӤȂӱԫ֥ԥ੖ழ‫ޠ‬౱ࠊӼᆎᆱҢષࠣท‫ޠ‬࿩֥໕η Ѡ૗ཽϛΚयȄစள݉ңѿఌҧ‫ޒ‬သષȞLT4ȟ‫ޠ‬υ‫ܓ‬ϑϛሰ्ӕ᚟ ѵ၅щ࿩Ȃӱ࣐ϑϛሰ्٘஋‫ޠ‬࿩‫ٿ‬࿌ձ঩ਠܼᡞϲ‫ם‬Ԛҧ‫ޒ‬သೊᅮ ᇍȄ ࡛ឋȈ ‫ܛ‬ԥѺஐؑЉᔗឹ‫ڦ‬ङ250 ȝ g‫ޠ‬࿩Ȅ࣐ΠؑЉឹ‫ڦ‬ᖃӔ250 ȝ g‫ޠ‬࿩Ȃ Ѡ૗ሰ्਴ᐄϛӤ‫୾ޠ‬ঢ়ᇅӵୣ‫ٿ‬୉ᎍ࿌‫ޠ‬໾ॶᇅ࿩၅щᏙ።ᐍȄ ା࡚࡛ឋȂାᜍᐄ઼๊ 13

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

࡛ឋȈєࢃज୾Ӷϲ‫ޠ‬τӼ኶ӵୣȂྦറॏდᛅѺȞഷԂӶॏდᛅѺ‫ࠊޠ‬3ঐ У൸໡ۗȟ‫ܗ‬ҔӶᛅѺ‫ޠ‬ஐυଷΠஆҐ໾ॶѵȂᔗ၏ؑСπ݉၅щ֥ ԥ150 ͢g࿩Ͼ႖‫ם‬ԓ‫ޠ‬࿩၅щᏙȄା࡚࡛ឋȂϜᜍᐄ઼๊ ࡛ឋȈӶၦྜვн‫୾ޠ‬ঢ়І‫ء‬ԥॶᢅђ࿩η‫ء‬ԥСள࿩၅щᏙ‫ޠ‬ӵୣȂᄈܼ Ѻஐ‫يڸ‬ឮஐυѠп‫ٻ‬ңؑԒ൑ΚᏙ໕400 mg࿩‫ٿݷ‬࿌ձᖞਣ‫ޠ‬၅щ РԓȂկ೼ϛᔗңձߞ෉೏ဋȂηϛ၏ңܼᗚԥ‫ڐ‬уᒶᐆ‫ޠ‬ӵୣȄ մ࡚࡛ឋȂϜᜍᐄ઼๊ ࡛ឋȈᄈܼҔӶ௦‫ڨ‬ҧ‫ޒ‬သѓ૗Ϧໍ‫ݾ‬ᕜ‫݉ܗ‬ң LT4‫ޠ‬ѺஐȂณሰ੬ր‫ٻ‬ң ֥࿩၅щᏙȄմ࡚࡛ឋȂմᜍᐄ઼๊ ѯᢋȈ୾΢ᑶॶᕋᎵષ୥Մឹ‫ڦ‬໕ঔॐಒΝ‫(ޏ‬Dietary Reference Intakes, DRIs)Ȃ࡛ឋѺஐؑС࿩ឹ‫ڦ‬໕࣐200 ȝg (58)Ȅ ΝȃѺஐ‫ڸ‬঴‫ٱ‬ஐυ࿩ឹ‫ڦ‬໕‫ޠ‬ԋӓα४࢑ӼЎȉ ᇴ݃Ȉ ҦܼWolff-Chaikoff‫ޠ‬ਞᔗȂτӼ኶‫ޠ‬΢૗஋ट‫ڨ‬໾ॶϜᄛ‫ڦឹܓ‬ႇ໕ ‫ޠ‬࿩Ȃկԥ‫ٳ‬΢ณ‫ݳ‬಴ᚕࡩ‫ܓ‬Wolff-ChaikoffਞᔗȂՅ‫ٻ‬ூ೼‫ٳ‬΢Ӷឹ Τႇ໕‫ޠ‬࿩௒‫ݸ‬ίܿொҧ‫ޒ‬သѓ૗մίȂफ‫ڌ‬Ѡ૗੬րৡܿึҢ೼ᆎ ௒‫ݸ‬Ȃӱ࣐फ‫ڌ‬಴ᚕଡᗘࡩ‫ܓ‬Wolff-Chaikoffਞᔗ‫ޠ‬૗Ω्‫ژ‬ᛅѺಒ36 ໋Ϙ‫׈‬ӓԚዤ(59,60)Ȅ ឹ‫ڦ‬໕‫ޠ‬α४ஆܼॶ‫ޑ‬ȃЬ‫ڸ‬၅щᏙϜ࿩‫ޠ‬ᖃឹΤ໕Ȃज୾ᚃᏱः‫ف‬ ‫ܛ‬ϑጃۢ‫ܛ‬ԥԚ΢ȞєࢃѺஐȟؑС࿩ឹ‫ڦ‬໕‫ޠ‬α४࣐1100 μgйзࣩ ፐҢಣᙒߓұȂᛅѺ෉໣ؑС࿩ឹ‫ڦ‬໕ົႇ500 μgѠ૗ႇ໕(25)Ȃ‫پ‬ѵ ‫ޠ‬௒‫࢑ݸ‬ӶСҐȂӶСҐԥ‫ٳ‬ӵୣ‫ޠ‬኶ᐄᡘұΚ‫ؑޣ‬Сឹ‫ົڦ‬ႇ500 μg‫ޠ‬࿩կࠔณ݃ᡘϛً๗‫ݏ‬Ȅ ᛿‫ޑ‬Ѡ૗࢑࿩ឹΤႇ໕‫ޠ‬঩ӱȂ‫׫‬Зࡢϛᐍ᛿amiodaroneؑ200 mg֥ ԥ75 mg࿩ȇ֥࿩ᡘኈᏙԥାႁ380 mg/ml‫ޠ‬࿩ȇΚ‫׌ٳ‬ഌ੒ࢴᏙ֥ԥ ࿩Ȃଷᝓ२ᐷ།ொ޲ѵȂӶԚ΢ӓٙ֝Ԟ೾ளϛ‫ڏ‬ԥᖞ‫ט‬ཏဏȄ֥࿩ ‫঺׫ޠ‬ൈ᛿‫ڸޑ‬‪࿏᛿ȂΚ‫࢑ܗޑॶٳ‬၅щࠣȂԄ੖ழ‫ڸ‬Κ‫ٳ‬࿩ᇨᏙ Ѡ૗֥ԥߩளτ໕‫ޠ‬࿩ȞЩؑСα४ାංξॼȟȂϛᔗ၏စள݉ңȄ ᛅѺ‫ܗ‬঴‫෉ٱ‬໣ϛ࡛ឋؑСឹΤ֥ԥົႇ500μg࿩‫ޠ‬၅щᏙ(єࢃ੖ழ ᇨᏙ) (61)Ȅ ኹ៪ܼႇ໕‫ޠ‬࿩ȂѠ૗Ᏻयҧ‫ޒ‬သѓ૗౵ளȃቩђାҧ‫ޒ‬သ‫ڗ‬ᐮષ՗ ઀ึҢ౦ᇅആԚᑰொҧ‫ޒ‬သѓ૗Ϧໍ‫ུޠ‬Ң‫੿ึڌ‬౦ቩђ(62)ȄԫѵȂ ෇ԥः‫ࡿف‬яȂᔊ‫ڌ‬ӱ࣐௦‫֥ڨ‬࿩ᡘኈᏙՅኹ៪Ӷႇ໕‫ޠ‬࿩ȂໍՅึ Ңҧ‫ޒ‬သѓ૗մί(63)Ȅѫѵ्‫ݨ‬ཏ‫࢑ޠژ‬Ȃ֊‫࢑ٻ‬մᏙ໕‫ޠ‬࿩၅щᏙ ηѠ૗ЖึΚϊഌϸυ‫ܓ‬ҧ‫ޒ‬သՍᡞռ࣬ࣁ‫ܓ‬αЁ(25)ȄดՅӶСҐԥ ‫ٳ‬ୣ஀Ȃԥः‫ف‬ᡘұτङήϸϟΚ‫ޠ‬СҐѺஐ‫׎‬࿩অົႇ500 μg/CrȂ կӶᛅѺႇโϜᇅफ‫ءٯيึڌ‬ԥึ౫౵ள(27)Ȅ ࡛ឋȈӶᛅѺ෉໣ᔗᗘռ௦ដ‫ژ‬ႇ໕‫ޠ‬࿩Ȃଷߩ࢑ӶК೛‫ݾ‬ᕜါ࿆Њ૮Ы઀ ࿩‫ޒ‬ᄙ‫ڸ‬ᕋᎵ

14

ࠊ;Ӷ๞ϡା֥࿩໕‫ޠ‬᛿‫ܗޑ‬ᔯࢦ᛿ᏙਣȂᖞ‫ט‬ᚃҢᔗсಡ᠍ᒌॴᓏ‫ڸ‬ Ԃ೏Ȅା࡚࡛ឋȂϜᜍᐄ઼๊ ࡛ឋȈ ҦܼᐋЗफ‫ึڌ‬Ңҧ‫ޒ‬သѓ૗౵ள‫ޠ‬Ѡ૗‫ܓ‬ȂᔗᗘռӶᛅѺ෉໣ؑС ௄໾ॶᇅᕋᎵ၅щᏙϜឹ‫ົڦ‬ႇ500 μg‫ޠ‬࿩Ȅା࡚࡛ឋȂϜᜍᐄ઼๊ ѯᢋȈ୾΢ᑶॶᕋᎵષ୥Մឹ‫ڦ‬໕ঔॐಒΝ‫(ޏ‬Dietary Reference Intakes, DRIs)Ȃ࡛ឋѺஐؑС࿩α४ឹ‫ڦ‬໕࣐1000 ȝg (58)Ȅ ஠ԥӫມϜऽНᄈྲߓ ‫׎‬࿩ᐩ࡚

Urinary iodine concentrations

ॶᢅђ࿩

Salt iodization

୥ Մ Нᝧ 1. Glinoer D 2007 The importance of iodine nutrition during pregnancy. Public Health Nutr 10:1542–1546.

2. Brander L, Als C, Buess H, Haldimann F, Harder M, Hanggi W, Herrmann U, Lauber K, Niederer U, Zurcher T, Burgi U, Gerber H 2003 Urinary iodine concentration during pregnancy in an area of unstable dietary iodine intake in Switzerland. J Endocrinol Invest 26:389–396.

3. Andersen S, Karmisholt J, Pedersen KM, Laurberg P 2008 Reliability of studies of iodine intake and recommendations for number of samples in groups and in individuals. Br J Nutr 99:813–818.

4. Koᣪnig F, Andersson M, Hotz K, Aeberli I, Zimmermann MB 2011 Ten repeat collections for urinary iodine from spot samples or 24-hour samples are needed to reliably estimate individual iodine status in women. J Nutr 141:2049–2054.

5. Tang KT, Wang FF, Pan WH, Lin JD, Won GS, Chau WK, Lin HD, Hsieh YT. 2016 Iodine status of adults in Taiwan 2005-2008, 5 years after the cessation of mandatory salt iodization.

J Formos Med Assoc. 115:645–51.

6. Tang KT, Pan WH, Wang FF, Lin JD, Won GS, Chau WK, Lin HD, Hsieh YT. 2014 Iodine status of Taiwanese children before the change in national salt iodization policy: a retrospective study of the nutrition and health survey in Taiwan 2001-2002. Asia Pac J Clin Nutr 23:481–487.

7. Wang FF, Tang KT, Pan WH, Won JG, Hsieh YT, Huang CJ. 2018 Iodine status of Taiwanese population in 2013: 10 years after changing from mandatory to voluntary salt iodization. Food Nutr Bull 39:75-85.

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'HODQJH )0 'XQQ -7 ,RGLQH GH¿FLHQF\ ,Q %UDYHUPDQ /( 8WLJHU 5' HGV :HUQHU DQG IngbarɅ s The Thyroid: A Fundamental and Clinical Text. Ninth edition. Lippincott, Williams and Wilkins, Philadelphia, pp 264–288. :RUOG +HDOWK 2UJDQL]DWLRQ ,QWHUQDWLRQDO &RXQFLO IRU WKH &RQWURO RI WKH ,RGLQH 'H¿FLHQF\

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Disorders/United Nations ChildrenɅ s Fund (WHO/ICCIDD/UNICEF) 2007 Assessment of WKH LRGLQH GH¿FLHQF\ GLVRUGHUV DQG PRQLWRULQJ WKHLU HOLPLQDWLRQ :RUOG +HDOWK 2UJDQL]DWLRQ Geneva.

11. Vermiglio F, Lo Presti VP, Castagna MG, Violi MA, Moleti M, Finocchiaro MD, Mattina F, Artemisia A, Trimarchi F 1999 Increased risk of maternal thyroid failure with pregnancy SURJUHVVLRQ LQ DQ LRGLQH GH¿FLHQW DUHD ZLWK PDMRU LRGLQH GH¿FLHQF\ GLVRUGHUV 7K\URLG ± 24.

GH (VFREDU *0 2EUHJRQ 0- GHO 5H\ )( ,RGLQH GH¿FLHQF\ DQG EUDLQ GHYHORSPHQW LQ WKH ¿UVW KDOI RI SUHJQDQF\ 3XEOLF +HDOWK 1XWU ± 13. Costeira MJ, Oliveira P, Santos NC, Ares S, Saenz-Rico B, Morreale de Escobar G, Palha -$ 3V\FKRPRWRU GHYHORSPHQW RI FKLOGUHQ IURP DQ LRGLQH GH¿FLHQW UHJLRQ - 3HGLDWU 159:447–453. =LPPHUPDQQ 0% 7KH HIIHFWV RI LRGLQH GH¿FLHQF\ LQ SUHJQDQF\ DQG LQIDQF\ 3DHGLDWU Perinat Epidemiol 26(Suppl 1):108–117.

15. Moreno-Reyes R, Glinoer D, Van Oyen H, Vandevijvere S 2013 High prevalence of thyroid GLVRUGHUV LQ SUHJQDQW ZRPHQ LQ D PLOGO\ LRGLQH GH¿FLHQW FRXQWU\ D SRSXODWLRQ EDVHG VWXG\ - Clin Endocrinol Metab 98:3694–3701.

16. Lean MI, Lean ME, Yajnik CS, Bhat DS, Joshi SM, Raut DA, Lubree HG, Combet E 2014 Iodine status during pregnancy in India and related neonatal and infant outcomes. Public Health Nutr 17:1353–1362.

17. Bath SC, Steer CD, Golding J, Emmett P, Rayman MP 2013 Effect of inadequate iodine status in UK pregnant women on cognitive outcomes in their children: results from the Avon Longitudinal Study of Parents and Children (ALSPAC). Lancet 382:331–337. +\QHV ./ 2WDKDO 3 +D\ , %XUJHVV -5 0LOG LRGLQH GH¿FLHQF\ GXULQJ SUHJQDQF\ LV associated with reduced educational outcomes in the offspring: 9-year follow-up of the gestational iodine cohort. J Clin Endocrinol Metab 98:1954–1962.

19. van Mil NH, Tiemeier H, Bongers-Schokking JJ, Ghassabian A, Hofman A, Hooijkaas H, Jaddoe VW, deMuinck Keizer-Schrama SM, Steegers EA, Visser TJ, Visser W, Ross HA, Verhulst FC, de Rijke YB, Steegers-Theunissen RP 2012 Low urinary iodine excretion during early pregnancy is associated with alterations in executive functioning in children. J Nutr 142:2167–2174.

20. Santiago P, Velasco I, Muela JA, SaɅ QFKH] % 0DUWÕɅ nez J, Rodriguez A, Berrio M, Gutierrez5HSLVR & &DUUHLUD 0 0RUHQR $ *DUFÕɅ a-Fuentes E, Soriguer F 2013 Infant neurocognitive development is independent of the use of iodised salt oriodine supplements given during pregnancy. Br J Nutr 110:831–839.

21. Trumpff C, De Schepper J, Tafforeau J, Van Oyen H, Vanderfaeillie J, Vandevijvere S 2013 0LOG LRGLQH GH¿FLHQF\ LQ SUHJQDQF\ LQ (XURSH DQG LWV FRQVHTXHQFHV IRU FRJQLWLYH DQG psychomotor development of children: a review. J Trace Elem Med Biol 27:174–183.

22. Caldwell KL, Pan Y, Mortensen ME, Makhmudov A, Merrill L, Moye J 2013 Iodine status in pregnant women in the National ChildrenɅ s Study and in U.S. women (15–44 years), National Health and Nutrition Examination Survey 2005–2010. Thyroid 23:927–937.

23. Pearce EN, Andersson M, Zimmermann MB 2013 Global iodine nutrition: where do we stand in 2013? Thyroid 23:523–528.

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supplementation during pregnancy: a review of observational and experimental studies in PLOG WR PRGHUDWH LRGLQH GH¿FLHQF\ DUHDV 5HY (SLGHPLRO 6DQWH 3XEOLTXH ± 25. Shi X, Han C, Li C, Mao J, Wang W, Xie X, Li C, Xu B, Meng T, Du J, Zhang S, Gao Z, Zhang X, Fan C, Shan Z, Teng W 2015 Optimal and safe upper limits of iodine intake for early SUHJQDQF\ LQ LRGLQH VXI¿FLHQW UHJLRQV DFURVV VHFWLRQDO VWXG\ RI SUHJQDQW ZRPHQ LQ China. J Clin Endocrinol Metab 100:1630–1638.

26. Cho YY, Kim HJ, Oh SY, Choi SJ, Lee SY, Joung JY, Jeong DJ, Sohn SY, Chung JH, Roh CR, .LP 6: ,RGLQH VWDWXV LQ KHDOWK\ SUHJQDQW ZRPHQ LQ .RUHD D ¿UVW UHSRUW (XU - 1XWU 55:469–475.

27. Orito Y, Oku H, Kubota S, Amino N, Shimogaki K, Hata M, Manki K, Tanaka Y, Sugino S, Ueta M, Kawakita K, Nunotani T, Tatsumi N, Ichihara K, Miyauchi A, Miyake M 2009 Thyroid function in early pregnancy in Japanese healthy women: relation to urinary iodine excretion, emesis, and fetal and child development. J Clin Endocrinol Metab 94:1683–1688.

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Matern Child Nutr 10:650–656. .HGLU + %HUKDQH < :RUNX $ 6XEFOLQLFDO LRGLQH GH¿FLHQF\ DPRQJ SUHJQDQW ZRPHQ LQ Haramaya district, Eastern Ethiopia: a community-based study. J Nutr Metab 2014:878926.

30. Amouzegar A, Khazan M, Hedayati M, Azizi F 2014 An assessment of the iodine status and the correlation between iodine nutritionand thyroid function during pregnancy in an iodine VXI¿FLHQW DUHD (XU - &OLQ 1XWU ± )HUUHLUD 60 1DYDUUR $0 0DJDOKD×HV 3. 0DFLHO /0 ,RGLQH LQVXI¿FLHQF\ LQ SUHJQDQW women from the State of Sa˜o Paulo. Arq Bras Endocrinol Metabol 58:282–287.

-LVNUD - )DLW 7 %ÕɅ lek R, KraɅ tkyɅJ, BartaɅ kovaɅJ, LukaɅ Vß - /ÕɅ manovaɅ = 7HOLFßND = Zamrazil V, PotlukovaɅ ( 0LOG LRGLQH GH¿FLHQF\ LQ ZRPHQ DIWHU VSRQWDQHRXV DERUWLRQV OLYLQJ LQ DQ LRGLQH VXI¿FLHQW DUHD RI &]HFK 5HSXEOLF SUHYDOHQFH DQG LPSDFW RQ UHSURGXFWLYH health. Clin Endocrinol (Oxf ) 80:452–458. $QGHUVHQ 6/ 6¡UHQVHQ /. .UHMEMHUJ $ 0¡OOHU 0 /DXUEHUJ 3 ,RGLQH GH¿FLHQF\ LQ Danish pregnant women. Dan Med J 60:A4657.

34. Raverot V, Bournaud C, Sassolas G, Orgiazzi J, Claustrat F, Gaucherand P, Mellier G, Claustrat B, Borson-Chazot F, Zimmermann M 2012 Pregnant French women living in the /\RQ DUHD DUH LRGLQH GH¿FLHQW DQG KDYH HOHYDWHG VHUXP WK\URJOREXOLQ FRQFHQWUDWLRQV 7K\URLG 22:522–528.

35. Konrade I, Kalere I, Strele I, Makrecka-Kuka M, Jekabsone A, Tetere E, Veisa V, Gavars D, 5H]HEHUJD ' 3 ÕU DJV 9 /HMQLHNV $ 'DPEURYD 0 ,RGLQH GH¿FLHQF\ GXULQJ SUHJQDQF\ D national cross-sectional survey in Latvia. Public Health Nutr 18:2990–2997.

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39.http://www.ilsitaiwan.org/Page/ArticleContent.aspx?ArticleID=wHO76hKYnsk%3d&ArticleT ypeID=T11P2UT2Yxc%3d 40. Fierro-Benitez R, Cazar R, Stanbury JB, Rodriguez P, Garces F, Fierro-Renoy F, Estrella E (൵HFWV RQ VFKRRO FKLOGUHQ RI SURSK\OD[LV RI PRWKHUV ZLWK LRGL]HG RLO LQ DQ DUHD RI LRGLQH GH¿FLHQF\ - (QGRFULQRO ,QYHVW ± 41. Cao XY, Jiang XM, Dou ZH, Rakeman MA, Zhang M, OɅ Donnell K, Ma T, Amette K, DeLong 1 'H/RQJ *5 7LPLQJ RI YXOQHUDELOLW\ RI WKH EUDLQ WR LRGLQH GH¿FLHQF\ LQ HQGHPLF cretinism. N Engl J Med 331:1739–1744.

42. DeLong GR, Leslie PW, Wang SH, Jiang XM, Zhang ML, Rakeman M, Jiang JY, Ma T, Cao XY 1997 Effect on infant mortality of iodination of irrigation water in a severely iodineGH¿FLHQW DUHD RI &KLQD /DQFHW ± &KDRXNL 0/ %HQPLORXG 0 3UHYHQWLRQ RI LRGLQH GH¿FLHQF\ GLVRUGHUV E\ RUDO administration of lipiodol during pregnancy. Eur J Endocrinol 130:547–551.

44. Anees M, Anis RA, Yousaf S, Murtaza I, Sultan A, Arslan M, Shahab M 2015 Effect of maternal iodine supplementation on thyroid function and birth outcome in goiter endemic areas. Curr Med Res Opin Feb 13:1–8.

45. Bouhouch RR, Bouhouch S, Cherkaoui M, Aboussad A, Stinca S, Haldimann M, Andersson M, Zimmermann MB 2014 Direct iodine supplementation of infants versus supplementation of their breastfeeding mothers: a double-blind, randomised, placebo-controlled trial. Lancet Diabetes Endocrinol 2:197–209.

46. Antonangeli L, Maccherini D, Cavaliere R, Di Giulio C, Reinhardt B, Pinchera A, Aghini/RPEDUGL ) &RPSDULVRQ RI WZR GL൵HUHQW GRVHV RI LRGLGH LQ WKH SUHYHQWLRQ RI JHVWDWLRQDO JRLWHU LQ PDUJLQDO LRGLQH GH¿FLHQF\ D ORQJLWXGLQDO VWXG\ (XU - (QGRFULQRO ± 47. Berbel P, Mestre JL, Santamaria A, Palazon I, Franco A, Graells M, Gonzalez-Torga A, de Escobar GM 2009 Delayed neurobehavioral development in children born to pregnant women ZLWK PLOG K\SRWK\UR[LQHPLD GXULQJ WKH ¿UVW PRQWK RI JHVWDWLRQ WKH LPSRUWDQFH RI HDUO\ LRGLQH supplementation. Thyroid 19:511–519.

48. Glinoer D, De Nayer P, Delange F, Lemone M, Toppet V, Spehl M, Grun JP, Kinthaert - /HMHXQH % $ UDQGRPL]HG WULDO IRU WKH WUHDWPHQW RI PLOG LRGLQH GH¿FLHQF\ GXULQJ SUHJQDQF\ PDWHUQDO QHRQDWDO H൵HFWV - &OLQ (QGRFULQRO 0HWDE ± 49. Liesenkotter KP, Gopel W, Bogner U, Stach B, Gruters A 1996 Earliest prevention of endemic goiter by iodine supplementation during pregnancy. Eur J Endocrinol 134:443–448.

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58. https://www.hpa.gov.tw/File/Attach/725/File_1674.pdf 59. Fisher DA, Klein AH 1981 Thyroid development and disorders of thyroid function in the newborn. N Engl J Med 304:702–712.

60. Theodoropoulos T, Braverman LE, Vagenakis AG 1979 Iodide-induced hypothyroidism: a potential hazard during perinatal life. Science 205:502–503.

61. Leung AM, Avram AM, Brenner AV, Duntas LH, Ehrenkranz J, Hennessey JV, Lee SL, Pearce EN, Roman SA, Stagnaro-Green A, Sturgis EM, Sundaram K, Thomas MJ, Wexler JA 2015 Potential risks of excess iodine ingestion and exposure: statement by the American Thyroid Association public health committee. Thyroid 25:145–146.

62. Medici M, Ghassabian A, Visser W, de Muinck Keizer-Schrama SM, Jaddoe VW, Visser WE, Hooijkaas H, Hofman A, Steegers EA, Bongers-Schokking JJ, Ross HA, Tiemeier H, Visser TJ, de Rijke YB, Peeters RP 2014 Women with high early pregnancy urinary iodine levels have an increased risk of hyperthyroid newborns: the population-based Generation R Study.

Clin Endocrinol (Oxf) 80:598–606.

63. Thaker VV, Leung AM, Braverman LE, Brown RS, Levine B 2014 Iodine-induced hypothyroidism in full-term infants with congenital heart disease: more common than currently appreciated? J Clin Endocrinol Metab 99:3521–3526.

19

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

Ᏻ᠟ ѯіᄹҖᖃᚃଲུചхᗃऌ еᖆ෡ᚃ৲ ‫׊ݔ‬ႁఁ௳

ᛅѺ෉໣࿩ሰ्໕Щ҂ਣቩђ 50% пαȂӱԫ WHO ࡛ឋΚૢԚԒ΢ؑС࿩ឹ‫ڦ‬໕ 150ཌྷջȂᛅѺυ‫ࠍܓ‬ቩՎ 250 ཌྷջȄҐ጖ 2017 Ԓज୾ҧ‫ޒ‬သᏱཽࡿЖҼ࡛ឋ 250 ཌྷ

ջȂดՅԫ኶অӶዊ࿘࣐200ཌྷջȂ઺ᐭ࣐220ཌྷջȇѯᢋ DRIಒΝ‫࣐ޏ‬200ཌྷջȂಒΥ‫ޏ‬૪਱ࠍ‫؂‬ᗎߗWHO኶অȄ

ᛅѺ෉໣‫֥ޠ‬࿩၅щࠣ‫ٻ‬ңȂ2007ԒWHOп၏୾‫ܗ‬ ӵୣ࿩ᢅోᇑ౦ᇅ‫׎‬࿩௒‫ݸ‬ϸԚήঐ઼๊‫࡛ޠ‬ឋȇՅज୾ ᗷᐍᡞ‫׎‬࿩Ϝ՞኶ҔளկᛅѺυ‫࣐ܓ‬ϛ٘Ȃӱԫ࡛ឋᛅѺ υ‫ؑܓ‬С‫ٻ‬ң֥150ཌྷջ࿩ϟ၅щᏙȄ೼Р८Ϭᔗпө୾ Ѻஐϟ࿩ᕋᎵ‫ٿݸޒ‬Մ໕Ȅ ᛅѺ෉໣࿩‫ޠ‬α४ឹ‫ڦ‬໕US Institute of Medicine࡛ឋ ᇅΚૢԚ΢Κኻ࣐1100ཌྷջ/ЉȂด2007ԒWHO൸ϑߓұ ѺஐؑС࿩ឹ‫ڦ‬τܼ500ཌྷջϛཽழ‫ٿ‬ઊ೏ЇՅቩђҧ‫ޒ‬ သѓ૗౵ளॴᓏȄഷߗϜ୾τ࠯Ѻஐः‫ف‬Ϝ‫׎‬࿩ᇅTSHȃ ҧ‫ޒ‬သ౩೗Ҫϟࣻᜱ௒‫ݸ‬ηᡘұα४1100ཌྷջᄈѺஐᔗ࢑ ႇାȂӱՅҐ጖ࡿЖ࡛ឋѺஐᔗᗘռߞ෉ؑСឹ‫ ڦ‬500ཌྷ ջпα‫ޠ‬࿩Ȅ

࿩‫ޒ‬ᄙ‫ڸ‬ᕋᎵ

20

‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ‫ׂڸ‬৓‫઀ึڂ‬ ᇄіᄹҖᖃᚃଲ ༂֘ᆃ ΚȃᛅѺஐυ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ޠܓ‬౿՘౦࣐ե? ᇴ݃Ȉ ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ - Anti-TPO‫ڸ‬anti-TgȂԇӶܼ2-17%‫ޠ‬ᛅѺஐυȂ਴ᐄᆎ ఋՅ౿՘౦ϛӤȂӶҪᆎ΢‫ٴڸ‬၃υ‫ܓ‬ၷାȂӶߩ၃ज୾΢ၷմ (1-5)Ȅ ࿩ᕋᎵ‫ޒ‬ᄙѠ૗ၮᛅѺ෉‫׫ޠ‬ҧ‫ޒ‬သ‫׫‬ᡞԥᜱȂߗ෉Shi І‫ڐ‬Ӥ‫ٲ‬ԥ Κ጖ൣᏳᡘұ‫׎‬࿩ᐩ࡚‫׫ڸ‬ҧ‫ޒ‬သ‫׫‬ᡞ֖౫U࠯ԣጤ‫ޠ‬ᜱ߾ (6)Ȅ ࡛ឋȈ ᗷด൑ᑀᔯขanti-TPOѠ૗ཽᅔ௭Κ‫ٳ‬Ѭԥanti-Tg‫׫‬ᡞ໩‫ޠܓ‬ѺஐȂ կӱ࣐Սᡞռ࣬‫ڸ‬ᖞ‫ט‬Ⴒࡤࣻᜱ‫ޠܓ‬ः‫ف‬пຠզanti-TPO࣐лȂӱԫ ࡛ឋӶຠզѺஐ‫ޠ‬ҧ‫ޒ‬သՍᡞռ࣬‫ޒ‬ᄙਣ‫ٻ‬ңanti-TPOȄ Ρȃ ᛅѺ෉໣‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ‫ޠ‬Սดѭ࣐եȉ‫ש‬উᔗ၏Ԅեଢᙺ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ ໩‫ܓ‬կҧ‫ޒ‬သѓ૗Ҕள‫ޠ‬Ѻஐȉ ᇴ݃Ȉ ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ޠܓ‬ѺஐȂЩၷৡܿӶᛅѺႇโϜ౱Ңҧ‫ޒ‬သѓ૗մ ίȄ1994ԒਣȂGlinoer ๊΢ึߓ‫ࠊޠ‬ᙂ‫ܓ‬ः‫ف‬ᡘұȂᛅѺࠊҧ‫ޒ‬သѓ ૗Ҕள޲Ȃस‫ڏ‬ԥ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞȂԥ20%ӶᛅѺ෉໣‫ڐ‬TSH኶অཽЁ ା‫ົژ‬ႇ4 mU/LȄ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞࠍ࢑ӶᛅѺߒ෉ഷାȂ‫ژ‬ᛅѺࡤ෉७ մ60%ѿѢ(7)Ȅ12ԒࡤȂNegro‫ޠ‬ყ໦ηึ౫anti-TPO໩‫ޠܓ‬ѺஐȂ‫ڐ‬ TSH҂ְঅཽᓎ຀ᛅѺႇโഃᅛЁାȂ௄12໋ਣ‫ޠ‬1.7 mU/LЁା‫ژ‬ᛅ ѺϜ෉࢑3.5 mU/LȂՎҢ౱ਣϑစԥ19%‫ޠ‬΢TSHົႇҔளঅ(8)Ȅ ࡛ឋȈ ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ܓ‬կ࢑ҧ‫ޒ‬သѓ૗Ҕள‫ޠ‬ஐυȂᔗ၏ӶᛅѺጃຩਣпІ ᛅѺ෉໣ؑႥ4໋ᔯขTSH኶অȂ‫ژޣ‬ᛅѺϜ෉пࡤȄ ା࡚࡛ឋȂାᜍᐄ઼๊ ήȃ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ܓ‬կҧ‫ޒ‬သѓ૗Ҕள‫ޠ‬Ѻஐ࢑֐ᔗ၏௦‫ڨ‬ȶ≫ȷ‫ݾ‬ᕜ? ᇴ݃Ȉ Ҧܼөӵୣ‫ޠ‬࿩ᕋᎵ‫ޒ‬ᄙϛӤȂȶ≫ȷ‫ݾ‬ᕜ࢑֐Ѡп७մ‫׫‬ҧ‫ޒ‬သ‫׫‬ ᡞᐩ࡚‫ޠ‬ः‫ف‬๗‫ݏ‬ηϛᅿࣻӤ (9, 10)ȄѫѵȂȶ≫ȷ‫ݾ‬ᕜѠ૗ཽቩђᑦ ‫ॴޠ੿׎‬ᓏ(11)Ȅ ࡛ឋȈ ‫ٯ‬ϛ࡛ឋ‫ٻ‬ңȶ≫ȷ‫ݾ‬ᕜ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ޠܓ‬ѺஐȄ մ࡚࡛ឋȂϜᜍᐄ઼๊ ѳȃ ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ܓ‬կҧ‫ޒ‬သѓ૗Ҕள‫ޠ‬ѺஐȂՍึ‫ࢻܓ‬౱‫ॴޠ‬ᓏ࢑֐ၷ ା? ᇴ݃Ȉ ϸ‫ ݚ‬8 ঐ੿‫پ‬ᄈྲः‫ޠف‬ಜӬϸ‫ݚ‬ᡘұȂ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ཽܓ‬ቩђࢻ ౱2.55ॼ‫ॴޠ‬ᓏ; ѫΚϸ‫ݚ‬14ঐзхः‫ޠف‬ಜӬϸ‫ݚ‬Ȃࠍࡿяԫᆎॴᓏ ङቩђ2.31ॼ (12, 13)Ȅᗷด‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ࢻڸܓ‬౱ॴᓏ‫ࣻޠ‬ᜱ‫݃࡟ܓ‬ 21

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

ጃȂկ೼‫ٯ‬ϛ૗၍មԚӱ‫ݏ‬ᜱ߾ȂՅйҭࠊҢ౪ᐡᙾϛ݃Ȅ ϥȃ ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ܓ‬կҧ‫ޒ‬သѓ૗Ҕள‫ޠ‬ѺஐȂЇ᙮‫ܓ‬ӵՍึ‫ࢻܓ‬౱‫ॴޠ‬ ᓏ࢑֐ၷା? ᇴ݃Ȉ ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ڸܓ‬Ї᙮‫ܓ‬ӵՍึ‫ࢻܓ‬౱ॴᓏ‫ࣻޠ‬ᜱ‫ܓ‬Ȃၷ൑Ԫ‫ޠ‬Ս ึ‫ࢻܓ‬౱‫ٿ‬ூ৶ȂѠ૗࢑ӱ࣐Ї᙮‫ࢻܓ‬౱ԥ࡟Ӽ዗Ӷ‫ޠ‬঩ӱȂєࢃ࢘ Քᡞ౵ளȃφয়੿౪ᡑϾȃ‫ڐ‬уռ࣬ЇᔗȂՅϲϸ‫ݫ‬౵ளѬխΠ‫ڐ‬Ϝ 15-20% ‫ޠ‬ԚӱȄτӼ኶‫ޠ‬ः‫ءٯف‬ԥଭᄈ೼‫ٳ‬዗Ӷ‫ޠ‬঩ӱໍ՘௢‫ښ‬ (14) Ȅ ϳȃ ҧ‫ޒ‬သષ‫ݾ‬ᕜ‫޲ܗ‬ռ࣬౩೗Ҫ‫ݾ‬ᕜȂ࢑֐Ѡп७մ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ܓ‬կ ҧ‫ޒ‬သѓ૗Ҕள‫ޠ‬ѺஐȂՍึ‫ࢻܓ‬౱‫ॴޠ‬ᓏ? ᇴ݃Ȉ Negro І‫ڐ‬Ӥ‫ߓึ෇ٲ‬Κঐࠊᙂ‫ܓ‬ᓎᐡϸࣃ‫ޠ‬ः‫ف‬ȂࡿяӶᛅѺಒΫ ໋ਣ໡ۗ๞ᇅ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ܓ‬կ࢑ҧ‫ޒ‬သѓ૗Ҕள‫ޠ‬ѺஐȂҧ‫ޒ‬ သષ‫ݾ‬ᕜѠп७մՍึ‫ࢻܓ‬౱‫ޠ‬ᐡཽȄկ࢑೼ঐः‫ف‬Ϝᢏᄇ‫ ޠژ‬8 ঐ ࢻ౱਱‫پ‬ȂଷΠΚ‫پ‬ϟѵȂഎ࢑ึҢӶᛅѺ11໋ϟࠊȂᡲ΢ᜳпጃᇰ ‫ݾ‬ᕜᄈ‫ٲ‬ӈึҢ‫ޠ‬ኈ៫(15)ȄѫԥΚঐߩᓎᐡϸࣃ‫ޠ‬Ӳ྘‫ܓ‬ः‫ف‬ᡘұȂ 65՞‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ܓ‬կ࢑ҧ‫ޒ‬သѓ૗Ҕள‫ޠ‬ѺஐϜȂԥ௦‫ڨ‬ҧ‫ޒ‬သ ષ‫ݾ‬ᕜ޲ഷಥഎ‫ء‬ԥึҢࢻ౱ȂՅґ‫ݾ‬ᕜಣࠍԥ16%ึҢࢻ౱(16)Ȅӱ ԫȂᗷดᐡᙾϛ݃Ȃկଭᄈ೼ঐఋထȂҧ‫ޒ‬သ‫ݾ‬ᕜѠ૗࢑ԥ዗Ӷ‫ޠ‬ઊ ೏Ȅҭࠊԥ 2 ঐ௥ଇԪୱᚡ‫ޠ‬ᓎᐡϸࣃࠊᙂ‫ܓ‬ः‫ف‬ҔӶໍ՘ϜȂΚঐ ࢑ऽ୾‫ޠ‬TABLET (The Thyroid AntiBodies and LEvoThyroxine study)Ȃ ѫΚঐ࢑ೊ៍‫ޠ‬T4LifetrialȄ ‫ٻ‬ңᓘ૖‫ৣݨ‬ռ࣬౩೗Ҫ‫ݾ‬ᕜ೼ঐఋထொ޲‫ޠ‬ः‫ف‬Ȃҭࠊഎၷ࣐ϊ࠯ й‫ء‬ԥᓎᐡϸࣃȂӱԫሰ्‫؂‬Ӽ‫ޠ‬ᄃᡜϘ૗էᜍ‫ڐ‬ᕜਞ(17-19)ȄՄ໕‫ژ‬ ᓘ૖‫ৣݨ‬ռ࣬౩೗Ҫ‫ޠ‬୚ձңၷାȃቌੀ݂ີȂӶ‫ء‬ԥ‫؂‬஽੩‫ޠ‬ᜍᐄ пࠊȂኸϛ௱ᙩȄ ࡛ឋȈ ‫ٯ‬ϛ࡛ឋ‫ٻ‬ңռ࣬౩೗Ҫ‫ݾ‬ᕜ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ܓ‬կ࢑ҧ‫ޒ‬သѓ૗Ҕள ‫ޠ‬ѺஐȄ‫ٻ‬ңҧ‫ޒ‬သષ‫ݾ‬ᕜԫᆎ੿ொ‫ޠ‬ᜍᐄ‫ٯ‬ϛщϸȂկҦܼԫᆎ‫ݾ‬ ᕜ‫ॴޠ‬ᓏၷմȂसѺஐ෇စᐤႇՍึ‫ࢻܓ‬౱ȂѠпՄኍؑЉ๞ܼ 2550ug‫ޠ‬ҧ‫ޒ‬သષȂп७մӕԪࢻ౱‫ॴޠ‬ᓏȄմ࡚࡛ឋȂմᜍᐄ઼๊ Νȃ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ཽ֐࢑ܓ‬ቩђԟ౱‫ॴޠ‬ᓏ? ᇴ݃Ȉήঐτ࠯‫ࠊޠ‬ᙂ‫ܓ‬зхः‫ف‬ᡘұȂᗷดԟ౱‫ޠ‬ᐡ౦Ӷ a n t i-T P O ໩‫ܓ‬ ಣȂЩanti-TPOജ‫ܓ‬ಣ‫ٿ‬ூାȂկಜॏα‫ٯ‬ґႁ‫ژ‬ᡘ຀ཏဏ(20-22)Ȅߗ ෉ήঐಜӬϸ‫ึࠍݚ‬౫‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ཽܓ‬ቩђԟ౱‫ॴޠ‬ᓏङ1.41-2.9 ॼ(23-25)Ȅᐍᡞ‫ٿ‬ᇴȂः‫ف‬๗‫ݏ‬་Ӫܼᇰ࣐‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ܓ‬ᇅԟ౱ॴ ᓏቩђԥᜱȄ

‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ‫ׂڸ‬৓‫઀ึڂ‬

22

Υȃ ҧ‫ޒ‬သષ‫ݾ‬ᕜȂ࢑֐Ѡп७մ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ܓ‬կҧ‫ޒ‬သѓ૗Ҕள‫ޠ‬Ѻ ஐȂึҢԟ౱‫ॴޠ‬ᓏ? ᇴ݃Ȉ ҭࠊѬԥΚ጖ᓎᐡϸࣃः‫ف‬ᡘұȂ๞ܼanti-TPO໩‫ܓ‬կ࢑ҧ‫ޒ‬သѓ૗ Ҕள‫ޠ‬Ѻஐҧ‫ޒ‬သષ‫ݾ‬ᕜȂѠп७մԟ౱‫ॴޠ‬ᓏȂ‫ݾ‬ᕜಣ‫ڸ‬ґ‫ݾ‬ᕜ ಣ‫ޠ‬ԟ౱౦ϸր࣐ 7% ‫ ڸ‬22.4% (15)ȄҭࠊҔӶऽ୾ໍ՘Ϝ‫ ޠ‬TABLET studyȂл्ࡿዀ࢑ຠզϛѺ‫޲ܗ‬Ї᙮‫ࢻܓ‬౱‫ޠ‬ᐡ౦ȂԪ्ࡿዀ࢑ԟ౱ ౦Ȃ࿌Ѡпණ‫؂ٽ‬Ӽ೼Р८‫ޠ‬ᜍᐄȄ ࡛ឋȈ ࢑֐ᔗ၏๞ᇅ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ܓ‬կ࢑ҧ‫ޒ‬သѓ૗Ҕள‫ޠ‬ѺஐȂ‫ٻ‬ңҧ ‫ޒ‬သષ‫ݾ‬ᕜȂп७մԟ౱‫ॴޠ‬ᓏȂҭࠊᜍᐄϛ٘Ȃณ‫ݳ‬ණ‫࡛ٽ‬ឋȄ ณ࡛ឋȂᜍᐄϛ٘ Οȃ ଷΠࢻ౱‫ڸ‬ԟ౱ϟѵȂ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ڐڸ֐࢑ܓ‬уᛅѺ‫޲ܗ઀ึڂ‬फ ‫ڌ‬Ⴒࡤԥᜱ? ᇴ݃Ȉ ӶᛅѺ‫઀ึڂޠ‬Р८Ȃԥ‫ڎ‬ঐः‫ึف‬౫ҧ‫ޒ‬သՍᡞռ࣬‫ޒ‬ᄙ‫ڸ‬फዻԟ ෉দᚕԥᜱ(21, 26)Ȅ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ܓ‬ᇅ໋౱෉Ԭκ‫ࣻޠ‬ᜱ‫ܓ‬Ȃԥ‫ٳ‬ः ‫ف‬ᇰ࣐ԥᜱ(22)Ȃԥ‫ึٳ‬౫ณᜱ(27)ȄѫѵȂη෇ԥൣᏳҕᡞ‫ޠ‬ҧ‫ޒ‬သՍ ᡞռ࣬‫ཽܓ‬ቩђ౱ࡤነ᢯઀‫ུڸ‬Ң‫֝ڴڌ‬ๅय़઀‫ॴޠ‬ᓏ(27-29)Ȅ Ӷࡇ่Ԛߞ‫ޠ‬Р८Ȃԥ‫ٳ‬ः‫ึف‬౫ҕᒒ‫ڏ‬ԥ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ޲Ȃࡇ่ࡤ ‫ޠٿ‬හΩȃ޵ᡞ୞ձึ৥ၷ࣐ጦᄛȂկ࢑‫ڸ‬ઢစᇰ‫ึޤ‬৥ณᜱ(30, 31)Ȅ ѫѵȂᛅѺ෉໣ҕᒒ‫ޠ‬anti-TPO໩‫ܓ‬ηೞึ౫ၮࡇ่‫ޠ‬ઢစ‫ܓ‬Շ᠙ԥ ᜱȂՅઢစ‫ܓ‬Շ᠙ηཽኈ៫‫่ࡇژ‬ԟ෉‫ޠ‬හΩึ৥(32)Ȅ ஠ԥӫມϜऽНᄈྲߓ

23

ҧ‫ޒ‬သႇੋϾ㢵‫׫‬ᡞ

Anti-TPO, thyroid peroxidase antibody

ҧ‫ޒ‬သ౩೗Ҫ‫׫‬ᡞ

Anti-Tg, thyroglobulin antibody

ҧ‫ޒ‬သѓ૗մί

Hypothyroidism

ߵҧ‫ޒ‬သષ (ҧ‫ޒ‬သ‫ڗ‬ᐮષȂҧߵષ)

TSH, thyroid stimulating hormone

≫

Selenium

ѿఌҧ‫ޒ‬သષ

Levothyroxine, LT4

ಜӬϸ‫ݚ‬

Meta-analysis

л्ࡿዀ

Primary outcome

Ԫ्ࡿዀ

Secondary outcome

ઢစᇰ‫ޤ‬

Neurocognition

ઢစ‫ܓ‬Շ᠙

Sensorineural hearing loss

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

୥ ՄНᝧ 1. Moreno-Reyes R, Glinoer D, Van Oyen H, Vandevijvere S. High prevalence of thyroid GLVRUGHUV LQ SUHJQDQW ZRPHQ LQ D PLOGO\ LRGLQH GH¿FLHQW FRXQWU\ D SRSXODWLRQ EDVHG VWXG\ - Clin Endocrinol Metab 2013;98:3694–3701.

2. Ashoor G, Maiz N, Rotas M, Jawdat F, Nicolaides KH. Maternal thyroid function at 11 to 13 weeks of gestation and subsequent fetal death. Thyroid 2010;20:989–993.

3. Benhadi N, Wiersinga WM, Reitsma JB, Vrijkotte TG, van der Wal MF, Bonsel GJ. Ethnic differences in TSH but not in free T4 concentrations or TPO antibodies during pregnancy.

Clin Endocrinol 2007;66:765–770.

4. LaɅulu SL, Roberts WL. Second-trimester reference intervals for thyroid tests: the role of ethnicity. Clin Chem 2007;53:1658–1664.

5. Hollowell JG, Staehling NW, Flanders WD, Hannon WH, Gunter EW, Spencer CA, Braverman LE. Serum TSH, T(4), and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III). J Clin Endocrinol Metab 2002;87:489–499.

6. Shi X, Han C, Li C, Mao J, Wang W, Xie X, Li C, Xu B, Meng T, Du J, Zhang S, Gao Z, Zhang X, Fan C, Shan Z, Teng W. Optimal and safe upper limits of iodine intake for early pregnancy in iodine-sufficient regions: a cross-sectional study of 7,190 pregnant women in China. J Clin Endocrinol Metab 2015;100:1630–1638.

7. Glinoer D, Riahi M, Gruᣪn JP, Kinthaert J. Risk of subclinical hypothyroidism in pregnant women with asymptomatic autoimmune thyroid disorders. J Clin Endocrinol Metab 1994;79:197–204.

8. Negro R, Formoso G, Mangieri T, Pezzarossa A, Dazzi D, Hassan H. Levothyroxine treatment in euthyroid pregnant women with autoimmune thyroid disease: effects on obstetrical complications. J Clin Endocrinol Metab 2006;91:2587–2591.

1HJUR 5 *UHFR * 0DQJLHUL 7 3H]]DURVVD $ 'D]]L ' +DVVDQ + 7KH LQÀXHQFH RI VHOHQLXP supplementation on postpartum thyroid status in pregnant women with thyroid peroxidase autoantibodies. J Clin Endocrinol Metab 2007;92:1263–1268.

10. Mao J, Pop VJ, Bath SC, Vader HL, Redman CW, Rayman MP. Effect of low-dose selenium on thyroid autoimmunity and thyroid function in UK pregnant women with mild-to-moderate LRGLQH GH¿FLHQF\ (XU - 1XWU ± 11. Stranges S, Marshall JR, Natarajan R, Donahue RP, Trevisan M, Combs GF, Cappuccio FP, &HULHOOR $ 5HLG 0( (൵HFWV RI ORQJ WHUP VHOHQLXP VXSSOHPHQWDWLRQ RQ WKH LQFLGHQFH RI W\SH 2 diabetes: a randomized trial. Ann Intern Med 2007;147:217–223.

12. Chen L, Hu R. Thyroid autoimmunity and miscarriage: a meta-analysis. Clin Endocrinol 2011;74:513–519.

13. Thangaratinam S, Tan A, Knox E, Kilby MD, Franklyn J, Coomarasamy A. Association between thyroid autoantibodies and miscarriage and preterm birth: metaanalysis of evidence.

BMJ 2011;342:d2616.

14. Baek KH, Lee EJ, Kim YS. Recurrent pregnancy loss: the key potential mechanisms. Trends Mol Med 2007;13:310–317.

15. Negro R, Formoso G, Mangieri T, Pezzarossa A, Dazzi D, Hassan H. Levothyroxine treatment in euthyroid pregnant women with autoimmune thyroid disease: effects on obstetrical

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complications. J Clin Endocrinol Metab 2006;91:2587–2591.

16. Lepoutre T, Debie`ve F, Gruson D, Daumerie C. Reduction of miscarriages through universal screening and treatment of thyroid autoimmune diseases. GynecolObstet Invest 2012;74:265– 273.0.

17. Kiprov DD, Nachtigall RD, Weaver RC, Jacobson A, Main EK, Garovoy MR. The use of intravenous immunoglobulin in recurrent pregnancy loss associated with combined alloimmune and autoimmune abnormalities. Am J Reprod Immunol 1996;36:228–234.

6WULFNHU 5% 6WHLQOHLWQHU $ %RRNR൵ &1 :HFNVWHLQ /1 :LQJHU (( 6XFFHVVIXO WUHDWPHQW RI immunologic abortion with low-dose intravenous immunoglobulin. Fertil Steril 2000;73:536– 540.

19. Vaquero E, Lazzarin N, De Carolis C, Valensise H, Moretti C, Ramanini C. Mild thyroid abnormalities and recurrent spontaneous abortion: diagnostic and therapeutical approach. Am J Reprod Immunol 2000;43:204–208.

20. Korevaar TI, Schalekamp-Timmermans S, de Rijke YB,Visser WE, Visser W, de Muinck Keizer-Schrama SM, Hofman A, Ross HA, Hooijkaas H, Tiemeier H, Bongers-Schokking JJ, Jaddoe VW, Visser TJ, Steegers EA, MediciM, Peeters RP. Hypothyroxinemia and TPOantibody positivity are risk factors for premature delivery: the generation generation R study.

J Clin Endocrinol Metab 2013;98:4382–4390.

21. Haddow JE, Cleary-Goldman J, McClain MR, Palomaki GE, Neveux LM, LambertMesserlian G, Canick JA, Malone FD, Porter TF, Nyberg DA, Bernstein PS, DɅ Alton ME; First- and Second-Trimester Risk of Aneuploidy (FaSTER) Research Consortium.

Thyroperoxidase and thyroglobulin antibodies in early pregnancy and preterm delivery. Obstet Gynecol 2010;116:58–62.

22. Männistö T, Vääräsmäki M, Pouta A, Hartikainen AL, Ruokonen A, Surcel HM, Bloigu A, Järvelin MR, Suvanto-Luukkonen E. Perinatal outcome of children born to mothers with thyroid dysfunction or antibodies: a prospective population-based cohort study. J Clin Endocrinol Metab 2009;94:772–779.

23. Thangaratinam S, Tan A, Knox E, Kilby MD, Franklyn J, Coomarasamy A. Association between thyroid autoantibodies and miscarriage and preterm birth: meta-analysis of evidence.

BMJ 2011;342:d2616.

24. Negro R. Thyroid autoimmunity and pre-term delivery: brief review and meta-analysis. J Endocrinol Invest 2011;34:155–158.

25. He X, Wang P, Wang Z, He X, Xu D, Wang B. Thyroid antibodies and risk of preterm delivery: a meta-analysis of prospective cohort studies. Eur J Endocrinol 2012;167:455–464 26. Abbassi-Ghanavati M, Casey BM, Spong CY, McIntire DD, Halvorson LM, Cunningham FG. Pregnancy outcomes in women with thyroid peroxidase antibodies. Obstet Gynecol 2010;116:381–386.

27. Negro R, Schwartz A, Gismondi R, Tinelli A, Mangieri T, Stagnaro-Green A. Thyroid antibody positivity in the first trimester of pregnancy is associated with negative pregnancy outcomes. J Clin Endocrinol Metab 2011;96:E920–E924.

28. Groer MW, Vaughan JH. Positive thyroid peroxidase antibody titer is associated with dysphoric moods during pregnancy and postpartum. J Obstet Gynecol Neonatal Nurs 2013;42:E26–E32.

29. Kuijpens JL, Vader HL, Drexhage HA, Wiersinga WM, van Son MJ, Pop VJ. Thyroid

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ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

peroxidase antibodies during gestation are a marker for subsequent depression postpartum.

Eur J Endocrinol 2001;145:579–584.

30. Li Y, Shan Z, Teng W, Yu X, Li Y, Fan C, Teng X, Guo R, Wang H, Li J, Chen Y, Wang W, Chawinga M, Zhang L, Yang L, Zhao Y, Hua T. Abnormalities of maternal thyroid function during pregnancy affect neuropsychological development of their children at 25–30 months.

Clin Endocrinol 2010;72:825–829.

31. Williams FL, Watson J, Ogston SA, Visser TJ, Hume R, Willatts P. Maternal and umbilical cord levels of T4, FT4, TSH, TPOAb, and TgAb in term infants and neurodevelopmental outcome at 5.5 years. J Clin Endocrinol Metab 2013;98:829–838.91:2587–2591.

32. Wasserman EE, Nelson K, Rose NR, Eaton W, Pillion JP, Seaberg E, Talor MV, Burek L, Duggan A, Yolken RH. Maternal thyroid autoantibodies during the third trimester and hearing GH¿FLWV LQ FKLOGUHQ DQ HSLGHPLRORJLF DVVHVVPHQW $P - (SLGHPLRO ±

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Ᏻ᠟ ࣐৿ख‫܉‬ᚃଲུചхᗃऌ ဩਐᖑఁ௳

τ྆2-17%‫ޠ‬ᛅѺஐυ‫׫‬՗Ϝҧ‫ޒ‬သ‫׫‬ᡞ - Anti-TPO ‫ڸ‬anti-Tgཽ֖໩‫ܓ‬ȂसѬ൑ᑀᔯขanti-TPOѠ૗ཽᅔ௭Κ ‫ٳ‬Ѭԥanti-Tg‫׫‬ᡞ໩‫ޠܓ‬ѺஐȂпѯᢋୋߴ๞рϟᘉ኶Յ ّȂҐ΢ᇰ࣐ᛅѺஐυᔗ၏ข‫ڎ‬ᆎҧ‫ޒ‬သ‫׫‬ᡞ - Anti-TPO ‫ڸ‬anti-TgȄसᛅѺ෉໣‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ֖໩‫ܓ‬ᔗ၏ӶᛅѺ෉ ໣ؑႥ 4 ໋ᔯข TSH І FT4 ኶অȂ‫ژޣ‬ᛅѺϜ෉пࡤȄᗷ ด‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ܓ‬կҧ‫ޒ‬သѓ૗Ҕள‫ޠ‬ѺஐȂՍึ‫ࢻܓ‬ ౱ІЇ᙮‫ܓ‬ӵ‫ॴޠ‬ᓏၷାȂկ࢑ϛ҇੬ր‫ޠ‬೏౪єࢃ≫ (selenium)ϟ၅щȃᓘ૖‫ৣݨ‬ռ࣬౩೗Ҫ‫ݾ‬ᕜȄ࢑֐Ѡп

ՄኍؑЉ๞ܼ25-50ug ‫ޠ‬ҧ‫ޒ‬သષ൸ُϧُහΠȄଷΠࢻ ౱‫ڸ‬ԟ౱ϟѵȂ‫׫‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ܓ‬ηཽЖକ‫ڐ‬уᛅѺ‫ึڂ‬ ઀‫ܗ‬ኈ៫‫ژ‬फ‫ڌ‬пࡤϟහΩȃ޵ᡞ୞ձึ৥ಜॏᏱαԥཏ ဏ‫ޠ‬ቩђȄΚૢՅّȂ՗Ϝҧ‫ޒ‬သ‫׫‬ᡞ໩‫ܓ‬ϟஐυηѠп ྲኻᛅѺҢ‫ي‬Ȅ

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ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

ҧ‫ޒ‬သ੾੿ᄈϛѺ઀‫ڸ‬ህֆҢ෦‫ޠ‬ኈ៫ ήॗᖃᚃଲ ֗Ϯ๽ ϛѺ઀࢑ࡿณᗘѺ‫ܓ‬՘࣐12ঐУ‫ܗ‬12ঐУпαϬณ‫ݳ‬ᛅѺ(1)ȄӶज୾Ȃ ϛѺ઀ኈ៫ङ7.4%‫ޠ‬15-44ྒυ‫(ܓ‬2)ȄആԚϛѺ઀‫ޠ‬঩ӱԥ35%࢑υ‫ܓ‬ӱષȃ 30%࢑‫ܓع‬ӱષпІ20%࢑ҦܼᚗРӱષ‫ܛ‬ആԚ‫ޠ‬ȂկϬԥ15%‫ޠ‬ϛѺ઀঩ӱ ۧϛఽྀ(3)Ȅ Κȃυ‫ޠܓ‬ϛѺ઀࢑֐ᇅ݃ᡘ‫ޠ‬ҧ‫ޒ‬သѓ૗౵ளԥᜱȉ ᇴ݃Ȉυ‫ܓ‬ԥҧ‫ޒ‬သѓ૗ϦໍѠ૗ཽя౫Ң౪෉ϛ೤ࠍȄ K r a s s a s ๊΢ (4)ൣ ᏳȂ22%‫ޠ‬ҧ‫ޒ‬သѓ૗Ϧໍொ޲ཽԥҢ౪෉ϛ೤ࠍȂᇅԒឮ‫ڸ‬ᡞ२Ͽ ପ‫ޠ‬ᄈྲಣࠍԥ 8% ȄӶΚ໷ᐘᘟ८ः‫ف‬ϜȂϛѺ઀ஐυҧ‫ޒ‬သѓ૗ ϦໍȞє֥‫ٴ‬ᖞ‫݃ڸ࠯ט‬ᡘϦໍ‫ޠ‬ொ޲ȟ‫ޠ‬Щ౦ᇅᛅѺஐυࣻծ(5)Ȅ ᄈܼυ‫ܓ‬ԥҧ‫ޒ‬သѓ૗մίՅആԚϛѺ઀ॴᓏ‫ޠ‬ः‫ف‬ၷЎȄΚ໷171 ӫυ‫ܓ‬TSH > 15mU / Lҧ‫ޒ‬သѓ૗մί‫ޠ‬ः‫ف‬ϜȂԥ68%Ң౪෉ϛ೤ ࠍȂሊାܼҧ‫ޒ‬သѓ૗Ҕள‫ޠ‬12%(6)ȄӶ129ӫϛѺஐυ‫ޠ‬Κ໷ᐘᘟ८ ः‫ف‬Ϝԥ5%‫ޠ‬ொ޲TSH > 4.5mU / L(7)ȄӶΚ໷ଭᄈ18-50ྒυ‫ޠܓ‬൑ᑀ ᐘᘟ८ः‫ف‬ϜȂGravesɅ diseaseொ޲ϛѺ઀Щ౦࣐52.3%ȂHashimotoɅ s (8) thyroiditisொ޲࣐47%ȇկԫः‫ف‬ณඣख़ொ޲ࣻᜱ‫ޠ‬ҧ‫ޒ‬သѓ૗ Ȅӱ ԫȂᏒᆔ኶ᐄϛ‫׈‬๢ȂկτӼ኶ᜍᐄծоഎМࡼҧ‫ޒ‬သѓ૗ϛҔளᇅ ቩђϛѺ઀ॴᓏϟ໣‫ޠ‬ᜱᖓ‫ܓ‬Ȅҧ‫ޒ‬သѓ૗౵ள࢑Ѡଜ‫ޠ‬Ȃ‫ݾ‬ᕜ೾ள ࢑ԋӓ‫ޠ‬ȂѠ૗ᄈҢ‫ي‬૗Ω౱ҢҔ८ኈ៫ȄӱԫȂ‫ݾ‬ᕜҧ‫ޒ‬သѓ૗౵ ள‫ޠ‬ϛѺ઀ஐυ஡ҧ‫ޒ‬သѓ૗࡯ඉҔள࢑Ӭоள౪‫ޠ‬Ȅ ѯᢋȈґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ Ρȃ‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մί࢑֐ᇅυ‫ܓ‬ϛѺԥᜱȉ ᇴ݃ȈϛӤः‫ف‬ЖңϛӤۢဏ‫ٴޠ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մίᏳयः‫ف‬๗‫ݏ‬ϛΚ यȄӶ704ӫϛѺஐυ‫ޠ‬ᐘᘟ८ः‫ف‬ϜȂTSHЁା‫ޠ‬ϛѺ౦࣐2.3%Ȃ ᇅΚૢनෂ‫ޠ‬Щ౦ࣻծ(9)ȄӶΚ໷ࠊᙂ‫ܓ‬ः‫ف‬ϜȂPoppe๊΢(5)ґึ౫ ϛѺஐυ‫ٴޠ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մίึҢ౦ቩђȂկᇅᄈྲಣࣻЩȂ ϛѺஐυTSH‫ޠ‬Ϝ՞኶౲ାȞ1.3 vs 1.1 mU / LȟȄӶΚ໷Ӳ྘‫ܓ‬ः ‫ف‬ϜȂϛѺஐυ‫ٴޠ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մίึҢ౦ᇅᄈྲಣࣻЩ‫؂‬ା Ȟ13.9% vs 3.9%ȟ(10)ȄTSH ஆᙄঅӶ2.5-5 mU / L‫ޠ‬υ‫ܓ‬ϜȂ‫ٻ‬ңߵ ҧ‫ޒ‬သᐮષមܺᐮષȞ T R H ȟ‫ڗ‬ᐮၑᡜึ౫Ȃӱυ‫ܓ‬ӱષՅϛѺ‫ޠ‬ υ‫ܓ‬ԥ46% TSH > 30mU / LȂӱ‫ܓع‬ӱષՅϛѺ‫ޠ‬υ‫ܓ‬ԥ7% TSH > 30mU / L (11)ȄӶϛѺ‫ޠ‬υ‫ܓ‬ϜȂӱ௷֋ѓ૗ሬᛥ‫ڸ‬ϛ݃঩ӱᏳयϛѺ

ҧ‫ޒ‬သ੾੿ᄈϛѺ઀‫ڸ‬ህֆҢ෦‫ޠ‬ኈ៫

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‫ޠ‬υ‫ܓ‬ԥഷା‫ޠ‬TSHȂӱᒰ֋ᆔ‫ܓعڸܓ‬ӱષᏳयϛѺ‫ޠ‬υ‫ܓ‬ԥၷմ ‫ޠ‬TSH(12)ȄӶુнᄈྲಣ‫ޠ‬ः‫ف‬ϜȂ94ӫԥҧ‫ޒ‬သѓ૗մίȞTSH > 4.2mU / Lȟ‫ޠ‬ϛѺஐυ௦‫ڨ‬eltroxin (LT4)‫ݾ‬ᕜȞ25-150 ȝg / dȟȂ‫ڐ‬Ϝ 72ӫϛѺஐυӶ1ԒϲՍด‫ڨ‬Ѻ(13)ȄӶΚ໷Ӳ྘‫ܓ‬ः‫ف‬ϜȂYoshioka๊ ΢(14)ൣᏳӶLT4‫ݾ‬ᕜࡤȂ84.1% ‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մίȞTSH > 3.0mU / Lȟ‫ޠ‬ϛѺஐυԚѓ‫ڨ‬Ѻ‫ٯ‬йϛѺਣ໣ᕼ฼Ȃ೼ߓ݃LT4‫ݾ‬ᕜѠпණ ା‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մίொ޲‫ڨޠ‬ѺЩ౦Ȅ२्‫࢑ޠ‬ӶᄈྲၑᡜϜ ۧґः‫ف‬LT4‫ݾ‬ᕜ࢑֐ཽቩђ‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մίկᗚ‫ء‬௦‫ڨ‬ህֆ Ң෦‫׭‬೛(ART)‫ޠ‬υ‫ڨܓ‬Ѻ‫ޠ‬Ѡ૗‫ܓ‬ȄӱԫȂӶ‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մ ίȂҧ‫ޒ‬သՍᡞ‫׫‬ᡞജ‫ޠܓ‬ϛѺஐυϜლၑ‫ڨ‬Ѻկґ௦‫ڨ‬ARTਣȂҭ ࠊۧณ٘஋‫ޠ‬ᜍᐄ‫ٿ‬ጃۢLT4ᕜ‫֐࢑ݳ‬૗‫׾‬๢ϛѺ௒‫ם‬Ȅ ѯᢋȈґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ ήȃҧ‫ޒ‬သՍᡞռ࣬࢑֐ᇅυ‫ܓ‬ϛѺԥᜱȉ ᇴ݃Ȉ ԥ४ᜍᐄᡘұȂ֊‫ٻ‬ҧ‫ޒ‬သѓ૗ҔளȂӱυ‫ܓ‬ӱષᏳयϛѺ‫ޠ‬υ‫ܓ‬Щ Ҕள‫ޠ‬υ‫؂ܓ‬Ѡ૗ཽԥ TPO ‫׫‬ᡞ໩‫( ܓ‬5)ȄӼ᠅‫֋ܓ‬லȞ PCOS ȟொ޲ ҧ‫ޒ‬သ‫׫‬ᡞ‫ޠ‬໩‫ܓ‬Щ౦Ѡ૗ାܼᇅԒឮϿପ‫ޠ‬ᄈྲಣ(15)Ȅҧ‫ޒ‬သ‫׫‬ᡞ ࢑֐ཽϔᘚԚዤ֋ҕಡब‫ڨޠ‬ᆡ௒‫ۧם‬ϛఽྀȂկஐυ‫֋ޠ‬லᘯ‫ݿ‬Ϝ Ѡᔯข‫ژ‬ҧ‫ޒ‬သ‫׫‬ᡞȂ‫ٯ‬ᇅ՗ఽҧ‫ޒ‬သ‫׫‬ᡞԥᜱ(16)Ȅ‫ٻ‬ңclomiphene citrate‫ݾ‬ᕜொԥPCOS‫ޠ‬ϛѺஐυȂѠ૗ཽ७մ֋லᘯ‫ݿ‬Ϝ‫ޠ‬ҧ‫ޒ‬သ‫׫‬ ᡞ(17)Ȅ ѯᢋȈґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ ࡛ឋȈ ࡛ឋ‫ܛ‬ԥ൷ؒϛѺ઀঩ӱ‫ޠ‬υ‫ܓ‬ሰຠզ՗ఽTSHᐩ࡚Ȅ մ࡚࡛ឋȂϜᜍᐄ઼๊ ࡛ឋȈ ࡛ឋᄈདྷ्ᛅѺ‫ޠ‬ҧ‫ޒ‬သѓ૗մίϛѺஐυໍ՘LT4‫ݾ‬ᕜȄ ା࡚࡛ឋȂϜᜍᐄ઼๊ ࡛ឋȈ ҭࠊᗚ‫ء‬ԥ٘஋‫ޠ‬ᜍᐄ‫ٿ‬ጃۢ LT4 ᕜ‫֐࢑ݳ‬Ѡп‫׾‬๢ლၑՍด‫ڨ‬Ѻ Ȟґ௦‫ ڨ‬A RT ȟգԥ‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մίȂҧ‫ޒ‬သՍᡞ‫׫‬ᡞജ‫ܓ‬ υ‫ڨޠܓ‬Ѻ௒‫ם‬ȄᗷดԄԫȂLT4‫ݾޠ‬ᕜ࢑ѠпӶ೼ᆎ௒‫ם‬ίՄኍȂ ӱ࣐LT4‫ݾޠ‬ᕜ૗஋ᗘռӶԚѓ‫ڨ‬Ѻࡤໍ৥࣐‫؂‬ᡘ຀‫ޠ‬ҧ‫ޒ‬သѓ૗մ ίȄՅйմᏙ໕LT4‫ݾޠ‬ᕜȞ25-50 ȝg / dȟॴᓏ࡟ϊȄ մ࡚࡛ឋȂմᜍᐄ઼๊ ࡛ឋȈ ҭࠊᗚ‫ء‬ԥ٘஋‫ޠ‬ᜍᐄ‫ٿ‬ጃۢ LT4 ᕜ‫֐࢑ݳ‬Ѡп‫׾‬๢ლၑՍด‫ڨ‬Ѻ Ȟґ௦‫ڨ‬ARTȟգԥҧ‫ޒ‬သѓ૗ҔளȂҧ‫ޒ‬သՍᡞ‫׫‬ᡞ໩‫ܓ‬υ‫ڨޠܓ‬ Ѻ௒‫ם‬ȄӶԫ௒‫ם‬LT4‫ݾޠ‬ᕜϛ࡛ឋȄณ࡛ឋȂᜍᐄϛ٘ ѳȃ ‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մί‫ޠ‬ஐυ࢑֐ᇅ௦‫ڨ‬ህֆҢ෦‫׭‬೛ȞARTȟԥၷৰ ‫ڨޠ‬Ѻ๗‫ࣻݏ‬ᜱȉ ѯᢋȈґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ 29

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

ϥȃ‫ݾ‬ᕜ‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մί‫ޠ‬ஐυ࢑֐૗‫׾‬๢ART‫ޠ‬๗‫ݏ‬ȉ ᇴ݃Ȉ Κ໷Ӳ྘‫ܓ‬ः‫ف‬ଭᄈ௦‫ڨ‬φয়ϲ΢Ϗ௳ᆡȞIUIȟ‫ޠ‬υ‫ܓ‬ϜȂ‫ٻ‬ңLT4 ‫ݾ‬ᕜ‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մίȞTSH > 2.5 mU / Lȟᇅၷା‫ڨޠ‬Ѻ౦ԥ ᜱȄ‫ٯ‬йңLT4‫ݾ‬ᕜ‫ڨ‬Ѻ౦մ‫ޠ‬ҧ‫ޒ‬သѓ૗մίொ޲Ȃ‫ٻ‬уউӶ௦‫ڨ‬ IUI࿌ਣTSH <2.5(18)ȄӶΚ໷൑ᑀ‫ࠊޠ‬ᙂ‫ܓ‬ः‫ف‬ϜȂᄈ1477ӫ௦‫ڨ‬IUI ‫ݾ‬ᕜ‫ޠ‬ः‫ف‬ȂѺࠊTSHӶ0.4-4.99 mU / Lጓ൝ϲᇅIUI୥኶Ԅ‫ڨ‬Ѻ౦‫ܗ‬ ࣁ౱౦ณᜱ(19)Ȅ τӼ኶ᜍᐄᡘұȂϛѺஐυ‫ޠ‬TSH <2.5 mU / L‫ڸ‬TSH 2.5-5 mU / Lᇅ௦ ‫ڨ‬ᡞѵ‫ڨ‬ᆡ(IVF) ‫ڨޠ‬Ѻ๗‫ءݏ‬ԥৰ౵ȄΚ໷195ӫIVF‫ޠ‬Ӳ྘‫ܓ‬ः‫ف‬ ᡘұȂѺҕTSH > 2.5 mU / Lࠍफ‫ڌ‬яҢਣफឮၷմй҂ְяҢᡞ२ၷ մ(20)ȄѫΚ໷164ӫӲ྘‫ܓ‬ः‫ف‬ϜȂTSH ɷ 2.5ᇅTSH> 2.5 mU / L‫ޠ‬υ ‫ࣻܓ‬ЩȂ‫ڨ‬Ѻ౦‫؂‬ାȞ22% vs 9%Ȃp = 0.045ȟ(21)ȄӶ1055ӫ௦‫ڨ‬ಒΚ ԪIVF໋෉‫ޠ‬υ‫ޠܓ‬Ӳ྘‫ܓ‬ः‫ف‬ϜȂӶԒឮ።ᐍϸ‫ݚ‬ϜȂTSH <2.5mU / LᇅTSH <4.5mU/ L‫ޠ‬υ‫ܓ‬Ӷ‫ڨ‬Ѻȃࢻ౱‫ܗ‬ϸ৕౦Р८‫ء‬ԥৰ౵(22)Ȅ ഷߗ‫ޠ‬ѫΚ໷Ӳ྘‫ܓ‬ः‫ف‬ᔯࢦΠ 627 ӫ‫ء‬ԥҧ‫ޒ‬သ੾੿‫ޠ‬υ‫ ܓ‬IVF ๗ ‫ݏ‬Ȃூя๗፤ȈᛅѺࠊ‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մίȞTSH > 4.5 mU / Lȟ ϛኈ៫‫ڨ‬Ѻ౦Ȃࣁ౱౦‫ࢻܗ‬౱౦(23)Ȅᄈ௦‫ڨ‬ಒΚԪIVF໋෉‫ޠ‬υ‫੿ܓ‬ ‫پ‬ᄈྲः‫ึف‬౫ TSH 0.45-2.5 mU / Lᇅ2.5-4.5 mU / L‫ޠ‬υ‫ܓ‬थफ፵໕ ณৰ౵(24)ȄѫΚ໷Ӳ྘‫ܓ‬ः‫ف‬ӤኻൣᏳȂTSHӶ0.5-4.5 mU / Lጓ൝ϲ ᇅIVF๗‫ݏ‬ณᜱ(25)ȄഷࡤȂӶΚ໷Ӳ྘‫ܓ‬ः‫ف‬ҭ‫ޠ‬ӶTSH ɷ 2.5mU / L ਣȂԥ1599ঐᐍॼᡞथ‫ݿ‬ෛΤ໋෉‫ٿ‬௢‫ښ‬थफ‫ޠ‬፵໕ᡑϾᇅෛΤȃࢻ ౱‫ࣁܗ‬౱౦ณᜱ(26)Ȅ ดՅȂԥः‫ف‬ᡘұၷା‫ޠ‬TSHᐩ࡚ȞᗷดϬೞᘫ᜹࣐‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ ૗մίȟᄈ‫ݾ‬ᕜծо࢑‫؂‬ԥਞ‫ޠ‬ȄΚ໷ᓎᐡᖞ‫ט‬ၑᡜ࣐20-40 ྒ‫ٴޠ‬ ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մίȞTSH > 4.5mU / LȂҔளFT4ȟ௦‫ڨ‬IVF‫ޠ‬ः‫ف‬Ȃ Ӕԥ64ӫυ‫ܓ‬ೞᓎᐡϸପ‫ژ‬LT4‫ݾ‬ᕜȞ֋ல‫ڗ‬ᐮ໡ۗਣᏙ໕࣐ 50ȝ g / dȂᇅԋኒᏙಣࣻЩȂӶಒ1‫ڻ‬౱෉Ꮩ໕።ᐍՎTSH <2.5 mU / LȟȄ ௦‫ݾڨ‬ᕜ‫ޠ‬υ‫ܓ‬ᖞ‫ڨט‬Ѻ౦ၷାȂࢻ౱౦ၷմȂࣁ౱౦ၷା (27)Ȅѫ Κ໷ၑᡜ஡64ӫொԥ‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մίȞTSH> 4.2mU / LȂҔள FT4ȟ‫ޠ‬ϛѺஐυᓎᐡϸପՎLT4 ‫ݾ‬ᕜ50ȝ g / dᇅԋኒᏙȂӤኻൣ֚ ΠЩᄈྲಣԥ‫؂‬ା‫ޠ‬Ң౱౦ȃ‫؂‬մ‫ࢻޠ‬౱౦‫؂ڸ‬ା‫ࣁޠ‬౱౦ (28)Ȅഷ ߗ‫ޠ‬Κ໷ಜӬϸ‫༙ݚ‬ᖃΠ೼‫ٳ‬ၑᡜ‫ޠ‬๗‫ݏ‬Ȃಒή໷ः‫( ف‬29)௥ଇ T P O ‫׫‬ᡞ໩‫ܓ‬ȃҧ‫ޒ‬သѓ૗Ҕளυ‫ܓ‬௦‫ڨ‬ARTȂңLT4‫ݾ‬ᕜ‫ޠ‬ኈ៫Ȃ‫ٯ‬ூ я๗፤ȂᏒᆔLT4‫ݾ‬ᕜᄈᖞ‫ڨט‬Ѻ౦‫ء‬ԥӉեኈ៫Ȟ༙ᖃࣻᄈॴᓏȟ 1.75 [95% CI 0.90-3.38]ȟȂጃᄃԥ‫؂‬ା‫ޠ‬Ң౱౦Ȟ༙ᖃࣻᄈॴᓏ2.76 [95%CI 1.20-6.44]ȟ(30)Ȅ೼‫ٳ‬኶ᐄߓ݃Ȃ‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մίѠ૗ ӱTSHᐩ࡚‫ٿ‬ኈ៫ART๗‫ݏ‬Ȃᓎ຀TSHᐩ࡚‫ޠ‬ЁାȂARTཽᡑৰȄ֊ ‫ݾٻ‬ᕜᏙ໕‫ء‬ԥ‫׾‬ᡑȂTSHᐩ࡚࢑Ѡпԥ໋ؑࣻৰංmU/L൑՞‫ޠ‬ᡑ ҧ‫ޒ‬သ੾੿ᄈϛѺ઀‫ڸ‬ህֆҢ෦‫ޠ‬ኈ៫

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Ͼ(31)ȄᄈܼTSH > 2.5mU / L‫ٴޠ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մίυ‫ܓ‬൷ؒ௦‫ڨ‬ ARTȂңLT4‫ݾ‬ᕜ࢑݃හ‫ޠ‬Ȅ ࡛ឋȈ ௦‫ڨ‬ᡞѵ‫ڨ‬ᆡ(IVF)‫֋ܗ‬ಡब፵ϲᆡᙬ‫(ৣݨ‬ICSI)‫ٴޠ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗ մίυ‫ܓ‬ᔗ௦‫ڨ‬LT4‫ݾ‬ᕜȂ‫ݾ‬ᕜ‫ޠ‬ҭዀ࢑‫ٻ‬TSH < 2.5mU / LȄ ା࡚࡛ឋȂϜᜍᐄ઼๊ ѯᢋȈ ґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ ϳȃ ᇅୋஷᄈྲࣻЩȂ‫ݾ‬ᕜஐυ‫ޠ‬ҧ‫ޒ‬သѓ૗մί࢑֐ᇅၷৰ‫ޠ‬ART๗‫ࣻݏ‬ ᜱȉ ᇴ݃Ȉ Κ໷Ӳ྘‫ܓ‬ः‫ف‬ȂӶ௦‫ॷڨ‬ԪIVFȂԒឮ ɷ 37ྒ‫ޠ‬240ӫυ‫ܓ‬ϜȂ21 ӫҧ‫ޒ‬သѓ૗մί‫ݾ‬ᕜࡤҧ‫ޒ‬သѓ૗ҔளȞTSH 0.35-4.0 mU / Lȟ‫ޠ‬ υ‫ܓ‬Ң౱౦մܼณҧ‫ޒ‬သ੾੿‫ޠ‬υ‫( ܓ‬32)Ȅᓎࡤ‫پ੿ޠ‬ᄈྲः‫ف‬єࢃ 137ӫLT4‫ݾ‬ᕜ‫ޠ‬ҧ‫ޒ‬သѓ૗մίυ‫ܓ‬Ȟ҂ְTSH 1.6ɲ0.7 mU / Lȟ‫ڸ‬ 274 ӫԒឮϿପ‫ޠ‬ҧ‫ޒ‬သѓ૗ҔளᄈྲಣȂҧ‫ޒ‬သѓ૗մί௦‫ݾڨ‬ᕜ ѓ૗Ҕளਣึ౫ᇅၷմ‫ڨޠ‬Ѻ౦ȃIVF / ICSIࡤෛΤ‫ࣁܗ‬౱౦ณᜱ(33)Ȅ ӱԫȂณ‫ݳ‬௄೼‫ٳ‬኶ᐄϜூя๗፤Ȅ ѯᢋȈґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ Νȃ‫ي‬ឮஐυҧ‫ޒ‬သ‫׫‬ᡞ໩‫֐࢑ܓ‬ᇅၷৰ‫ޠ‬ART๗‫ࣻݏ‬ᜱȉ ᇴ݃Ȉ ҭࠊԥ೩Ӽः‫ف‬ଭᄈԥϛӤ੿ӱᏳयϛѺ઀‫ޠ‬౵፵΢ထȂϛ፤ҧ‫ޒ‬သ Սᡞ‫׫‬ᡞ໩‫ڸܓ‬ജ‫ܓ‬υ‫ܓ‬௦‫ڨ‬ART‫ޠ‬ः‫ف‬๗‫ݏ‬Ȃԥ‫ٳ‬ः‫ف‬༊४ܼҧ‫ޒ‬ သѓ૗Ҕள‫ޠ‬υ‫ܓ‬ȄϛӤ‫ޠ‬ART / IVFРԓηϑစӶϛӤ‫ޠ‬ӵР‫ڸ‬ਣ໣ ‫ٻ‬ңȄࠊᙂ‫ܓ‬ः‫ޠف‬ಜӬϸ‫ݚ‬ᇴ݃IVFࡤ‫ڨ‬Ѻ౦Ӷҧ‫ޒ‬သՍᡞ‫׫‬ᡞ໩ ‫ڸܓ‬ജ‫ܓ‬υ‫ܓ‬ϟ໣‫ء‬ԥৰ౵ȂկԄࠊ‫ܛ‬ख़(ُαΚത࿾)Ȃҧ‫ޒ‬သՍᡞ ‫׫‬ᡞ໩‫ܓ‬υ‫ࢻޠܓ‬౱ॴᓏ‫؂‬ା(34)Ȅഷߗ‫ޠ‬Κ໷Ӳ྘‫ܓ‬ः‫ف‬።ࢦΠ627 ӫґொҧ‫ޒ‬သ੾੿υ‫ޠܓ‬IVF๗‫ݏ‬Ȃ‫ٯ‬ூя๗፤ȂᛅѺࠊҧ‫ޒ‬သՍᡞ ռ࣬ϛཽኈ៫‫ڨ‬Ѻ౦ȃࢻ౱౦‫ࣁܗ‬౱౦(23)Ȅ‫ڎ‬ঐഷߗӲ྘‫ܓ‬ൣ֚ȂӶ ௦‫ڨ‬ICSI‫ڸ‬IVF‫ݾ‬ᕜ‫ޠ‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ܓ‬ᇅ‫׫‬ᡞജ‫ܓ‬Ȃҧ‫ޒ‬သѓ૗Ҕள ‫ޠ‬υ‫ܓ‬ϜȂ‫ڨ‬Ѻ౦ȃࢻ౱౦‫ࣁܗ‬౱౦‫ء‬ԥৰ౵(35, 36)ȄΚ໷ࠊᙂ‫ܓ‬ः‫ف‬ ึ౫ȂӶTPO‫׫‬ᡞ໩‫ڸ ܓ‬/‫ܗ‬Tg‫׫‬ᡞ໩‫ܓ‬ᇅҧ‫ޒ‬သѓ૗Ҕளկ‫׫‬ᡞജ ‫ޠܓ‬υ‫ܓ‬ϜȂIVFᇅICSI๗‫ݏ‬ณৰ౵(37)Ȅഷߗ‫ޠ‬Κ໷Ӳ྘‫ܓ‬IVF ः‫ึف‬ ౫Ȃᇅ676ӫ‫׫‬ᡞജ‫ܓ‬υ‫ࣻܓ‬ЩȂ90ӫ‫׫‬ᡞ໩‫ܓ‬ொ޲‫ڨޠ‬ᆡȃෛΤ‫ڸ‬ ‫ڨ‬Ѻ౦ၷմȂկ‫ڎ‬ಣְґൣ֚ҧ‫ޒ‬သѓ૗(38)Ȅ ѯᢋȈґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ Υȃ‫ݾ‬ᕜҧ‫ޒ‬သѓ૗Ҕளկҧ‫ޒ‬သ‫׫‬ᡞ໩‫ޠܓ‬υ‫֐࢑ܓ‬૗‫׾‬๢ART๗‫ݏ‬ȉ ᇴ݃Ȉ ஆܼΚ໷ϊ࠯ᓎᐡᖞ‫ט‬ၑᡜ‫ڸ‬Κ໷Ӳ྘‫ܓ‬ः‫ف‬Ȃᄈ‫ء‬ԥҧ‫ޒ‬သѓ૗౵ ளկ‫׫‬ᡞ໩‫ໍܓ‬՘IVF‫ޠ‬ொ޲ȂңLT4‫ݾ‬ᕜծо‫ء‬ԥ‫׾‬๢Ⴒࡤ(29, 39)Ȅ‫ڎ‬

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ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

໷ϊ࠯ၑᡜߓ݃Ȃҧ‫ޒ‬သ‫׫‬ᡞ໩‫ܓ‬ϛѺஐυӶ௦‫ڨ‬ARTࠊ௦‫ڨ‬ᑦҫ፵ ᐮષ‫ݾޠ‬ᕜȂ‫ڨ‬Ѻ౦Ѡ૗ཽԥ‫ܛ‬ණା(40, 41)ȄӶLitwicka๊΢‫ޠ‬ः‫ف‬Ϝ (40) Ȃ60ӫҧ‫ޒ‬သѓ૗ҔளȞTSH <2.5mU / LȟTPO‫׫‬ᡞ໩‫ڸ ܓ‬/‫ ܗ‬Tg‫׫‬ ᡞ໩‫ޠܓ‬υ‫ܓ‬௦‫ڨ‬IVFᓎᐡϸ࣐prednisolone 5mg / dayȂ௄‫֋ڦ‬࿌Љ໡ ۗȂࡼ៊‫ׂژ‬৓ԟ෉Ȅ‫ݾ‬ᕜಣᇅґ‫ݾ‬ᕜಣ‫ޠ‬υ‫ܓ‬ᖃᡞ‫ڨ‬Ѻ౦Ȟ60% vs 30%Ȃp = 0.02ȟ‫ࣁڸ‬౱౦Ȟ46.6% vs 20%Ȃp = 0.05ȟְၷାȄӶIUI ϟࠊȂTuri๊΢(41) ஡48ӫTPO‫׫‬ᡞ໩‫ܓ‬ϛѺஐυᓎᐡϸ࣐prednisolone ‫ݾ‬ᕜಣ‫ڸ‬ԋኒᏙಣȄ௦‫ݾڨ‬ᕜ‫ޠ‬ஐυ‫ڨ‬Ѻ౦࣐ 33.3%ȂՅԋኒᏙಣ࣐ 8.4%Ȟp = 0.03ȟȄ‫ڎ‬ಣϟ໣‫ࢻޠ‬౱౦‫ء‬ԥᡘ຀ৰ౵ȄᏒᆔ೼‫ٳ‬ϊ࠯ၑ ᡜծо࡟ԥ‫ו‬గȂկԟѺ෉‫ٻ‬ңҫ፵᜹‫ڿ‬᎖‫ॴޠ‬ᓏۧϛఽྀ(42)Ȅ ࡛ឋȈ ҭࠊۧณ٘஋‫ޠ‬ᜍᐄ‫ٿ‬ጃۢLT4ᕜ‫֐࢑ݳ‬૗‫׾‬๢TPO‫׫‬ᡞ໩‫ܓ‬ҧ‫ޒ‬သ ѓ૗Ҕளυ‫ܓ‬ARTࡤ‫ڨ‬Ѻ‫ޠ‬Ԛѓ౦ȄดՅȂᄈܼ௦‫ڨ‬ART‫ޠ‬TPO‫׫‬ᡞ ໩‫ܓ‬ҧ‫ޒ‬သѓ૗Ҕளυ‫ܓ‬ȂѠпՄኍ๞ϡLT4Ȃӱ࣐ᇅ‫ڐ‬ഷϊॴᓏࣻ ЩȂѻ‫ڏ‬ԥ዗Ӷ‫ޠ‬ઊ೏ȄӶ೼ᆎ௒‫ݸ‬ίȂ25-50 ȝ g‫ޠ‬LT4࢑‫ޠ࠯ڑ‬କۗ Ꮩ໕Ȅմ࡚࡛ឋȂմᜍᐄ઼๊ ࡛ឋȈ ᄈܼ௦‫ڨ‬ART‫ޠ‬ҧ‫ޒ‬သՍᡞ‫׫‬ᡞ໩‫ܓ‬ҧ‫ޒ‬သѓ૗Ҕளυ‫ܓ‬Ȃϛ௱ᙩ‫ٻ‬ ңprednisolone‫ݾ‬ᕜȄմ࡚࡛ឋȂϜᜍᐄ઼๊ ѯᢋȈґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ Οȃ֋லႇ࡚‫ڗ‬ᐮཽ‫׾‬ᡑҧ‫ޒ‬သѓ૗༞ȉ ᇴ݃Ȉ ᏒᆔҭࠊҔӶ‫ٻ‬ңӼᆎARTР਱ȂկICSI‫ޠ‬IVF‫ܗ‬IVFРԓ೾ளॷӒ‫ٻ‬ ңߵ‫ܓ‬သᐮષȂߵ‫ܓ‬သᐮષមܺᐮષ᜹ծ‫ܓߵܗޑ‬သᐮષមܺᐮષࡽ ‫׫‬Ꮩᇅߵ‫ܓ‬သᐮષ‫ޠ‬ಣӬᇷᏳ‫ڨ‬௢‫֋ޠ‬லႇ࡚‫ڗ‬ᐮȄ೾ႇົॲ‫ݱ‬ᆀข ֋‫يึݿ‬Ȃ‫ٯ‬й࿌ࠊᏳ֋‫٘ݿ‬஋τਣȂࢋ҉hCGп౱Ң‫׈‬ӓԚዤ‫֋ޠ‬ ҕಡबȄ‫ڨ‬௢‫֋ޠ‬லႇ࡚‫ڗ‬ᐮᏳय՗ఽሮΡ᎖ٟഁЁՎົҢ౪ᐩ࡚ Ȟ4000-6000ng / LȟȂᇅׂ৓ఐ෉ᔯข‫ࣻޠژ‬ծ(43)Ȅ೼‫ٳ‬ᐮષᐈձѠ ૗ཽ‫׾‬ᡑҧ‫ޒ‬သѓ૗Ȅ೼ᆎਞᔗ௱ขᇅାሮᐮષᐩ࡚ആԚTBGЁାԥ ᜱȂTBGЁାཽ७մ෭ᚕҧ‫ޒ‬သᐮષᐩ࡚Ȃ॓Ӳ㔴ᏳयTSHЁାȄࢋ ҉hCGѠ‫ޣ‬௦‫ڗ‬ᐮҧ‫ޒ‬သTSH‫ڨ‬ᡞȂᏳयҧ‫ޒ‬သᐮષቩђȂᓎࡤTSH ෶ЎȄ‫ق‬ಜ‫ܓ‬ः‫ف‬ຠ፤(44) ึ౫֋ல‫ڗ‬ᐮᄈ՗ఽҧ‫ޒ‬သᐮષ‫ޠ‬ኈ៫ϛΚ यȄӶ֋ல‫ڗ‬ᐮࡤᢏᄇ1ঐУਣ໣Ȃ՗ఽTSHӶ5ঐः‫ف‬Ϝԥ3ঐቩђȂ FT4Ӷ2ঐः‫ف‬ϜቩђȂ1ঐः‫ف‬෶ЎȂѫ1ঐः‫ءف‬ԥᡑϾȄӶΚ‫ٳ‬υ ‫(ܓ‬45-47)Ȃ֋ல‫ڗ‬ᐮࡤ՗ఽTSHᐩ࡚ቩђՎ ɸ2.5 mU / LȂGracia๊΢(48) ൣᏳȂӶhCG๞᛿ࡤ1໋Ȃ֋ல‫ڗ‬ᐮ෉໣՗ఽTSH‫ڸ‬FT4ְቩђȂ‫ڐ‬Ϝ 44%঩TSH࣐2.5mU / L‫ޠ‬υ‫ܓ‬ቩђՎ> 2.5mU / LȄReinblatt๊΢(49) ൣᏳ Ӷ֋ல‫ڗ‬ᐮႇโϜ՗ఽTSHᇅ՗ఽሮΡ᎖҂՘ቩђȂӶTPO‫׫‬ᡞ໩‫ܓ‬ υ‫ܓ‬Ϝᢏᄇ‫ژ‬TSH‫݃؂‬ᡘ‫ޠ‬ቩђȄ ֋லႇ࡚‫ڗ‬ᐮᆤӬ઀Ȟ O H S S ȟ࢑௢‫֋ܓښ‬லႇ࡚‫ڗ‬ᐮ‫ޠ‬ΚᆎፓӬ ҧ‫ޒ‬သ੾੿ᄈϛѺ઀‫ڸ‬ህֆҢ෦‫ޠ‬ኈ៫

32

‫ޑ‬Ȃ‫ڐ‬Ϝ՗ᆔ೾ഇ‫ܓ‬ቩђᏳयషᡞ௄՗ᆔϲᙾಌ‫ژ‬ಒήޫ໣Ȅሇ࡚ OHSS઀‫ߓޒ‬౫࣐ሇ࡚ဝЬ‫ڸ‬ဝഌϛᎍȂӶ‫ܛ‬ԥIVF໋෉ϜึҢ౦ା ႁ20%-33%Ȅᝓ२‫ޠ‬OHSSึҢӶIVF໋෉‫ޠ‬0.1%-2%ȂѠ૗ᇅ՗੄‫ם‬ Ԛ‫֝ڴڸ‬ๅय़ࣻᜱȂୌᅮηཽय‫(ڽ‬50)Ȅഷߗ‫ޠ‬Κঐ੿‫پ‬ൣ֚ඣख़ΠΚ ӫொԥIVFࠊ‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մί‫ޠ‬ொ޲Ȃ၏ொ޲௦‫ڨ‬ΠLT4щϸ ‫ݾ‬ᕜȄொ޲Ӷᝓ२OHSS‫ޠ‬௒‫ݸ‬ίٟഁึ৥࣐݃ᡘ‫ޠ‬ҧ‫ޒ‬သѓ૗մί (51) ȄPoppe๊΢(43) ‫ࠊޠ‬ᙂ‫ܓ‬ः‫ف‬Ȃᢏᄇ௦‫ڨ‬௢‫֋ܓښ‬லႇ࡚‫ڗ‬ᐮ‫ޠ‬υ ‫ܓ‬ҧ‫ޒ‬သѓ૗Ȃึ౫25ӫOHSSொ޲‫ڸ‬52ӫґึҢOHSS‫ޠ‬υ‫ܓ‬՗ఽ TSH‫ܗ‬FT4ᐩ࡚ณৰ౵Ȅ ௦‫ڨ‬ႇщϸ‫ݾ‬ᕜ‫ޠ‬ҧ‫ޒ‬သѓ૗մί઀Ȟ֊௦‫ڨ‬LT4‫ݾ‬ᕜȟ‫ޠ‬υ‫ܓ‬ϜȂ ԥൣᏳ֋φ‫ڗ‬ᐮӶ‫֋ڦ‬ਣཽᇷึҧ‫ޒ‬သѓ૗մί (52) ȄӶΚ໷ः‫ف‬ ϜȂࢋ҉ hCG ࡤ 1 ໋Ȃ LT4 ‫ݾ‬ᕜ‫ޠ‬υ‫ܓ‬Ϝ֋ல‫ڗ‬ᐮ෉໣՗ఽ TSH ‫ޠ‬ቩ ђЩ‫ء‬ԥ዗Ӷҧ‫ޒ‬သѓ૗մί‫ޠ‬υ‫݃؂ܓ‬ᡘȄ‫ׂژ‬৓ၑᡜਣȂөಣ ໣TSHᐩ࡚ϛӕϛӤ(48)ȄӶΚ໷ࠊᙂ‫ܓ‬ः‫ف‬ϜȂ72ӫ‫ݾ‬ᕜ‫ޠ‬ҧ‫ޒ‬သѓ ૗մίυ‫ܓ‬Ӷ֋ல‫ڗ‬ᐮࠊ TSH <2.5mU / LȂTSH௄঩ҐhCG๞᛿ਣ‫ޠ‬ 1.7ɲ0.7mU / LαЁՎhCG๞᛿ࡤ16Љ‫ޠ‬3.2ɲ1.7mU / L (53)ȄΚ໷Ӳ྘ ‫ܓ‬ः‫ف‬ᇴ݃௦‫ڨ‬IVF‫ݾ‬ᕜ‫ޠ‬ҧ‫ޒ‬သѓ૗մίυ‫ܓ‬ϜȂτӼ኶Ӷׂ৓ࠊ 5-7໋ϲȂԥ84%ሰ्ቩђLT4Ꮩ໕(54)ȄΚ໷ϊ࠯ࠊᙂ‫ܓ‬ः‫ึف‬౫Ȃ௦ ‫ܓߵڨ‬သᐮષ‫ݾ‬ᕜࡤ‫ڨ‬ႇ‫ݾ‬ᕜ‫ޠ‬ҧ‫ޒ‬သѓ૗մίொ޲‫ٯ‬ϛሰ्ЩՍึ ‫ڨ‬Ѻ‫ޠ‬ҧ‫ޒ‬သѓ૗մίொ޲ሰ्ቩђ‫؂‬τ‫ޠ‬LT4Ꮩ໕(55)Ȅ ࡛ឋȈ Ԅ‫ݏ‬Ѡ૗Ȃҧ‫ޒ‬သѓ૗ᔯࢦᔗӶ௢‫֋ܓښ‬லႇ࡚‫ڗ‬ᐮϟࠊ‫ܗ‬ϟࡤ1-2໋ ໍ՘Ȃӱ࣐Ӷ௢‫֋ܓښ‬ல‫ڗ‬ᐮႇโϜᕖூ‫ޠ‬๗‫ݏ‬Ѡ૗ᜳп၍មȄ մ࡚࡛ឋȂϜᜍᐄ઼๊ ࡛ឋȈᄈܼӶ௢‫֋ܓښ‬லႇ࡚‫ڗ‬ᐮࡤႁ‫ڨژ‬Ѻ‫ޠ‬υ‫ܓ‬Ȃᔗ਴ᐄಒVII ࿾Ϝ࿌ TSHЁା࡛ឋ‫ݾ‬ᕜȄӶ௢‫֋ܓښ‬ல‫ڗ‬ᐮࡤTSHЁା‫ޠ‬ґ‫ڨ‬ѺஐυϜȂ ՗ఽTSHข໕ᔗӶ2-4໋ϲ२ፓȂӱ࣐ᐩ࡚Ѡ૗ᙾ࣐ҔளȄ մ࡚࡛ឋȂϜᜍᐄ઼๊ ѯᢋȈґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ ஠ԥӫມϜऽНᄈྲߓ

33

ህֆҢ෦‫׭‬೛

assisted reproductive techniques (ART)

Ӽ᠅‫֋ܓ‬ல

polycystic ovarian syndrome (PCOS)

φয়ϲ΢Ϗ௳ᆡ

intrauterine insemination (IUI)

ᡞѵ‫ڨ‬ᆡ

in vitro fertilization (IVF)

֋ಡब፵ϲᆡᙬ‫ৣݨ‬

intracytoplasmic sperm injection (ICSI)

֋லႇ࡚‫ڗ‬ᐮᆤӬ઀

ovarian hyperstimulation syndrome (OHSS)

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

୥ ՄНᝧ 1. Zegers-Hochschild F, Adamson GD, de Mouzon J, Ishihara O, Mansour R, Nygren K, et al.

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Vital Health Stat 23. 2005(25):1-160.

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6. Krassas GE, Pontikides N, Kaltsas T, Papadopoulou P, Paunkovic J, Paunkovic N, et al.

Disturbances of menstruation in hypothyroidism. Clin Endocrinol (Oxf) 1999;50(5):655-659.

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11. Lee YJ, Kim CH, Kwack JY, Ahn JW, Kim SH, Chae HD, et al. Subclinical hypothyroidism diagnosed by thyrotropin-releasing hormone stimulation test in infertile women with basal thyroid-stimulating hormone levels of 2.5 to 5.0 mIU/L. Obstet Gynecol Sci 2014;57(6):507512.

12. Arojoki M, Jokimaa V, Juuti A, Koskinen P, Irjala K, Anttila L. Hypothyroidism among infertile women in Finland. Gynecol Endocrinol 2000;14(2):127-131.

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14. Yoshioka W, Amino N, Ide A, Kang S, Kudo T, Nishihara E, et al. Thyroxine treatment may be useful for subclinical hypothyroidism in patients with female infertility. Endocr J 2015;62(1):87-92.

15. Kachuei M, Jafari F, Kachuei A, Keshteli AH. Prevalence of autoimmune thyroiditis in patients with polycystic ovary syndrome. Arch Gynecol Obstet 2012;285(3):853-856.

16. Monteleone P, Parrini D, Faviana P, Carletti E, Casarosa E, Uccelli A, et al. Female infertility related to thyroid autoimmunity: the ovarian follicle hypothesis. Am J Reprod Immunol 2011;66(2):108-114.

ҧ‫ޒ‬သ੾੿ᄈϛѺ઀‫ڸ‬ህֆҢ෦‫ޠ‬ኈ៫

34

17. Ott J, Aust S, Kurz C, Nouri K, Wirth S, Huber JC, et al. Elevated antithyroid peroxidase antibodies indicating Hashimoto's thyroiditis are associated with the treatment response in infertile women with polycystic ovary syndrome. Fertil Steril 2010;94(7):2895-2897.

18. Jatzko B, Vytiska-Bistorfer E, Pawlik A, Promberger R, Mayerhofer K, Ott J. The impact of thyroid function on intrauterine insemination outcome--a retrospective analysis. Reprod Biol Endocrinol 2014;12:28.

19. Karmon AE, Batsis M, Chavarro JE, Souter I. Preconceptional thyroid-stimulating hormone levels and outcomes of intrauterine insemination among euthyroid infertile women. Fertil Steril 2015;103(1):258-263 .

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5HK $ *ULIR - 'DQR൵ $ :KDW LV D QRUPDO WK\URLG VWLPXODWLQJ KRUPRQH 76+ OHYHO" (൵HFWV of stricter TSH thresholds on pregnancy outcomes after in vitro fertilization. Fertil Steril 2010;94(7):2920-2922.

23. Chai J, Yeung WY, Lee CY, Li HW, Ho PC, Ng HY. Live birth rates following in vitro fertilization in women with thyroid autoimmunity and/or subclinical hypothyroidism. Clin Endocrinol (Oxf) 2014;80(1):122-127.

24. Weghofer A, Himaya E, Kushnir VA, Barad DH, Gleicher N. The impact of thyroid function and thyroid autoimmunity on embryo quality in women with low functional ovarian reserve: a case-control study. Reprod Biol Endocrinol 2015;13:43.

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26. Green KA, Werner MD, Franasiak JM, Juneau CR, Hong KH, Scott RT, Jr. Investigating the optimal preconception TSH range for patients undergoing IVF when controlling for embryo quality. J Assist Reprod Genet 2015;32(10):1469-1476.

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28. Kim CH, Ahn JW, Kang SP, Kim SH, Chae HD, Kang BM. Effect of levothyroxine treatment on in vitro fertilization and pregnancy outcome in infertile women with subclinical hypothyroidism undergoing in vitro fertilization/intracytoplasmic sperm injection. Fertil Steril 2011;95(5):1650-1654.

29. Negro R, Mangieri T, Coppola L, Presicce G, Casavola EC, Gismondi R, et al. Levothyroxine treatment in thyroid peroxidase antibody-positive women undergoing assisted reproduction technologies: a prospective study. Hum Reprod 2005;20(6):1529-1533.

30. Ve l k e n i e r s B, Va n M e e r h a e g h e A, P o p p e K, U n u a n e D, To u r n a y e H, H a e n t j e n s P. Levothyroxine treatment and pregnancy outcome in women with subclinical hypothyroidism undergoing assisted reproduction technologies: systematic review and meta-analysis of RCTs. Hum Reprod Update 2013;19(3):251-258.

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ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

31. Karmisholt J, Andersen S, Laurberg P. Variation in thyroid function in subclinical h y p o t h y r o i d i s m: i m p o r t a n c e o f c l i n i c a l f o l l o w-u p a n d t h e r a p y. Eu r J E n d o c r i n o l 2011;164(3):317-323.

32. Scoccia B, Demir H, Kang Y, Fierro MA, Winston NJ. In vitro fertilization pregnancy rates in levothyroxine-treated women with hypothyroidism compared to women without thyroid dysfunction disorders. Thyroid 2012;22(6):631-636.

33. Busnelli A, Somigliana E, Benaglia L, Leonardi M, Ragni G, Fedele L. In vitro fertilization outcomes in treated hypothyroidism. Thyroid 2013;23(10):1319-1325.

34. Toulis KA, Goulis DG, Venetis CA, Kolibianakis EM, Negro R, Tarlatzis BC, et al. Risk of spontaneous miscarriage in euthyroid women with thyroid autoimmunity undergoing IVF: a meta-analysis. Eur J Endocrinol 2010;162(4):643-652.

35. Tan S, Dieterle S, Pechlavanis S, Janssen OE, Fuhrer D. Thyroid autoantibodies per se do not impair intracytoplasmic sperm injection outcome in euthyroid healthy women. Eur J Endocrinol 2014;170(4):495-500.

36. Lukaszuk K, Kunicki M, Kulwikowska P, Liss J, Pastuszek E, Jaszczolt M, et al. The impact of the presence of antithyroid antibodies on pregnancy outcome following intracytoplasmatic sperm injection-ICSI and embryo transfer in women with normal thyreotropine levels. J Endocrinol Invest 2015;38(12):1335-1343.

37. Karacan M, Alwaeely F, Cebi Z, Berberoglugil M, Batukan M, Ulug M, et al. Effect of antithyroid antibodies on ICSI outcome in antiphospholipid antibody-negative euthyroid women. Reprod Biomed Online 2013;27(4):376-380.

38. Zhong YP, Ying Y, Wu HT, Zhou CQ, Xu YW, Wang Q, et al. Relationship between antithyroid antibody and pregnancy outcome following in vitro fertilization and embryo transfer. Int J Med Sci 2012;9(2):121-125.

39. Revelli A, Casano S, Piane LD, Grassi G, Gennarelli G, Guidetti D, et al. A retrospective study on IVF outcome in euthyroid patients with anti-thyroid antibodies: effects of levothyroxine, acetyl-salicylic acid and prednisolone adjuvant treatments. Reprod Biol Endocrinol 2009;7:137.

40. Litwicka K, Arrivi C, Varricchio MT, Mencacci C, Greco E. In women with thyroid autoimmunity, does low-dose prednisolone administration, compared with no adjuvant therapy, improve in vitro fertilization clinical results? J Obstet Gynaecol Res 2015;41(5):722728.

41. Turi A, Giannubilo SR, Zanconi S, Mascetti A, Tranquilli AL. Preconception steroid treatment in infertile women with antithyroid autoimmunity undergoing ovarian stimulation and intrauterine insemination: a double-blind, randomized, prospective cohort study. Clin Ther 2010;32(14):2415-2421.

0LFKDHO $( 3DSDJHRUJKLRX $7 3RWHQWLDO VLJQL¿FDQFH RI SK\VLRORJLFDO DQG SKDUPDFRORJLFDO glucocorticoids in early pregnancy. Hum Reprod Update 2008;14(5):497-517.

43. Poppe K, Unuane D, D'Haeseleer M, Tournaye H, Schiettecatte J, Haentjens P, et al.

Thyroid function after controlled ovarian hyperstimulation in women with and without the hyperstimulation syndrome. Fertil Steril 2011;96(1):241-245.

44. Mintziori G, Goulis DG, Toulis KA, Venetis CA, Kolibianakis EM, Tarlatzis BC. Thyroid function during ovarian stimulation: a systematic review. Fertil Steril 2011;96(3):780-785.

0XOOHU $) 9HUKRH൵ $ 0DQWHO 0- 'H -RQJ )+ %HUJKRXW $ 'HFUHDVH RI IUHH WK\UR[LQH OHYHOV ҧ‫ޒ‬သ੾੿ᄈϛѺ઀‫ڸ‬ህֆҢ෦‫ޠ‬ኈ៫

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after controlled ovarian hyperstimulation. J Clin Endocrinol Metab 2000;85(2):545-548.

46. Poppe K, Glinoer D, Tournaye H, Schiettecatte J, Devroey P, van Steirteghem A, et al.

Impact of ovarian hyperstimulation on thyroid function in women with and without thyroid autoimmunity. J Clin Endocrinol Metab 2004;89(8):3808-3812.

47. Poppe K, Glinoer D, Tournaye H, Schiettecatte J, Haentjens P, Velkeniers B. Thyroid function after assisted reproductive technology in women free of thyroid disease. Fertil Steril 2005;83(6):1753-1757.

48. Gracia CR, Morse CB, Chan G, Schilling S, Prewitt M, Sammel MD, et al. Thyroid function during controlled ovarian hyperstimulation as part of in vitro fertilization. Fertil Steril 2012;97(3):585-591.

49. Reinblatt S, Herrero B, Correa JA, Shalom-Paz E, Ata B, Wiser A, et al. Thyroid stimulating hormone levels rise after assisted reproductive technology. J Assist Reprod Genet 2013;30(10):1347-1352.

50. Corbett S, Shmorgun D, Claman P, Reproductive Endocrinology Infertility C, Special C. The prevention of ovarian hyperstimulation syndrome. J Obstet Gynaecol Can 2014;36(11):10241033.

51. Skweres T, Wojcik D, Ciepluch R, Sliwinski W, Czech R, Gruszczynski W, et al. Thyroid dysfunction during severe ovarian hyperstimulation syndrome. A case report. Ginekol Pol 2014;85(6):472-475.

52. Stuckey BG, Yeap D, Turner SR. Thyroxine replacement during super-ovulation for in vitro fertilization: a potential gap in management? Fertil Steril 2010;93(7):2414 e1-3.

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54. Busnelli A, Vannucchi G, Paffoni A, Faulisi S, Fugazzola L, Fedele L, et al. Levothyroxine dose adjustment in hypothyroid women achieving pregnancy through IVF. Eur J Endocrinol 2015;173(4):417-424.

55. Davis LB, Lathi RB, Dahan MH. The effect of infertility medication on thyroid function in hypothyroid women who conceive. Thyroid 2007;17(8):773-777.

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ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

Ᏻ᠟ ࿳߀ᚃଲུചхᗃऌ ؄߫቉лӉ

ҧ‫ޒ‬သ࢑΢ᡞ࡟२्‫ޠ‬ϲϸ‫ݫ‬ᏣۣȂ‫ڐ‬ѓ૗ϛ٘‫࢑ܗ‬ ϦໍഎཽᏳय੾੿Ȃᄈஐυ‫ޠ‬Ң‫ي‬ηԥϛӤኈ៫Ȅ‫ي‬ឮυ ‫ܓ‬Ԅ‫ݏ‬ҧ‫ޒ‬သϦໍ‫࢑ܗ‬մίȂѠ૗ആԚϛѺ‫ึޠ‬ҢȄѺஐ Ԅ‫ݏ‬ҧ‫ޒ‬သѓ૗౵ளȂৡܿᏳयࢻ౱Ȃ‫࢑ܗ‬फ‫ึڌ‬৥౵ ளȄՅҧ‫ޒ‬သѓ૗౵ளစႇ‫ݾ‬ᕜࡤѠпೞᕥҔȂໍՅᄈϛ Ѻ౱ҢҔ८‫ޠ‬ኈ៫Ȅӱԫ‫ש‬উᔗ၏௵‫ڦ‬ᑗ྄௪ࢋȂ‫ݾ‬ᕜϛ Ѻυ‫ޠܓ‬ҧ‫ޒ‬သ੾੿ȂՅණା‫ڐ‬Ң‫ي‬౦‫࢑ܗ‬ህֆҢ෦‫ޠ‬Ԛ ѓ౦Ȅҭࠊ೼ഌϸѯᢋ‫ءٯ‬ԥ٘஋‫ޠ‬ः‫ف‬๗‫ݏ‬ȂӱԫҐത ࿾л्਴ᐄ2017Ԓज୾ҧ‫ޒ‬သᏱཽ‫ܛ‬ණҧ‫ޒ‬သ੾੿ᄈϛѺ ઀‫ڸ‬ህֆҢ෦‫ޠ‬ኈ៫ϟࣻᜱࡿЖ‫ܛ‬ᐍ౪ጢቹȄ

ҧ‫ޒ‬သ੾੿ᄈϛѺ઀‫ڸ‬ህֆҢ෦‫ޠ‬ኈ៫

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ҧ‫ޒ‬သѓ૗մίᇅׂ৓ ଼୎ख‫܉‬ᚃଲ ቔ‫ݙ‬ᑹ Κȃׂ৓෉໣ҧ‫ޒ‬သѓ૗մί‫ۢޠ‬ဏ࣐ե? ᇴ݃Ȉ 2011ԒATAࡿЖ࡛ឋׂ৓෉TSH୥Մጓ൝α४(upper reference limit) ׂ࣐৓ॷήঐУ2.5 mU/Lȇׂ৓ϜήঐУІׂ৓ҒήঐУ3.0mU/LȄ կ࢑ߗ෉‫ޠ‬ः‫ف‬ᡘұଷΠ‫ژڨ‬࿩ᕋᎵ‫ݸޒ‬ኈ៫ѵȂׂ৓෉ T S H ‫ޠ‬୥ Մጓ൝ηཽӱٙᡞ፵໕ࡿ኶ȃӵୣᇅᆎఋ‫ޠ‬ϛӤՅԥৰ౵Ȅӱԫ 2017ԒATAࡿЖ࡛ឋөӵୣഷԂѠп‫ۢښ‬яөѺ෉஠ԥ‫ޠ‬TSH୥Մঅ WULPHVWHU VSHFL¿F 76+ UHIHUHQFHV Ȅ ࡛ឋȈ ׂ৓෉ҧ‫ޒ‬သѓ૗մίۢဏ࣐TSHົႇөѺ෉஠ԥ‫ޠ‬TSH୥ՄঅȄ ା࡚࡛ឋȂାᜍᐄ઼๊ ࡛ឋȈ Ԅ‫ۢښݏ‬࿌ӵ۩ҖөѺ෉஠ԥ‫ޠ‬TSH୥Մঅ‫ޠ‬ҭዀณ‫ݳ‬ႁԚȂѠ୥Մ ᇅ࿌ӵ۩Җࣻծ΢πಣԚӵୣ‫ޠ‬ၦਠȂ‫ٻٯ‬ңࣻӤ‫ޠ‬TSHᔯขР‫ݳ‬Ȅ ା࡚࡛ឋȂାᜍᐄ઼๊ ࡛ឋȈ Ԅ‫ݏ‬ᗚ࢑‫ء‬ԥᎍӬ‫ޠ‬өѺ෉஠ԥ‫ޠ‬TSH୥ՄঅѠ‫ٻ‬ңȂѠՄኍ஡ׂ৓ ෉TSH୥Մጓ൝α४࣐ۢ~4.0 mU/LȄᄈτഌϸ‫ޠ‬ᔯࢦР‫ݳ‬Ȃԫα४Щ ߩׂ৓ஐυTSH୥Մα४ङ෶Ў0.5 mU/LȄା࡚࡛ឋȂϜᜍᐄ઼๊ Ρȃ ׂ৓෉໣ҧ‫ޒ‬သѓ૗մίІ‫ٴ‬ᖞ‫ܓט‬ҧ‫ޒ‬သѓ૗մί (s u b c l i n i c a l hypothyroidism) ‫ࣻޠ‬ᜱϛׂً৓๗‫࣐ݏ‬ե? ᇴ݃Ȉ ೩ӼᜍᐄᡘұȂׂ৓෉ґစ‫ݾ‬ᕜ‫ޠ‬ҧ‫ޒ‬သѓ૗մίொ޲ึҢϛׂً৓ ๗‫ޠݏ‬ᐡཽၷାȂєࢃԟ౱ȃմяҢᡞ२ȃࢻ౱ȃઢစึ‫ي‬ϛӓȃϊ ࡇහ୧(IQ)ၷմІׂ৓ା՗ᔇ๊௒‫ݸ‬Ȅׂ৓෉໣‫ٴ‬ᖞ‫ܓט‬ҧ‫ޒ‬သѓ૗ մί‫ޠ‬ொ޲ଷΠӶઢစึ‫ي‬Іϊࡇහ୧Р८‫ޠ‬ኈ៫ҭࠊᗚԥ‫ލ‬ឋѵȂ ึҢ‫ڐ‬уϛׂً৓๗‫ޠݏ‬ᐡཽࠍᓎ຀TSH኶অ຺ାη຺τȄԫѵᗷด ঩ӱۧϛ݃ҪȂԥ‫ٳ‬ः‫ึف‬౫Ӷҧ‫ޒ‬သѓ૗ࣻӤ‫ޠ‬௒‫ם‬ίȂҧ‫ޒ‬သႇ ੋϾ㢵‫׫‬ᡞ(TPOAb)໩‫ޠܓ‬ஐυึҢϛׂً৓๗‫ޠݏ‬ᐡཽၷା(1,2)Ȅ ࡛ឋȈᛅѺஐυसTSH኶অ>2.5 mU/LȂ҇໹ᔯࢦTPOAb‫ࡿޠ‬኶Ȅ ήȃׂ৓෉໣ҧ‫ޒ‬သѓ૗մί࢑֐ሰ्‫ݾ‬ᕜ? ᇴ݃Ȉ ᗷดҧ‫ޒ‬သѓ૗մίொ޲ึҢϛׂً৓๗‫ޠݏ‬ᐡཽၷାȂկ࢑‫ژ‬ҭࠊ ࣐ЦȂ‫ء‬ԥ࡟Ԃ‫ࠊޠ‬ᙂ‫ܓ‬ः‫ف‬ᜍᄃׂ৓෉໣ҧ‫ޒ‬သѓ૗մίஐυ௦‫ڨ‬ ҧ‫ޒ‬သષ‫ݾ‬ᕜӶϛׂً৓๗‫ݏ‬ᇅϊࡇઢစึ‫ي‬Іහ୧αԥၷԂ‫ޠ‬๗‫ݏ‬ (3,4) ȄΚ‫ٳ‬ᢏᄇ‫ܓ‬ः‫ف‬ᡘұTSH኶অ຺ାึҢϛׂً৓๗‫ݏ‬ᐡ຺ཽτȂ ‫پ‬ԄӶᛅѺࠊϑ௦‫ڨ‬ҧ‫ޒ‬သષ‫ݾ‬ᕜஐυ‫ޠ‬ः‫ึف‬౫Ȃ஡ T S H ௢‫ښ‬Ӷ 0.2–2.5 mU/LึҢࢻ౱‫ޠ‬ᐡཽഷմȂTSH>4.5 mU/Lࠍτൾቩђࢻ౱‫ޠ‬ 39

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

ᐡཽ(5)Ȅ ࡛ឋȈׂ৓෉໣ҧ‫ޒ‬သѓ૗մίᔗ၏௦‫ݾڨ‬ᕜȄା࡚࡛ឋȂϜᜍᐄ઼๊ ѳȃׂ৓෉໣‫ٴ‬ᖞ‫ܓט‬ҧ‫ޒ‬သѓ૗մί࢑֐ሰ्‫ݾ‬ᕜ? ᇴ݃Ȉ ᗷด೩Ӽᢏᄇ‫ܓ‬ः‫ف‬ᡘұׂ৓෉໣‫ٴ‬ᖞ‫ܓט‬ҧ‫ޒ‬သѓ૗մίЏ‫࢑ڐ‬Ӥ ਣӬ‫ڂ‬TPOAb ໩‫ޠܓ‬ொ޲ึҢϛׂً৓๗‫ޠݏ‬ᐡཽၷା(1,2)Ȅկ࢑‫ء‬ ԥᜍᐄΩ٘஋‫ޠ‬ः‫ف‬ᜍᄃׂ৓෉໣‫ٴ‬ᖞ‫ܓט‬ҧ‫ޒ‬သѓ૗մίஐυ௦‫ڨ‬ ҧ‫ޒ‬သષ‫ݾ‬ᕜӶϛׂً৓๗‫ݏ‬ᇅϊࡇઢစึ‫ي‬Іහ୧αԥၷԂ‫ޠ‬๗‫ݏ‬ (3,4,6) Ȅ ࡛ឋȈ ׂ৓෉໣‫ٴ‬ᖞ‫ܓט‬ҧ‫ޒ‬သѓ૗մί‫ݾޠ‬ᕜ࡛ឋԄί: (a) пί௒‫࡛ݸ‬ឋ௦‫ڨ‬ѿఌҧ‫ޒ‬သષȞLevothyroxine, LT4ȟ‫ݾ‬ᕜȈ TPOAb໩‫ܓ‬йTSHົႇөѺ෉஠ԥ‫ޠ‬TSH୥ՄঅȄ ା࡚࡛ឋȂϜᜍᐄ઼๊ TPOAbജ‫ܓ‬կTSH>10 mU/LȄା࡚࡛ឋȂմᜍᐄ઼๊ (b) пί௒‫ݸ‬Մኍ௦‫ڨ‬LT4‫ݾ‬ᕜȈ TPOAb໩‫ܓ‬йTSHϮܼ2.5 mU/LІөѺ෉஠ԥ‫ޠ‬TSH୥Մঅα४ϟ ໣Ȅ ା࡚࡛ឋȂϜᜍᐄ઼๊ TPOAbജ‫ܓ‬йTSHϮܼөѺ෉஠ԥ‫ޠ‬TSH୥Մঅα४І10.0 mU/L ϟ໣Ȅ ା࡚࡛ឋȂմᜍᐄ઼๊ (c) LT4ϛ࡛ឋ‫ٻ‬ңܼTPOAbജ‫ܓ‬йTSHҔள‫ޠ‬ѺஐȄ ା࡚࡛ឋȂାᜍᐄ઼๊ ϥȃׂ৓෉໣൑ᑀ‫ܓ‬մҧ‫ޒ‬သષ՗઀(isolated hypothyroxinemia)࢑֐ሰ्‫ݾ‬ᕜ? ᇴ݃Ȉ ൑ᑀ‫ܓ‬մҧ‫ޒ‬သષ՗઀ۢဏ࣐TSH ᐩ࡚ҔளȂկfree T4 ᐩ࡚ϮܼҔள ୥Մঅ‫ޠ‬ί2.5-5.0ঐԼϸЩȄึҢ൑ᑀ‫ܓ‬մҧ‫ޒ‬သષ՗઀ਣ໹ຠզ࢑ ֐ӱ࿩ឹ‫ڦ‬ϛ٘‫ܛ‬ആԚ(7)Ȅᗷดԥ‫ٳ‬ः‫ف‬ᡘұ൑ᑀ‫ܓ‬մҧ‫ޒ‬သષ՗઀ ᇅϛׂً৓๗‫ݏ‬ԥᜱ(7,8)ȂկϮΤ‫ܓ‬ः‫ف‬ᡘұҧ‫ޒ‬သષ‫ݾ‬ᕜ‫ءٯ‬ԥ७մ ൑ᑀ‫ܓ‬մҧ‫ޒ‬သષ՗઀ஐυึҢϛׂً৓๗‫ޠݏ‬ᐡཽ(8, 9)Ȅ ࡛ឋȈׂ৓෉໣൑ᑀ‫ܓ‬ҧ‫ޒ‬သષ՗઀ϛ࡛ឋள೤௦‫ݾڨ‬ᕜȄ մ࡚࡛ឋȂմᜍᐄ઼๊ ϳȃׂ৓෉໣ҧ‫ޒ‬သѓ૗մίᎍ࿌‫ݾޠ‬ᕜР‫࣐ݳ‬ե? ᇴ݃Ȉफ‫ޠڌ‬Ϝ኿ઢစ‫ق‬ಜᄈή࿩ҧ‫ޒ‬သષ(T3)೾ഇ‫ࣻܓ‬ᄈၷৰȂୂᕎҧ‫ޒ‬ သᏙ(desiccated thyroid)Щ΢ᡞՍดϸ‫ޠݫ‬ҧ‫ޒ‬သષ֥ԥၷାЩ‫ޠپ‬ T3Ȅ ࡛ឋȈׂ৓෉໣ҧ‫ޒ‬သѓ૗մί࡛ឋпπ݉LT4‫ݾ‬ᕜȂT3ᇅୂᕎҧ‫ޒ‬သᏙϛ ҧ‫ޒ‬သѓ૗մίᇅׂ৓

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࡛ឋӶׂ৓෉໣‫ٻ‬ңȄା࡚࡛ឋȂմᜍᐄ઼๊ Νȃׂ৓෉໣ҧ‫ޒ‬သѓ૗մί‫ݾ‬ᕜ‫ޠ‬ҭዀ࣐ե? ࡛ឋȈׂ৓෉໣ҧ‫ޒ‬သѓ૗մί‫ݾ‬ᕜ‫ޠ‬ҭዀ࣐஡ T S H ௢‫ښ‬ӶөѺ෉஠ԥ‫ޠ‬ TSH୥Մঅ‫ޠ‬ίΡϸϟΚȂ‫࢑ܗ‬஡TSH௢‫ښ‬Ӷϊܼ2.5 mU/LȄ մ࡚࡛ឋȂϜᜍᐄ઼๊ Υȃ ׂ৓෉໣ึҢҧ‫ޒ‬သѓ૗մί‫ޠ‬ାॴᓏఋထ࣐ե? ׂ৓෉໣ҧ‫ޒ‬သѓ૗ մίᇅାॴᓏఋထ्Ԅեଢᙺ? ᇴ݃Ȉҧ‫ޒ‬သՍᡞ‫׫‬ᡞTPOAb‫ܗ‬thyroglobulin antibody (TgAb)໩‫ܓ‬ȃ௦‫ڨ‬ႇ൑ ୐ҧ‫ޒ‬သϹଷ‫ܗ‬௦‫ڨ‬ႇܺৣ‫ܓ‬࿩‫ݾ‬ᕜ‫ޠ‬ѺஐȂึҢҧ‫ޒ‬သѓ૗մί‫ޠ‬ ᐡཽၷାȄ ࡛ឋȈׂ৓෉໣ึҢҧ‫ޒ‬သѓ૗մίȃ‫ٴ‬ᖞ‫ܓט‬ҧ‫ޒ‬သѓ૗մί‫ޠ‬ѺஐпІ ҧ‫ޒ‬သѓ૗մίାॴᓏఋထ‫ޠ‬ѺஐȂᔗؑ4໋ᔯࢦΚԪTSHᐩ࡚‫ׂژޣ‬ ৓Ϝ෉ȂйӶׂ৓30໋ѿѢՎЎӕଢᙺΚԪȄା࡚࡛ឋȂାᜍᐄ઼๊ Οȃϑစ݉ңLT4‫ݾ‬ᕜҧ‫ޒ‬သѓ૗մί‫ޠ‬ѺஐӶׂ৓෉໣ҧ‫ޒ‬သѓ૗Ⴒ෉ཽ ԄեᡑϾ?्Ԅե።ᐍLT4‫ޠ‬Ꮩ໕? ொԥҧ‫ޒ‬သѓ૗մί‫ޠ‬ஐυӶॏฬ् ᛅѺਣ‫ݨޠ‬ཏ‫ٲ‬໷࣐ե? ᇴ݃Ȉׂ৓෉໣ङሰቩђ 40-50% ‫ޠ‬ҧ‫ޒ‬သષϘ૗ᆱࡼٙᡞҧ‫ޒ‬သષᐩ࡚‫ޠ‬ ҔளȂՅйӶׂ৓‫ޠ‬4-6໋֊ሰ्ቩђȂ೼ᆎቩђ‫ژ៊ࡼݸޒޠ‬16-20 ໋Ȃϟࡤࡼ҂ՎҢ౱(10)Ȅቩђ‫ޠ‬Ꮩ໕ᇅആԚҧ‫ޒ‬သѓ૗մί‫ޠ‬঩ӱԥ ᜱȂ‫پ‬Ԅ௦‫ڨ‬ႇܺৣ‫ܓ‬࿩‫ݾ‬ᕜ‫ܗ‬К೛ࡤංо‫ء‬ԥѓ૗‫ܓ‬ҧ‫ޒ‬သಣᙒ‫ޠ‬ ொ޲໹्Щԥ෥੽ѓ૗‫ܓ‬ҧ‫ޒ‬သಣᙒ(‫پ‬ԄᐞҐЫҧ‫ޒ‬သ‫ޠ)ވ‬ஐυቩ ђၷӼ‫ޠ‬Ꮩ໕Ȅԥॏฬ्ᛅѺ‫ޠ‬ஐυȂ࡛ឋᛅѺࠊѠ஡TSH ᐩ࡚७‫ژ‬ ϊܼ2.5 mU/LȂӶׂ৓ߒ෉TSH Ёା‫ॴޠ‬ᓏၷմ(11)Ȅ ࡛ឋȈҔӶ݉ңLT4‫ݾ‬ᕜҧ‫ޒ‬သѓ૗մί‫ޠ‬Ң‫ي‬ԒឮஐυȂ҇໹ፐఁӶׂ৓ ෉໣Ѡ૗ሰ्ቩђ᛿‫ޠޑ‬Ꮩ໕Ȅη҇໹ፐఁொ޲ΚҎጃۢᛅѺ‫ܗ‬ᛅᅹ ϑစᛅѺሰ଼्αᇅᚃ৲ᖓ๝Ȅା࡚࡛ឋȂାᜍᐄ઼๊ ࡛ឋȈҔӶ݉ңLT4‫ݾ‬ᕜҧ‫ޒ‬သѓ૗մί‫ޠ‬ஐυसॏฬ्ᛅѺȂᛅѺࠊሰᔯ ࢦTSHᐩ࡚Ȃ‫ٯ‬።ᐍLT4‫ޠ‬Ꮩ໕ᡲTSHᆱࡼӶҔளጓ൝ί४Վ2.5 mU/L ϟ໣Ȅା࡚࡛ឋȂϜᜍᐄ઼๊ ࡛ឋȈҔӶ݉ңLT4‫ݾ‬ᕜҧ‫ޒ‬သѓ૗մί‫ޠ‬ஐυȂΚҎጃۢᛅѺ‫ܗ‬ᛅᅹϑစ ᛅѺ֊ѠՍ՘ቩђLT4ؑСᏙ໕‫ޠ‬20-30%‫໋ؑܗ‬ቩђ‫ڎ‬ᏙLT4(10, 12)Ȃ‫ٯ‬ й଼αᇅᚃ৲ᖓ๝пԋ௷ໍΚؐ‫ޠ‬ᔯࢦᇅຠզȄ ା࡚࡛ឋȂାᜍᐄ઼๊ ΫȃҢ౱ࡤLT4‫ޠ‬Ꮩ໕्Ԅե።ᐍ? ᇴ݃ȈτӼ኶‫ޠ‬ѺஐӶϸ৕ࡤȂLT4‫ޠ‬Ꮩ໕Ѡ።ᐍӲ‫ڨ‬Ѻࠊ‫ޠ‬Ꮩ໕Ȃ‫ٯ‬йӶ6 41

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

໋ࡤᔯࢦΚԪTSHᐩ࡚Ȅԥः‫ف‬ᡘұொԥᐞҐЫҧ‫ޒ‬သ‫ޠވ‬ஐυȂӱ ࣐౱ࡤautoimmune thyroid dysfunctionඍϾȂϸ৕ࡤLT4‫ޠ‬Ꮩ໕ԥѠ૗ ሰ्Щ‫ڨ‬Ѻࠊ‫؂‬ା(13)Ȅ ࡛ឋȈ ϸ৕ࡤȂLT4‫ޠ‬Ꮩ໕҇໹።ᐍӲ‫ڨ‬Ѻࠊ‫ޠ‬Ꮩ໕Ȃ‫ٯ‬йӶङ6໋ࡤᔯࢦΚ ԪTSHᐩ࡚Ȅା࡚࡛ឋȂϜᜍᐄ઼๊ ࡛ឋȈ ԥ‫ٳ‬ᛅѺࡤϘ‫ٻ‬ңLT4‫ݾ‬ᕜ‫ޠ‬ஐυȂӶϸ৕ࡤѠ૗Ѡп୅ңLT4ȂЏ‫ڐ‬ ࢑ؑСLT4‫ޠ‬Ꮩ໕ ͢ g‫ޠ‬ஐυȄԄ‫ݏ‬୅ңLT4҇໹Ӷङ6໋ࡤᔯࢦΚ ԪTSHᐩ࡚Ȅմ࡚࡛ឋȂϜᜍᐄ઼๊ ΫΚȃ௦‫ݾڨ‬ᕜ‫ޠ‬ҧ‫ޒ‬သѓ૗մίѺஐȂ࢑֐໹्ԋ௷᚟ѵ‫ޠ‬༿​༿ᇅफ‫ޠڌ‬ ᔯࢦ? ᇴ݃Ȉ ௦ԞًԂ‫ݾ‬ᕜ‫ׂޠ‬৓෉໣ҧ‫ޒ‬သѓ૗մίІ‫ٴ‬ᖞ‫ܓט‬ҧ‫ޒ‬သѓ૗մί ஐυȂ‫ء‬ԥः‫ف‬ᡘұཽቩђӉե౱ऌ‫ޠ઀ึڂ‬ᐡཽȄ ࡛ឋȈ ଷΠҧ‫ޒ‬သѓ૗ѵȂ௦ԞًԂ‫ݾ‬ᕜ‫ׂޠ‬৓෉໣ҧ‫ޒ‬သѓ૗մίІ‫ٴ‬ᖞ ‫ܓט‬ҧ‫ޒ‬သѓ૗մίஐυȂϛሰ्ԋ௷᚟ѵ‫ޠ‬༿​༿ᇅफ‫ޠڌ‬ᔯࢦȄկ Ԅ‫࢑ݏ‬ӱ࣐௦‫ڨ‬ႇܺৣ‫ܓ‬࿩‫ݾ‬ᕜ‫ܗ‬ҧ‫ޒ‬သϹଷ‫ޠ‬ҧ‫ޒ‬သѓ૗Ϧໍஐ υȂ໹्ᔯࢦTSH receptor antibodyȄା࡚࡛ឋȂϜᜍᐄ઼๊ ஠ԥӫມϜऽНᄈྲߓ ҧ‫ޒ‬သ‫ڗ‬ᐮષ (ߵҧ‫ޒ‬သષȂҧߵષ)

thyroid-stimulating hormone (TSH)

ή࿩ҧ‫ޒ‬သષ

triiodothyronine (T3)

ѿఌҧ‫ޒ‬သષ

levothyroxine (LT4)

ୂᕎҧ‫ޒ‬သᏙ

desiccated thyroid

୥ ՄНᝧ 1. Negro R, Schwartz A, Gismondi R, Tinelli A, Mangieri T, Stagnaro-Green A. Increased pregnancy loss rate in thyroid antibody negative women with TSH levels between 2.5 and 5.0 LQ WKH ¿UVW WULPHVWHU RI SUHJQDQF\ - &OLQ (QGRFULQRO 0HWDE ( ±( 2. Liu H, Shan Z, Li C, Mao J, Xie X, Wang W, Fan C, Wang H, Zhang H, Han C, Wang X, Liu X, Fan Y, Bao S, Teng W. Maternal subclinical hypothyroidism, thyroid autoimmunity, and the risk of miscarriage: a prospective cohort study. Thyroid 2014; 24:1642–1649.

3. Thompson W, Russell G, Baragwanath G, Matthews J, Vaidya B, Thompson-Coon J. Maternal WK\URLG KRUPRQH LQVX൶FLHQF\ GXULQJ SUHJQDQF\ DQG ULVN RI QHXURGHYHORSPHQWDO GLVRUGHUV LQ R൵VSULQJ $ V\VWHPDWLF UHYLHZ DQG PHWD DQDO\VLV &OLQ (QGRFULQRO 2[I 4. Casey BM, Thom EA, Peaceman AM, Varner MW, Sorokin Y, Hirtz DG, Reddy UM, Wapner RJ, Thorp JM Jr, Saade G, Tita AT, Rouse DJ, Sibai B, Iams JD, Mercer BM, Tolosa J, Caritis SN, VanDorsten JP; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network. Treatment of Subclinical Hypothyroidism or Hypothyroxinemia in Pregnancy. N Engl J Med 2017;376:815-825.

5. Taylor PN, Minassian C, Rehman A, Iqbal A, Draman MS, Hamilton W, Dunlop D,

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Robinson A, Vaidya B, Lazarus JH, Thomas S, Dayan CM, Okosieme OE. TSH levels and risk of miscarriage in women on long-term levothyroxine: a community-based study. J Clin Endocrinol Metab 2014 ;99:3895-902.

6. Yamamoto JM, Benham JL, Nerenberg KA, Donovan LE. Impact of levothyroxine therapy on obstetric, neonatal and childhood outcomes in women with subclinical hypothyroidism diagnosed in pregnancy: a systematic review and meta-analysis of randomised controlled trials. BMJ Open 2018 ;8:e022837.

7. Dosiou C, Medici M. MANAGEMENT OF ENDOCRINE DISEASE: Isolated maternal h y p o t h y r o x i n e m i a d u r i n g p r e g n a n c y: k n o w n s a n d u n k n o w n s. E u r J E n d o c r i n o l 2017;176:R21-R38.

8. Gong X, Liu A, Li Y, Sun H, Li Y, Li C, Yu X, Fan C, Shan Z, Teng W. The impact of isolated maternal hypothyroxinemia during the first and second trimester of gestation on pregnancy outcomes: an intervention and prospective cohort study in China. J Endocrinol Invest 2018. doi: 10.1007/s40618-018-0960-7. [Epub ahead of print] 9. Lazarus JH, Bestwick JP, Channon S, Paradice R, Maina A, Rees R, Chiusano E, John R, Guaraldo V, George LM, Perona M, DallɅ Amico D, Parkes AB, Joomun M, Wald NJ. Antenatal thyroid screening and childhood cognitive function. N Engl J Med 2012; 366:493– 501.

10. Alexander EK, Marqusee E, Lawrence J, Jarolim P, Fischer GA, Larsen PR Timing and magnitude of increases in levothyroxine requirements during pregnancy in women with hypothyroidism. N Engl J Med 2004; 351:241–249.

11. Yassa L, Marqusee E, Fawcett R, Alexander EK. Thyroid hormone early adjustment in pregnancy (the THERAPY) trial. J Clin Endocrinol Metab 2010; 95:3234–3241.

12. Alexander EK, Marqusee E, Lawrence J, Jarolim P, Fischer GA, Larsen PR. Timing and magnitude of increases in levothyroxine requirements during pregnancy in women with hypothyroidism. N Engl J Med 2004; 351:241–249.

13.Galofre JC, Haber RS, Mitchell AA, Pessah R, Davies TF. Increased postpartum thyroxine replacement in HashimotoɅs thyroiditis. Thyroid 2010; 20:901–908.

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ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

Ᏻ᠟ ଼୎ᚃଲུചхᗃऌ ᙐም‫ع‬ఁ௳

਴ᐄࢻ՘੿Ᏹः‫ف‬ᡘұȂҧ‫ޒ‬သ੾੿‫܂܂‬ᇅՍᡞռ࣬ ᐡ૗ѷ።ԥᜱȂՅйԂึܼҢ‫ي‬Ԓឮ໧ࢳ‫ޠ‬υ‫݊ܓ‬ЅȄӱ ԫȂԥณ೏Ӷׂ৓‫ޒ‬ᄙ‫ޠ‬ҧ‫ޒ‬သ੾੿υ‫ܓ‬Ȃԃউ‫ܛ‬ᑰொ‫ޠ‬ ҧ‫ޒ‬သ੾੿८ࣻІ઀‫ޒ‬ȂпІࡤ៊‫ޠڦ௵ܛ‬ຩᘟІ‫ݾ‬ᕜᄈ ๋࢑֐ԥ‫ܛ‬ϛӤȉΚ‫ޣ‬п‫ٿ‬Ȃഎ࢑ӓ౩ҧ‫ޒ‬သᚃᏱࣩစள ଇ፤‫ޠ‬ឋᚡȄ Ґത࿾࡟ᄹ۸Ҧѯі଼୎ख‫܉‬ᚃଲϲϸ‫ݫ‬ᄳུചхᗃ ऌၦ౐л‫ݾ‬ᚃ৲ቔ‫ݙ‬ᑹ‫ש࣐ٿ‬উ၍‫ׂݚ‬৓ᇅ౱ࡤҧ‫ޒ‬သ੾ ੿‫ޠ‬ຩᘟІ‫ݾ‬ᕜȄቔᚃ৲௄ज୾ҧ‫ޒ‬သᏱཽ‫ࡿޠ‬Ж࡛ឋȂ ഀ๗ᄃᜍᚃᏱ‫ޠ‬ຠ‫ݚ‬Ȃّᙐཏၬӵඣख़ׂ৓෉໣І౱ࡤ‫ޠ‬ ҧ‫ޒ‬သѓ૗մί‫ٴڸ‬ᖞ‫ܓט‬ҧ‫ޒ‬သѓ૗մί‫ޠ‬өᆎቺԪ‫ޠ‬ ೏ဋР‫ݳ‬Ȃ‫پ‬ԄLT4‫ޠ‬Ꮩ໕्Ԅե።ᐍ๊Ȅཽࣻ߭ழ๞ҭ ࠊ௄‫ٲ‬ҧ‫ޒ‬သᖞ‫ט‬Ϗձ‫ޠ‬ӀգউȂΚ৉ུ‫ࡧޠ‬ᆱІР‫ݳ‬Ȅ

ҧ‫ޒ‬သѓ૗մίᇅׂ৓

44

ׂ৓ਣ‫ޠ‬ҧ‫ޒ‬သѓ૗Ϧໍ ᇄτᚃଲ ࢋ๣ᇉ ΚȃӶᛅѺ෉໣ԥ঻‫ٳ‬঩ӱཽആԚҧ‫ޒ‬သѓ૗Ϧໍ? ᇴ݃Ȉ ါ࿆Њ૮Ы઀࢑Ң‫ي‬Ԓឮυ‫ܓ‬ഷளُ‫ޠ‬ആԚҧ‫ޒ‬သѓ૗Ϧໍ‫ޠ‬঩ӱȄ ѻึҢӶτङ 0.2 % ‫ޠ‬Ѻஐ (1)Ȅ‫ڐ‬уၷЎُ‫ޠ‬঩ӱєࢃࢴ‫ܓ‬ҧ‫ޒ‬သድ (toxic multinodular goiter, toxic adenoma)‫ܗ‬ณฯ‫ܓ‬ҧ‫ޒ‬သึ‫(ވ‬painless thyroiditis)Ȅ ‫؂‬Ўُ‫ޠ‬঩ӱєࢃϸ‫ ݫ‬TSH‫ޠ‬ဟί࠮ᡞလድȃ֋லҧ‫ޒ‬သድ (struma ovarii)ȃѓ૗‫ܓ‬ҧ‫ޒ‬သᕝᙾಌȃTSH‫ڨ‬ᡞऐᡑ(2-4)ȄᛅѺ෉໣Щါ࿆Њ ૮Ы઀‫؂‬ளُആԚାҧ‫ޒ‬သષ՗઀‫ޠ‬঩ӱ࢑ᛅѺኸਣ‫ܓ‬ҧ‫ޒ‬သࢴ઀ Ȟgestational transient thyrotoxicosisȟȂѻึҢӶτङ1-3%‫ޠ‬ѺஐȂ‫ٯ‬ йࠂ४ӶᛅѺࠊљਣ෉ึҢȄ೼࢑ҦܼᛅѺਣhCGαЁ‫ܛ‬ആԚ(5,6)Ȃ‫ٯ‬ йစளᇅׂ৓ቒӦ(hyperemesis gravidarum)ࣻᜱȄׂ৓ቒӦึҢӶτ ङ3-10/1000ԪᛅѺȂۢဏ࣐ӶᛅѺߒ෉ᝓ२⭇ЗნӦȂգᓎτङ5% ᡞ२෶ሇȃ಴Ь‫ڸ‬⢅ሗ‫઀׎‬Ȅ‫ڐ‬уӱhCGആԚ‫ޠ‬ҧ‫ޒ‬သᐡ૗Ϧໍ঩ӱ єࢃӼबफȃီຊफ(hydatidiform mole)ȃ๘ЪጱᕝȃT S H‫ڨ‬ᡞऐᡑ ᏳयᄈhCGႇ࡚ఄད(7-9)Ȅ ѯᢋȈґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ ΡȃसӶׂ৓ॷήঐУึ౫՗ϜTSHၷմȂΚ໡ۗ၏Ԅեຠզȉ ήȃ ᛅѺኸਣ‫ܓ‬ҧ‫ޒ‬သࢴ઀(gestational transient thyrotoxicosis)ᇅါ࿆Њ૮Ы઀ hyperthyroidism)ᔗԄեϸᒲȉ ҧ‫ޒ‬သѓ૗Ϧໍ(GravesɅ ᇴ݃ȈӶׂ৓ॷήঐУӱ‫ڨ‬hCG‫ڗ‬ᐮTSH‫ڨ‬ᡞ‫ޠ‬ኈ៫ȂTSHཽί७Ȃτङԥ 5%‫ޠ‬Ѻஐ‫ژ‬ΠᛅѺಒ11໋ਣ՗ϜTSHཽ७‫ژ‬ϊܼ0.1mU/L (10)Ȅ݃ᡘҧ ‫ޒ‬သѓ૗Ϧໍ‫ޠ‬ጃᇰຩᘟᔗє֥՗ϜTSHႇմ‫ڸ‬՗ϜTT4/FT4‫ܗ‬T3α ЁȄ स्ୣϸᛅѺኸਣ‫ܓ‬ҧ‫ޒ‬သࢴ઀ᇅါ࿆Њ૮Ыҧ‫ޒ‬သѓ૗ϦໍȂᔗс ಡၛୱ੿ѭ‫ڸ‬୉ٙᡞᔯࢦȄसႇџ‫ء‬ԥҧ‫ޒ‬သ੿ѭȃ‫ء‬ԥါ࿆Њ૮ Ы઀‫(ޒ઀࠯ڑޠ‬єࢃҧ‫ޒ‬သလτȃಂ੿ᡑ)ȃҧ‫ޒ‬သϦໍ࢑ሇཌྷՅՍ ४‫ޠܓ‬ȃԥნӦ઀‫๊ޒ‬Ȃၷ་Ӫ࣐ᛅѺኸਣ‫ܓ‬ҧ‫ޒ‬သѓ૗ϦໍȄ՗Ϝ hCG‫ڸ‬ҧ‫ݱॲົޒ‬ณ‫ݳ‬ԥਞୣϸ‫޲ڎ‬Ȅ सᛅᅹ‫ڐ‬у঩ӱആԚҧ‫ޒ‬သѓ૗ϦໍȂѠӒข໕՗Ϝҧߵષ‫ڨ‬ ᡞ (T R A b) ȇस T R A b Ҕள‫ܗ‬ដຩᅹԥҧ‫ޒ‬သ๗࿾Ȃࠍໍ՘ົॲ‫ݱ‬ ᔯࢦ‫ڟ‬ֆຠզ࢑֐ԥҧ‫ޒ‬သလድȄข໕T3Ѡп‫ڟ‬ֆຩᘟԥณT3

45

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

thyrotoxicosisȄΚૢՅّȂस࢑ҧ‫ޒ‬သҐٙࣁ୞‫ܓ‬Ћ஽ȂࠍT3‫ޠ‬αЁ ཽϛԚЩ‫ޠپ‬ЩT4αЁ्‫ٿ‬ூӼȇस࢑ҧ‫ޒ‬သೞખᚾ(‫پ‬Ԅҧ‫ޒ‬သ‫)ވ‬ ആԚ‫ޠ‬ѓ૗ϦໍȂࠍT4‫ޠ‬αЁཽϛԚЩ‫ޠپ‬ЩT3αЁ्‫ٿ‬ூӼȄ

࡛ឋȈ1. ᔗၛୱ੿ѭȃ୉ٙᡞᔯࢦȃข໕ҕᒒ՗Ϝ‫ޠ‬FT4‫ܗ‬TT4ᐩ࡚Ȅข໕ TRAb‫ڸ‬TT3Ѡ૗ᄈᚅఽҧ‫ޒ‬သѓ૗Ϧໍ‫ޠ‬঩ӱԥᔔֆȄ ା࡚࡛ឋȂϜᜍᐄ઼๊ 2. ϛ࡛ឋӶᛅѺ࿌Ϝໍ՘ܺৣ‫ܓ‬ᔯࢦȄା࡚࡛ឋȂାᜍᐄ઼๊

ѯᢋȈґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ ѳȃᔗԄե೏౪ᛅѺኸਣ‫ܓ‬ҧ‫ޒ‬သࢴ઀ȉ ᇴ݃Ȉ T4 ೾ளӶᛅѺಒ 14-18໋Ս୞࡯ඉҔளȄᛅѺԟ෉‫ٻ‬ң‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬ Ѡ૗ቩђफ‫ڌ‬౵ள‫ॴޠ‬ᓏȄ ࡛ឋȈ๞ϡМࡼ‫ݾܓ‬ᕜȃ೏౪಴Ь౫ຬȃसሰ्ᔗ՟ଲ‫ݾ‬ᕜȄϛ࡛ឋ‫ٻ‬ң‫׫‬ ҧ‫ޒ‬သ᛿‫ޑ‬ȄѠՄኍ‫ٻ‬ң͘‫ښ׼‬ᏙȄା࡚࡛ឋȂϜᜍᐄ઼๊ ѯᢋȈґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ ϥȃᔗ၏๞ϡԥါ࿆Њ૮Ы઀‫ٯ‬йॏდӶ஡‫ٿ‬ᛅѺ‫ޠ‬υ‫ܓ‬Ϩቅኻ‫࡛ޠ‬ឋȉ ᇴ݃Ȉ஽੩࡛ឋᗘѺ‫ژޣ‬ҧ‫ޒ‬သѓ૗Ϧໍ‫ژڨ‬௢‫ښ‬Ȅᔗᅿ໕ӶᛅѺࠊႁ‫ژ‬ᛨ ۢйҔள‫ޠ‬ҧ‫ޒ‬သѓ૗‫ޒ‬ᄙȄ‫ܛ‬ᒞᛨۢйҔள‫ޠ‬ҧ‫ޒ‬သѓ૗‫ޒ‬ᄙȂ࢑ ࡿӶ‫ء‬ԥ።ᐍ᛿‫ޒޠޑ‬ᄙίȂࣻ຾ΚঐУпα‫ڎޠ‬Ԫ‫ܫ‬՗ข໕ҧ‫ޒ‬သ ѓ૗ࣲҔளȄ ᔗՄኍ‫ݾ‬ᕜҧ‫ޒ‬သѓ૗Ϧໍ‫ޠ‬өᆎᒶᐆ‫ޠ‬Ԃᚾ೏(ߓΚ)Ȅसொ޲ᒶᐆ ‫׫‬ҧ‫ޒ‬သ᛿‫ݾޑ‬ᕜȂࠍᔗ֚‫੿ޤ‬΢ίӗ‫ٲ‬໷: (1)ӶᛅѺԟ෉‫ٻ‬ңҧ‫ޒ‬ သ᛿‫ޑ‬Ѡ૗ཽቩђུҢ‫ુޠڌ‬ടȄ(2)सѠп‫ၘޠ‬ȂӶׂ৓ॷήঐУᔗ ᅿ໕ᗘռ‫ٻ‬ң‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬Ȃस҇໹‫ٻ‬ң‫ၘޠ‬ȂΚૢᇰ࣐PTUၷ‫ٺ‬Ȅ (3)Ӷׂ৓ॷήঐУ๗‫ࡤ؃‬ȂՄኍ୅ңPTUȂ‫׾‬ңMMIȂп෶ЎѺஐ‫ن‬ ૿ᆒॴᓏȄ

ׂ৓ਣ‫ޠ‬ҧ‫ޒ‬သѓ૗Ϧໍ

46

ߓΚȃ ொԥါ࿆Њ૮Ыҧ‫ޒ‬သѓ૗Ϧໍ‫ޠ‬υ‫ܓ‬ᒶᐆөᆎ‫ݾ‬ᕜ‫ޠ‬Ԃᚾ೏ ‫ݾ‬ᕜ

Ԃ೏

Κȃ‫ڎ‬ঐУϜѠпԥਞӵ‫ݾ‬ᕜҧ‫ޒ‬သ ‫׫‬ҧ‫ ޒ‬ѓ૗‫ژ‬ҔளȄ သ᛿‫ ޑ‬೾ளѠ‫׫ٻ‬ᡞࡿ኶ᄛᄛ७մȄ ৡܿ።ᐍȄৡܿ݉ңȄ߰ۤȄ

ᚾ೏ ᛿‫ޑ‬୚ձң(ሇཌྷ: 5-8%;ᝓ२: 0.2%) ᛅѺ࿌Ϝ‫ٻ‬ңᇅུҢ‫ڌ‬౵ள ࣻᜱȄ ԥਣሰ२ፓ‫ݾ‬ᕜංԪȄ ‫ݾ‬ᕜࡤ‫׫‬ᡞࡿ኶ЁାȂѠ૗

π݉࡟ৡܿȄ ܺৣ‫ܓ‬ ᕼϊҧ‫ޒ‬သလȄ ࿩ ґ‫ٿ‬ҧ‫ޒ‬သϦໍඉึ‫࡟ݸޒޠ‬ЎȄ

ӱԫђ२ಂ੿ᡑᝓ२โ࡚ȃ ‫ܗ‬ቩђफ‫ڌ‬ҧ‫ޒ‬သѓ૗౵ள ‫ॴޠ‬ᓏȄ ໹ಥҢ݉ңҧ‫ޒ‬သષȄ(࡛ឋ Ӷܺৣ‫ܓ‬࿩‫ݾ‬ᕜࠊ48ϊਣᡜ ѺпጃᇰณᛅѺȄܺৣ‫ܓ‬࿩ ‫ݾ‬ᕜࡤљԒϲϛۤᛅѺȄ)

݃ጃ‫ݾ‬ᕜҧ‫ޒ‬သѓ૗ϦໍȄ೛ࡤ၅щ ಥҢ໹݉ңҧ‫ޒ‬သષȄ ҧ‫ޒ‬သષ૗ሇܿႁ‫ژ‬ҧ‫ޒ‬သѓ૗Ҕள К೛୚ձң(2-5%)Ȅ ҧ‫ޒ‬သ ‫ޒޠ‬ᄙȄ Ϲଷ೛ К೛‫ޠ‬ඉ঩Ȅ К೛ࡤȂՍᡞռ࣬౵ளѠഃᅛጦ၍Ȅ Ҙε‫ޠ‬ᓜഌК೛࣭౸Ȅ ϛӕԥҧ‫ޒ‬သလ‫ݸޒޠ‬Ȅ ࡛ឋȈ1. ᔗᇅ‫ܛ‬ԥԥҧ‫ޒ‬သѓ૗Ϧໍ‫ޠ‬Ң‫ي‬Ԓឮυ‫ܓ‬ଇ፤஡‫ٿ‬सᛅѺਣᔗ‫ݨ‬ ཏ‫ٲޠ‬໷Ȅ࿌ԥါ࿆Њ૮Ы઀‫ޠ‬υ‫ٿܓ‬୉ᛅѺࠊᒛၛਣȂᔗ֚‫ޤ‬ԃ উᛅѺਣ೏౪ԫ੿‫ޠ‬ፓᚖ‫ܓ‬Ȃєࢃᇅ‫׫‬ҧ‫ޒ‬သ᛿‫ࣻޑ‬ᜱ‫ޠ‬फ‫ુڌ‬ ടȄᚃ৲ᔗсಡՄኍ‫ܛ‬ԥѠᒶ‫ݾ‬ᕜ‫ޠ‬Ԃᚾ೏Ȃ‫ٯ‬Մ໕੿΢དྷ्ᛅѺ ‫ޠ‬ਣ໣Ȅା࡚࡛ឋȂାᜍᐄ઼๊ 2. ҧ‫ޒ‬သϦໍ‫ޠ‬ஐυᔗᅿ໕ӶᛅѺࠊႁ‫ژ‬ᛨۢйҔள‫ޠ‬ҧ‫ޒ‬သѓ૗‫ޒ‬ ᄙȄԥΚ‫ݾٳ‬ᕜРԓѠпᒶᐆȂєࢃܺৣ‫ܓ‬࿩‫ݾ‬ᕜȃК೛Ϲଷҧ‫ޒ‬ သȃ‫׫࢑ܗ‬ҧ‫ޒ‬သ᛿‫ݾޑ‬ᕜȄؑᆎ‫ݾ‬ᕜРԓഎԥ‫ࣻڐ‬ᜱ‫ॴޠ‬ᓏᇅԂ ೏Ȅା࡚࡛ឋȂϜᜍᐄ઼๊

ѯᢋȈґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ ϳȃ ᔗԄե‫ݾ‬ᕜᛅѺ෉໣‫ޠ‬ါ࿆Њ૮Ы઀ҧ‫ޒ‬သѓ૗Ϧໍȉ Νȃ ᛅѺԟ෉࢑֐ᔗ෶Ў‫ܗ‬።ᐍ‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬ȉ

47

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

ᇴ݃ȈѺஐ‫ޠ‬ҧ‫ޒ‬သѓ૗ϦໍᇅΚ‫ࣻ઀ึڂٳ‬ᜱȄҧ‫ޒ‬သѓ૗Ϧໍ௢‫ښ‬ϛً ᇅࢻ౱ȃѺஐା՗ᔇȃԟዤȃᔊ‫ڌ‬яҢᡞ२ႇմȃφয়ϲҢߞ‫ڨ‬४ȃ Ԭफȃҧ‫ޒ‬သॴኹȃѺஐЗ᠛૿ᆒࣻᜱ(11)Ȅηԥः‫ࡿف‬яȂसफ‫ڌ‬ਣ ෉ኹ៪‫ٿژ‬ՍҕᡞႇӼ‫ޠ‬ҧ‫ޒ‬သષȂ‫ࡤڐ‬Ӷߨࢍ෉‫ܗ‬ԚԒࡤѠ૗ཽ౱ ҢΚ‫੿੾ٳ‬Ȃ‫پ‬Ԅัᡀȃઢစ՘࣐౵ள(12)Ȅ ‫׫‬ҧ‫ޒ‬သ᛿‫࢑ޑ‬ᛅѺਣ෉ഷளң‫ݾٿ‬ᕜҧ‫ޒ‬သϦໍ‫ޠ‬РԓȂକۗᏙ໕ ᇅ઀‫ڸޒ‬Ϧໍ‫ᝓޠ‬२โ࡚ࣻᜱȂ೾ள࢑MMI 5-30mg/dȂCM 10-40mg/ d ‫ܗ‬PTU 100-600mg/dȄMMIᇅPTU‫ࣻޠ‬࿌ਞΩ(equivalent potency)τ ङ࢑1:20ȄCM 10mg࡟‫ཽץ‬ೞхᗃ࣐MMI 6mg (13-15)ȄMMIѠпΚЉ݉ ңΚԪȂկPTUљ૿෉ၷ฼ȂᔗϸԚΚЉ2-3Ԫ݉ңȄ3-5%‫੿ޠ‬΢Ѡ ૗ཽԥ‫׫‬ҧ‫ޒ‬သ᛿‫ޠޑ‬୚ձңȂτഌϸ࢑ҫጴႇఄȂկԥਣ঑ηཽԥ ᝓ२‫ޠ‬୚ձңȂ‫پ‬ԄҪ՗౩ႇմ‫نڸ‬ѓ૗౵ளȄτഌϸ୚ձң࢑Ӷ໡ ۗ‫ٻ‬ң᛿‫ޠࡤޑ‬ංঐУ൸౱Ң(16)ȄӶज୾ȂPTU࢑ആԚ‫ن‬᠛ಌෛ‫ޠ‬᛿ ‫ޑ‬Ϝ௷՘ಒήӫ‫ޠ‬Ȃज୾ॶࠣ᛿ࠣᆔ‫׌ښ‬ණᒻτঢ়्‫ݨ‬ཏPTU‫ࢴنޠ‬ ‫ܓ‬Ȃ‫ܛ‬пΚૢཽ‫ױ‬PTU‫ٻޠ‬ңࠂ४ӶᛅѺׂ৓ॷήঐУȂଷߩ੿΢ᄈ MMIႇఄȂ‫ܗ‬ԥҧ‫ޒ‬သॴኹȄ‫ٯ‬йѠпՄኍᔔ‫ٻ‬ңPTU‫ޠ‬ொ޲ᔯข‫ن‬ ѓ૗ȄดՅȂѯᢋ‫ޠ‬ः‫ف‬๗‫ݏ‬ᇅज୾ϛӤȂ਴ᐄήᖃ‫ޠ‬ः‫ف‬Ȃ݉ң MMI‫ܗ‬CM‫ޠ‬ொ޲ᑰொ‫ॴޠވن‬ᓏЩ݉ңPTU޲‫ٿ‬ூା(17)Ȅ਴ᐄѫΚ ໷ѯіᚃᏱτᏱᇅ໩݃τᏱ‫ޠ‬ः‫ف‬ȂᛅѺ෉໣݉ңPTU‫ޠ‬Ѻஐ౱ίմ ᡞ२‫ޠ‬ᔊ‫ޠڌ‬ᐡ౦ȂЩґ݉ң‫׫‬ҧ‫ޒ‬သ᛿‫ޠޑ‬Ѻஐ‫ٿ‬ூାȂՅ݉ң MMI‫ٯ‬ณ೼ᆎ‫(ݸޒ‬18)Ȅ೼ԥѠ૗࢑΢ᆎϟ໣‫ޠ‬ৰ౵Ȅ ᛅѺਣഷᡲ΢ᐋЗ‫ޠ‬ᗚ࢑‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬Ѡ૗౱Ң‫ޠ‬य࿍फ୚ձңȄ Syndrome of methimazole/carbimazole embryopathyєࢃߓҫึ‫ي‬ϛً (aplasia cutis) ȃࡤቆЍ‫ॶܗ‬ၿഗᚈ(choanal or esophageal atresia)ȃဝᏪ ુ཭ȃಂ࿙ȃ‫ق׎ݫ‬ಜୱᚡȃЗ᠛ϜႥુ཭(19-21)Ȅ2-3%ᛋ៪‫ژ‬PTU‫ޠ‬ फ‫ڌ‬ȂӶяҢࡤ౱ҢΚ‫ુٳ‬ടȂл्࢑Ӷᖜ‫ڸ‬ಲφ‫᠅ޠ‬လ‫׎ݫܓعڸ‬ ၿ౵ளȄPTUᇅMMIࣻЩȂ‫ڐ‬яҢࡤึҢӒЉ౵ள‫ึޠ‬Ң౦ᇅMMIৰ ϛӼկၷϛᝓ२Ȅ͘ߣᘟᏙ(‫پ‬Ԅpropranolol 10-40mg q6-8h)Ѡңܼ௢ ‫ښ‬ҧ‫ޒ‬သϦໍ‫ޒ઀ޠ‬Ȃ‫ژޣ‬ҧ‫ޒ‬သѓ૗ҔளȂτഌϸѠпӶ 2-6 ໋ࡤ ୅Ц‫ٻ‬ңȂߞ෉‫ٻ‬ңѠ૗ᇅφয়ϲҢߞ‫ڨ‬४ȃफ‫ڌ‬Зၱႇᄛȃ‫ུڸ‬Ң ‫ڌ‬մ՗ᑦࣻᜱ(22)Ȅ ାᏙ໕࿩‫ݾ‬ᕜϛΚۢᎍңܼᛅѺȄCholestyramineѠӱ෶Ўဘ‫ن‬ඊᕘ ਣҧ‫ޒ‬သષೞӕ֝Ԟ‫ޠ‬໕Յ‫׾‬๢ҧ‫ޒ‬သϦໍȄկѻѠ૗ཽആԚဘदϛ ᎍȂηѠ૗ኈ៫ဘၿᄈᛅѺ‫ܛ‬ሰ‫ޠ‬Κ‫ٳ‬ᆱу‫֝ޠڽ‬ԞȄᎥᢅѠ૗ཽय ࿍फȂ‫ܛ‬пηϛᎍӬӶᛅѺ෉໣‫ٻ‬ңȄ ࡛ឋȈ1. ᔗ၏࡛ឋҔӶ݉ң‫׫‬ҧ‫ޒ‬သ᛿‫ޠޑ‬υ‫ܓ‬Ȃ࿌ᅹԥᛅѺਣȂ्ᅿԟጃ ᇰ࢑֐ԥᛅѺȄΚҎጃᇰԥᛅѺȂᔗҴ‫ڔ‬ᇅᚃ৲ᖓᛯȄ ା࡚࡛ឋȂାᜍᐄ઼๊ ׂ৓ਣ‫ޠ‬ҧ‫ޒ‬သѓ૗Ϧໍ

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2. ӱ࣐‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬ԥय࿍फ‫ޠ‬Ѡ૗‫ܓ‬ȂࢉӶ݉ңմᏙ໕‫׫‬ҧ‫ޒ‬သ᛿ (MMI < 10 mg/d or PTU < 200 mg/d)‫ٯ‬йҧ‫ޒ‬သѓ૗Ҕள‫ޠ‬ါ࿆Њ૮ Ы઀υ‫ܓ‬থᛅѺਣȂᔗՄኍ୅ң‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬Ȅ࢑֐૗஋୅᛿Ȃᔗ ୥Մ੿ѭȃҧ‫ޒ‬သτϊȃ‫ݾ‬ᕜਣ໣ȃഷߗ‫ޠ‬ҧ‫ޒ‬သѓ૗ᔯࢦ๗‫ݏ‬ȃ TRAbࡿ኶ȃ‫ڐڸ‬уᖞ‫ט‬ӱષȄմ࡚࡛ឋȂմᜍᐄ઼๊ (a) ᔗӶ୅ң‫׫‬ҧ‫ޒ‬သ᛿‫ࡤޑ‬Ȃؑ 1-2 ໋‫ܫ‬՗ᔯࢦѺஐҧ‫ޒ‬သѓ૗ (TSH ‫ڸ‬FT4‫ܗ‬TT4)‫ڸ‬୉ᖞ‫ט‬ᔯࢦпຠզҕᒒᇅफ‫ޠڌ‬ҧ‫ޒ‬သ‫ޒ‬ ‫ݸ‬ȄसѺஐӶᖞ‫ט‬ᇅҢϾᔯࢦࣲᆱࡼҧ‫ޒ‬သѓ૗ҔளȂࠍᔯࢦ ໣ႥӶׂ৓ϜήঐУᇅҒήঐУѠ‫࣐ؑߞ۾‬2-4໋ᔯࢦΚԪȄ մ࡚࡛ឋȂմᜍᐄ઼๊ (b)ؑԪຠզਣȂᔗ‫ྲٸ‬ᖞ‫ט‬ᇅҢϾᔯࢦூ‫ޠޤ‬Ѻஐҧ‫ޒ‬သѓ૗‫ޒ‬ ‫ݸ‬Ȃ‫֐࢑ۢ؛ٿ‬᝸៊ᆱࡼ୅ң‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬Ȅ մ࡚࡛ឋȂմᜍᐄ઼๊ 3. Ӷस୅ң‫׫‬ҧ‫ޒ‬သ᛿‫ࡤޑ‬൸࡟Ѡ૗ཽึҢҧ‫ޒ‬သѓ૗Ϧໍ‫ޠ‬ାॴᓏ ѺஐȂѠ૗҇໹ࡼ៊‫ٻ‬ң‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬Ȅԫାॴᓏ‫ޠ‬ӱφєࢃȈ ҭࠊҧ‫ޒ‬သѓ૗ϦໍȂ‫ܗ‬ሰ्ၷାᏙ໕‫׫ޠ‬ҧ‫ޒ‬သ᛿‫>(ޑ‬5–10 mg/ d MMI‫>ܗ‬100–200 mg/d PTU)пᆱࡼҧ‫ޒ‬သѓ૗ҔளȄӶ೼ኻ‫ޠ‬ொ ޲Ȉ (a)ӶᛅѺ‫ࠊޠ‬16໋Ȃ࡛ឋпPTU‫ݾ‬ᕜȄା࡚࡛ឋȂϜᜍᐄ઼๊ (b)঩Ґ‫ٻ‬ңMMI‫ޠ‬ѺஐȂसԥሰ्ӶᛅѺႇโϜ᝸៊‫ݾ‬ᕜȂᔗᅿ ԟඳԚPTUȄմ࡚࡛ឋȂմᜍᐄ઼๊ (c)स्஡MMI‫࣐׾‬PTUȂࠍᙾඳЩ‫پ‬τङ࣐1:20Ȅ ା࡚࡛ឋȂϜᜍᐄ઼๊ (d)सᛅѺ16໋ࡤϬሰ्‫׫‬ҧ‫ޒ‬သ᛿‫ݾޑ‬ᕜȂҭࠊ‫ٯ‬ϛఽྀ࢑᝸៊ ‫ٻ‬ңPTU‫ᙾ࢑ܗ‬ඳ࣐MMIЩၷԂȂӱ࣐೼‫ڎ‬ᆎ᛿‫ޑ‬എԥѠ૗ԥ ୚ձңȂ Յйᙾඳ᛿‫ޑ‬Ѡ૗ཽആԚԥΚࢳਣ໣௢‫ښ‬ூၷϛԂȄ ‫ܛ‬пҭࠊ‫ٯ‬ณ‫࡛ݳ‬ឋ࢑֐ᙾඳ᛿‫ޑ‬Ȅณ࡛ឋȂᜍᐄϛ٘

ѯᢋȈ1. ਴ᐄ‫ݔ‬πߞ۹‫ޠ‬ः‫ف‬Ȃҧ‫ޒ‬သѓ૗Ϧໍ࢑ึҢφᡫࠊ઀ (preeclampsia)‫ॴޠ‬ᓏӱφϟΚ(23)Ȅ 2. ਴ᐄ໩݃τᏱ‫ޠ‬ः‫ف‬Ȃ݉ңPTU‫ݾ‬ᕜҧ‫ޒ‬သϦໍ‫ޠ‬ѺஐȂҢίᡞ२ ႇሇᔊ‫ޠڌ‬ᐡ౦Щґ݉ң‫׫‬ҧ‫ޒ‬သ᛿‫ݾޑ‬ᕜҧ‫ޒ‬သѓ૗Ϧໍ‫ޠ‬Ѻஐ ्‫ٿ‬ூτȄՅ݉ңMMI‫ݾ‬ᕜҧ‫ޒ‬သϦໍ‫ޠ‬ѺஐȂ‫ڐ‬फ‫ึڌ‬Ң౵ளЩ ‫پ‬ᇅґ݉ң‫׫‬ҧ‫ޒ‬သ᛿‫ݾޑ‬ᕜ‫ޠ‬Ѻஐϟफ‫ࣻڌ‬Ӥ(18)Ȅ

Υȃ ӶᛅѺ࿌Ϝ‫ݾ‬ᕜါ࿆Њ૮Ыҧ‫ޒ‬သѓ૗ϦໍਣȂข໕ҧ‫ޒ‬သѓ૗ᇅ‫׫‬ҧ ‫ޒ‬သ᛿‫ޑ‬๞ϡ‫ޠ‬঩ࠍ࣐եȉ ᇴ݃Ȉҧ‫ޒ‬သ‫ڗ‬ᐮ‫׫‬ᡞȃ‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬ȃ‫ڸ‬τഌϸ‫ޠ‬ҕᡞ‫ޠ‬ҧ‫ޒ‬သೊᅮᇍѠ 49

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

п࡟ԥਞ‫ޠ‬೾ႇफዻȄτഌϸ࢑ึҢӶ࿌ᛅѺಒ"20"໋‫ܗ‬ϟࡤफ‫ޠڌ‬ ҧ‫ޒ‬သ໡ۗԥѓ૗‫ޠ‬ਣ঑Ȃԫਣ೾ႇफዻ‫ޠ‬ҕᡞTRAb૗ആԚफ‫ڌ‬ҧ ‫ޒ‬သѓ૗ϦໍȄ‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬૗ԥਞӵ೾ႇफዻ‫ژ‬ႁफ‫ڌ‬Ȃ‫ܛ‬ԥ‫׫ޠ‬ ҧ‫ޒ‬သ᛿‫ޑ‬ᄈफ‫ޠڌ‬ਞ‫ݏ‬എЩᄈҕᒒ्‫ٿ‬ூԂȄࢉ࿌ҕᒒೞ‫ݾ‬ᕜ‫ژ‬ҧ ‫ޒ‬သѓ૗ҔளਣȂफ‫ڌ‬Ѡ૗ཽԥೞႇ࡚‫ݾ‬ᕜ‫ݸޒޠ‬Ȃ೼ਣѠ૗Жึफ ‫ڌ‬ҧ‫ޒ‬သလ‫ܗ‬ѓ૗մί(24)Ȅӱԫ‫ݾ‬ᕜѺஐҧ‫ޒ‬သѓ૗ϦໍਣȂᔗ‫ױ‬ҭ ዀܺӶҕᡞ‫ޠ‬TT4/FT4ӶҔளঅα४ѿѢ‫ܗ‬เାΚᘉȂᅿ໕ңഷЎሰ ्‫׫ޠ‬ҧ‫ޒ‬သ᛿‫ޑ‬໕‫ݾ‬ᕜȄӶഷࡤΚঐѺ෉ਣȂτङԥ20-30%‫ޠ‬Ѻஐ Ѡп୅ң‫׫‬ҧ‫ޒ‬သ᛿‫(ޑ‬25)Ȅҕᒒ՗ϜTSHӶҔளጓ൝࢑ΚঐѠп෶ң ‫׫‬ҧ‫ޒ‬သ᛿‫ޠޑ‬ኊӑȄसᛅѺఐ෉ҕᡞTRAb੒ѷȂߓұԥѠ૗Ѡп Ԛѓ෶Ў‫ژ‬୅ң‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬Ȅ Ѻஐሰೞ֚‫ޤ‬ȂҢ౱ࡤ‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬ሰؒѠ૗ཽቩђȂ‫ܗ‬ҧ‫ޒ‬သѓ૗ ϦໍԥѠ૗ཽඉึ(26)Ȅ ӱ࣐फዻᄈ‫׫‬ҧ‫ޒ‬သ᛿‫ޠޑ‬೾ഇ‫ܓ‬ၷLT4೾ഇ‫ٿ्ܓ‬ூԂȂ‫ٯ‬йफ‫ڌ‬ ‫ޠ‬ҧ‫ޒ‬သᄈܼ‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬ၷҕᒒ‫ޠ‬ҧ‫ޒ‬သ्‫ٿ‬ூఄདȂӱԫᅿ໕ϛ ्ң‫ٻ‬ңӬ‫ڂ‬LT4‫׫ڸ‬ҧ‫ޒ‬သ᛿‫ޑ‬೼ᆎblock-replace‫ޠ‬Рԓ‫ݾٿ‬ᕜѺஐ ҧ‫ޒ‬သѓ૗ϦໍȂ೼ᆎРԓளளཽആԚफ‫ڌ‬ҧ‫ޒ‬သလ‫ڸ‬ҧ‫ޒ‬သѓ૗մ ί(27)Ȅ ࡛ឋȈ1. ᛅѺ෉໣௦‫׫ڨ‬ҧ‫ޒ‬သ᛿‫ݾޑ‬ᕜ‫ޠ‬ஐυȂᔗτङؑѳ໋‫ܫ‬՗ข໕ FT4/TT4‫ڸ‬TSHȄା࡚࡛ឋȂϜᜍᐄ઼๊ 2. ᛅѺ࿌Ϝᔗ๞ϡഷЎሰ्໕‫׫ޠ‬ҧ‫ޒ‬သ᛿‫ޑ‬Ȃ‫ٯ‬஡ҕᒒ՗షϜ‫ޠ‬ FT4/TT4ҭዀ೪ӶҔளঅ‫ޠ‬α४‫࢑ܗ‬ЩҔளঅ‫ޠ‬α४เཌྷାΚ‫ٳ‬Ȅ ା࡚࡛ឋȂାᜍᐄ઼๊ 3. ᛅѺ࿌Ϝᔗᅿ໕ᗘռ‫ٻ‬ңӬ‫ڂ‬ҧ‫ޒ‬သષᇅ‫׫‬ҧ‫ޒ‬သ᛿‫ݾޠޑ‬ᕜȂଷ ߩ࢑Ӷ൑ᑀѬԥफ‫ڌ‬ҧ‫ޒ‬သϦໍ೼ᆎߩள‫ݸޒޠُك‬Ȅ ା࡚࡛ឋȂାᜍᐄ઼๊

ѯᢋȈґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ ΟȃӶᛅѺ෉໣пҧ‫ޒ‬သϹଷ೛‫ݾ‬ᕜါ࿆Њ૮Ы઀‫ޠ‬ᎍᔗ઀ᇅਣᐡ࣐եȉ ᇴ݃Ȉ सҧ‫ޒ‬သѓ૗Ϧໍ‫ޠ‬Ѻஐᄈ‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬ႇఄȃ‫ܗ‬ณ‫ٻݳ‬ң‫׫‬ҧ‫ޒ‬သ ᛿‫ޑ‬ȃ‫ܗ‬ᄈ᛿‫ޠޑ‬ᒴ௄‫࡟ܓ‬ৰȃ‫ܗ‬ሰ्ңߩளτ໕‫׫ޠ‬ҧ‫ޒ‬သ᛿‫ޑ‬Ϙ ૗ႁ‫ژ‬ҧ‫ޒ‬သѓ૗Ҕள‫ၘޠ‬ȂᔗՄኍ‫ٻ‬ңҧ‫ޒ‬သϹଷ೛‫ݾٿ‬ᕜȄׂ৓ ϜήঐУ࢑ഷԂ‫ޠ‬ਣᐡȄҧ‫ޒ‬သϹଷ೛ࡤȂTRAbཽጦᄛ‫ޠ‬ί७կϛ ཽҴ‫ڔ‬੒ѷȂՅ೼‫ٳ‬TRAbԥѠ૗ཽആԚफ‫ڌ‬ҧ‫ޒ‬သѓ૗ϦໍȂЏ‫ڐ‬ ࢑TRAbࡿ኶࡟ା޲(27)Ȅ‫ܛ‬п࿌ҕᒒ௦‫ڨ‬ҧ‫ޒ‬သϹଷ೛‫ٯ‬й୅ң‫׫‬ҧ ‫ޒ‬သ᛿‫ࡤޑ‬Ȃᔗ၏्ϊЗᆀขफ‫ݸޒڌ‬Ȃ‫ٯ‬ॏდѠ૗‫ݾޠ‬ᕜȄ࿌Ѻஐ ԥҧ‫ޒ‬သѓ૗Ϧໍ‫ٯ‬ณ‫ݳ‬ң‫׫‬ҧ‫ޒ‬သ᛿‫ݾޑ‬ᕜȂྦറ्௦‫ڨ‬ҧ‫ޒ‬သϹ ଷ೛ਣȂ࡛ឋ‫ٻ‬ң͘ߣᘟᏙ‫ڸ‬฼ኸӵ‫ٻ‬ңpotassium iodide solution (50ׂ৓ਣ‫ޠ‬ҧ‫ޒ‬သѓ૗Ϧໍ

50

100mg/d) (28)Ȅस੿΢Ӷҧ‫ޒ‬သϹଷ೛ࠊᛅᅹԥҧ‫ޒ‬သࣁ‫࡟ܓ‬஽‫ݸޒޠ‬ ਣȂηѠ‫ٻ‬ңpotassium iodide‫ٿ‬෶Ў೛Ϝя՗Ȅ

࡛ឋȈ1. ᛅѺਣȂѬӶ੬ੇ௒‫ݸ‬ίϘໍ՘ҧ‫ޒ‬သϹଷ೛Ȅसሰ्௦‫ڨ‬ҧ‫ޒ‬သ Ϲଷ೛ȂഷԂ࢑Ӷׂ৓ϜήঐУȄ 2. सѺஐ‫ޠ‬TRAbା(τܼҔளঅ‫ޠ‬ήॼ)Ȃ٦ቅ֊‫ٻ‬ѺஐӶҧ‫ޒ‬သϹଷ ࡤҧ‫ޒ‬သѓ૗ҔளȂӶᐍঐᛅѺ‫ޠ‬ႇโϜϬሰϊЗᆀขफ‫֐࢑ڌ‬ԥ ౱Ңҧ‫ޒ‬သѓ૗ϦໍȄା࡚࡛ឋȂାᜍᐄ઼๊ 3. ਴ᐄ2015Ԓ‫ޏ‬ज୾ஐ౱ऌ‫ݾޠ‬ᕜӔᜌࡿЖ: (1) ϛᆔ࢑Ӷ঻ঐѺ෉Ȃ सК೛࢑्҇‫ޠ‬ȂѺஐᗚ࢑ᔗ௦‫ڨ‬К೛‫ݾ‬ᕜȄ (2) ߩࡩሰ‫ޠ‬К೛ (elective surgery)ᔗೞ‫۾‬ᒷ‫ژ‬Ң౱‫ࡤ׈‬ӕໍ՘Ȅ(3) स҇໹ӶᛅѺϜໍ ՘К೛ȂࠍߩᆨࡩК೛ᔗӶׂ৓ϜήঐУໍ՘Ȃӱׂ৓ϜήঐУЩ ၷϛཽԥԟึ‫ܓ‬φয়Ԟᕼȃၷϛཽࢻ౱Ȅ 4. सѺஐ‫ޠ‬ҧ‫ޒ‬သϦໍԥೞ‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬ԂԂ‫ޠ‬௢‫ၘޠښ‬ȂӶ௦‫ߩڨ‬ ҧ‫ޒ‬သ‫ޠ‬К೛ਣϛሰ्‫ڐ‬у੬ր‫ྦޠ‬റȄसԥሰ्Ѡ‫ٻ‬ң͘ߣᘟ ᏙȄ

ѯᢋȈґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ ΫȃӶԥါ࿆Њ૮Ыҧ‫ޒ‬သѓ૗Ϧໍ‫ޠ‬Ѻஐข໕TRAb‫ޠ‬ቌঅ࣐ե? ᇴ݃Ȉ सѺஐႇџ‫ܗ‬౫Ӷԥါ࿆Њ૮Ыҧ‫ޒ‬သѓ૗ϦໍȂࠍ‫ࡤڐ‬хѠ૗ཽ౱ Ңफ‫ڌ‬ҧ‫ޒ‬သѓ૗ϦໍȃུҢ‫ڌ‬ҧ‫ޒ‬သѓ૗Ϧໍȃफ‫ڌ‬ҧ‫ޒ‬သѓ૗մ ίȃུҢ‫ڌ‬ҧ‫ޒ‬သѓ૗մίȃ‫ڸ‬Ϝ኿‫ܓ‬ҧ‫ޒ‬သѓ૗մίȄसѺஐӶᛅ Ѻ෉໣ҧ‫ޒ‬သѓ૗Ϧໍ௢‫ښ‬ூ࡟ৰȂࠍѠ૗ЖึུҢ‫ڌ‬ኸਣ‫ܓ‬Ϝ኿࠯ ҧ‫ޒ‬သѓ૗մί(29)ȄႇӼ‫׫ޠ‬ҧ‫ޒ‬သ᛿‫ޑ‬Ѡ૗ཽആԚफ‫ུڸڌ‬Ң‫ޠڌ‬ ҧ‫ޒ‬သѓ૗մί(27)ȄӶᛅѺࡤљࢳȂႇା‫ޠ‬ҧ‫ޒ‬သ‫ڗ‬ᐮ‫׫‬ᡞȂѠ૗Ж ึफ‫ུڸڌ‬Ң‫ڌ‬ҧ‫ޒ‬သѓ૗Ϧໍ(30)Ȅ Ӷԥါ࿆Њ૮Ы઀‫ޠ‬ѺஐᔯࢦTRAb‫ޠ‬ᎍᔗ઀єࢃ: ᛅѺ࿌Ϝԥґ‫ݾ‬ᕜ ‫ܗޠ‬п‫׫‬ҧ‫ޒ‬သ᛿‫ݾޑ‬ᕜ‫ޠ‬ҧ‫ޒ‬သѓ૗Ϧໍȃԥစႇܺৣ‫ܓ‬࿩‫ܗ‬ҧ‫ޒ‬ သӓϹଷ೛‫ݾ‬ᕜါ࿆Њ૮Ы઀‫੿ޠ‬ѭȃႇџԥҢίҧ‫ޒ‬သѓ૗Ϧໍ‫ޠ‬ ᔊ‫ޠڌ‬စᡜȃӶᛅѺϜԥңҧ‫ޒ‬သϹଷ೛‫ݾ‬ᕜҧ‫ޒ‬သѓ૗Ϧໍ‫੿ޠ‬ѭ (31) Ȅ Ӷԥࣁ୞‫ܓ‬ါ࿆Њ૮Ыҧ‫ޒ‬သѓ૗Ϧໍ‫ܗ‬ԥԫ੿ѭ‫ޠ‬ஐυȂ‫ڐ‬फ‫ܗڌ‬ ུҢ‫ึڌ‬Ңҧ‫ޒ‬သѓ૗Ϧໍ‫ޠ‬ᐡ౦࢑1-5%Ȃसґึ౫‫ܗ‬ґ‫ݾ‬ᕜȂࠍཽ ቩђफ‫ڌ‬/ུҢ‫ڸ੿੾ޠڌ‬Ԭκ(32)Ȅ ᛅѺԟ෉ข໕TRAbԥֆܼຠզॴᓏȂ‫پ‬ԄȂ਴ᐄज୾ҧ‫ޒ‬သᏱཽ‫ݾ‬ ᕜࡿЖȂӶԥ௦‫ڨ‬ႇҧ‫ޒ‬သఽଷ‫ݾ‬ᕜ‫ޠ‬ொ޲ȂसᛅѺਣTRAbঅτܼ 5U/L‫ܗ‬τܼҔளঅα४‫ޠ‬3ॼ‫ၘޠ‬Ȃ٦ቅᔗ၏ᇅҕफᚃᏱ஠ঢ়ΚକӬ ձȂᝓஞᆀ௢फ‫ݸޒޠڌ‬Ȅ ӶᛅѺఐ෉Ϭሰ݉ң‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬пᆱࡼҔளҧ‫ޒ‬သѓ૗‫ޠ‬ѺஐȂ 51

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

ข໕՗ϜTRAbȂԥֆܼ୏ขུҢ‫ึڌ‬Ңҧ‫ޒ‬သϦໍ‫ॴޠ‬ᓏȄ࿌ҕᡞ TRAbঅτܼ5 U/L‫ܗ‬τܼҔளঅα४‫ޠ‬3ॼਣȂTRAbѠ૗೾ႇफዻ‫ڗ‬ ᐮफ‫ڌ‬ȄΚяҢࡤȂ঩Ґ೾ႇफዻ‫׫ޠٿ‬ҧ‫ޒ‬သ᛿‫ཽޑ‬ЩTRAb‫ץ؂‬ Ӷᔊ‫ڌ‬ᡞϲఽଷȂࢉུҢ‫ڌ‬Ѡ૗ཽึҢҧ‫ޒ‬သѓ૗ϦໍȄ ࡛ឋȈ1. सѺஐԥါ࿆Њ૮Ы઀੿ѭȂ‫ٯ‬௦‫ڨ‬ႇܺৣ‫ܓ‬࿩‫ܗ‬К೛‫ݾ‬ᕜȂࠍ࡛ ឋӶᛅѺߒ෉ಒΚԪข໕ҧ‫ޒ‬သѓ૗ਣȂηข໕՗ϜTRAbࡿ኶Ȅ ା࡚࡛ឋȂϜᜍᐄ઼๊ 2. सᛅѺԟ෉Ѻஐ TRAb ାȂࠍ࡛ឋӶᛅѺಒ 18-22 ໋२ུᔯᡜ՗Ϝ TRAbᐩ࡚Ȅା࡚࡛ឋȂϜᜍᐄ઼๊ 3. सᛅѺԟ෉TRAb࢑մ‫ޠ‬ȂࠍϛሰໍΚؐଢᙺᔯᡜȄ մ࡚࡛ឋȂϜᜍᐄ઼๊ 4. सѺஐೞᜍᄃᛅѺਣȂҔ࣐Πါ࿆Њ૮Ыҧ‫ޒ‬သѓ૗ϦໍӶ݉ң‫׫‬ ҧ‫ޒ‬သ᛿‫ޑ‬Ȃࠍᔗ‫ܫ‬՗ข໕՗ϜTRAbᐩ࡚Ȅ մ࡚࡛ឋȂϜᜍᐄ઼๊ 5. सѺஐӶᛅѺϜ෉Ϭ໹݉ң‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬Ȃࠍ࡛ឋӶᛅѺಒ18-22 ໋ӕԪᔯᡜ՗ϜTRAbᐩ࡚Ȅା࡚࡛ឋȂϜᜍᐄ઼๊ 6. सᛅѺಒ18-22໋ਣTRAb౵ளȂ‫ܗ‬ѺஐӶׂ৓ҒήঐУϬ݉ң‫׫‬ҧ ‫ޒ‬သ᛿‫ޑ‬ȂࠍᔗӶᛅѺࡤ෉(ಒ30-34໋)ӕԪข໕TRAbȂпຠզུ Ң‫ڌ‬౱ࡤଢᙺ‫ܓ्҇ޠ‬Ȅା࡚࡛ឋȂାᜍᐄ઼๊

ѯᢋȈґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ ΫΚȃҕᒒொԥါ࿆Њ૮Ыҧ‫ޒ‬သѓ૗Ϧໍ‫ޠ‬फ‫ڌ‬ȂӶեᆎ௒‫ݸ‬ίሰ्௦‫ڨ‬ ᚟ѵ‫ݱॲົޠ‬ᔯࢦȂпଢᙺҢߞȃЗၱȃ‫ڸ‬ҧ‫ޒ‬သလ‫ޠ‬௒‫ם‬Ȅ ᇴ݃Ȉफ‫ڌ‬Ѡ૗ԥҧ‫ޒ‬သѓ૗Ϧໍ‫ޠ‬ኊӑȂєࢃफ‫ڌ‬Зၱႇ‫>(ץ‬170 BPMȂ ࡼ៊τܼ10ϸយ)ȃφয়ϲҢߞ‫ڨ‬४ȃफ‫ڌ‬ҧ‫ޒ‬သလȃଽԚዤႇ‫ץ‬ȃЗ ᠛૿ᆒȃ‫ڸ‬फ‫ڌ‬ЬလȄ(33-36) ࡛ឋȈसѺஐ‫ޠ‬ҧ‫ޒ‬သѓ૗ϦໍӶᛅѺ‫ࡤޠ‬љࢳґ௢‫ښ‬ԂȂ‫ܗ‬Ѻஐ‫ޠ‬TRAbӶ ᛅѺ‫ޠ‬Ӊեਣ෉Ћା(τܼҔளঅ‫ޠ‬ήॼпα)Ȃࠍᔗໍ՘᚟ѵ‫ޠ‬फ‫ڌ‬ ᔯࢦȄ ԫਣᔗྲཽԥစᡜ‫ޠ‬౱ऌᚃ৲‫ܗ‬ҕᔊᚃᏱ஠ঢ়Ȃᔗпົॲ‫ݱ‬ຠզफ‫ڌ‬ ‫ޠ‬ЗၱȃҢߞȃՁЬ໕ȃ‫ڸ‬ຠզ࢑֐ԥफ‫ڌ‬ҧ‫ޒ‬သလȄ ା࡚࡛ឋȂϜᜍᐄ઼๊ ѯᢋȈґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ ΫΡȃ եਣᔗՄኍӶԥါ࿆Њ૮Ы઀‫ޠ‬Ѻஐ௵໲ᙞழ՗ᔯࢦ? ᇴ݃Ȉ ௵໲ᙞழ՗ᇅफ‫ڸ੿੾ڌ‬ԬκࣻᜱȂ‫ܛ‬пѬӶ੬ੇ௒‫ໍݸ‬՘Ȅ ࡛ឋȈ࡟Ўሰ्௵໲ᙞழ՗ᔯࢦȂሰ्ਣᔗӶԥӬᎍ‫ޠ‬΢স೪റᕘძϘໍ

ׂ৓ਣ‫ޠ‬ҧ‫ޒ‬သѓ૗Ϧໍ

52

՘Ȅ࿌Ѻஐԥ݉ң‫׫‬ҧ‫ޒ‬သ᛿‫ٯޑ‬йफ‫ڌ‬ԥҧ‫ޒ‬သလਣȂໍ՘ԫᔯࢦ Ѡ‫ڟ‬ֆຩᘟफ‫֐࢑ڌ‬ԥҧ‫ޒ‬သѓ૗౵ளȄմ࡚࡛ឋȂմᜍᐄ઼๊ ѯᢋȈґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ ΫήȃᛅѺ෉໣ᔗԄե೏౪ӱՍлϸ‫ޠݫ‬ҧ‫ޒ‬သ๗࿾(autonomous thyroid nodules)ആԚ‫ޠ‬ҧ‫ޒ‬သѓ૗Ϧໍ? ᇴ݃Ȉӱ࣐ᛅѺ෉໣݉ң‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬Ѡ૗ആԚΚ‫ٳ‬ୱᚡȂ‫ܛ‬пसϑ‫੿ޤ‬ ΢ԥՍл‫ޠ‬ҧ‫ޒ‬သ๗࿾Ȃᔗ࡛ឋӶᛅѺϟࠊ൸௦‫ఽڨ‬ଷ‫ݾ‬ᕜ(ablation therapy)ȄԥՍлϸ‫ޠݫ‬ҧ‫ޒ‬သ๗࿾‫ޠ‬ѺஐȂᔗ४‫ښ‬࿩‫ڦឹޠ‬Ȅ ࡛ឋȈस‫ۢ؛‬п‫׫‬ҧ‫ޒ‬သ᛿‫ݾޑ‬ᕜȂࠍᔗ๞ϡմᏙ໕‫׫ޠ‬ҧ‫ޒ‬သ᛿‫ޑ‬Ȃ஡ ѺஐFT4/TT4ҭዀ೪ӶҔளঅ‫ޠ‬α४ȃ‫࢑ܗ‬ЩҔளঅ‫ޠ‬α४เཌྷାΚ ᘉȄӶᛅѺࡤљࢳȂᔗϊЗᆀࣽफ‫֐࢑ڌ‬ԥҧ‫ޒ‬သလ‫ܗ‬ҧ‫ޒ‬သѓ૗մ ί‫ޠ‬ኊӑȄା࡚࡛ឋȂմᜍᐄ઼๊ ѯᢋȈґ‫ࣻژ׳‬ᜱНᝧൣ֚Ȅ ஠ԥӫມϜऽНᄈྲߓ

53

ࢴ‫ܓ‬ҧ‫ޒ‬သድ

toxic multinodular goiter, toxic adenoma

ณฯ‫ܓ‬ҧ‫ޒ‬သึ‫ވ‬

painless thyroiditis

ᛅѺኸਣ‫ܓ‬ҧ‫ޒ‬သࢴ઀

gestational transient thyrotoxicosis

ׂ৓ቒӦ

hyperemesis gravidarum

ီຊफ

hydatidiform mole

ါ࿆Њ૮Ыҧ‫ޒ‬သѓ૗Ϧໍ

Graves’ hyperthyroidism

ҧߵષ‫ڨ‬ᡞ‫׫‬ᡞ

TRAb

ࣻ࿌ਞΩ

equivalent potency

ߓҫึ‫ي‬ϛً

aplasia cutis

ࡤቆЍ‫ॶܗ‬ၿഗᚈ

choanal or esophageal atresia

φᡫࠊ઀

preeclampsia

ߩࡩሰ‫ޠ‬К೛

elective surgery

Սлϸ‫ޠݫ‬ҧ‫ޒ‬သ๗࿾

autonomous thyroid nodules

ఽଷ‫ݾ‬ᕜ

ablation therapy

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

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J, Boissinot C, Schlageter MH, Garel C, Tebeka B, Oury JF, Czernichow P, Polak M. 2005 Management of Graves' disease during pregnancy: the key role of fetal thyroid gland monitoring. J Clin Endocrinol Metab 90:6093–6098.

34. Polak M, Le Gac I, Vuillard E, Guibourdenche J, Leger J, Toubert ME, Madec AM, Oury JF, Czernichow P, Luton D. 2004 Fetal and neonatal thyroid function in relation to maternal GravesɅ disease. Best Pract Res Clin Endocrinol Metab 18:289–302.

35. Cohen O, Pinhas-Hamiel O, Sivan E, Dolitski M, Lipitz S, Achiron R 2003 Serial in utero ultrasonographic measurements of the fetal thyroid: a new complementary tool in the management of maternal hyperthyroidism in pregnancy. Prenat Diagn 23:740–742.

36. Huel C, Guibourdenche J, Vuillard E, Ouahba J, Piketty M, Oury JF, Luton D. 2009 Use of ultrasound to distinguish between fetal hyperthyroidism and hypothyroidism on discovery of a goiter. Ultrasound Obstet Gynecol 33:412–420.

ׂ৓ਣ‫ޠ‬ҧ‫ޒ‬သѓ૗Ϧໍ

56

Ᏻ᠟ ‫ݔ‬πߞ۹ᚃଲུചхᗃऌ ചࡧႁлӉ

ါ࿆Њ૮Ы઀࢑Ң‫ي‬Ԓឮυ‫ܓ‬ഷளُആԚҧ‫ޒ‬သѓ૗ Ϧໍ‫ޠ‬঩ӱȂկሰᇅӱׂ৓ቒӦᇷึ‫ޠ‬ାҧ‫ޒ‬သષ՗઀ᠧ րຩᘟȄΚҎጃຩȂ‫ݾ‬ᕜϬп‫׫‬ҧ‫ޒ‬သ᛿‫࣐ޑ‬лȂկሰབྷ ᒶ᛿‫ޑ‬Ȃଫ௒෶໕Іᎍਣ‫֐࢑ۢ؛‬Ѡп๗‫ݾ؃‬ᕜȄӶज ୾ҦܼPTUܿᏳयࡩ‫૿نܓ‬ᆒϟൣᏳȂࢉ࡛ឋӶѺโϜȃ ࡤ෉‫׾‬ңMMZȂկ୾ϲΚ‫ٳ‬ः‫ٯف‬ณ݃ጃᜍᐄᡘұ୾΢ ӱ‫ٻ‬ңPTUആԚࡩ‫૿نܓ‬ᆒȂӱԫ࢑֐ሰܼѺโϜඳ᛿Ȃ ҭࠊϬณ٘஋ᜍᐄМࡼȄՎܼPTUпࠊೞᇰ࣐ၷณय࿍फ ‫ܓ‬Ȃկ࢑Ϟബ‫ޠ‬ൣ֚ࡿяPTUϬԥ2-3%ϟय࿍फ‫ܓ‬ൣᏳȂ ϛѠϛབྷȄഷࡤ֊߰Ѻஐҧ‫ޒ‬သѓ૗ϑစҔளȂϬሰᆀ௢ TRAbȂп٪ུҢ‫ڌ‬ҧ‫ޒ‬သѓ૗ϦໍȄ

57

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

ᛅѺ෉໣ҧ‫ޒ‬သ๗࿾Іҧ‫ޒ‬သᕝ‫ޠ‬೏౪ ᇄϜᄹҖᖃᚃଲ ؄ԈⰩ ΚȃѺஐ‫ޠ‬ҧ‫ޒ‬သ๗࿾౿՘౦ȉ ᇴ݃ȈႇџԥЩւਣȂ኉୾ȂϜ୾ήঐࣻᜱः‫(ف‬1,2,3)Ȉ (ήঐ୾ঢ়ࣲ࣐ሇཌྷ࿩ુн‫୾ޠ‬ঢ়Ȃңົॲ‫ݱ‬ຩᘟ๗࿾) ௄೼ήঐः‫ึف‬౫Ȉ • Ѻஐҧ‫ޒ‬သ๗࿾౿՘౦3%- 21%Ȅ • ๗࿾౿՘౦ᓎѺஐҢ౱Ԫ኶ቩђȄ (ಒΚफ 9.4%ȂಒΡ~ήफ 20.7%Ȃಒѳफпα33.9%) • 11-20%ѺஐཽӶԫѺ෉ུߞΚᗼ๗࿾Ȅ • 60%‫ޠ‬๗࿾ӶѺ෉ᡞᑗߞτ‫ॼڎ‬Ȃկ๗࿾҂ְτϊϬӶ5-12mmϟ ໣Ȅ • ӶѺ෉ᡞᑗቩђ‫ޠ‬๗࿾ȂཽӶҢ౱ࡤಒήঐУӲ‫ׂژ‬৓ॷήঐУ τϊȄ ѯᢋȈณࣻᜱः‫ف‬Ȅ ΡȃӶѺ෉ึ౫ҧ‫ޒ‬သ๗࿾‫ޠ‬ѺஐȂ‫ڐ‬ҧ‫ޒ‬သᕝ‫ޠ‬౿՘౦ȉ ᇴ݃Ȉႇџࣻᜱ‫ޠ‬ः‫ف‬Ȉ • ज୾ήঐᚃᏱϜЗӲ྘‫ܓ‬ः‫( ف‬4,5,6) Ȉ౿՘౦ϸր࣐ 15% ȃ 12% ȃ 43%Ȅ (ુᘉȈѠ૗ӱ࣐ᚃᏱϜЗԥᒶᐆ‫୒ܓ‬ৰ) • Ϝ୾‫ޠ‬ᚃᏱϜЗ‫ࠊޠ‬ᙂ‫ܓ‬ः‫(ف‬3)Ȉ౿՘౦࣐0% (ુᘉȈኻҐ኶ЎȂԫः‫ف‬221՞ஐυѬԥ34՞ԥ๗࿾) • ђԏ‫ޠ‬΢π።ࢦः‫(ف‬Population base retrospective analysis)(7)Ȉ౿ ՘౦ 14.4/100,000( ‫ٸ‬ϛӤѺ෉ຩᘟҧ‫ޒ‬သᕝ‫ޠ‬౿՘౦ȈҢ౱ࠊ 3.3/100,000ȂҢ౱ਣ 0.3/100,000Ȃ౱ࡤΚԒϲ 10.8/100,000 ) ѯᢋȈ ณࣻᜱः‫ف‬Ȅ ήȃѺஐ‫ޠ‬ҧ‫ޒ‬သ๗࿾ຠզȉ ᇴ݃Ȉ੿ѭᇅٙᡞᔯࢦ • ঢ়ఋѭȈঢ়ఋ࢑֐ԥϸϾًԂ࠯ҧ‫ޒ‬သᕝȂঢ়ఋ‫ܓ‬ҧ‫ޒ‬သᡝ፵ ᕝȂMultiple endocrine neoplasia type 2 (MEN2)Ȃ ܿூҧ‫ޒ‬သᕝ‫ޠ‬ঢ়ఋ‫੿੾ܓ‬Ȉ Phosphatase and tensin homolog [PTEN]Ȃ Hamartoma tumor syndrome [Cowden's disease]Ȃ

ׂ৓෉໣ҧ‫ޒ‬သ๗࿾Іҧ‫ޒ‬သᕝ೏౪

58

Familial adenomatous polyposisȂ Carney complexȂWerner syndrome.

• ঐ΢ѭȈӶ18ྒࠊȂᓟᓜഌ෇௦‫ڨ‬ᒮৣጤ‫ݾ‬ᕜཽቩђඍ‫ॴܓ‬ᓏ(8,9) • ٙᡞᔯࢦȈដຩҧ‫ޒ‬သІᓜഌిВ๗Ȅ ҧ‫ޒ‬သົॲ‫ݱ‬ • ҧ‫ޒ‬သົॲ‫࣐ݱ‬ຠզҧ‫ޒ‬သ๗࿾ІᓜഌిВ๗ഷྦጃ‫ޠ‬Ϗ‫ڏ‬Ȅ • ົॲ‫ݱ‬ί๗࿾‫ڏ‬ԥӼ໷੬ኊཽЩ൑Κ੬ኊ‫؂‬૗Ⴒข๗࿾‫ޠ‬ඍ‫ܓ‬ᐡ ౦Ȅ • 2015 ATA guideline(10)஡๗࿾੬ኊ‫ٸ‬ඍ‫ܓ‬ᐡ౦ϸԚϥ᜹Ȃ‫ྲٸٯ‬๗ τϊ࡛ឋ࢑֐ए‫ڗ‬ȞߓΚȟȄ ҧ‫ޒ‬သѓ૗ᔯࢦ Κૢ΢ҧ‫ޒ‬သ๗࿾‫ޠ‬ຠզє֥ᡜTSHȂԄ‫ݏ‬TSHϊܼҔளঅ࡛ឋ ୉ҧ‫ޒ‬သਰᚃᔯࢦ௷ଷࢴ‫ܓ‬သድȄկҧ‫ޒ‬သᕝ‫੿ޠ‬΢τഌϸTSHӶҔ ளጓ൝Ȅ ᛅѺஐυӶԫਣຠզሰϊЗ‫ڎ‬ӈ‫ٲ‬௒Ȉ • ѺஐTSHҔளঅί४ЩΚૢ΢մȄ • ѺஐϛᎍӬ୉ਰᚃᔯࢦȄ ७໘ષ‫ڸ‬ҧ‫ޒ‬သ౩೗Ҫ • ԥ๗࿾‫ޠ‬Ѻஐ࢑֐ሰள೤ᔯข७໘ષҭࠊϬԥ‫ލ‬ឋ(11)Ȅ • կӶԥMEN2ȃҧ‫ޒ‬သᡝ፵ᕝȂ‫࢑ܗ‬ϑ‫ޤ‬RETஆӱऐᡑ‫ޠ‬ঢ়ఋѭ‫ޠ‬ ѺஐѠՄኍᔯขȄ • ԥ๗࿾‫ޠ‬Ѻஐϛ࡛ឋขҧ‫ޒ‬သ౩೗ҪȄ • Ӷҧ‫ޒ‬သϬԇӶ‫ޠ‬௒‫ݸ‬ίȂᔯขҧ‫ޒ‬သ౩೗Ҫᄈҧ‫ޒ‬သᕝ‫ء‬ԥ٘஋ ‫ޠ‬ఄད࡚І੬౵࡚(12)Ȅ ಡଭए‫ڗ‬ᔯࢦȈ • ಡଭए‫ڗ‬ᄈӉեѺ෉‫ޠ‬Ѻஐഎ࢑ԋӓ‫ޠ‬ᔯࢦȄ • ӶӲ྘‫ܓ‬ः‫ف‬ȂᛅѺᄈए‫ڗ‬ಡबຩᘟ๗࿾ًඍ‫ءܓ‬ԥኈ៫(4,5)Ȅկ ҭࠊ‫ء‬ԥࣻᜱ‫ࠊޠ‬ᙂ‫ܓ‬ः‫ف‬Ȅ • ӶѺ෉Ԅ‫ݏ‬ಡଭए‫ึڗ‬౫ҧ‫ޒ‬သᕝȂϛ፤ᒶᐆӶѺ෉Ϝ‫࢑ܗ‬౱ࡤ ୉ҧ‫ޒ‬သϹଷȂᄈ‫ڐ‬ҧ‫ޒ‬သᕝԬκ౦‫ء‬ԥᡘ຀ኈ៫(13,14,15)Ȅ ҧ‫ޒ‬သਰᚃᔯࢦ • ӶᛅѺ12~13໋ࡤȂѺஐԄ‫ٻݏ‬ң࿩131Ȃ࿩131஡ཽစႇफዻತᑗ ܼफ‫ޠڌ‬ҧ‫ޒ‬သಣᙒȂആԚफ‫ڌ‬ҧ‫ޒ‬သմί(16)Ȅ • ԄӶѺஐϛ‫ޤ‬௒௒‫ݸ‬ί‫ٻ‬ң‫ژ‬࿩131ȂӶ‫ٻ‬ң࿩131‫ޠ‬12ϊਣϲ݉ ң࿩Ͼ႖60-130mgѠпഌϸ෶Ўफ‫ڌ‬ҧ‫ޒ‬သ֝Ԟ࿩131(17)Ȅ • ӶᛅѺ12໋ࠊ‫ٻ‬ң࿩131‫ٯ‬ϛཽኈ៫फ‫ڌ‬ҧ‫ޒ‬သȄկӶѺ෉‫ٻ‬ң࿩ 131ཽ‫ٻ‬फ‫ڌ‬ኹ៪Ӷᒮৣጤϲ(18)Ȅ • ӶѺ෉‫ٻ‬ң࿩ 131 ȂӶѺஐᆽ્ತᑗ‫ޠ‬ᐩཽ࡚‫ٻ‬फ‫ڌ‬ኹ៪Ӷङ 5059

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

100 mGy/GBq‫ޠ‬ᒮৣᏙ໕ȄѺஐӼേЬІ௷ޫᆽ્ԥֆܼ෶Ўᒮ ৣᏙ(16)Ȅ • ᗷด‫ء‬ԥः‫ف‬௥ଇѺஐ‫ٻ‬ң࿩123 ௮ඣᄈफ‫ޠڌ‬ኈ៫ȂկӶѺ෉௦ ‫ڨ‬ਰᚃᔯࢦࣲ࣐࿲‫(઀ס‬16)Ȅ ࡛ឋȈԥ๗࿾‫ޠ‬Ѻஐ‫ڐ‬TSHӶᛅѺ16໋ࡤմܼѺ෉ҔளঅȈ ಡଭए‫ڗ‬Ѡ๊Ң౱‫׈‬ӕ୉ȇҢ౱‫ࡤ׈‬Ԅ‫ءݏ‬ԥᗾҕ‫ٱ‬Ȃ࡛ឋ୉ҧ‫ޒ‬သ ਰᚃ௮ඣȄା࡚࡛ឋȂմᜍᐄ઼๊ȁȁ ࡛ឋȈ ԥ๗࿾‫ޠ‬Ѻஐ‫ڐ‬TSHӶѺ෉ҔளঅȈ ๗࿾࢑֐ሰ୉ಡଭए‫ߓ(ٸڗ‬Κ)‫࡛ޠ‬ឋȂಡଭए‫ޠڗ‬ਣ໣ᘉ‫ٸ‬ᖞ‫ט‬ᛅ ᅹඍ‫ޠܓ‬โ࡚І੿΢ཏ᜺࣐л्Մ໕Ȅ ା࡚࡛ឋȂϜᜍᐄ઼๊ȁȁȁȁȁȁȁȁȁ

࡛ឋȈѺ෉ϛ࡛ឋ୉ਰᚃ௮ඣ‫ڸ‬࿩ឹ‫ڦ‬௮ඣȄା࡚࡛ឋȂϜᜍᐄ઼๊Ȅ ࡛ឋȈѺ෉࢑֐ள೤ଢᙺ७໘ષȂҐࡿЖϛ࡛ឋηϛЇᄈȄ ณ࡛ឋȂᜍᐄϛ٘ ѯᢋȈณࣻᜱः‫ف‬Ȅ ߓΚ ȃATA‫ޠ‬ҧ‫ޒ‬သ๗࿾ົॲ‫ݱ‬შࣻ੬ኊᇅඍ‫ॴޠ࡚ܓ‬ᓏႲข(10)

ѳȃᛅѺ࢑֐ཽኈ៫ҧ‫ޒ‬သᕝ‫ޠ‬Ⴒࡤȉ ᇴ݃Ȉ ᛅѺ‫࢑ܗ‬౱ࡤಒΚԒຩᘟҧ‫ޒ‬သᕝ‫ޠ‬ஐυၮ‫ء‬ԥᛅѺਣຩᘟҧ‫ޒ‬သᕝ ‫ޠ‬ஐυȂ‫ڎ‬ಣ੿΢Ԭκ౦Щၷȉ ҭࠊӔԥ6጖ः‫ف‬௥ଇ(13,14,15,19,20,21)Ȃึ౫Ȉ • ‫ڎ‬ಣ੿΢Ԭκ౦‫ء‬ԥৰ౵Ȅ • ҧ‫ޒ‬သϹଷК೛ਣ໣ᘉϛ፤ӶѺ෉‫࢑ܗ‬౱ࡤȂᄈԬκ౦‫ء‬ԥᡘ຀ ኈ៫ ȞુᘉȈ೼6ঐः‫ࣲ࣐ف‬Ӳ྘‫ܓ‬ः‫ف‬ȂኻҐ኶ϊȂ‫ܛ‬ԥ੿΢࣐stage Iȇ Յй‫ڐ‬Ϝ4ঐः‫ف‬ϛ࢑ңఄད‫ܓ‬ା‫ޠ‬ҧ‫ޒ‬သ౩೗ҪၑᏙᔯขȄ) ׂ৓෉໣ҧ‫ޒ‬သ๗࿾Іҧ‫ޒ‬သᕝ೏౪

60

ᛅѺ‫࢑ܗ‬౱ࡤಒΚԒຩᘟҧ‫ޒ‬သᕝ‫ޠ‬ஐυၮ‫ء‬ԥᛅѺਣຩᘟҧ‫ޒ‬သᕝ ‫ޠ‬ஐυȂ‫ڎ‬ಣ੿΢ᕝ઀ඉึᐡ౦‫ޠ‬Щၷȉ ҭࠊӔԥ2጖ः‫ف‬௥ଇ(19,21)Ȃึ౫Ȉ • ᛅѺ‫࢑ܗ‬౱ࡤಒΚԒຩᘟҧ‫ޒ‬သᕝ‫੿ޠ‬΢ԥᡘ຀ၷାඉึ౦Ȅ • ӶѺ෉‫࢑ܗ‬౱ࡤ௦‫ڨ‬ҧ‫ޒ‬သϹଷК೛Ȃᄈඉึ౦‫ء‬ԥᡘ຀ኈ៫Ȅ Ȟ೼2጖ः‫ࣲف‬ଢᙺ6Ԓ, ඉึۢဏ࣐ a. ‫ٻ‬ңҧ‫ޒ‬သષί‫ޠ‬ҧ‫ޒ‬သ౩೗Ҫ>2ng/ml b. αЁϜ‫ޠ‬ҧ‫ޒ‬သ౩೗Ҫ‫׫‬ᡞ c. ົॲ‫ึݱ‬౫ిВ๗ᙾಌ d. Ӷ࿩௮ᆁԥึ౫঩ҧ‫ޒ‬သ՞ဋѵ‫֝ޠ‬Ԟ ӶVannucchi et al(19)ः‫ف‬Ϝ ᛅѺ‫࢑ܗ‬౱ࡤ1Ԓϲຩᘟҧ‫ޒ‬သᕝஐυȈ60% ඉึ ౱ࡤ1Ԓຩᘟҧ‫ޒ‬သᕝஐυȈ4% ඉึ ґ෇ᛅѺஐυȈ13% ඉึ ӶMessuti et alः‫(ف‬21)Ϝ ᛅѺ‫࢑ܗ‬౱ࡤ1Ԓϲຩᘟҧ‫ޒ‬သᕝஐυȈ10% ඉึ ౱ࡤ2Ԓຩᘟҧ‫ޒ‬သᕝஐυȈ1.3% ඉึ ґ෇ᛅѺஐυȈ4.3% ඉึ ആԚඉึᐡ౦ၷା‫ࣻޠ‬ᜱᐡᙾϬґ݃Ȃሰ‫؂‬Ӽः‫ف‬ᜍᄃȄկԇࣁ౦‫ء‬ ԥ‫ژڨ‬ᛅѺኈ៫Ȅ ᛅѺᄈҧ‫ޒ‬သᡝ፵ᕝႲࡤ‫ޠ‬ኈ៫Ȃҭࠊณࣻᜱः‫ف‬Ȅ ϥȃҧ‫ޒ‬သК೛ᄈѺஐІफ‫ޠڌ‬ӡᓏ‫ܓ‬ȉ ᇴ݃Ȉ ਴ᐄज୾2009Ԓः‫(ف‬22)Ȉ ᛅѺ෉໣௦‫ڨ‬ҧ‫ޒ‬သ/୚ҧ‫ޒ‬သК೛‫ޠ‬ஐυၮΚૢஐυࣻЩȂԥ‫؂‬ା‫ޠ‬ ‫઀ึڂ‬Ȃ՟ଲЉ኶‫ڸ‬՟ଲ߇ຳηၷӼȄ ( ԫः‫ف‬Ѡ૗ӱ࣐ᛅѺஐυӼӱᆨࡩ‫ݸޒ‬Ϙཽᒶᐆ໡ΧȂ‫ٯ‬йѺஐԥ ၷାЩ‫پ‬ᚃᕜߴᓏՅኈ៫๗‫ݏ‬ȄѫѵӶ೼ः‫ف‬ϜȂѬԥ46%࣐ҧ‫ޒ‬သ ᕝ੿΢Ȅ) ਴ᐄСҐߗ෉ः‫(ف‬23)Ȉ ҧ‫ޒ‬သᕝஐυӶѺ෉К೛ᇅӶ౱ࡤК೛ࣻЩȂᄈᕝ઀ඉึ౦Ȃࢻ౱Ȃ ‫࢑ܗ‬फ‫ء઀ึڂڌ‬ԥᡘ຀ኈ៫Ȅ Ԅ‫ݏ‬ሰӶᛅѺ෉໣୉ҧ‫ޒ‬သК೛ȂΚૢ࡛ឋӶׂ৓ϜήঐУп෶ЎѺ ஐІफ‫઀ึڂޠڌ‬Ȅ ѯᢋȈณࣻᜱः‫ف‬Ȅ ϳȃ๗࿾ए‫ޠܓًڗ‬ѺஐȂ೏౪‫ޠ‬Рԓȉ ᇴ݃Ȉϛ࡛ឋѺஐӭҧ‫ޒ‬သષ‫ښ׼‬๗࿾ҢߞȂӱ࣐‫ء‬ԥः‫ف‬ᜍᄃԥਞȄ 61

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

Ԅ‫ݏ‬๗࿾ԥඍ‫ܓ‬੬ኊ‫ٯ‬Ңߞ‫ץ‬ഁȂ࡛ឋ२ፓए‫ڗ‬ȄԄ‫ءݏ‬ԥαख़௒‫ݸ‬ Յйϟࠊए‫ܓًࣲڗ‬ȂӶѺ෉ϛሰӼ୉ए‫ڗ‬ᔯࢦ(24)Ȅ ࡛ឋȈϟࠊए‫ޠܓً࣐ڗ‬๗࿾ȂѺ෉ଢᙺ‫ޠ‬Рԓၮ2015 ATA guideline(10)Κ ኻȂϛ໹ӱᛅѺ੬ր‫׾‬ᡑȄା࡚࡛ឋȂϜᜍᐄ઼๊ ѯᢋ: ณࣻᜱः‫ف‬Ȅ Νȃ๗࿾ए‫࣐ڗ‬ϛጃًۢඍ‫ޠܓ‬ѺஐȂ೏౪Рԓȉ(є֥atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS)ȃ suspicious for follicular neoplasm (SFN)ȃsuspicious for malignancy (SUSP)ȟ ᇴ݃Ȉए‫࣐ڗ‬AUS/FLUSȂSFNȂSUSP‫ޠ‬ҧ‫ޒ‬သ๗࿾Ȉ • ҭࠊ‫ء‬ԥࠊᙂ‫ܓ‬ः‫ف‬ଇ፤ए‫࣐ڗ‬ϛጃًۢඍ‫ޠܓ‬Ѻஐ‫ޠ‬ႲࡤȄ • ϸφᔯข‫ྦޠ‬ጃ‫ܓ‬ӶѺஐ‫ء‬ԥᡜᜍः‫ف‬Ȅ౪፤αȂᛅѺ‫ޠ‬ೊᅮᇍ ‫ڗ‬ᐮԥѠ૗ኈ៫RNA‫ߓޠ‬౫ȂկᄈDNA‫ޠ‬ᔯขኈ៫ၷϊȄ • ӱ࣐ҧ‫ޒ‬သᕝ‫ޠ‬ѺஐӶᛅѺ෉໣‫࢑ܗ‬౱ࡤ௦‫ڨ‬К೛Ȃᄈҧ‫ޒ‬သᕝ Ⴒࡤ‫ء‬ԥᡘ຀ኈ៫Ȃ‫ܛ‬пए‫ڗ‬ϛጃًۢඍ‫ޠܓ‬๗࿾ȂԄ‫ءݏ‬ԥ‫ץ‬ ഁໍ৥‫ޠ‬ᖞ‫ט‬ᡑϾȂϛ࡛ឋӶᛅѺ෉໣К೛Ȅ ࡛ឋȈ ๗࿾ए‫࣐ڗ‬ϛጃًۢඍ‫ܓ‬ȞAUS/FLUSȃSFNȃSUSPȟ‫ޠ‬ѺஐȂԄ‫ݏ‬ ‫ء‬ԥిВ๗ᙾಌ‫࢑ܗ‬ሊᆓᙾಌȂϛ࡛ឋӶѺ෉௦‫ڨ‬К೛Ȅ ା࡚࡛ឋȂϜᜍᐄ઼๊ȁȁȁȁȁ ࡛ឋȈ ๗࿾ए‫࣐ڗ‬ϛጃًۢඍ‫ܓ‬ȞAUS/FLUSȃSFNȃSUSPȟ‫ޠ‬ѺஐȂԄ‫ݏ‬ ๗࿾ᖞ‫ߓט‬౫ໍ৥‫ץ‬ഁȂѠՄኍӶѺ෉௦‫ڨ‬К೛Ȅ ା࡚࡛ឋȂϜᜍᐄ઼๊ȁȁȁȁ ࡛ឋȈ ๗࿾ए‫࣐ڗ‬ϛጃًۢඍ‫ܓ‬ȞAUS/FLUSȃSFNȃSUSPȟ‫ޠ‬ѺஐȂϛ࡛ ឋ୉ϸφᔯขȄା࡚࡛ឋȂմᜍᐄ઼๊ȁ ѯᢋȈณࣻᜱः‫ف‬Ȅ ΥȃѺ෉ུຩᘟҧ‫ޒ‬သᕝȂ೏౪Рԓȉ ᇴ݃Ȉ ਴ᐄ2015 ATA guideline(10) ࡛ឋሰӶᛅѺ෉໣К೛‫ݸޒޠ‬Ȉ (К೛ࣲ࡛ឋӶׂ৓ϜήঐУ) • Ӷ24໋ࠊ๗࿾݃ᡘᡑτ(ᡞᑗቩђ50% ‫ޣ࢑ܗ‬৸ቩђ20%)Ȅ • ಡबए‫ڗ‬ᛅᅹҧ‫ޒ‬သґϸϾᕝ‫࢑ܗ‬ᡝ፵ᕝȄ ࡛ឋѠп๊Ң౱ࡤӕК೛‫ݸޒޠ‬Ȉ • ๗࿾ᡞᑗ‫ء‬ԥ݃ᡘ‫׾‬ᡑȄ • ӶᛅѺࡤљ෉ུຩᘟ‫ޠ‬ҧ‫ޒ‬သᕝȄ ҭࠊ‫ء‬ԥः‫ف‬௥ଇҧ‫ޒ‬သᕝѺஐӶ‫ڐ‬ҧ‫ޒ‬သК೛ࠊȂ‫ٻ‬ңҧ‫ޒ‬သષ‫׼‬ ‫ښ‬TSHᄈႲࡤ‫ޠ‬ኈ៫ȂկΚૢ࡛ឋTSHӶѺ෉௢‫ښ‬Ӷ0.3-2.0mU/Lϟ໣ (25) Ȅ

ׂ৓෉໣ҧ‫ޒ‬သ๗࿾Іҧ‫ޒ‬သᕝ೏౪

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࡛ឋȈ Ѻ෉ུຩᘟҧ‫ޒ‬သ‫ٱ‬ऐᕝ‫ޠ‬ѺஐȂ໹ӶѺ෉ᆀขົॲ‫ݱ‬ȄԄӶ24໋ࠊ ݃ᡘᡑτ(ᡞᑗቩђ50%‫ޣ࢑ܗ‬৸ቩђ20%)‫ి࢑ܗ‬ВᙾಌȂ࡛ឋӶѺ෉ ௦‫ڨ‬К೛ȂԄӶѺ෉๗࿾ᡞᑗᛨۢȂ‫࢑ܗ‬ӶᛅѺࡤљ෉ຩᘟ‫ޠ‬ҧ‫ޒ‬သ ᕝȂ࡛ឋ๊౱ࡤК೛Ȅմ࡚࡛ឋȂմᜍᐄ઼๊ ࡛ឋȈ Ѻ෉ུຩᘟҧ‫ޒ‬သᡝ፵ᕝ‫࢑ܗ‬ґϸϾҧ‫ޒ‬သᕝ‫ޠ‬ѺஐȂ࡛ឋӶѺ෉௦ ‫ڨ‬К೛Ȅା࡚࡛ឋȂմᜍᐄ઼๊ ѯᢋȈณࣻᜱः‫ف‬Ȅ Οȃҧ‫ޒ‬သᕝ‫ޠ‬ѺஐȂᛅѺϟࡤ‫ޠ‬TSHҭዀȉ ᇴ݃Ȉҧ‫ޒ‬သᕝ‫੿ޠ‬΢ᛅѺϟࡤ‫ٻ‬ңҧ‫ޒ‬သષȈ • ҭࠊ‫ء‬ԥᜍᐄᡘұᛅѺ෉໣‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သϦໍȞ s u b c l i n i c a l hyperthyroidismȟཽቩђѺஐ‫࢑ܗ‬फ‫઀ึڂޠڌ‬Ȅ • ѺஐTSH‫ޠ‬ҭዀȂϬ‫ྲٸ‬2015 ATA guideline(10)࡛ឋȂၮᛅѺࠊҧ‫ޒ‬ သᕝ‫ݾޠ‬ᕜҭዀΚኻȄ • ҧ‫ޒ‬သᕝ‫ޠ‬ѺஐȂᛅѺਣቩђҧ‫ޒ‬သષ‫ޠ‬Ꮩ໕ၮӱ‫ڐ‬у঩ӱആԚ ҧ‫ޒ‬သմί‫ޠ‬ѺஐΚኻȂሰቩђङ49%‫ޠ‬Ꮩ໕ȂпᆱࡼᛅѺࠊTSH ‫ݾޠ‬ᕜҭዀ(26)Ȅ • Ӷথ‫ޤ‬ၿᛅѺਣ൸ᔗᔯขҧ‫ޒ‬သѓ૗Ȃ‫ٯ‬ӶؑԪ።ᐍᏙ໕4໋ࡤଢ ᙺҧ‫ޒ‬သѓ૗Ȅ ࡛ឋȈ ҧ ‫ ޒ‬သ ᕝ ‫ ޠ‬Ѻ ஐ T S H ‫ ݾ‬ᕜ ҭ ዀ ၮ ᛅ Ѻ ࠊ Κ ኻ Ȃ ሰ ࡹ ྲ 2 0 1 5 ATA guideline‫ٸ‬ඉึॴᓏ୉።ᐍȄ ӶᛅѺ16-20໋ࠊؑ4໋ᔗᆀขTSHȇӶᛅѺ26-32໋ਣՎЎሰขΚԪȄ ା࡚࡛ឋȂϜᜍᐄ઼๊ ѯᢋȈณࣻᜱः‫ف‬Ȅ 2015 ATA guideline ᄈTSH ‫ݾ‬ᕜҭዀ‫࡛ޠ‬ឋ

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ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

ΫȃᛅѺࠊ୉ႇ঩φ࿩‫ݾ‬ᕜȂᄈϟࡤᛅѺ‫ޠ‬ኈ៫ȉ ᇴ݃Ȉ঩φ࿩‫ݾ‬ᕜᄈҢ‫ޠي‬ኈ៫Ȉ • ҭࠊԥ‫ڎ‬ঐ୾ѵࣻᜱः‫ف‬Ȃկഎ‫ء‬ԥᜍᐄᡘұԥ୉ႇ঩φ࿩‫ݾ‬ᕜ ‫ޠ‬ҧ‫ޒ‬သᕝஐυȂཽቩђϟࡤϛѺȂࢻ౱Ȃԟ౱ȂུҢ‫ڌ‬ԬκȂ яҢᡞ२ႇմȂ࿍फ๊ᐡ౦(27,28)Ȅ • կӱ࣐঩φ࿩‫ݾ‬ᕜѠ૗Жକҧ‫ޒ‬သѓ૗౵ளȂ‫ܛ‬п࡛ឋՎЎ๊঩ φ࿩‫ݾ‬ᕜ‫׈‬6ঐУࡤϘՄኍᛅѺȄ • ᄈ‫ܓع‬ՅّȂ঩φ࿩ཽኈ៫ᆡφҢԚȂӱԫ࡛ឋ๊঩φ࿩‫ݾ‬ᕜ120 Љ(ᆡφҢԚ‫)෉ڻ‬ӕՄኍҢ‫(ي‬29)Ȅ ࡛ឋȈҧ‫ޒ‬သᕝஐυᔗӶ঩φ࿩‫ݾ‬ᕜՎЎ6ঐУࡤȂӕՄኍᛅѺȄ ା࡚࡛ឋȂմᜍᐄ઼๊Ȅȁ ѯᢋȈӶѯᢋୋߴၦਠ৳‫ޠ‬ः‫(ف‬30)Ȉ • ୉ႇ঩φ࿩‫ݾ‬ᕜၮ‫ء‬୉ႇ‫ޠ‬ҧ‫ޒ‬သᕝஐυࣻЩԥၷմ‫ޠ‬ᛅѺ౦ (adjusted HR = 0.77Ȃ95%CIȈ0.70–0.86)Ȅ • ӶԒख25-34 ྒ‫ޠ‬ҧ‫ޒ‬သᕝஐυȂԥ୉ႇ঩φ࿩‫ݾ‬ᕜ޲ԥၷմ‫ޠ‬Ң ‫ي‬౦(OR = 0.60Ȃ95%CIȈ0.45–0.80)Ȅ կԫः‫ف‬Ѡ૗‫੿ژڨ‬΢‫ޠ‬ᒶᐆ‫࢑ܗ‬ᚃ৲࡛ឋᗘѺ๊ኈ៫Ȅ ΫΚȃዀႱ‫ݾ‬ᕜ᛿‫ޑ‬ᄈᛅѺ‫ޠ‬ኈ៫ȉ ᇴ݃ȈӶѺஐ‫ٻ‬ңҧ‫ޒ‬သᕝ‫ޠ‬ዀႱ‫ݾ‬ᕜ᛿‫ޑ‬Ȉ • FDA೾ႇᄈӶ঩φ࿩‫ݾ‬ᕜณਞҧ‫ޒ‬သᕝ‫ܗ‬ҧ‫ޒ‬သᡝ፵ᕝѠ‫ٻ‬ң‫ޠ‬ ዀႱ᛿‫ޑ‬Ȉ SorafenibȂlenvatinibȂcarbozantinibȄ೼ήᆎ᛿‫ء‬ԥӶѺஐ‫ޠ‬ः‫ف‬Ȃ կӶ୞‫ޑ‬ᄃᡜαᜍᄃԥय࿍फ‫ܓ‬Іथफࢴ‫(ܓ‬31)Ȅ • FDAӶዀႱ‫ݾ‬ᕜ᛿‫ޠ‬ឍᇮȈ SorafenibȈ݉ңਣᗘռᛅѺȄ LenvatinibȈ݉ңਣᗘռᛅѺȄ CarbozantinibȈ‫ء‬ԥࣻᜱឍᇮȄ ΫΡȃᛅѺ࢑֐ቩђҧ‫ޒ‬သᕝ‫ޠ‬ඉึᐡ౦ȉ ᇴ݃ȈҭࠊӔԥ5጖ࣻᜱः‫ف‬Ȉ • ‫ڎ‬጖50Ԓࠊ‫ޠ‬ः‫ءف‬ԥึ౫ᛅѺཽቩђလድඉึ‫ޠ‬ᐡ౦(32,33)Ȅ • ߗ෉ή጖ः‫( ف‬ଢᙺਣ໣ϸր࣐4.3ԒȂ6ঐУȂ4.8Ԓ) (34,35,36ȟȈ ᛅѺࠊԥӭҧ‫ޒ‬သષίҧ‫ޒ‬သ౩೗Ҫ(Thyroglobulin) <~2 ng/ml йົॲ‫ݱ‬ณ౵ள‫ޠ‬ѺஐȈ‫ء‬ԥ΢ԥඉึᜍᐄȄ ᛅѺࠊϑ‫ޤ‬ԥလድඉึ‫ޠ‬ѺஐȈङ50% ‫੿ޠ‬΢လድӶѺ෉ඍϾ (є֥ᙾಌ‫ిޠ‬В๗ᡑτІུ‫ిޠ‬В๗ᙾಌ) ӱԫȂӶ‫ء‬ԥလድඉึᜍᐄ‫ޠ‬ҧ‫ޒ‬သᕝஐυȂᛅѺϛཽቩђလድ ׂ৓෉໣ҧ‫ޒ‬သ๗࿾Іҧ‫ޒ‬သᕝ೏౪

64

ඍϾ‫ޠ‬ᐡ౦ȇկӶᅹծԥလድඉึၭຬ‫ޠ‬ҧ‫ޒ‬သᕝஐυȂᛅѺ ෉ሰ्ଢᙺᔯࢦȄ Ϋήȃҧ‫ޒ‬သᕝ‫ޠ‬ஐυȂᛅѺ෉ሰ्Ԅեଢᙺᔯࢦȉ ࡛ឋȈ Ӷ‫ء‬ԥလድඉึᜍᐄ‫ޠ‬ҧ‫ޒ‬သᕝஐυȂϛ࡛ឋӶѺ෉ቩђଢᙺົॲ‫ݱ‬ Іᆀขҧ‫ޒ‬သ౩೗ҪȄା࡚࡛ឋȂϜᜍᐄ઼๊ ࡛ឋȈ Ӷᅹծԥလድඉึ(biochemical or structural incomplete response)‫ޠ‬ҧ‫ޒ‬ သᕝஐυȂ࡛ឋӶѺ෉ቩђଢᙺົॲ‫ݱ‬Іᆀขҧ‫ޒ‬သ౩೗ҪȄ ା࡚࡛ឋȂϜᜍᐄ઼๊ ѯᢋȈณࣻᜱः‫ف‬Ȅ Ϋѳȃҧ‫ޒ‬သ‫ٱ‬ऐཌྷϊᕝ(papillary microcarcinoma) ᒶᐆᑗ྄ᆀขґ໡Χ‫ޠ‬ஐ υȂᛅѺ෉ᔗԄեଢᙺ? ᇴ݃Ȉ ϟࠊСҐึߓӶҧ‫ޒ‬သ‫ٱ‬ऐཌྷϊᕝᑗ྄ᆀข(active surveillance)‫ޠ‬ः ‫ف‬Ȉ1253՞‫ٱ‬ऐཌྷϊᕝ੿΢ϜȂԥ9՞Ӷᑗ྄ᆀข෉໣ᛅѺȄ‫ڐ‬Ϝ5΢ ӶᛅѺ෉໣လድԥᡘ຀ቩђ (ቩђ>3mm)ȂၮґᛅѺ‫ޠ‬ᄈྲಣࣻЩᡞ ᑗቩђЩ‫پ‬ၷା( 44% vs 11%ȂP=0.00497)Ȅԥ3΢Ӷ౱ࡤᒶᐆ໡Χȇ ‫ڐ‬ᎸϬᒶᐆᑗ྄ᆀข‫ޠ‬ஐυȂѺ෉ቩђ‫ޠ‬လድᡞᑗӶ౱ࡤᕼϊ(37)Ȅ ࡛ឋȈҧ‫ޒ‬သ‫ٱ‬ऐཌྷϊᕝᒶᐆᑗ྄ᆀขґ໡Χ‫ޠ‬ஐυȂӶᛅѺ෉໣ᔗؑঐѺ ෉എଢᙺົॲ‫ݱ‬ᔯࢦȄմ࡚࡛ឋȂմᜍᐄ઼๊ ѯᢋȈณࣻᜱः‫ف‬Ȅ Ϋϥȃҧ‫ޒ‬သᡝ፵ᕝ‫ޠ‬ஐυӬ‫ڂ‬Ң෦ಡब‫ޠق‬RETஆӱऐᡑ(germline RET mutation)ȂᛅѺ‫ޠ‬੬ੇՄ໕ȉ ᇴ݃ȈҢ෦ಡब‫ޠق‬RET ஆӱऐᡑѠ૗ཽЖକᒹ༉‫ޠܓ‬ҧ‫ޒ‬သᡝ፵ᕝȄ MEN2AȂMEN2B ‫੿ޠ‬΢ٙαϑ‫׳‬яӼᆎRETࣻᜱऐᡑȄ ਴ᐄATAҧ‫ޒ‬သᡝ፵ᕝ‫ࡿޠ‬ЖȂϑ‫ޤ‬RETஆӱऐᡑ‫ޠ‬ஐυ(ϛᆔ࢑֐ԥ ҧ‫ޒ‬သᡝ፵ᕝ ) ȂᔗӶՄኍᛅѺਣ‫࢑ܗ‬ᛅѺਣ֚‫ޤ‬ҧ‫ޒ‬သᡝ፵ᕝ‫ॴޠ‬ ᓏȂ‫ࣻڐޤ֚ٯ‬ᜱஆӱᔯขȄϛ‫ו‬గ୉౱ࠊஆӱᔯข‫ޠ‬ЯҕȂѠණ‫ٽ‬ ‫ڐ‬ᒹ༉ᒛၛ‫ޠ‬ၦଊȂ‫ٯ‬ණ‫ࡇٽ‬φяҢࡤஆӱᔯข‫ޠ‬ၦଊ(38)Ȅ ӶMEN2‫ޠ‬ஐυȂᛅѺࠊᔗ௷ଷ༟ሟಡबድ‫ޠ‬ԇӶȄ

65

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

஠ԥӫມϜऽНᄈྲߓ ࢴ‫ܓ‬သድ

Functioning thyroid nodule

ਰᚃ௮ඣ

Radionuclide scan

࿩ឹ‫ڦ‬௮ᆁ

Radioiodine uptake determination

ߵҧ‫ޒ‬သષ (ҧ‫ޒ‬သ‫ڗ‬ᐮષȃҧߵષ)

Thyroid stimulating hormone TSH

७໘ષ

Calcitonin

Ӽึ‫ܓ‬ϲϸ‫ݫ‬လድ

Multiple endocrine neoplasia

༟ሟಡबድ

Pheochromocytoma

ЇᔗًԂ

Excellent response

ҢϾґ‫׈‬ӓጦ၍

Biochemical incomplete response

๗ᄻґ‫׈‬ӓጦ၍

Structural incomplete response

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ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

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29. Pacini F, Gasperi M, Fugazzola L, Ceccarelli C, Lippi F, Centoni R, Martino E, Pinchera A. 7HVWLFXODU IXQF WLRQ LQ SDWLHQWV ZLWK GL൵HUHQWLDWHG WK\URLG FDUFLQRPD WUHDWHG ZLWK UDGLRLRGLQH J Nucl Med 1994:35:1418–1422.

30. Kuan-Yin Ko, MD, Ruoh-Fang Yen, MD, PhD, Cheng-Li Lin, MSc, Mei-Fang Cheng, MD,Wen-Sheng Huang, MD, and Chia-Hung Kao, MD. Pregnancy Outcome After I-131 Therapy for Patients With Thyroid Cancer: A Nationwide Population-Based Cohort Study Medicine 2016; 95(5):e268 31. FDA. Drug Approvals and Databases. Available at: www .fda.gov/Drugs/InformationonDrugs/ default.htm (accessed February 11, 2017).

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38. Wells SA Jr, Asa SL, Dralle H, Elisei R, Evans DB, Gagel RF, Lee N, Machens A.Moley JF, Pacini F, Raue F, Frank-Raue K, Robinson B, Rosenthal MS, Santoro M, Schlumberger M, Shah M, Waguespack SG, American Thyroid Association Guidelines Task Force on Medullary Thyroid Carcinoma 2015 Revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma. Thyroid 2015;25:567–610.

ׂ৓෉໣ҧ‫ޒ‬သ๗࿾Іҧ‫ޒ‬သᕝ೏౪

68

Ᏻ᠟ ѯіᄹҖᖃᚃଲུചхᗃऌ ചో਷лӉ

Ѻஐҧ‫ޒ‬သ๗࿾౿՘౦3%- 21%Ȃ๗࿾౿՘౦ᓎѺஐ Ң౱Ԫ኶ቩђȄӶѺ෉ึ౫ҧ‫ޒ‬သ๗࿾‫ޠ‬ѺஐȂ‫ڐ‬ҧ‫ޒ‬သ ᕝ‫ޠ‬౿՘౦࡟ᜳԥਞ‫ޠ‬զॏȄѺஐ‫ޠ‬ҧ‫ޒ‬သ๗࿾ຠզ‫ߩڸ‬ Ѻஐ᜹ծȂ‫ڐ‬๗࿾࢑֐ሰ୉ಡଭए‫ڗ‬Ȃ‫ٸ‬ᖞ‫ט‬ᛅᅹඍ‫࡚ܓ‬ ‫ޠ‬โ࡚І੿΢ཏ᜺࣐л्Մ໕ȄᛅѺ‫࢑ܗ‬౱ࡤಒΚԒຩᘟ ҧ‫ޒ‬သᕝၮ‫ء‬ԥᛅѺ‫ޠ‬ஐυຩᘟҧ‫ޒ‬သᕝȂ‫ڎ‬ಣԬκ౦‫ء‬ ԥৰ౵ȄᛅѺ෉໣௦‫ڨ‬ҧ‫ޒ‬သК೛‫ޠ‬ஐυЩΚૢஐυԥ‫؂‬ ା‫઀ึڂޠ‬Ȅए‫ڗ‬ϛጃًۢඍ‫ޠܓ‬๗࿾ȂԄ‫ءݏ‬ԥ‫ץ‬ഁໍ ৥‫ޠ‬ᖞ‫ט‬ᡑϾȂϛ࡛ឋӶᛅѺ෉໣К೛ȄѺ෉ུຩᘟҧ‫ޒ‬ သ‫ٱ‬ऐᕝ‫ޠ‬ѺஐȂ໹ӶѺ෉ᆀขົॲ‫ݱ‬ȄԄӶ24໋ࠊ݃ᡘ ᡑτ‫ి࢑ܗ‬ВᙾಌȂ࡛ឋӶѺ෉௦‫ڨ‬К೛ȇԄӶѺ෉๗࿾ ᡞᑗᛨۢȂ‫࢑ܗ‬ӶᛅѺࡤљ෉ຩᘟ‫ޠ‬ҧ‫ޒ‬သᕝȂ࡛ឋ๊౱ ࡤК೛ȄѺஐTSH௢‫ޠښ‬ҭዀȂၮᛅѺࠊҧ‫ޒ‬သᕝ‫ݾޠ‬ᕜ ҭዀΚኻȄҧ‫ޒ‬သᕝஐυᔗӶ঩φ࿩‫ݾ‬ᕜՎЎ6ঐУࡤȂ ӕՄኍᛅѺȄFDA೾ႇӶ঩φ࿩‫ݾ‬ᕜณਞҧ‫ޒ‬သᕝѠ‫ٻ‬ң ‫ޠޠ‬ήᆎዀႱ᛿‫ޑ‬: Sorafenibȃlenvatinib‫ڸ‬carbozantinibӶ ୞‫ޑ‬ᄃᡜαᜍᄃԥय࿍फ‫ܓ‬Іथफࢴ‫ܓ‬Ȅҧ‫ޒ‬သᕝஐυӶ ‫ء‬ԥလድඉึ‫ޠ‬ᜍᐄਣȂϛ࡛ឋӶѺ෉ቩђଢᙺົॲ‫ݱ‬І ᆀขҧ‫ޒ‬သ౩೗Ҫ‫ޠ‬ᓝ౦Ȅ

69

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फ‫ڌ‬ᇅུҢ‫ڌ‬ϟྲៗ‫ٲ‬໷ ୾੏ᆤӬᚃଲ ༂ೈෙ Κȅҕᡞᇅफ‫ޠڌ‬ҧ‫ޒ‬သೊᅮᇍϟᜱ߾ ᇴ݃Ȉफ‫ڌ‬ဟഌҧ‫ޒ‬သೊᅮᇍ‫ڨ‬ᡞӶಒ10໋пմᐩ࡚ߓ౫ȂӶಒ16໋‫ץ‬ഁቩ ђ‫ژ‬10ॼ (1)Ȅफ‫ڌ‬Ӷಒ12-14໋໡ۗѠข໕‫ژ‬մᐩ࡚‫ޠ‬՗ఽTT4‫ڸ‬FT4 ኶অ(2-4)Ȅफ‫ڌ‬՗ఽTT4Ӷಒ12໋ङ࣐2 ȝg/dL (26 nmol/L)ȂᛅѺϜ෉ࠍ ໡ۗቩђȂ36໋ࠍႁ‫ژ‬10 ȝg/dL (138 nmol/L)Ȅ ‫ڸ‬T4ࣻЇȂफ‫ޠڌ‬T4ࣁ‫ܓ‬౱‫ޑ‬T3Ӷҕᡞϲ‫ޠ‬኶অሊմܼ౱ࡤȂՅณࣁ ‫ܓ‬౱‫ޑ‬reverse T3‫ڸ‬T3 sulfateࠍ࢑Ёା‫ޠ‬ȅफ‫ڌ‬՗ఽT3ᐩ࡚Ӷಒ12໋ङ ࣐6 ng/dL (0.09 nmol/L)Ȃ36໋ࠍቩђ‫ژ‬45 ng /dL (0.68 nmol/L)Ȅ फ‫ڌ‬՗ఽTSHᐩ࡚Ӷಒ12໋௄4 mU/L໡ۗαЁ‫٘ژ‬У‫ޠ‬8 mU/LȂ‫ٯ‬й ۗಥЩӤ෉ϟҕᡞᐩ࡚ା(3)Ȅ Ρȅफዻ༉ሏ‫ِޠ‬Ք ᇴ݃Ȉҧ‫ޒ‬သೊᅮᇍ Ҕள‫ޒ‬ᄙίȂ΢᜹फዻԥτ໕‫ޠ‬deiodinase(D)ȂѠ஡ҕᡞ༉ሏՎफ‫ڌ‬ ‫ޠ‬ҧ‫ޒ‬သೊᅮᇍџࣁ‫ܓ‬ȂӱԫѠණ‫ٽ‬T4٘஋‫ޠ‬ᅥഇ౦Ȅ ᛅѺࠊљ෉फ‫ڌ‬ҧ‫ޒ‬သึ‫ي‬ґԚዤࠊȂफ‫ڌ‬ဟഌ൸Ѡп୏ข‫ژ‬T4ȅ೼ ໷༉ሏᐡᙾӶҧ‫ޒ‬သѓ૗մί‫ޠ‬फ‫࡟ڌ‬२्Ȃᝓ२‫ޠ‬ӒЉ‫ܓ‬ҧ‫ޒ‬သѓ ૗մί‫ུޠ‬Ң‫ڌ‬Ȃसᅿԟ๞ϡᎍ࿌‫٘ٯ‬஋‫ݾޠ‬ᕜȂ൸ཽԥҔள‫ܗ‬ංо Ҕள‫ޠ‬ᇰ‫ޤ‬ѓ૗Ȅ ࿩ ࿩Ѡпഇႇफዻα‫ޠ‬໙࿩ᙾၽᏣ (sodium iodide transporter) ᐩᕼ࿩Ȃ஡ ࿩௄ҕᡞ༉ሏ‫ژ‬फ‫ڌ‬ᡞϲȂ࿩‫ޠ‬ᐩ࡚ᓎ຀ᛅѺ‫෉ڻ‬ቩђՅቩђ(5)Ȅ ռ࣬౩೗ҪG ҕᡞ‫ޠ‬ռ࣬౩೗ҪGՍᡞռ࣬‫׫‬ᡞӶᛅѺϜ෉ȂစҦུҢ‫ڌ‬Fc௦‫ڨ‬Ꮳ (neonatal Fc receptor)Ȃ೾ႇफዻණ‫ٽ‬फ‫ུڸڌ‬Ң‫ڌ‬ռ࣬೗ҪȂ‫ژޣ‬ ᔊ‫ڌ‬໡ۗᇨആՍϐ‫ޠ‬ռ࣬౩೗ҪG (6)Ȅொԥҧ‫ޒ‬သՍᡞռ࣬੾੿‫ޠ‬ҕ ᒒȂTPOȂTgȂTSH receptor‫׫‬ᡞηң᜹ծРԓ༉ሏ‫ژ‬फ‫ڌ‬ᡞϲȂ೼ኻ ‫ޠ‬༉ሏРԓ෇စೞᇰ࣐࢑ӒЉ‫ܓ‬ҧ‫ޒ‬သѓ૗մί‫ޠ‬঩ӱϟΚ(7)Ȅ ᔊ‫ޠڌ‬ҧ‫ޒ‬သѓ૗Ϧໍ೾ளึҢӶԥାਞΩ‫ܗ‬ାᐩ࡚TRAbࣁ‫ޠܓ‬ҕ ᒒ(8)Ȅ 1%-2%‫ޠ‬Graves' disease (GD)ҕᒒȂ‫ؑܗ‬50,000ུҢ‫ึڌ‬Ң1 ‫پ‬ҧ‫ޒ‬သ ϦໍȂ‫ึڐ‬Ң౦࢑ԥTSH receptor blocking‫׫‬ᡞ‫ޠ‬ҕᡞ‫ܛ‬Жକ‫ޠ‬ኸਣ‫ܓ‬ ུҢ‫ڌ‬ҧ‫ޒ‬သѓ૗մί‫ޠ‬4ॼȅTSH receptor blocking‫׫‬ᡞЖକ‫ޠ‬ӒЉ फ‫ڌ‬ᇅུҢ‫ڌ‬ϟྲៗ‫ٲ‬໷

70

‫ܓ‬ҧ‫ޒ‬သѓ૗մίȂЩུҢ‫ ڌ‬GD Ўُ೩ӼȂկ࢑ொԥᝓ२Սᡞռ࣬ ҧ‫ޒ‬သ੾੿ҕᒒ౱ί‫ࡇޠ‬φȂϬᔗ၏्ᛅᅹ࢑֐ԥӒЉ‫ܓ‬ҧ‫ޒ‬သѓ૗ մί(9)Ȅҧ‫ޒ‬သѓ૗մί‫ޠ‬ҕᒒसᛅѺ෉໣‫ء‬ԥ‫ݾ‬ᕜȂᔊ‫ڌ‬яҢࡤ֊ ‫ٻ‬๞ϡᎍ࿌‫ݾ‬ᕜȂϬดཽԥᇰ‫ޤ‬ѓ૗ϛ٘‫ޠ‬๗‫(ݏ‬10)Ȅ ‫׫‬ҧ‫ޒ‬သ᛿‫ (ޑ‬PTU‫ڸ‬MMI)‫ڸ‬TSH receptor‫׫‬ᡞഎཽ௄ҕᡞ༉ሏ‫ژ‬फ ‫ڌ‬Ȃᄈफ‫ུڸڌ‬Ң‫ޠڌ‬ҧ‫ޒ‬သѓ૗എཽആԚᡘ຀‫ޠ‬ኈ៫Ȅ ήȃ ҕᡞҧ‫ޒ‬သ౵ளਣȂեਣᔗ၏֚‫ޤ‬пІᔗ၏ණ‫ٳ঻ٽ‬ଊਁ๞ུҢ‫ڌ‬ऌ‫ܗ‬ ϊ‫ڌ‬ऌᚃ৲ȉ ᇴ݃Ȉҧ‫ޒ‬သ‫׫‬ᡞ‫׫ڸ‬ҧ‫ޒ‬သ᛿‫ޑ‬എཽ༉ሏ‫ژ‬फ‫ڌ‬Ȃ‫ٯ‬ኈ៫ུҢ‫ޠڌ‬ҧ‫ޒ‬သ ୋஷȅҐٙϑစԥҧ‫ޒ‬သ੾੿ȃҧ‫ޒ‬သѓ૗౵ளȃԥTSH-receptor‫׫‬ ᡞ(TRAb)ȃ‫ܗ‬ᛅѺϜϬ‫ٻ‬ң‫׫‬ҧ‫ޒ‬သ᛿‫ޠޑ‬ҕᒒȂഎѠ૗ᄈུҢ‫ڌ‬ԥ ϛًኈ៫ȅ࡛ឋӶҕᒒᛅѺӓโ஡੿ӱȃึ੿ਣ໣ȃᝓ२࡚ȃпІ‫ݾ‬ ᕜ᛿‫ޑ‬༉ႁ๞ུҢ‫ڌ‬ऌ‫ܗ‬ϊ‫ڌ‬ऌᚃ৲Ȅ ࡛ឋȈԥҧ‫ޒ‬သ੾੿੿ѭȂᛅѺႇโ݉ң‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬Ȃ‫ܗ‬ҧ‫ޒ‬သѓ૗౵ ளȂ‫ܗ‬ԥTSH-receptor‫׫‬ᡞȂഎᔗ၏ᖓᛯུҢ‫ڌ‬ऌ‫ܗ‬ϊ‫ڌ‬ऌᚃ৲Ȅ ା࡚࡛ឋȂϜᜍᐄ઼๊ ࡛ឋȈ ᛅѺ෉໣ҧ‫ޒ‬သ੾੿‫ᝓޠ‬२โ࡚Ȃໍ৥пІፓᚖ‫ܓ‬ȂӶҢ౱ࠊᔗ၏ᇅ ུҢ‫ڌ‬ऌ‫ܗ‬ϊ‫ڌ‬ऌᚃ৲ଇ፤ȂпІՄኍཽຩϊ‫ڌ‬ϲϸ‫ݫ‬ऌᚃ৲Ȅ ା࡚࡛ឋȂϜᜍᐄ઼๊ ѳȅ‫ܛ‬ԥུҢ‫ڌ‬എᔗ၏ᑣᔯҧ‫ޒ‬သѓ૗༞ȉ ᇴ݃ȈӒЉ‫ܓ‬ҧ‫ޒ‬သѓ૗մίҭࠊ࢑Ѡ‫ݾ‬ᕜ‫ޠ‬හΩϛ٘‫ޠ‬ഷளُ঩ӱϟΚȂ ೩Ӽϑ໡ึ୾ঢ়എϑစӗུ࣐Ң‫ڌ‬ᑣᔯ‫ޠ‬໷ҭ(11)Ȅ࣐Π෶ЎུҢ‫ڌ‬Ң ౪‫ܓ‬᡾Ё‫ޠ‬TSHঅϟϔᘚȂഷᎍ࿌‫ޠ‬ᔯࢦਣ໣࣐яҢࡤ2-5ЉȅུҢ‫ڌ‬ ᑣᔯ‫ٯ‬ᅿԟ๞ϡᎍ࿌‫ݾ‬ᕜ‫ޠ‬௱՘ϑစ෶Ў೩ӼӱӒЉ‫ܓ‬ҧ‫ޒ‬သѓ૗մ ί‫ޠݾܛ‬හΩϛ٘ (12)Ȅ ࡛ឋȈ ‫ܛ‬ԥུҢ‫ڌ‬എᔗӶяҢࡤ2-5Љ௦‫ڨ‬՗б(blood spot analysis)ᑣᔯҧ‫ޒ‬ သѓ૗մίȄା࡚࡛ឋȂାᜍᐄ઼๊ ϥȅུҢ‫ڌ‬ҧ‫ޒ‬သѓ૗մί‫ݾޠ‬ᕜ ᇴ݃Ȉ ҕᒒसҢ౱ਣϬ݉ң‫׫‬ҧ‫ޒ‬သ᛿‫(ޑ‬ATDs)Ȃ᛿‫ཽޑ‬೾ႇफዻ༉ሏ‫ུژ‬ Ң‫ڌ‬ȂяҢࡤ3-5ЉϲхᗃȂҧ‫ޒ‬သѓ૗η࡯ඉҔளȅӒЉ‫ܓ‬ҧ‫ޒ‬သѓ ૗մί‫ུޠ‬Ң‫҇ڌ‬໹ӶяҢࡤ2໋ϲ໡ۗ݉ңҧ‫ޒ‬သષ(LT4)Ȃ࡛ឋᏙ ໕࣐10-15 ug/kg/d (12)Ȅ ϳȅུҢ‫ڌ‬ҧ‫ޒ‬သѓ૗Ϧໍ‫ݾޠ‬ᕜ ᇴ݃Ȉ τഌϸུҢ‫ڌ‬ҧ‫ޒ‬သѓ૗Ϧໍ࢑Ҧҕᡞ‫ޠ‬TRAb༉ሏ‫ژ‬फ‫ܛڌ‬यȂུ Ң‫ڌ‬ҧ‫ޒ‬သѓ૗Ϧໍ‫ޠ‬༉ಜ‫ݾ‬ᕜ᛿‫࢑ޑ‬ϸᏙ໕๞ϡPTU 5-10mg/kgȂ

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सя౫‫ܓࢴنޠُك‬Ȃࠍ‫ٻ׾‬ңMMI 0.5-1mg/kgȅԄ‫ݏ‬я౫ᝓ२‫ޠ‬ҧ ‫ޒ‬သѓ૗ϦໍȂѠђpropranolol 2mg/kgȅུҢ‫ޠڌ‬ҧϦ੿โ‫׫ڸ‬ᡞਞ ΩԥᜱȂτഌϸङ1-3ঐУȅTSH-receptorऐᡑ‫࢑ܗ‬McCune-Albright઀ ঑ထ๊‫ܛ੿੾ُك‬ആԚ‫ޠ‬ҧ‫ޒ‬သѓ૗ϦໍȂ൸҇໹Ҙε‫ݾ‬ᕜ(13)Ȅ

୥ ՄНᝧ 1. Bernal J, Pekonen F. Ontogenesis of the nuclear 3,5,3Ʌ -triiodothyronine receptor in the human fetal brain. Endocrinology 1984; 114:677–679.

2. Thorpe-Beeston JG, Nicolaides KH, Felton CV, Butler J, McGregor AM. Maturation of the secretion of thyroid hormone and thyroid-stimulating hormone in the fetus. N Engl J Med 1991; 324:532–536.

3. Thorpe-Beeston JG, Nicolaides KH, AM. Fetal thyroid function. Thyroid 1992 ; 2:207–217.

4. Burrow GN, Fisher DA, Larsen PR. Maternal and fetal thyroid function. N Engl J Med 1994; 331:1073–1078.

5. Li H, Patel J, Mortimer RH, Richard K. Ontogenic changes in human placental sodium iodide symporter expression. Placenta 2012; 33:946–948.

6. Mathieson L, Nielsen LK, Andersen JT, Grevys A, Sandlie I, Michaelsen TE, Hedegaard M, Knudsen LE, Dziegiel MH. Maternofetal transplacental transport of recombinant IgG DQWLERGLHV ODFNLQJ H൵HFWRU IXQFWLRQV %ORRG ± 7. Benvenga S, Ordookhani A, Pearce EN, Tonacchera M, Azizi F, Braverman LE. Detection of circulating autoantibodies against thyroid hormones in an infant with permanent congenital hypothyroidism and her twin with transient congenital hypothyroidism: possible contribution of thyroid hormone autoantibodies to neonatal and infant hypothyroidism. J Pediatr EndocrinolMetab 2008; 21:1011–1020.

8. Zakarija M, McKenzie JM. Pregnancy-associated changes in the thyroid-stimulating antibody of GravesɅ disease and the relationship to neonatal hyperthyroidism. J Clin Endocrinol Metab 1983; 57:1036–1040.

9. Brown RS, Bellisaro RL, Botero D, Fournier L, AbramsCA, Cowger ML, David R, Fort P, Richman RA. Incidence of transient congenital hypothyroidism due to maternal thyrotropin receptor-blocking antibodies in over one million babies. J Clin Endocrinol Metab 1996; 81:1147–1151.

10. Matsuura N, Konishi J. Transient hypothyroidism in infants born to mothers with chronic thyroiditisșa nationwide study of twenty-three cases. The Transient Hypothyroidism Study Group. Endocrinol Jpn 1990; 37:369–379.

11. Ford G, LaFranchi SH. Screening for congenital hypothyroidism: a worldwide view of strategies. Best Pract Res Clin Endocrinol Metab 2014; 28:175–187.

12. Rose SR, Brown RS, Foley T, Kaplowitz PB, Kaye CI, Sundararajan S, Varma SK. Update of newborn screening and therapy for congenital hypothyroidism. Pediatrics 2006; 117:2290– 2303.

13. Brown RS. Disorders of the thyroid gland in infants, children, and adolescents. In DeGroot LJ, ed. Thyroid Disease Manager. Available at http://www.thyroidmanager.org.

फ‫ڌ‬ᇅུҢ‫ڌ‬ϟྲៗ‫ٲ‬໷

72

Ᏻ᠟ ୾੏ᆤӬᚃଲུചхᗃऌ ༂Љಉఁ௳

फ‫يึޠڌ‬ȂЏ‫࢑ڐ‬Ϝ኿ઢစȂ‫ژڨ‬ҧᐮષኈ៫Վ τȂՅफ‫ڌ‬ҧ‫ޒ‬သϟҢԚᇅձң्‫ژ‬12໋пࡤȂࢉׂ৓ॷ ήঐУफ‫ڌ‬ҧᐮષӓᎭҕᒒȄҧᐮષ༉ᒰᓎ຀Ѻ෉።ᐍȂ ೼൸Ꭽफዻ‫ޠ‬ಒ 3 ࠯џ࿩㢵஡ T4 ᙾඳԚณхᗃࣁ‫ ޠܓ‬r T3 ІಆϾ㢵ᇅџಆ㢵‫ٿ‬።࿾ໍΤफ‫ޠڌ‬T4ІT3ȇHCG‫ڏ‬ԥ 1/1000 TSHࣁ‫ܓ‬Ȃ‫ڗ‬ᐮफ‫ڌ‬ҧ‫ޒ‬သ౱ҢҧᐮષȄ

फዻӶׂ৓ϜήঐУᇅҒήঐУѠ༉ᒰIgGȂொԥՍ ᡞռ࣬ҧသ੾੿‫ޠ‬ҕᒒ՗Ϝ‫׫‬ᡞѠ༉ᒰ๞फ‫ڌ‬Ȃ೼‫׫ٳ‬ᡞ ԥ‫ڗ‬ᐮ‫ޠܓ‬Ȃηԥ‫ޠܓښ׼‬ȂԄ‫׫ݏ‬ᡞࣁ‫ܓ‬ା(>3ॼᐩ࡚) फ‫ڌ‬ԥѠ૗ҧသᐡ૗౵ளȂл्ࣽTSH receptor antibody‫ޠ‬ ࣁ‫ܓ‬ՅۢȄ ҧသՍᡞռ࣬੾੿ԂึܼҢ‫ي‬Ԓឮυ‫ܓ‬ȂѺஐ‫ޠ‬ҧသ ‫ݸޒ‬ኈ៫फ‫يึڌ‬Վ႟Ȃᚃ৲Ӷྲ៬੿΢ਣϛ༊्Մኍҕ ᒒη्Մኍफ‫ڌ‬ȂԫࡿЖණ‫ࠍྦ៬ྲٽ‬Ȅ

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ҧ‫ޒ‬သ੾੿‫ڸ‬঴‫ٱ‬ ା໱ߞ۹ख‫܉‬ᚃଲ ‫ڻ‬ਐസ Κȃ঴‫෉ٱ‬ஐυҧ‫ޒ‬သѓ૗࢑֐ཽኈ៫঴‫ٱ‬ȉ Ρȃ‫ݾ‬ᕜҧ‫ޒ‬သѓ૗մί࢑֐Ѡп‫׾‬๢ஐυӶ௳‫ޠ෉ٱ‬঴‫ݸޒٱ‬ȉ ήȃ‫ݾ‬ᕜҧ‫ޒ‬သѓ૗Ϧໍ࢑֐Ѡп‫׾‬๢ஐυӶ௳‫ޠ෉ٱ‬঴‫ݸޒٱ‬ȉ ᇴ݃Ȉҕᡞҧ‫ޒ‬သѓ૗౵ளȞєࢃҧ‫ޒ‬သѓ૗մί‫ڸ‬ҧ‫ޒ‬သѓ૗Ϧໍȟཽኈ ៫‫ٱ‬ҙϸ‫ݫ‬ኈ៫঴‫ٱ‬Ԛѓ౦Ȃկҭࠊᗚ‫ء‬ԥщϸ‫ޠ‬΢ᡞၑᡜ‫ٿ‬ᜍᄃȂ կ਴ᐄӶӠུ࡚኉٩੿‫پ‬ϸ‫ึݚ‬౫ӶᛅѺਣӬ‫ڂ‬ҧ‫ޒ‬သѓ૗մί‫ޠ‬ঐ ਱၈Ȃ19.2 ʦ‫ڨޠ‬ၑ޲ԥ‫ٱݫ‬౵ள‫(ݸޒޠ‬1)ȄѫѵӶ‫ڐ‬у੿‫پ‬ൣ֚η ᇴ݃ΠԚѓ‫ݾ‬ᕜҧ‫ޒ‬သѓ૗մίѠп‫׾‬๢௳‫ٱ‬௒‫(ם‬2)Ȅ ᗷดӶԥ४‫ޠ‬ᜍᐄηᡘұҕᒒҧ‫ޒ‬သѓ૗ϦໍηѠ૗཭ড়঴‫ٱ‬Ȃկҭ ࠊϬુнτ࠯΢ᡞၑᡜ‫ٿ‬ᜍᄃȄ ࡛ឋȈ Ҧܼҕᒒ‫ޠ‬ҧ‫ޒ‬သѓ૗մίཽᄈ঴‫෉ٱ‬౱ҢϛԂኈ៫ȂӱԫӶ‫ء‬ԥ‫ڐ‬ у঩ӱ‫ޠ‬௒‫ݸ‬ίя౫‫ٱݫ‬ѓ૗ϛً‫ޠ‬υ‫ܓ‬ᔗ၏ᔯขҧ‫ޒ‬သ‫ڗ‬ᐮષпຠ զҧ‫ޒ‬သѓ૗ሬᛥȄմ࡚࡛ឋȂմᜍᐄ઼๊ ࡛ឋȈԥᠧܼҧ‫ޒ‬သѓ૗մίᄈܼ௳‫෉ٱ‬Ϝ‫ޠ‬ҕᒒ‫ٱ‬ҙϸ‫ཽݫ‬౱Ң॓८ኈ ៫ȂӱԫӶ঴‫෉ٱ‬Ϝ‫ٴޠ‬ᖞ‫ڸט‬ҧ‫ޒ‬သѓ૗մί‫ޠ‬ஐυᔗ௦‫ݾڨ‬ᕜȄ մ࡚࡛ឋȂմᜍᐄ઼๊ ࡛ឋȈ ӱ࣐ҧ‫ޒ‬သѓ૗Ϧໍᄈܼ঴‫ޠٱ‬ኈ៫‫ٯ‬ϛఽྀȂӱԫᄈܼ‫ݾ‬ᕜ௳‫ٱ‬Ϝ ஐυ‫ޠ‬ҧ‫ޒ‬သѓ૗Ϧໍ‫ٯ‬ณ੬ր‫ݾ‬ᕜ࡛ឋȄณ࡛ឋȂᜍᐄϛ٘ ѯᢋȈ‫ٯ‬ณၦਠȄ ѳȃҕᒒᡞϲ‫ޠ‬ҧ‫ޒ‬သೊᅮᇍ࢑֐ཽഇႇ‫ٱ‬ҙᙾಌՎུҢ‫ڌ‬ᡞϲȉ ᇴ݃ᇅ࡛ឋȈ঴‫෉ٱ‬ஐυ‫ޠ‬ҕ‫ٱ‬Ϝ֥ԥЎ໕ҕᡞҧ‫ޒ‬သೊᅮᇍȂӶΚ໷ԟ౱ ‫ڌ‬ҕᒒ‫ޠ‬ҕ‫ٱ‬Ϝ‫ޠ‬T4‫ڸ‬T3‫ޠ‬ः‫ف‬Ϝᡘұҕ‫ٱ‬Ϝ‫ޠ‬ҧ‫ޒ‬သષᐩ࡚ ጓ൝࣐0.17Վ1.83 ཌྷջ/Ё(3)Ȅӱԫ୆೪ᔊ‫ڌ‬ΚЉ्੒૊τङ750 రЁ‫ޠ‬ҕ‫ٱ‬Ȃ೼ࣻ࿌ܼؑЉཽ௦ដ‫ژ‬τङ0.62 ཌྷջ‫ޠ‬T4Ȅӱԫ пτӼ኶ᔊ‫ޠڌ‬T4ᖃሰ्໕ङ࣐ؑЉ40-60 ཌྷջ‫ٿ‬ॏᆘȂ೾ႇ ‫ٱ‬ҙᙾಌ‫ژ‬ᔊ‫ޠڌ‬ҧ‫ޒ‬သષ‫ޠ‬໕τङѬխؑСᖃሰؒ໕‫ޠ‬ϛ‫ژ‬ 1ʦȄ ӱԫစҦᄃᜍᚃᏱᜍᐄᡘұҕᡞϲҧ‫ޒ‬သೊᅮᇍഇႇ‫ٱ‬ҙϸ‫ݫ‬ ᙾಌ‫ژ‬ᔊ‫ٯڌ‬ϛཽኈ៫‫ڐ‬ҧ‫ޒ‬သѓ૗Ȅ ѯᢋȈ‫ٯ‬ณၦਠȄ

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ϥȃ Ӷ঴‫෉ٱ‬ஐυ࢑֐Ѡп௦‫ڨ‬ຩᘟ࠯‫ݾܗ‬ᕜ࠯ܺৣ‫ܓ‬঩φ࿩ࣻᜱ‫ݾ‬ᕜᇅᔯ ࢦȉ ᇴ݃Ȉ ӱ࣐ܺৣ‫ܓ‬࿩ཽӶҕ‫ٱ‬ϜᐩᕼȂй࿩131‫ޠ‬љ૿෉ࣻᄈηၷߞȞτङ8 ЉȟȂӱԫ‫ٻ‬ң࿩131ңܼ௮ඣ‫ݾܗ‬ᕜӶ௳‫ޠ෉ٱ‬ஐυҕᒒ࢑๙ᄈ࿲ ‫઀ס‬Ȅ ӱ࣐࿩123‫ޠ‬љ૿෉࣐13ϊਣȂԄ‫ݏ‬Ӷ೼ᆎ௒‫ݸ‬ίȂԄ҇ሰ्‫ٻ‬ң࿩ 123 ໍ՘ܺৣጤ௮ඣਣȂ኶Сϲ‫ޠ‬ҕ‫ࠍٱ‬ϛᔗ၏‫ٻ‬ң‫ܓৣܺژޣ‬࿩ϑ ‫׈‬ӓ௄ᡞϲఽଷȄ ࡛ឋȈ ஽੩࡛ឋ঴‫෉ٱ‬Ϝ࿲Ц௦‫ڨ‬࿩131ȂԄ‫ݏ‬઎‫ޠ‬ԥሰ्ȂѠпՄኍ‫ٻ‬ң ࿩ 123Ȃկ‫ٻ‬ңϟࡤήՎѳСϲҕ‫ٱ‬ϛ૗‫ٻ‬ңȄӤኻȂηѠпՄኍ‫ٻ‬ ңTc-99m๞᛿Ȃկ௦‫ڨ‬ᔯࢦ࿌Љ‫ޠ‬ҕ‫ٱ‬ϛ૗‫ٻ‬ңȂ҇໹ҶతȄ ା࡚࡛ឋȂϜᜍᐄ઼๊ ѯᢋȈ‫ٯ‬ณၦਠȄ ϳȃ ‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬ȞPTUȂMMIȟ࢑֐ཽစҦҕᡞᙾಌ‫ژ‬Վҕ‫ٱ‬Ϝ? ᄈ௦‫ڨ‬ ҕ‫ٱ‬ᗾॶ‫ޠ‬ᔊ‫ཽڌ‬ԥϨቅᖞ‫ݏࡤט‬ȉ Νȃ঴‫ޠ෉ٱ‬ஐυसԥҧ‫ޒ‬သѓ૗ϦໍȂ౪དྷ‫ݾ‬ᕜР‫࢑ݳ‬Ϩቅȉ Υȃ ঴‫ޠ෉ٱ‬ஐυसԥҧ‫ޒ‬သѓ૗Ϧໍйሰ᛿‫ݾޑ‬ᕜਣȂᔗ၏Մኍ݉ңϨቅ ᛿‫ޑ‬ȉ ᇴ݃ȈӶ‫ݾ‬ᕜϜ‫ޠ‬ҧϦஐυϸ‫ޠݫ‬ҕ‫ٱ‬ϜѠೞᔯขяPTU‫ڸ‬MMI‫ޠ‬ᐩ࡚Ȃ೼ ঐ౫ຬЖକ΢উᐋነᄈܼॶң೼‫ٳ‬᛿‫ཽޑ‬ᄈ௦‫ڨ‬ҕ‫ུޠٱ‬Ң‫ڌ‬ୋஷ౱ Ңϛւኈ៫Ȅ ӶΚঐϊ࠯ः‫ف‬Ϝᔯข9ӫ঴‫ޠޠ෉ٱ‬υ‫ܓ‬Ӷπ݉200రջ PTUࡤ‫ޠ‬4 ϊਣࡤȂข໕‫ܛ‬ϸ‫ٱޠݫ‬ҙϜ‫ޠ‬PTUᐩ࡚Ȃึ౫༊࢑ឹΤᏙ໕‫ޠ‬0.007 ʦ-0.077ʦ(4)ȄӱԫӶ೼ቅմܼኹ៪Ꮩ໕ίϵᇰᄈ௦‫ڨ‬ҕ‫ٱ‬ᗾᎵ‫ޠ‬ᔊ‫ڌ‬ ᔗ၏࢑‫ء‬ԥॴᓏȄѫѵࣻᜱः‫ف‬ηᜍᄃȂᄈܼ௦‫ڨ‬ҕ‫ٱ‬ᗾᎵ‫ޠ‬ᔊ‫ڌ‬Ϝ स࢑уউ‫ޠ‬ҕᒒ෇݉ңPTU‫ٯ‬ϛཽᄈуউҐٙ‫ޠ‬ҧ‫ޒ‬သѓ૗ആԚኈ៫ (5) Ȅ ӶMMI‫ܗ‬CM‫ޠ‬ः‫ف‬ᜍᄃπ݉ MMI / CMཽᙾಌ‫ژ‬ҕ‫ٱ‬Ϝ‫ޠ‬໕ङ࣐0.1 ʦ-0.2ʦȂ࢑PTU‫ޠ‬4‫ژ‬7ॼ(5)ȄՅΚ‫ٳ‬ः‫ف‬ϸրः‫ف‬ΠҕᡞឹΤ‫ޠ‬MMI ‫ܗ‬CMᄈҕ‫ٱ‬঴‫ޠࡤٱ‬ᔊ‫ڌ‬ҧ‫ޒ‬သѓ૗࢑‫ء‬ԥኈ៫‫(ޠ‬6)Ȅ Azizi (6)෇ึߓः‫ف‬።ࢦ঴‫෉ٱ‬ҕᡞ‫ڸ‬MMI‫ޠ‬ः‫ف‬Ȃ೼໷ः‫ف‬ຠզΠ௦ ‫ڨ‬ҕ‫ٱ‬ᗾᎵ‫ུޠ‬Ң‫ڌ‬ҧ‫ޒ‬သѓ૗ȂහΩึ‫ڸي‬ٙᡞึ‫ي‬ৰ౵Ȃᇅᄈྲ ‫่ࣻڌ‬ЩȂ௦‫ڨ‬ҕ‫ޠ่ڌޠٱ‬හ୧‫ܗ‬ٙᡞึ‫ءٯي‬ԥӱ࣐෇௦‫֥ڨ‬ԥ MMI‫ٱޠ‬ҙՅԥ‫ܛ‬ৰ౵ȄดՅȂᏱ޲উϬ࡛ឋഷτؑСᏙ໕ϛ्ົႇ ࣐20 mg‫ ޠ‬MMI‫ܗ‬450 mg‫ ޠ‬PTU (7)Ȅ ࡛ឋȈ‫ݾ‬ᕜ঴‫෉ٱ‬ஐυ‫ޠ‬ҧ‫ޒ‬သѓ૗Ϧໍ઀‫ޠ‬঩ࠍᔗ၏ᇅ঴‫෉ٱ‬ஐυ঩ࠍࣻ 75

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ӤȄା࡚࡛ឋȂմᜍᐄ઼๊ ࡛ឋȈ ࿌঴‫෉ٱ‬ஐυ‫ٻ‬ң‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬ਣȂѠпՄኍ๞ϡMMIȞഷାᏙ໕ؑ Љ20రջȟ‫ڸ‬PTUȞഷାᏙ໕ؑЉ450రջȟȄӱ࣐PTU‫ڸ‬MMIᙾಌ‫ژ‬ ҕ‫ٱ‬Ϝ‫ޠ‬໕ᗷѠೞขяկ໕྄ЎȂӱԫѠӒ௄ԥਞ‫ޠ‬ഷմᏙ໕໡ۗՄ ኍ‫ٻ‬ңȄା࡚࡛ឋȂϜᜍᐄ઼๊ ѯᢋȈ‫ٯ‬ณၦਠȄ Οȃ ௦‫ڨ‬ҕ‫ٱ‬ᗾᎵйҕᒒϬӶ݉ңҧ‫ޒ‬သ᛿‫ޠޑ‬ϊࡇȂ࢑֐ሰᔯࢦҧ‫ޒ‬သѓ ૗‫ޒ‬ᄙȉ ࡛ឋȈ ௦‫ڨ‬ҕ‫ٱ‬ᗾᎵйҕᒒϬӶ݉ңҧ‫ޒ‬သ᛿‫ޠޑ‬ϊࡇȂӶϊ‫ڌ‬ऌୋஷᔯࢦ ਣᔗ௦‫ڨ‬ᎍ࿌Ңߞ‫يึڸ‬௒‫ޠݸ‬ຠզȄկ‫ٯ‬ϛ࡛ឋӶள೤ຠզϜᔯข ՗ఽϲҧ‫ޒ‬သѓ૗Ȅմ࡚࡛ឋȂϜᜍᐄ઼๊ ѯᢋȈ‫ٯ‬ณၦਠȄ Ϋȃ೏ܼ঴‫ޠ෉ٱ‬ஐυӶ࿩‫ޠ‬၅щαᕋᎵՄኍ࢑Ϩቅȉ ᇴ݃Ȉ ࿩࢑ҧ‫ޒ‬သೊᅮᇍᇨആ‫҇ޠ‬ሰᕋᎵષȂл्‫ٿྜٿޠ‬Սܼ໾ॶȄᄈܼ τӼ኶ҔӶ௦‫ڨ‬ҕ‫ٱ‬ᗾᎵ‫ޠ‬ᔊ‫ڌ‬Ȃҕ‫࢑ٱ‬ᕋᎵ‫୳ޠ‬ΚȞ‫ܗ‬л्ȟ‫ޠ‬࿩ ‫ྜٿ‬ȄӱԫȂ঴‫෉ٱ‬ҕᒒឹΤϛ٘‫ޠ‬࿩ཽᄈᔊ‫ڌ‬ୋஷ౱Ңኈ៫Ȅ ᛅѺ෉໣‫ޠ‬࿩ሰؒ໕ӱᔗҕफԚߞՅቩђȄՅӶ౱ࡤȂᓎ຀࿩ཽഇႇ ҕ‫ᙾٱ‬ಌ๞ᔊ‫ڌ‬Ȃӱԫ௳‫ٱ‬Ϝஐυ࿩ሰؒ໕ሰໍΚؐቩђȄзࣩፐҢ ಣᙒ࡛ឋѺஐ‫ڸ‬঴‫෉ٱ‬ஐυ‫ޠ‬࿩၅щҭዀؑЉ࣐250ཌྷջ (9)Ȅ ࡛ឋȈ ‫ܛ‬ԥ௳‫ٱ‬ϜஐυؑЉӶ໾ॶϜᔗឹΤङ250ཌྷջ‫ޠ‬࿩Ȅ ା࡚࡛ឋȂାᜍᐄ઼๊ ࡛ឋȈ ௳‫ٱ‬ϜஐυѠпπ֥݉ԥ150ཌྷջ࿩‫ޠ‬၅щᏙȄѠпп࿩Ͼ႖(ᒼᏙ‫ܗ‬ ‫ڐ‬уᏙ࠯‫םޠ‬ԓȂ‫ܗ‬є֥ܼᆤӬᆱу‫ڽ‬Ϝȟ‫םޠ‬ԓ‫ٿ‬Մኍ၅щȂՅ‫ڐ‬ у‫ם‬ԓ‫ޠ‬࿩ᕋᎵࠣ(Ԅ:੖ழȂ੖᝾)‫ޠ‬၅щϛΚۢ૗ණ‫ٽ‬Κयࡰۢ‫ؑޠ‬ С࿩ሰ्໕‫ޠ‬၅щȄା࡚࡛ឋȂϜᜍᐄ઼๊ ࡛ឋȈ ᇅᛅѺ෉໣‫ޠ‬௒‫ݸ‬ΚኻȂ௳‫ٱ‬Ϝஐυᔗ၏ᗘռࡼ៊ឹΤЋାᏙ໕‫ޠ‬࿩ ঩ਠ၅щ(ؑСົႇ500-1100ཌྷջ)Ȃӱ࣐ЋାᏙ໕‫ޠ‬࿩ЇՅཽӶᔊ‫ڌ‬ Ϝᇷึҧ‫ޒ‬သᐡ૗෶ଞȄା࡚࡛ឋȂϜᜍᐄ઼๊ ѯᢋȈ ‫ٯ‬ณၦਠȄ

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Journal of developmental and behavioral pediatrics : JDBP 2004; 25:S69-73 3. van Wassenaer AG, Stulp MR, Valianpour F, Tamminga P, Ris Stalpers C, de Randamie JS,

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van Beusekom C, de Vijlder JJ. The quantity of thyroid hormone in human milk is too low to influence plasma thyroid hormone levels in the very preterm infant. Clinical endocrinology 2002; 56:621-627 Kampmann JP, Johansen K, Hansen JM, Helweg J. Propylthiouracil in human milk. Revision of a dogma. Lancet 1980; 1:736-737 Momotani N, Yamashita R, Makino F, Noh JY, Ishikawa N, Ito K. Thyroid function in wholly breast-feeding infants whose mothers take high doses of propylthiouracil. Clinical endocrinology 2000; 53:177-181 Azizi F, Khoshniat M, Bahrainian M, Hedayati M. Thyroid function and intellectual development of infants nursed by mothers taking methimazole. The Journal of clinical endocrinology and metabolism 2000; 85:3233-3238 Mandel SJ, Cooper DS. The use of antithyroid drugs in pregnancy and lactation. The Journal of clinical endocrinology and metabolism 2001; 86:2354-2359 Trumbo P, Yates AA, Schlicker S, Poos M. Dietary reference intakes: vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc. Journal of the American Dietetic Association 2001; 101:294-301 Sebotsa ML, Dannhauser A, Jooste PL, Joubert G. Assessment of the sustainability of the iodine-deficiency disorders control program in Lesotho. Food and nutrition bulletin 2007; 28:337-347

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

Ᏻ ᠟ġ ġ ġ ġ ġ ġ ġ ġ ġ ġ ġ ġ ġġġġġġġ ሊ‫ݎ‬ᖓӬຩ‫ ܛ‬ጿջངଲߞ

ҧ‫ޒ‬သѓ૗Ϧໍ‫࢑ܗ‬մίȂӶஐυ౱ࡤഎ࡟ளُȂՅ йң᛿ਣȂ༿​༿‫ڸ‬ᚃៗ΢সഎሰ्Մኍ࢑֐Ѡп঴ᗾҕ ‫ٱ‬Ȃң࢛‫ٳ‬᛿‫्ޑ‬ϊЗȄҐ࿾ୱᇅ๏ණ‫ٽ‬ԥ݃ጃ‫ޠ‬ᇴ݃ᇅ ࡛ឋȂ‫ٽ‬୥ՄᇅᔗңȄ

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౱ࡤҧ‫ޒ‬သ‫ވ‬ ା໱ᚃᏱτᏱߤ೪ᚃଲ ࠻‫ְڸ‬ Κȃեᒞ౱ࡤҧ‫ޒ‬သ‫ވ‬І‫ڐ‬ᖞ‫ט‬ཏဏ? ᇴ݃Ȉ ౱ࡤҧ‫ޒ‬သ‫ۢޠވ‬ဏ࢑ᛅѺࠊஐυҧ‫ޒ‬သѓ૗ҔளȂկ࢑౱ࡤಒΚԒ ϲ౱Ңҧ‫ޒ‬သѓ૗౵ளȂ‫ٯ‬й௷ଷါ࿆Њ૮Ы઀‫(ݸޒޠ‬1)Ȃ೼࢑Κᆎ Սᡞռ࣬‫੿੾ޠ‬ȂӶ‫ޠ࠯ڑ‬౱ࡤҧ‫ޒ‬သ‫ވ‬ϜȂኸਣ‫ޠܓ‬ҧ‫ޒ‬သࢴ઀Ӓ ౱ҢȂᓎࡤ࢑ҧ‫ޒ‬သѓ૗մίȂഷಥӶ౱ࡤॷԒ๗‫؃‬ਣӲ‫ژ‬ҧ‫ޒ‬သѓ ૗Ҕள‫ޒޠ‬ᄙ(2)Ȅ౱ࡤҧ‫ޒ‬သ‫ޠވ‬ᖞ‫ט‬ႇโߓ౫ৰ౵‫࡟ܓ‬τȂङԥ1/4 ‫ޠ‬ொ޲࣐αख़‫ޠ࠯ڑ‬ႇโߓ౫Ȃ1/4‫ޠ‬ொ޲࣐൑હҧ‫ޒ‬သࢴ઀ȂѫѵΚ љ‫ޠ‬ொ޲ߓ౫࣐൑હҧ‫ޒ‬သѓ૗մί(3)Ȅ౱ࡤҧ‫ޒ‬သ‫ވ‬౱Ң‫ޠ‬ҧ‫ޒ‬သ ࢴ઀໧ࢳ೾ளഎึҢӶ౱ࡤ2Վ6ঐУȂկηԥൣ֚෇Ӷ౱ࡤΚԒϘึ ҢȂՅҧ‫ޒ‬သࢴ઀໧ࢳ೾ள࢑Սึ‫ܓ‬ጦ၍ȇѫѵȂึҢҧ‫ޒ‬သѓ૗մ ί໧ࢳ೾ளึҢӶ౱ࡤ3Վ12ঐУȂՅङԥ10-20%‫ޠ‬ொ޲౱ҢΠҘε ‫ޠܓ‬ҧ‫ޒ‬သѓ૗մίȂࣦՎԥτ࠯‫ࠊޠ‬ᙂ‫ܓ‬ः‫ࡿف‬яȂାႁ50%пα ౱ࡤҧ‫ޒ‬သ‫ވ‬ொ޲Ӷ౱ࡤΚԒϬ֖౫ҧ‫ޒ‬သѓ૗մί‫ޒ‬ᄙ(4)Ȅ Ρȃ౱ࡤҧ‫ޒ‬သ‫੿ޠވ‬ӱ࣐ե? ᇴ݃Ȉ౱ࡤҧ‫ޒ‬သ‫࢑ވ‬ΚᆎՍᡞռ࣬‫੿੾ޠ‬Ȃᇅҧ‫ޒ‬သ‫׫‬ᡞ (T P O A b ‫ڸ‬ TgAb)ȃిВ౩‫ޠ‬౵ள‫ޒ‬ᄙȃ၅ᡞࣁϾȃ IgG1ቩђȃNKಡबࣁ‫ܓ‬ቩ ђȃ‫ڸ‬੬ր‫ޠ‬HLAϸ࠯ࣲԥᜱᖓ‫(ܓ‬5-7)ȇѺஐӶׂ৓ॷήঐУसழԥҧ ‫ޒ‬သ‫׫‬ᡞȂԥ࡟ା‫ޠ‬ᐡཽ(33~50%)ึ৥Ԛ౱ࡤҧ‫ޒ‬သ‫ވ‬ȂՅ຺ା‫ޠ‬ҧ ‫ޒ‬သ‫׫‬ᡞηཏ‫ک‬຀ԥ຺ା‫ॴޠ‬ᓏ(3)Ȃ౱ࡤҧ‫ޒ‬သ‫ޠވ‬౱Ң঩ӱȂᇅᛅ Ѻਣ෉ռ࣬ᔇ‫ژ׼‬౱ࡤռ࣬‫ޒ‬ᄙ‫ޠ‬ЇኇԥᜱȄ ήȃԄեցր౱ࡤུึҢ‫ޠ‬ҧ‫ޒ‬သࢴ઀‫ึޠ‬Ң঩ӱ? ᇴ݃Ȉ ౱ࡤ‫ޠ‬ҧ‫ޒ‬သࢴ઀Ȃഷ२्࢑्ୣϸ࢑౱ࡤҧ‫ޒ‬သ‫࢑ܗވ‬ါ࿆Њ૮Ы ઀‫ܛ‬ЖକȂ೼࢑Ҧܼ‫ޠ޲ڎ‬ᖞ‫੿ט‬โ‫ݾڸ‬ᕜР‫ݳ‬ϛӤȂึ੿‫ޠ‬ਣ໣Ѡ ණ‫ٽ‬ᠧրຩᘟ‫ޠ‬ጤસȂΚ጖СҐः‫ࡿف‬яȂ42՞౱ࡤಒΚԒϲя౫ҧ ‫ޒ‬သࢴ઀‫ޠ‬ொ޲ϜȂτഌϸ౱ࡤҧ‫ޒ‬သ‫ވ‬ொ޲ (85.7%) я౫ҧ‫ޒ‬သࢴ ઀‫ޠ‬ਣ໣࢑Ӷ౱ࡤήঐУϲȂՅ‫ܛ‬ԥါ࿆Њ૮Ы઀ொ޲я౫ҧ‫ޒ‬သ ࢴ઀‫ޠ‬ਣ໣࢑ӶҢ౱‫׈‬6.5ঐУпࡤ(8)ȄӶါ࿆Њ૮Ы઀‫ޠ‬ொ޲ϜTSH receptor Abංоഎཽ֖౫໩‫ܓ‬ȂՅӶ౱ࡤҧ‫ޒ‬သ‫ވ‬ொ޲TSH receptor Ab೾ள࣐ജ‫ܓ‬Ȃկԥ‫ٳ‬ொ޲֖౫ెӬߓ౫ȇ೾ள౱ࡤҧ‫ޒ‬သ‫ވ‬ொ޲‫ޠ‬ T4ȈT3Щ‫ཽپ‬αЁȂՅٙᡞ౪ᏱᔯࢦѠпึ౫ါ࿆Њ૮Ы઀‫ޠ‬ொ޲ԥ ҧ‫ޒ‬သလ‫ڸ‬ᚖॲ(bruit)‫࢑ܗ‬ऐಂ੿ᡑᙥпጃຩȂՅܺৣ࿩௮ඣӶါ࿆ Њ૮Ы઀‫ৣܺޠ‬࿩֝Ԟ࢑Ҕள‫ܗ‬ቩђȂկ࢑Ӷ౱ࡤҧ‫ޒ‬သ‫ޠވ‬ҧ‫ޒ‬သ

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ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

ࢴ઀ਣ෉‫ৣܺޠ‬࿩֝Ԟࠔ࢑մ‫ޠ‬ȂկΚૢՅّ‫ٯ‬ϛ࡛ឋӶ঴‫ٱ‬ਣ෉ၽ ңܺৣ࿩௮ඣȂस࢑љ૿෉ၷ฼‫ޠ‬123I‫࢑ܗ‬Tc-99mࠍѠ‫ٻ‬ңӶ঴‫ޠٱ‬ஐ υȂѬ्஡௮ᆁࡤ኶Љϲ‫ޠ‬ҕ‫ٱ‬ᔡяҶత֊ѠȂՅ‫ٻ‬ң131IӶ঴‫ٱ‬ਣ෉ ࠍ࢑๙ᄈ࿲‫ס‬Ȅ ѳȃ౱ࡤҧ‫ޒ‬သ‫ޠވ‬౿՘౦࣐ե? ᇴ݃Ȉ ౱ࡤҧ‫ޒ‬သ‫ޠވ‬౿՘౦௄ 1.1% ‫ ژ‬16.7% ࣲԥНᝧൣ֚ȂΚૢᇰ࣐ึ Ң౦ङ 5% (9)Ȃसஐυொԥ‫ڐ‬уՍᡞռ࣬੾੿ࠍཽቩђ౱ࡤҧ‫ޒ‬သ‫ވ‬ ‫ॴޠ‬ᓏȂЩԄಒΚ࠯ᑦ‫ޠ੿׎‬ஐυ౱ࡤҧ‫ޒ‬သ‫ޠވ‬౿՘౦࢑Κૢஐ υ‫ ޠ‬3 Վ 4 ॼ (10, 11)ȂՅ౱ࡤҧ‫ޒ‬သ‫ވ‬я౫Ӷᄛ‫ވنܓࢴ੿ܓ‬ஐυ‫ޠ‬Щ ‫ ࢑پ‬25% (12)ȃӶकර‫ܓ‬੭ዷஐυ‫ޠ‬Щ‫ ࢑پ‬14% (13)ȃӶႇџ෇ԥါ࿆ Њ૮Ы઀੿ѭஐυ‫ޠ‬Щ‫࢑پ‬44%(14)ȃӶழԥantipituitary‫׫‬ᡞ‫ޠ‬Щ‫࢑پ‬ 27%(15)ȂՅࠊΚफ෇ᑰொ౱ࡤҧ‫ޒ‬သ‫ވ‬౺ᘿ‫ޠ‬ஐυҼԥ 70%‫ޠ‬ᐡཽӶ ؑԪ౱ࡤึҢ౱ࡤҧ‫ޒ‬သ‫(ވ‬16)ȂொԥᐞҐЫҧ‫ޒ‬သ‫ޠވ‬ஐυӶҧ‫ޒ‬သ သᡞґ‫׈‬ӓຉᕼࠊȂϬѠ૗ึҢ౱ࡤҧ‫ޒ‬သ‫(ވ‬17)Ȃԥ਱‫پ‬ൣ֚ࡿяஐ υࢻ౱ࡤҼѠ૗ึҢ౱ࡤҧ‫ޒ‬သ‫ވ‬Ȃկ‫ึڐ‬Ң౦ҭࠊϛ݃(18)Ȅ ѯᢋȈҭࠊۧґԥҐρ౱ࡤҧ‫ޒ‬သ‫ࢻވ‬՘੿Ᏹः‫ف‬Ȅ ϥȃ౱ࡤҧ‫ޒ‬သ‫࣐ޒ઀ޠވ‬ե? ᇴ݃Ȉ ౱ࡤҧ‫ޒ‬သ‫ވ‬ΚૢϛཽആԚ઄ฯȂொ޲τӼ࢑‫ء‬ԥ઀‫࢑ܗޒ‬ԥሇཌྷ‫ޠ‬ ҧ‫ޒ‬သࢴ઀‫ޒ઀ޠ‬Ȃ೼࢑ӱ࣐౱ࡤҧ‫ޒ‬သ‫ވ‬ആԚҧ‫ޒ‬သೊᅮᇍቩђ‫ޠ‬ ൾ࡚೾ளၷሇཌྷȂՅйT4αЁ‫ޠ‬ൾ࡚೾ளཽାܼT3Ȃ࢛‫ٳ‬ः‫ف‬ൣ֚ࡿ яொ޲Ѡ૗я౫ྯបȃܑዦȃઁॿ‫ڸ‬З௛๊઀‫(ޒ‬3, 19-21)ȂՅ೾ளҧ‫ޒ‬သ ѓ૗մίਣ෉ொ޲‫ཽޒ઀ޠ‬Щၷ݃ᡘȂєܑ֥տȃҫጴୂᕎȃઁॿȃ ‫ݨ‬ཏΩϛ໲Ϝ‫ڸ‬དញ౵ள๊(20, 21)Ȃԥः‫ف‬ൣ֚ࡿяழԥTPOAb‫ޠ‬౱ࡤ ҧ‫ޒ‬သ‫ވ‬ொ޲ЩTPOAbജ‫ܓ‬ொ޲‫ޒ઀ޠ‬ၷ࣐݃ᡘ(22)Ȅ ϳȃ౱ࡤҧ‫ޒ‬သ‫֐࢑ވ‬ᇅነ᢯઀ࣻᜱ? ᇴ݃Ȉ ౱ࡤҧ‫ޒ‬သ‫ވ‬ᇅነ᢯઀‫ޠ‬ᜱᖓ‫ܓ‬ः‫ف‬ҭࠊ๗፤ϛΚयȇ෇ԥ‫ڎ‬጖ः‫ف‬ ࡿяነ᢯઀ᇅҧ‫ޒ‬သ‫׫‬ᡞ‫ڏ‬ᜱᖓ‫(ܓ‬22, 23)ȂկҼԥः‫ف‬ᇰ࣐TPOAb໩‫ܓ‬ ᇅ֐‫ڸ‬౱ࡤነ᢯઀ณᜱᖓ‫(ܓ‬24)ȂࣦՎԥࠊᙂ‫ܓ‬ः‫ࡿف‬яȂ౱ࡤTPOAb ໩‫ܓ‬ஐυ௦‫ڨ‬ҧ‫ޒ‬သષ‫ڸ‬ԋኒᏙࣻЩȂณ‫׾ݳ‬ᡑ౱ࡤነ᢯‫ޠ‬Щ‫(پ‬25)Ȅ ࡛ឋȈ‫ܛ‬ԥነ᢯઀ொ޲Ȃє֥౱ࡤነ᢯Ȃഎᔗ၏௦‫ڨ‬ҧ‫ޒ‬သѓ૗ᔯࢦȄ ା࡚࡛ឋȂմᜍᐄ઼๊ ѯᢋȈѯᢋୋߴၦਠ৳(1996-2013)‫ޠ‬ः‫ึف‬౫‫ژ‬ᑰொ౱ࡤነ᢯‫ޠ‬ொ޲Ȃ౱ࡤ ԥၷା‫ޠ‬ᐡཽя౫Սᡞռ࣬੾੿ȂЩԄඍ‫ܓ‬೵՗ȃ᜹ॴྡྷ‫ܓ‬ᜱ࿾‫ڸވ‬ ါ࿆Њ૮Ы઀๊Ȃկः‫ف‬Ϝґଭᄈ౱ࡤҧ‫ޒ‬သ‫ވ‬ᚅఽ‫ڐ‬ᜱᖓ‫(ܓ‬26)Ȅ Νȃ౱ࡤҧ‫ޒ‬သ‫ޠވ‬ҧ‫ޒ‬သࢴ઀໧ࢳᔗ၏्Ԅե‫ݾ‬ᕜ?

౱ࡤҧ‫ޒ‬သ‫ވ‬

80

ᇴ݃Ȉ ҭࠊଭᄈ౱ࡤҧ‫ޒ‬သ‫ݾވ‬ᕜۧґԥ‫׈‬ᐍ‫ࠊޠ‬ᙂ‫ܓ‬ः‫ف‬Ȃ౱ࡤҧ‫ޒ‬သ‫ވ‬ ‫ޠ‬ҧ‫ޒ‬သࢴ઀ਣ෉࣐ኸਣ‫ޠܓ‬ႇโȂ೼࢑ӱ࣐౱ࡤҧ‫ޒ‬သ‫ޠވ‬ҧ‫ޒ‬သ ࢴ઀ਣ෉࢑Κᆎખᚾ‫ޠܓ‬ҧ‫ޒ‬သ‫ܛވ‬ЖକȂՍٙҧ‫ޒ‬သೊᅮᇍ‫ޠ‬ӬԚ ‫ٯ‬ґቩђȂӱԫ‫׫‬ҧ‫ޒ‬သ᛿‫(ޑ‬PTU‫ڸ‬MMI)ณ‫ݾݳ‬ᕜ౱ࡤҧ‫ޒ‬သ‫ވ‬Ж କ‫ޠ‬ҧ‫ޒ‬သࢴ઀Ȃկ઀‫ޒ‬೾ள࢑ሇཌྷ‫ޠ‬Ȃӱԫ೏ဋпጦ၍ᖞ‫࣐ޒ઀ט‬ лȂЩԄѠпՄኍпഷմᏙ໕‫ޠ‬propranolol‫ٿ‬ጦ၍઀‫ޒ‬ȂᖃՅّϟȂ ౱ࡤҧ‫ޒ‬သ‫҇ވ‬໹ᇅུҢ‫ܗ‬ඉึ‫ޠ‬ါ࿆Њ૮Ы઀ձୣրȄ ࡛ឋȈ Ӷ౱ࡤҧ‫ޒ‬သ‫ޠވ‬ҧ‫ޒ‬သࢴ઀໧ࢳȂѠпՄኍпΛ࠯ߣᘟᏙ‫ٿ‬ጦ၍઀ ‫ޒ‬Ȃ೾ளΛ࠯ߣᘟᏙӶ঴‫ٱ‬ஐυ‫ٻޠ‬ң࢑ԋӓ‫ޠ‬ȂԄȈpropranolol‫ܗ‬ metoprololߴࡼ૗ጦ၍઀‫ޠޒ‬ഷմᏙ໕Ȃ೾ள‫ݾ‬ᕜ༊ሰ኶໋‫ޠ‬ਣ໣Ȅ ା࡚࡛ឋȂϜᜍᐄ઼๊ ࡛ឋȈ ‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬ϛ࡛ឋң‫ݾٿ‬ᕜ౱ࡤҧ‫ޒ‬သ‫ވ‬Жକ‫ޠ‬ҧ‫ޒ‬သࢴ઀Ȅ ା࡚࡛ឋȂାᜍᐄ઼๊ Υȃ ΚҎ౱ࡤҧ‫ޒ‬သ‫ޠވ‬ҧ‫ޒ‬သࢴ઀໧ࢳϑጦ၍Ȃ၏ӼεଢᙺΚԪҧ‫ޒ‬သ‫ڗ‬ ᐮષ‫ٿ‬ᑣᔯҧ‫ޒ‬သѓ૗մί໧ࢳ? ࡛ឋȈ ࿌౱ࡤҧ‫ޒ‬သ‫ޠވ‬ҧ‫ޒ‬သࢴ઀໧ࢳጦ၍ࡤȂ࡛ឋ4‫ژ‬8໋‫ޒ઀ޠུ࢑ܗ‬ я౫ਣଢᙺΚԪҧ‫ޒ‬သ‫ڗ‬ᐮષȄା࡚࡛ឋȂାᜍᐄ઼๊ ΟȃԄե‫ݾ‬ᕜ౱ࡤҧ‫ޒ‬သ‫ޠވ‬ҧ‫ޒ‬သѓ૗մί໧ࢳ? ᇴ݃Ȉ ᄈܼԥ݃ᡘ઀‫ޒ‬ȃ঴‫ٱ‬Ϝ‫࢑ܗ‬ҔӶლၑᛅѺ‫ޠ‬ஐυȂӶҧ‫ޒ‬သѓ૗մ ί໧ࢳഎᔗ၏໡ۗ‫ݾ‬ᕜ(3)Ȃѿఌҧ‫ޒ‬သષ(LT4)ѠпңӶҧ‫ޒ‬သѓ૗մ ί໧ࢳӬ‫ڂ‬ሇཌྷ઀‫࢑ܗޒ‬ՄኍᛅѺ‫ޠ‬ஐυȇस‫۾‬ᒷҧ‫ޒ‬သષ‫ݾ‬ᕜȂ҇ ໹ؑ4‫ژ‬8໋‫ܫ‬ขҧ‫ޒ‬သѓ૗‫ژޣ‬ӲඉҔளȂ‫ٯ‬й्ՄኍኸਣᗘѺȄ ࡛ឋȈ ౱ࡤҧ‫ޒ‬သ‫ޠވ‬ҧ‫ޒ‬သѓ૗մί໧ࢳसԥ઀‫ޒ‬Ȃᔗ၏௦‫ڨ‬ѿఌҧ‫ޒ‬သ ષ‫ݾ‬ᕜȂԄ‫ݏ‬ᗚ‫ء‬ԥ໡ۗ‫ݾ‬ᕜȂ҇໹ؑ4‫ژ‬8໋‫ܫ‬ขҧ‫ޒ‬သ‫ڗ‬ᐮષ‫ژޣ‬ ҧ‫ޒ‬သѓ૗࡯ඉҔள࣐ЦȂसҧ‫ޒ‬သѓ૗մί‫ޠ‬ஐυమᛅѺ‫࢑ܗ‬঴ ‫ٱ‬Ȃࠍ҇໹‫׺‬ᇅѿఌҧ‫ޒ‬သષ‫ݾ‬ᕜȄմ࡚࡛ឋȂϜᜍᐄ઼๊ Ϋȃҧ‫ޒ‬သષሰ्‫ٻ‬ңӼε? ᇴ݃Ȉ ѿఌҧ‫ޒ‬သષᔗ၏‫ٻ‬ңӼεҭࠊ‫ءٯ‬ԥ‫׈‬ᐍ‫ޠ‬НᝧᜍᐄȂҭࠊϵᇰ‫ޠ‬ ‫ݾ‬ᕜҭ‫࢑ޠ‬ᆱࡼҧ‫ޒ‬သѓ૗Ҕள‫ޒޠ‬ᄙȂ።७Ꮩ໕‫ޠ‬ਣ໣ᘉѠпӶ౱ ࡤ12ঐУȂпᢏᄇҧ‫ޒ‬သѓ૗մί࢑ኸਣ‫ܓ‬Ҽ‫࢑ܗ‬Ҙε‫ޠܓ‬ȂՅ።७ Ꮩ໕ሰ्ᅛໍԓ‫ޠ‬Ȃйҧ‫ޒ‬သ‫ڗ‬ᐮષؑ6‫ژ‬8໋ᔗ၏‫ܫ‬ขΚԪȄ ࡛ឋȈ ҧ‫ޒ‬သષ҇໹Ӷ‫ٻ‬ң12ঐУࡤლၑ୅ңȂկसொ޲ҔӶლၑᛅѺ‫࢑ܗ‬ ϑစᛅѺȂ൸ϛ࡛ឋ።७ҧ‫ޒ‬သષȄմ࡚࡛ឋȂմᜍᐄ઼๊ ΫΚȃӶ౱ࡤҧ‫ޒ‬သ‫ޠވ‬ҧ‫ޒ‬သѓ૗մί໧ࢳጦ၍ࡤȂҧ‫ޒ‬သѓ૗ᔗ၏Ӽε ଢᙺΚԪ?

81

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

ᇴ݃Ȉ ௄ႇџΝ጖Нᝧூ‫ޤ‬Ȃ౱ࡤҧ‫ޒ‬သ‫ވ‬ᄈܼҧ‫ޒ‬သѓ૗ߞ෉ኈ៫‫ٲ‬ᄃα ࢑ԇӶ‫(ޠ‬4, 16, 27-31)Ȃ೼‫ٳ‬ः‫ف‬ᜍᄃȂᖄ‫ٻ‬10-50%‫ޠ‬ொ޲௄ҧ‫ޒ‬သѓ૗մ ί໧ࢳ๗‫ࡤ؃‬Ȃഷಥᗚ࢑ໍ৥‫ژ‬Ҙε‫ޠܓ‬ҧ‫ޒ‬သѓ૗մίȂՅЖକҘ ε‫ܓ‬ҧ‫ޒ‬သѓ૗մί‫ޠ‬ӱષє֥Ӽ౱ஐȃົॲ‫ݱ‬ҧ‫ޒ‬သ֖մӲॲ‫ޒ‬ȃ ၷᝓ२‫ޠ‬ҧ‫ޒ‬သѓ૗մί෉ȃၷା‫ޠ‬TPOAbȃᛅѺԒឮၷτпІႇџ ෇စᐤႇࢻ౱‫ޠ‬ொ޲Ȅ ࡛ឋȈसӒࠊԥ౱ࡤҧ‫ޒ‬သ‫੿ވ‬ѭ‫ޠ‬ஐυᔗ၏ؑԒ௦‫ڨ‬ҧ‫ޒ‬သ‫ڗ‬ᐮષᔯขȂ пຠզ࢑֐ԥҘε‫ܓ‬ҧ‫ޒ‬သѓ૗մί‫ޠ‬౱ҢȄା࡚࡛ឋȂାᜍᐄ઼๊ ΫΡȃழԥҧ‫ޒ‬သ‫׫‬ᡞկҧ‫ޒ‬သѓ૗Ҕள‫ޠ‬Ѻஐ࢑֐ᔗ၏௦‫ݾڨ‬ᕜ‫ٿ‬Ⴒ٪౱ ࡤҧ‫ޒ‬သ‫?ވ‬ ᇴ݃Ȉ ‫ڎ‬ঐᓎᐡԋኒᏙᄈྲၑᡜ෇ຠզ၅щ࿩‫ܗ‬ѿఌҧ‫ޒ‬သષңܼҧ‫ޒ‬သ‫׫‬ ᡞ໩‫ܓ‬կҧ‫ޒ‬သѓ૗ҔளѺஐ‫ޠ‬ᕜਞȂկഎ‫ء‬ԥᒳ‫ݳ‬७մ౱ࡤҧ‫ޒ‬သ ‫ึޠވ‬Ң౦(32, 33)Ȃ‫ڐ‬ϜΚ጖ः‫ࡿف‬я၅щ≫ѠႲ٪ழԥҧ‫ޒ‬သ‫׫‬ᡞկ ҧ‫ޒ‬သѓ૗Ҕள‫ޠ‬Ѻஐя౫౱ࡤҧ‫ޒ‬သ‫ވ‬ȂҦܼુн‫ڐ‬уᜍᐄМࡼȂ й≫‫ڦឹޠ‬ᇅቩђᑰொಒΡ࠯ᑦ‫ॴޠ੿׎‬ᓏԥᜱᖓ(34)Ȃӱԫҭࠊ‫ءٯ‬ ԥщ٘‫ޠ‬ᜍᐄ࡛ឋӶҧ‫ޒ‬သ‫׫‬ᡞ໩‫ܓ‬կҧ‫ޒ‬သѓ૗Ҕள‫ޠ‬Ѻஐ၅щ≫ ‫ٿ‬Ⴒ٪౱ࡤҧ‫ޒ‬သ‫ވ‬Ȅ ࡛ឋȈҧ‫ޒ‬သ‫׫‬ᡞ໩‫ܓ‬կҧ‫ޒ‬သѓ૗Ҕள‫ޠ‬ѺஐȂ‫ٯ‬ϛ࡛ឋ‫ٻ‬ң≫‫ܗ‬ѿఌҧ ‫ޒ‬သષ‫ٿ‬Ⴒ٪౱ࡤҧ‫ޒ‬သ‫ވ‬Ȃӱ‫࢑ڐ‬ณਞ‫ޠ‬Ȅା࡚࡛ឋȂାᜍᐄ઼๊ ஠ԥӫມϜऽНᄈྲߓ ါ࿆Њ૮Ы઀

Graves’ disease

ҧ‫ޒ‬သࢴ઀

Thyrotoxicosis

ҧ‫ޒ‬သࢴ઀ਣ෉/໧ࢳ

Thyrotoxic phase

ҧ‫ޒ‬သѓ૗մίਣ෉/໧ࢳ

Hypothyroid phase

ҧ‫ޒ‬သѓ૗մί

Hypothyroidism

ׂ৓ॷήঐУ

1st trimester

ᚖॲ

Bruit

ܺৣ࿩֝Ԟ

Radioiodine uptake

୥ ՄНᝧ 1. Amino N, Mori H, Iwatani Y, Tanizawa O, Kawashima M, Tsuge I, et al. High prevalence of transient post-partum thyrotoxicosis and hypothyroidism. N Engl J Med 1982;306(14):849852.

2. Qaseem A, Snow V, Owens DK, Shekelle P. The development of clinical practice guidelines and guidance statements of the American College of Physicians: summary of methods. Ann Intern Med 2010;153(3):194-199.

3. Stagnaro-Green A. Approach to the patient with postpartum thyroiditis. J Clin Endocrinol ౱ࡤҧ‫ޒ‬သ‫ވ‬

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Metab 2012;97(2):334-342.

4. Stagnaro-Green A, Schwartz A, Gismondi R, Tinelli A, Mangieri T, Negro R. High rate of persistent hypothyroidism in a large-scale prospective study of postpartum thyroiditis in southern Italy. J Clin Endocrinol Metab 2011;96(3):652-657.

5. Muller AF, Drexhage HA, Berghout A. Postpartum thyroiditis and autoimmune thyroiditis in women of childbearing age: recent insights and consequences for antenatal and postnatal care.

Endocr Rev 2001;22(5):605-630.

6. Kuijpens JL, De Hann-Meulman M, Vader HL, Pop VJ, Wiersinga WM, Drexhage HA. Cellmediated immunity and postpartum thyroid dysfunction: a possibility for the prediction of disease? J Clin Endocrinol Metab 1998;83(6):1959-1966.

7. Stagnaro-Green A, Roman SH, Cobin RH, el-Harazy E, Wallenstein S, Davies TF. A prospective study of lymphocyte-initiated immunosuppression in normal pregnancy: evidence of a T-cell etiology for postpartum thyroid dysfunction. J Clin Endocrinol Metab 1992;74(3):645-653.

8. Ide A, Amino N, Kang S, Yoshioka W, Kudo T, Nishihara E, et al. Differentiation of postpartum Graves' thyrotoxicosis from postpartum destructive thyrotoxicosis using DQWLWK\URWURSLQ UHFHSWRU DQWLERGLHV DQG WK\URLG EORRG ÀRZ 7K\URLG 9. Nicholson WK, Robinson KA, Smallridge RC, Ladenson PW, Powe NR. Prevalence of postpartum thyroid dysfunction: a quantitative review. Thyroid 2006;16(6):573-582.

10. Gerstein HC. Incidence of postpartum thyroid dysfunction in patients with type I diabetes mellitus. Ann Intern Med 1993;118(6):419-423.

11. Tally M, Eriksson U, Thoren M, Brismar K, Hall K. Immunoreactive proinsulin-like growth IDFWRU ,, OHYHOV LQ KHDOWK\ VXEMHFWV SDWLHQWV ZLWK JURZWK KRUPRQH GH¿FLHQF\ DQG SDWLHQWV ZLWK type 1 diabetes: effects of insulin-like growth factor-I and insulin. J Clin Endocrinol Metab 1994;79(6):1576-1581.

12. Elefsiniotis IS, Vezali E, Pantazis KD, Saroglou G. Post-partum thyroiditis in women with chronic viral hepatitis. J Clin Virol 2008;41(4):318-319.

13. Stagnaro-Green A, Akhter E, Yim C, Davies TF, Magder L, Petri M. Thyroid disease in pregnant women with systemic lupus erythematosus: increased preterm delivery. Lupus 2011;20(7):690-699.

14. Tagami T, Hagiwara H, Kimura T, Usui T, Shimatsu A, Naruse M. The incidence of gestational hyperthyroidism and postpartum thyroiditis in treated patients with Graves' disease. Thyroid 2007;17(8):767-772.

15. Manetti L, Parkes AB, Lupi I, Di Cianni G, Bogazzi F, Albertini S, et al. Serum pituitary antibodies in normal pregnancy and in patients with postpartum thyroiditis: a nested casecontrol study. Eur J Endocrinol 2008;159(6):805-809.

16. Lazarus JH, Ammari F, Oretti R, Parkes AB, Richards CJ, Harris B. Clinical aspects of recurrent postpartum thyroiditis. Br J Gen Pract 1997;47(418):305-308.

17. Caixas A, Albareda M, Garcia-Patterson A, Rodriguez-Espinosa J, de Leiva A, Corcoy R. Postpartum thyroiditis in women with hypothyroidism antedating pregnancy? J Clin Endocrinol Metab 1999;84(11):4000-4005.

18. Marqusee E, Hill JA, Mandel SJ. Thyroiditis after pregnancy loss. J Clin Endocrinol Metab 1997;82(8):2455-2457.

19. Walfish PG, Meyerson J, Provias JP, Vargas MT, Papsin FR. Prevalence and characteristics

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ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

20.

21.

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23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

of post-partum thyroid dysfunction: results of a survey from Toronto, Canada. J Endocrinol Invest 1992;15(4):265-272.

Hayslip CC, Fein HG, O'Donnell VM, Friedman DS, Klein TA, Smallridge RC. The value of serum antimicrosomal antibody testing in screening for symptomatic postpartum thyroid dysfunction. Am J Obstet Gynecol 1988;159(1):203-209.

Lazarus JH. Clinical manifestations of postpartum thyroid disease. Thyroid 1999;9(7):685689.

Kuijpens JL, Vader HL, Drexhage HA, Wiersinga WM, van Son MJ, Pop VJ. Thyroid peroxidase antibodies during gestation are a marker for subsequent depression postpartum.

Eur J Endocrinol 2001;145(5):579-584.

Harris B, Othman S, Davies JA, Weppner GJ, Richards CJ, Newcombe RG, et al. Association between postpartum thyroid dysfunction and thyroid antibodies and depression. Bmj 1992;305(6846):152-156.

Pop VJ, de Rooy HA, Vader HL, van der Heide D, van Son MM, Komproe IH. Microsomal antibodies during gestation in relation to postpartum thyroid dysfunction and depression. Acta Endocrinol (Copenh) 1993;129(1):26-30.

Harris B, Oretti R, Lazarus J, Parkes A, John R, Richards C, et al. Randomised trial of thyroxine to prevent postnatal depression in thyroid-antibody-positive women. Br J Psychiatry 2002;180:327-330.

Lin CY, Li CK, Liu JM, Hsu RJ, Chuang HC, Chang FW. Postpartum Depression and Subsequent Autoimmune Diseases in Taiwan. Int J Environ Res Public Health 2018;15(8).

Fung HY, Kologlu M, Collison K, John R, Richards CJ, Hall R, et al. Postpartum thyroid dysfunction in Mid Glamorgan. Br Med J (Clin Res Ed) 1988;296(6617):241-244.

Vargas MT, Briones-Urbina R, Gladman D, Papsin FR, Walfish PG. Antithyroid microsomal autoantibodies and HLA-DR5 are associated with postpartum thyroid dysfunction: evidence supporting an autoimmune pathogenesis. J Clin Endocrinol Metab 1988;67(2):327-333.

Rasmussen NG, Hornnes PJ, Hoier-Madsen M, Feldt-Rasmussen U, Hegedus L. Thyroid size and function in healthy pregnant women with thyroid autoantibodies. Relation to development of postpartum thyroiditis. Acta Endocrinol (Copenh) 1990;123(4):395-401.

Azizi F. The occurrence of permanent thyroid failure in patients with subclinical postpartum thyroiditis. Eur J Endocrinol 2005;153(3):367-371.

Nohr SB, Jorgensen A, Pedersen KM, Laurberg P. Postpartum thyroid dysfunction in pregnant thyroid peroxidase antibody-positive women living in an area with mild to moderate iodine GH¿FLHQF\ LV LRGLQH VXSSOHPHQWDWLRQ VDIH" - &OLQ (QGRFULQRO 0HWDE Negro R, Greco G, Mangieri T, Pezzarossa A, Dazzi D, Hassan H. The influence of selenium supplementation on postpartum thyroid status in pregnant women with thyroid peroxidase autoantibodies. J Clin Endocrinol Metab 2007;92(4):1263-1268.

Kampe O, Jansson R, Karlsson FA. Effects of L-thyroxine and iodide on the development of autoimmune postpartum thyroiditis. J Clin Endocrinol Metab 1990;70(4):1014-1018.

Stranges S, Marshall JR, Natarajan R, Donahue RP, Trevisan M, Combs GF, et al. Effects of long-term selenium supplementation on the incidence of type 2 diabetes: a randomized trial.

Ann Intern Med 2007;147(4):217-223.

౱ࡤҧ‫ޒ‬သ‫ވ‬

84

Ᏻ᠟ ᇄτᚃଲུചхᗃऌ е‫ݾ‬ϰ୚ఁ௳

ߗԒ‫ٿ‬Ȃϲϸ‫ུݫ‬ചхᗃስ஀ϜȂԥᜱׂܼ৓ࣻᜱ‫ޠ‬ ୱᚡȂԚ࣐୾ϲଇ፤‫ޠ‬२ᘉȄӶᑦ‫ޠ੿׎‬ഌϸȂׂ৓‫ܓ‬ᑦ ‫ܗ੿׎‬ᑦ‫੿׎‬ஐυᛅѺȂϑԥߒؐ‫׈‬ᐍ‫ݾޠ‬ᕜ࡛ឋȄҐԪ ᏱཽໍΚؐଇ፤‫ژ‬Ң౱ࡤȂҧ‫ޒ‬သ੾੿‫ޠ‬ᡑϾȄ౱ࡤҧ‫ޒ‬ သ‫ވ‬Ȃ࢑စளя౫ӶᛅѺҢ౱ࡤȂஐυ‫ޠ‬ҧ‫ޒ‬သ੾੿Ȃη စளೞ‫܈‬౲ȄҖ୾90ԒߤߗȂѯᢋߩҔԓࣻᜱࢻ՘੿Ᏹ‫ޠ‬ ൣ֚ᡘұȂӶॶᢅђ࿩सϔԒϟࡤȂՍᡞռ࣬ҧ‫ޒ‬သ੾੿ ௄4%ቩђ‫ژ‬15%‫ژ‬20%Ȃ‫ڐ‬ϜஐυխτӼ኶‫੿ޠ‬ொȂՅҢ ౱ࡤ‫ޠ‬ҧ‫ޒ‬သึ‫ވ‬Ȃ‫؂‬ሰ्ᇅՍᡞռ࣬ҧ‫ޒ‬သᐡ૗Ϧໍ‫ܗ‬ ѓ૗մίȂໍ՘ᠧրຩᘟȂҐത࿾‫ٸ‬ᐄ୾ѵІ୾ϲः‫ޠف‬ ࣻᜱൣ֚Ȃ၍ម౱ࡤҧ‫ޒ‬သ‫ވ‬І‫ڐ‬ᖞ‫ט‬ཏဏȂпІ‫ڐ‬ᖞ‫ט‬ ཏဏ/੿ӱȂηᄈ౿՘౦ȃ઀‫ޒ‬ȃ ᖞ‫ט‬ᢏᄇ೏ဋȂпІଢ ᙺዂԓԥၐᅿ‫ޠ‬ᇴ݃Ȅ‫ٸ‬ᐄҐത࿾‫࡛ޠ‬ឋȂໍ՘ࣻᜱ੿ொ ‫ޠ‬ଢ㢿І‫ݾ‬ᕜȂ࢑ஐυ౱ࡤୋஷ‫ޠ‬२्ྦࠍȄ

85

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

ׂ৓ࠊ‫ׂܗ‬৓෉໣ҧ‫ޒ‬သѓ૗‫ޠ‬ᑣᔯ ᄕϾஆ࿝ఁᚃଲ е๳቉ Ԅ‫ݏ‬Κঐ੾੿౿՘౦୒ାȂཽᄈୋஷആԚӡড়Ȃկ࢑Ѡпೞ‫ݾ‬ᕜȂй ‫ݾ‬ᕜР‫ݳ‬ಓӬစᔽਞᔗȂࠍԥӓ८ᑣᔯԫ੾੿‫ܓ्҇ޠ‬Ȅҧ‫ޒ‬သ੾੿࢑ளُ ‫ޠ‬ୱᚡȂӶ‫ي‬ឮஐυ౿՘౦ϸր࣐:ҧ‫ޒ‬သѓ૗մί2~3%ȃҧ‫ޒ‬သѓ૗Ϧໍ 0.1~0.4%ȃՍᡞռ࣬ҧ‫ޒ‬သ੾੿17%(1)Ȅ

‫ي‬ឮஐυ࢑֐ᔗӓ८ᑣᔯҧ‫ޒ‬သѓ૗Ϭԥ‫ލ‬ឋȂґ‫ݾ‬ᕜ‫݃ޠ‬ᡘҧ‫ޒ‬သѓ ૗մί‫ܗ‬ϦໍཽᄈҕᡞІफ‫ڌ‬ആԚϛًኈ៫ȄӶҔளׂ৓ԟ෉Ȃ՗Ϝҧ‫ޒ‬သ ‫ڗ‬ᐮષ(TSH)ᐩཽ࡚մܼѺࠊȂ֊‫ٻ‬TSHဤӶׂ৓Ҕளጓ൝ϲ(0.008-0.668 mU/ LȂ਴ᐄϛӤׂ৓໋኶)ഷմ‫ޠ‬Լϸϟ2.5пίȂѬ्෭ᚕѳ࿩ҧ‫ޒ‬သષ(FT4)ߴ

ࡼӶҔளጓ൝Ȃࠍᇅ౱ऌ‫ޠ‬ϛًࡤ‫ݏ‬ณࣻᜱᖓ(2)Ȅׂ৓෉‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗ մί( TSHሇཌྷαЁȂFT4Ҕள)Щ݃ᡘҧ‫ޒ‬သѓ૗մί‫؂‬ளُȂ‫ܛ‬пӓ८ᑣᔯ ҧ‫ޒ‬သѓ૗ഷᡘ຀‫ޠ‬ኈ៫ཽ࢑ᔯขяӼ኶‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մί‫ޠ‬ѺஐȄτ Ӽ኶‫ޠ‬ः‫ف‬ᡘұTSH αЁโ࡚ᇅׂ৓ॴᓏԚҔࣻᜱȂՅҧ‫ޒ‬သՍᡞ‫׫‬ᡞԇӶ ᇅ֐ηཽኈ៫ԫࣻᜱ(3)Ȅ Κȃ ຩᘟІ၅щҧ‫ޒ‬သષ๞‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մί‫ܗ‬Սᡞռ࣬ҧ‫ޒ‬သ੾੿ஐ υ࢑֐ཽ७մׂ৓‫઀ึڂ‬Іࢻ౱ᐡཽ? ᇴ݃Ȉ ࡟ӼӲ྘‫ܓ‬ः‫ف‬ᡘұ‫ݾ‬ᕜׂ৓ஐυሇཌྷ‫ޠ‬TSHαЁȂᇅ७մࢻ౱ॴᓏ ֖ҔࣻᜱȂ‫پ‬ԄΚঐӶЩւਣ‫ܛ‬୉ः‫ف‬ȂTSH >1mU/LйTPO-Ab (ҧ ‫ޒ‬သષႇੋϾ㢵‫׫‬ᡞ) ໩‫ܓ‬ஐυ๞ϡҧ‫ޒ‬သષ‫ݾ‬ᕜȂѠ෶Ўࢻ౱ᐡཽ ௄16% Վ0%(4)Ȅ Negro๊΢‫ܛ‬୉‫ޠ‬ΚঐᓎᐡᄈྲၑᡜϜึ౫FT4ҔளȂTSH <4.2mU/L йTPO-Ab໩‫ܓ‬ஐυ‫ٻ‬ңҧ‫ޒ‬သષ‫ݾ‬ᕜЩ‫ء‬௦‫ݾڨ‬ᕜ޲ၷЎԟ౱ᇅԬ फᐡཽ(5)ȄߗԒӶϜ୾‫ܛ‬୉‫ࠊޠ‬ᙂ‫ܓ‬ः‫ึف‬౫ȂӶׂ৓ԟ෉ӓ८ᑣᔯ ᛅѺஐυȂ‫ٯ‬ଭᄈTSHτܼ2.5 mU/Lпα๞ϡҧ‫ޒ‬သષ‫ݾ‬ᕜѠ७մࢻ ౱ᐡཽІѽᔊ઀(6)ȄѫΚঐNegro๊΢‫ܛ‬୉‫ࠊޠ‬ᙂ‫ܓ‬ः‫ف‬ȂΚಣ࣐ӓ८ ᑣᔯஐυȂѫΚಣѬᔯขାॴᓏஐυȂTSHτܼ2.5 mU/LпαйTPOAb໩‫ܓ‬๞ϡҧ‫ޒ‬သષ‫ݾ‬ᕜȂ๗‫ึݏ‬౫‫ڎ‬ಣׂ৓‫ٯ઀ึڂ‬ณৰ౵(7)Ȅഷ ߗึߓ‫ޠ‬ज୾୾ঢ়ः‫ึف‬౫Ȃ‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մίѺஐ௦‫ڨ‬ҧ‫ޒ‬သ ષ‫ݾ‬ᕜԥၷմ‫ࢻޠ‬౱ᐡཽȂดՅ्‫ݨ‬ཏ‫࢑ޠ‬௦‫ڨ‬ҧ‫ޒ‬သષ‫ݾ‬ᕜԥၷା ԟ౱ȃׂ৓ᑦ‫੿׎‬Іׂ৓ࢴ՗઀ᐡ౦(8)Ȅ

ׂ৓ࠊ‫ׂܗ‬৓෉໣ҧ‫ޒ‬သѓ૗‫ޠ‬ᑣᔯ

86

Ρȃ ຩᘟІ၅щҧ‫ޒ‬သષ๞‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մίஐυ࢑֐ཽ‫׾‬๢ϊࡇ‫ޠ‬ઢ စᇰ‫?ޤ‬ ᇴ݃Ȉ ҭࠊः‫ف‬๗‫ۧݏ‬ґΚयȄΚঐτ࠯Ӳ྘‫پ੿ܓ‬ᄈྲः‫ف‬ᔯขΠ 25,216 ঐ҂ְׂ৓໋኶࣐17໋‫ޠ‬ஐυ՗ϜTSHȂ‫ٯ‬йଢᙺ‫ڐ‬ϊࡇՎ8ྒȂः ‫ึف‬౫ґ௦‫ݾڨ‬ᕜ‫ٴޠ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մίׂ৓ஐυ‫ڐ‬ϊࡇ‫ޠ‬හΩϸ ኶Щၷմ(9)Ȅ ѫΚঐτ࠯ᓎᐡϸପ‫ࠊޠ‬ᙂ‫ܓ‬ः‫( ف‬CATS study) ଢᙺΠ 22,000ׂ৓໋኶ϊܼ16໋‫ޠ‬ஐυȂၑᡜಣԄ‫ݏ‬TSH ᐩ࡚ϸҁӶԼϸϟ 97.5th пαȂ‫࢑ܗ‬FT4ϊܼԼϸϟ2.5th Ȃࠍ๞ϡҧ‫ޒ‬သષ‫ݾ‬ᕜȄᄈྲಣ ࠍϛᡲः‫ޤ޲ف‬ၿ TSH ᐩ࡚Ȃϛ๞ϡ‫ݾ‬ᕜȄഷࡤЩၷ‫ڎ‬ಣ‫ޠ‬ϊࡇ‫ڐ‬ ήྒਣ‫ޠ‬හΩߓ౫Ȃึ౫‫ء‬ԥಜॏᏱα‫ޠ‬ৰ౵(10)ȄѫΚঐः‫ف‬ᢏᄇΠ 667՞ׂ৓໋኶ϊܼ20໋Ȃ‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մί (TSHɸ4.0 mU/LȂ ҔளFT4)І526՞մҧ‫ޒ‬သષ՗઀(hypothyroxinemiaۢဏ࣐ TSH ᐩ࡚Ҕ ளȂկ FT4< 0.86 ng/dL)‫ޠ‬ஐυȂᓎᐡϸପ๞ϡҧ‫ޒ‬သષ၅щ‫ݾ‬ᕜȂഷ ࡤЩၷϊࡇϥྒਣ‫ޠ‬හΩߓ౫Ȃ๗‫ึݏ‬౫ϛ፤࢑‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մ ί‫࢑ܗ‬մҧ‫ޒ‬သષ՗઀޲၅щҧ‫ޒ‬သષᇅ֐‫ء‬ԥಜॏᏱα‫ޠ‬ৰ౵(11)Ȅ ήȃ࢑֐ᔗᄈׂ৓ࠊ‫ׂܗ‬৓෉໣ஐυӓ८ᑣᔯҧ‫ޒ‬သѓ૗? ᇴ݃Ȉ ҕᡞ‫ޠ‬TSHᐩ࡚αЁᇅࢻ౱౦ቩђࣻᜱȂЏ‫࢑ڐ‬࿌TPO-Ab֖౫໩‫ܓ‬ ਣȂՅҧ‫ޒ‬သѓ૗౵ளӶѺஐ࢑࡟඾ႈ‫ޠ‬ȂѠпᙐ൑ӵစҦ‫ܫ‬՗ᔯข я‫ٿ‬ȂดՅҧ‫ޒ‬သષ‫ݾ‬ᕜ‫ޠ‬ਞ‫ۧݏ‬ґۢ፤Ȅӱࢻ౱౦ᇅᔊ‫ڌ‬ઢစᇰ‫ޤ‬ ึ৥എӶׂ৓ߒ෉ȂഷԂ૗ӶᛅѺ 4-7 ໋ਣᑣᔯҧ‫ޒ‬သѓ૗Ȃп෉૗ ԟΚ‫ٻٳ‬ңҧ‫ޒ‬သષ‫ݾ‬ᕜȂկ೼Ӷҭࠊ‫ޠ‬ᖞ‫ט‬ᄃଡ଼αԥ‫ᜳ֩ܛ‬ȂӼ኶ ‫ޠ‬ஐυഎ࢑Ӷ 10-15 ໋Ϙ௦‫ڨ‬ಒΚԪ౱ᔯȄӱԫҭࠊ‫ء‬ԥ٘஋ᜍᐄ࡛ ឋӓ८ᑣᔯҧ‫ޒ‬သѓ૗ȂଷΠॏฬ΢ϏҢ෦‫࢑ܗ‬ϑ‫ޤ‬TPO-Ab໩‫ޠܓ‬ ஐυȄԫѵη࡛ឋ‫ܛ‬ԥॏฬᛅѺ‫࢑ܗ‬থຩᘟяᛅѺஐυᔗ௦‫ڨ‬ᖞ‫ט‬ຠ զȂԄԥҧ‫ޒ‬သѓ૗౵ளӡᓏӱφȂᔗᔯขTSHȄ ࡛ឋȈ ‫ء‬ԥ٘஋ᜍᐄ࡛ឋ‫ܗ‬Їᄈׂ৓ߒ෉ӓ८ᑣᔯҧ‫ޒ‬သ‫ڗ‬ᐮષ(TSH) Ȅ ณ࡛ឋȂᜍᐄϛ٘ (ѯᢋȈҭࠊґ‫ࣻژ׳‬ᜱၦਠ) ࡛ឋȈ ‫ء‬ԥ٘஋ᜍᐄ࡛ឋ‫ܗ‬Їᄈׂ৓ࠊӓ८ᑣᔯҧ‫ޒ‬သ‫ڗ‬ᐮષ (TSH)ȂଷΠ Ⴒॏ΢ϏҢ෦‫࢑ܗ‬ϑ‫ޤ‬TPO-Ab໩‫ޠܓ‬ஐυȄณ࡛ឋȂᜍᐄϛ٘ (ѯᢋȈҭࠊґ‫ࣻژ׳‬ᜱၦਠȂԥ‫ٳ‬΢ϏҢ෦ϜЗཽ࡛ឋѺஐՍຳᔯข TSHȄ) ࡛ឋȈ ϛ࡛ឋׂ৓ஐυӓ८ᑣᔯ෭ᚕѳ࿩ҧ‫ޒ‬သષ(FT4)Ȅ մ࡚࡛ឋȂϜᜍᐄ઼๊ (ѯᢋȈҭࠊґ‫ࣻژ׳‬ᜱၦਠ) ࡛ឋȈԥҧ‫ޒ‬သѓ૗౵ள੿ѭІпࠊ‫ܗ‬ҭࠊ݉ңҧ‫ޒ‬သષ‫׫ܗ‬ҧ‫ޒ‬သᇨᏙ‫ޠ‬ ׂ৓ஐυӶߒԪ౱ࠊᔯࢦᔗ၏ᔯขҧ‫ޒ‬သѓ૗Ȅ ା࡚࡛ឋȂାᜍᐄ઼๊ 87

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

࡛ឋȈ ‫ܛ‬ԥॏฬׂ৓‫ܗ‬থׂ৓‫ޠ‬ஐυᔗ၏௦‫ڨ‬ᖞ‫ט‬ຠզȄԄ‫ݏ‬ԥпίӡᓏӱ φȂ࡛ឋᔯข TSHȈ 1. ԥҧ‫ޒ‬သѓ૗մί‫ܗ‬ҧ‫ޒ‬သѓ૗Ϧໍ੿ѭȂ‫ܗ‬ҭࠊԥҧ‫ޒ‬သѓ૗౵ ள‫ޒ઀ޠ‬Ȅ 2. ϑ‫ޤ‬ҧ‫ޒ‬သ‫׫‬ᡞ໩‫ܗܓ‬ԥҧ‫ޒ‬သလ 3. ԥᓜഌ‫ܗ‬ᓟഌᒮৣጤኹ៪ѭ‫ܗ‬пࠊԥҧ‫ޒ‬သК೛ѭ 4. Ԓឮົႇ30ྒ(12) 5. ಒΚ࠯ᑦ‫(੿׎‬13)‫ڐ࢑ܗ‬уՍᡞռ࣬੾੿(14) 6. ෇စࢻ౱ȃԟ౱ȃ‫ܗ‬ϛѺ޲(15) 7. ԥႇ‫ڎ‬Ԫ‫ܗ‬пαҢ‫ي‬စᐤ‫ޠ‬စ౱ஐ(16) 8. ԥՍᡞռ࣬ҧ‫ޒ‬သ੾੿‫ܗ‬ҧ‫ޒ‬သѓ૗౵ளঢ়ఋѭ 9. २࡚޴ण( BMIɸ40 kg/m2) (17) 10. ҔӶ݉ңamiodarone (18)Ȃlithium ‫ܗ‬ഷߗ෇௦‫֥ڨ‬࿩ᡘኈᏙᔯࢦ(19) 11. ۩՟ӶϜ२࡚࿩ુнӵୣ‫ޠ‬ஐυ(20)

пαࣲ࣐ା࡚࡛ឋȂϜᜍᐄ઼๊ შΚ ׂ৓෉ҧ‫ޒ‬သѓ૗ᔯข

ׂ৓ࠊ‫ׂܗ‬৓෉໣ҧ‫ޒ‬သѓ૗‫ޠ‬ᑣᔯ

88

஠ԥӫມϜऽНᄈྲߓ ҧ‫ޒ‬သ‫ڗ‬ᐮષ (ߵҧ‫ޒ‬သષȃҧߵષ)

TSH

ҧ‫ޒ‬သႇੋϾ㢵‫׫‬ᡞ

TPO-Ab

෭ᚕѳ࿩ҧ‫ޒ‬သષ

FT4

մҧ‫ޒ‬သષ՗઀

hypothyroxinemia

୥ Մ Нᝧ 1. Ashoor G, Maiz N, Rotas M, Jawdat F, Nicolaides KH. Maternal thyroid function at 11 to 13 weeks of gestation and subsequent fetal death. Thyroid 2010; 20:989–993.

2. Casey BM, Dashe JS, Wells CE, McIntire DD, Leveno KJ,Cunningham FG. Subclinical hyperthyroidism and pregnancy outcomes. Obstet Gynecol 2006; 107:337–341.

3. Liu H, Shan Z, Li C, Mao J, Xie X, Wang W, Fan C,Wang H, Zhang H, Han C, Wang X, Liu X, Fan Y, Bao S,Teng W. Maternal subclinical hypothyroidism, thyroid autoimmunity, and the risk of miscarriage: a prospective cohort study. Thyroid 2004; 24:1642–1649.

4. Lepoutre T, Debie`ve F, Gruson D, Daumerie C . Reduction of miscarriages through universal screening and treatment of thyroid autoimmune diseases. Gynecol Obstet Invest 2012; 74:265–273.

5. Negro R, Formoso G, Mangieri T, Pezzarossa A, Dazzi D,Hassan H. Levothyroxine treatment in euthyroid pregnant women with autoimmune thyroid disease: effects on obstetrical complications. J Clin Endocrinol Metab 2006; 91:2587–2591.

6. Ma L, Qi H, Chai X, Jiang F, Mao S, Liu J, Zhang S, Lian X, Sun X, Wang D, Ren, Yan Q . The effects of screening and intervention of subclinical hypothyroidism on pregnancy outcomes: a prospective multicenter single blind, randomized, controlled study of thyroid function screening test during pregnancy. J Matern Fetal Neonatal Med 2016; 29:1391–1394.

7. Negro R, Schwartz A, Gismondi R, Tinelli A, Mangieri T, Stagnaro-Green. A Universal screening versus case finding for detection and treatment of thyroid hormonal dysfunction during pregnancy. J Clin Endocrinol Metab 2010; 95:1699–1707.

8. Maraka S, Mwangi R, McCoy RG, Yao X, Shagaralinghan LR, Singh Ospina NM, De Ycaza AE, Rodriguez-Gutierres R, C, Coddington CCIII, Stan MN, Brito JP, Montori VM. Thyroid hormone treatment among pregnant women with subclinical hypothyroidism: US national assessment. BMJ 2017; 356:i6865.

9. Haddow JE, Palomaki GE, Allan WC, Williams JR, Knight GJ, Gagnon J, OɅHeir CE, 0LWFKHOO 0/ +HUPRV5- :DLVEUHQ 6( )DL[ -' .OHLQ 5= 0DWHUQDO WK\URLG GH¿FLHQF\ GXULQJ pregnancy and subsequent neuropsychological development of the child. N Engl J Med 1999; 341:549–555.

10. Lazarus JH, Bestwick JP, Channon S, Paradice R, Maina A, Rees R, Chiusano E, John R, Guaraldo V, George LM, Perona M, DallɅAmico D, Parkes AB, Joomun M, Wald NJ. Antenatal thyroid screening and childhood cognitive function. N Engl J Med 2012; 366:493– 501.

11. Casey Brian M, Thom Elizabeth A, Peaceman Alan M, Varner Michael W, Sorokin Yoram.

Treatment of Subclinical Hypothyroidism or Hypothyroxinemia in Pregnancy. N Engl J Med

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2017; 376: 815-825.

12. Hollowell JG, Staehling NW, Flanders WD, Hannon WH, Gunter EW, Spencer CA, Braverman LE. Serum TSH, T(4), and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III). J Clin Endocrinol Metab 2002; 87:489–499.

13. Jovanovic-Peterson L, Peterson CM. De novo clinical hypothyroidism in pregnancies complicated by type I diabetes, subclinical hypothyroidism, and proteinuria: a new syndrome.

Am J Obstet Gynecol 1988; 159:442–446.

14. Ladenson PW. Diagnosis of hypothyroidism. In: Braverman LE, Utiger RD (eds) Werner & IngbarɅ s The Thyroid: A Fundamental and Clinical Text. Ninth edition. Lippincott, Williams & Wilkins, Philadelphia, PA 2005; pp 857–863.

15. Krassas GE, Poppe K, Glinoer D, Thyroid function and human reproductive health. Endocr Rev 2010; 31:702–755.

16. Carle A, Pedersen IB, Knudsen N, Perrild H, Ovesen L, Rasmussen LB, Laurberg P. Development of autoimmune overt hypothyroidism is highly associated with live births and induced abortions but only in premenopausal women. J Clin Endocrinol Metab 2014; 99:2241–2249.

17. Michalaki MA, Vagenakis AG, Leonardou AS, Argentou MN, Habeos IG, Makri MG, Psyrogiannis AI, Kalfarentzos FE, Kyriazopoulou VE. Thyroid function in humans with morbid obesity. Thyroid 2006; 16:73–78.

18. Eskes SA, Wiersinga WM. Amiodarone and thyroid. Best Pract Res Clin Endocrinol Metab 2009; 23:735–751.

9DJHQDNLV $* %UDYHUPDQ /( $GYHUVH H൵HFWV RI LRGLGHV RQ WK\URLG IXQFWLRQ 0HG &OLQ 1RUWK Am 1975; 59:1075–1088.

20. Zimmermann MB, Boelaert K. Iodine deficiency and thyroid disorders. Lancet Diabetes Endocrinol 2015; 3:286–295.

ׂ৓ࠊ‫ׂܗ‬৓෉໣ҧ‫ޒ‬သѓ૗‫ޠ‬ᑣᔯ

90

Ᏻ᠟ ା໱ߞ۹ख‫܉‬ᚃଲུചхᗃऌ е‫ڄ‬Нఁ௳

ᛅѺஐυҧ‫ޒ‬သѓ૗մί౿՘౦࣐ 2~3% ȃҧ‫ޒ‬သѓ ૗Ϧໍ࣐ 0.1~0.4%ȃՍᡞռ࣬ҧ‫ޒ‬သ੾੿ 17%(1)Ȅ TPO ‫׫‬ᡞ໩‫ޠܓ‬ఋထϜȃᛅѺϜึҢҧ‫ޒ‬သѓ૗մί޲ङ 20%ȃ౱ࡤҧ‫ޒ‬သ‫޲ވ‬ङ30-50%Ȅӱ࣐ҧ‫ޒ‬သѓ૗я౫౵

ளᐡ౦‫ٯ‬ϛմȂཽᄈᛅѺആԚӡড়ȂՅйѠп‫ݾ‬ᕜȂй‫ݾ‬ ᕜР‫ݳ‬ಓӬစᔽਞᔗȂ‫ܛ‬пԥ࡛ҴᑣᔯࡿЖ‫ܓ्҇ޠ‬Ȅկ ࢑‫ي‬ឮஐυ࢑֐ᔗӓ८ᑣᔯҧ‫ޒ‬သѓ૗Ϭԥ‫ލ‬ឋȂԫΞҦ ܼᑣᔯ‫ޠ‬ਣ໣҇໹஋ԟȃՅй‫ݾ‬ᕜਞ‫ޠݏ‬ຢᐄԥ‫ލ‬ឋȂЏ ‫࢑ڐ‬ᛅѺஐυ‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մίϟ‫ݾ‬ᕜȃᗷดԥӲ྘ ‫ܓ‬ः‫࡛ف‬ឋҧ‫ޒ‬သષ‫ݾ‬ᕜԥԂ೏ȂՎϭϬХુࠊᙂ‫ܓ‬ᚗ‫ޢ‬ ϸ‫ޠݚ‬МࡼȄ ‫ٸ‬౫ԥ‫ޠ‬ၦਠҐᏱཽ਴ᐄ2017Ԓज୾ҧ‫ޒ‬သᏱཽᄈᛅ ѺІ౱ࡤஐυ‫ܛ‬ණࡿЖձԚпα࡛ឋȄଭᄈାӡᓏထѺஐ (ၐُୱᚡή)ΚҎຢᄃᛅѺȂ଼αᑣᔯTSHІTPO‫׫‬ᡞȄ

ӕ‫ٸ‬ᐄ‫ݸޒڐ‬ଢᙺ‫ۢ؛‬եਣ‫ݾ‬ᕜ(ၐُშΚ)Ȅ

91

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

ᇄᢋӵୣӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀‫ུޠ‬Ң‫ڌ‬ᑣᔯ ᇄτ‫่ڌ‬ᚃଲ ጿНЅ ӱ࣐ӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀੿΢‫ޠ‬ԟ෉઀‫ޒ‬ϛ‫ڏ‬੬౵‫ܓ‬Ȃ‫ܛ‬пᖞ‫ט‬α࡟ ᜳԟ෉ຩᘟ(1)ȄՅ΢᜹ӶήྒпࠊȂЏ‫࢑ڐ‬яҢࡤήঐУϲȂҔள‫ޠ‬ҧ‫ޒ‬သ ѓ૗࢑ဟഌҔளึ‫ܛي‬ϛѠ‫(ޠુܗ‬2)Ȃ‫ܛ‬пȂп‫܂‬ӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀੿΢ Ӷጃຩпࡤ֊‫ٻ‬ђп‫ݾ‬ᕜτӼณѠᗘռӵԚ࣐හ૗ሬᛥ‫( ڌ‬3, 4)Ȅ۸ԂҦܼᔯ ᡜᚃᏱ‫ؐໍޠ‬Ȃܼ1970Ԓхजђӵୣ౦Ӓ௱՘ӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀‫ུޠ‬Ң‫ڌ‬ ᑣᔯȂ‫ٻ‬೼‫੿ٳ‬΢ѠпІԟ௦‫ݾڨ‬ᕜпᗘռහ૗ሬᛥ‫ึޠ‬Ң (5, 6)Ȅѯᢋӵୣ ҼՍ1984Ԓକӓ८௱՘ӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀‫ུޠ‬Ң‫ڌ‬ᑣᔯȈུܼҢ‫ڌ‬௄ᔊ‫ڌ‬ ࡊяଲࠊ௵‫ڦ‬ရၮ՗ձԚ՗бଛ‫ژ‬ᑣᔯϜЗขۢ‫ڐ‬ҧߵષঅȄ࿌՗бҧߵ ષঅົႇ‫๋؛‬অ(cut-off point)ਣȂ֊ց࣐ۢᅹ໩‫ܓ‬ঐ਱Ȅକߒԫ‫๋؛‬অङॐ Ӷ12 μIU/mLȂӶ‫ޠࡤ܂‬Сφ㠆ᓎ຀စᡜ‫ޠ‬ತᑗ஡ԫ‫๋؛‬অձᎍ࿌ӵ።ᐍȂ ߗΫӼԒ‫ٿ‬ԫ‫๋؛‬অᆱࡼӶ9-10 μIU/mLȄ਴ᐄп‫܂‬ᇄτུҢ‫ڌ‬ᑣᔯϜЗ‫ޠ‬ စᡜȂҧߵષᑣᔯঅົႇ40 μIU/mL޲ङԥΚљ‫ޠ‬ঐ਱ࡤ‫ٿ‬ᜍᄃ࣐ӒЉ‫ܓ‬ҧ ‫ޒ‬သմ૗઀ொ޲Ȃ‫ܛ‬пᑣᔯϜЗཽҴ֊೾‫ޤ‬ঢ়឵ழϊ݊ЅՎጃຩϜЗጃຩȇ सҧߵષᑣᔯঅϮܼ9ᇅ40 μIU/mLϟ໣޲ࠍ೾‫ޤ‬঩ᑣᔯ൑՞ӕ௵ΚԪ՗бȂ सಒΡԪҧߵષᑣᔯঅϬାܼ‫๋؛‬অࠍ࡛ឋ‫ڐ‬ՎጃຩϜЗጃຩпռ‫۾‬ᇳ‫ڐ‬ ‫ݾ‬ᕜȄ‫ٲ‬ᄃαȂ೩Ӽӱષཽኈ៫ུҢ‫ޠڌ‬ҧ‫ޒ‬သѓ૗ȂԄȈҕᒒԥᐞҐЫҧ ‫ޒ‬သ‫(ވ‬Hashimoto thyroiditis)Ȃ‫׫ڐ‬ҧ‫ޒ‬သ‫׫‬ᡞ(ԄȈanti-TPO antibody, antithyroglobulin antibody, TBII๊)឵ܼռ࣬౩೗ҪG(IgG)᜹ཽ೾ႇफዻՅኈ៫फ ‫ڌ‬Ȃҕᒒ࿩ુнȂҕᒒ݉ң‫׫‬ҧ‫ޒ‬သ᛿‫ޑ‬ȂུҢ‫ڌ‬ӱК೛‫ܗ‬ᚃᕜྲៗ௦ដτ ໕‫ޠ‬࿩‫ུܗ‬Ң‫݉ڌ‬ң‫׫‬ӼВ(ԄȈmetoclopramide)᛿‫ְ๊ཽޑ‬ആԚାҧߵષ ᑣᔯঅ‫ޠ‬ᔯࢦ๗‫ݏ‬Ȃ‫ܛ‬пȂ‫ܛߩٯ‬ԥུҢ‫ڌ‬ᑣᔯᅹ໩‫ܓ‬ঐ਱ְ࣐ӒЉ‫ܓ‬ҧ‫ޒ‬ သմ૗઀ொ޲Ȃԫԥᒧຩ‫ݾ‬ᚃ৲஠ཿ‫ޠ‬ցᘟȂϘ૗‫ٻ‬೼‫ٳ‬ொ‫ڌ‬ூ‫ژ‬ᎍϹ‫ྲޠ‬ ៬Ȅ ೼‫ٳ‬ᑣᔯ‫ึܛ‬౫ᑰொӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀‫ུޠ‬Ң‫ڌ‬ଷΠၷৡܿԥӭூ ϛԂȃ߰બȃҫጴୂᕎȃᙞ‫੊ޝ‬Іࡤ᪅ߟၷτ๊ϛ‫ڏ‬੬౵‫ޒ઀ޠܓ‬ѵᇅҔள ུҢ‫ڌ‬ณ౵(7)Ȅ೾ளຩ‫ݾ‬ᚃ৲ཽԋ௷ҧ‫ޒ‬သѓ૗ȃҧ‫ޒ‬သ‫׫‬ᡞȃҧ‫ޒ‬သӤ՞ ષ௮ඣІҧ‫ޒ‬သົॲ‫๊ݱ‬ᔯࢦȂ्҇ਣཽӤਣԋ௷ҕᒒձҧ‫ޒ‬သ‫׫‬ᡞᔯࢦȄ ࿌ኈ჌ᔯࢦ๗‫ݏ‬ᡘұ࣐ҧ‫ޒ‬သึ‫ي‬ϛӓ(thyroid dysgenesis)ԄȈҧ‫ޒ‬သ౵՞ (ectopic thyroid)ȃҧ‫ޒ‬သึ‫ي‬ϛً(hypoplasia)‫ܗ‬ณҧ‫ޒ‬သਣȂංѠጃۢԫུҢ

ᇄᢋӵୣӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀‫ུޠ‬Ң‫ڌ‬ᑣᔯ

92

‫࣐ڌ‬Ҙε‫ܓ‬ӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀(permanent congenital hypothyroidism)੿΢Ȅ सҧ‫ޒ‬သኈ჌ᔯࢦ๗‫ݏ‬ᡘұҧ‫ޒ‬သӶҔள՞ဋйѵ‫ם‬ҔளਣȂࠍѠ૗࣐ҧ‫ޒ‬ သષӬԚ౵ள(dyshormonogenesis)‫ܗ‬ኸਣ‫(ܓ‬transient)ӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀Ȅ կस࿌ਣ੿΢ҧ‫ޒ‬သѓ૗ᔯࢦ๗‫ݏ‬ϬϛҔளਣȂΚૢл‫ݾ‬ᚃ৲ཽҴ֊๞ϡҧ ‫ޒ‬သષ၅щ‫ݾ‬ᕜпռ‫۾‬ᇳȄ ਴ᐄѯτུҢ‫ڌ‬ᑣᔯϜЗ‫ޠ‬စᡜȂᑣᔯ‫ึܛ‬౫‫ޠ‬Ҙε‫ܓ‬ӒЉ‫ܓ‬ҧ‫ޒ‬သմ ૗઀੿่‫ޠ‬ҧ‫ޒ‬သ੿ᡑпҧ‫ޒ‬သ౵՞ഷளُќ67%ȂՅҧ‫ޒ‬သึ‫ي‬ϛً(ԄȈ ൑ဩҧ‫ޒ‬သsingle lobe)‫ܗ‬ณҧ‫ޒ‬သ޲ќ13%Ȃҧ‫ޒ‬သષӬԚ౵ள޲ќ20%(8)Ȃ ࠊ‫ڎ‬ᆎҧ‫ޒ‬သึ‫ي‬ϛӓ޲Ӽ࣐ୌึ‫(ܓ‬sporadic)਱‫پ‬ȂՅҧ‫ޒ‬သષӬԚ౵ள޲ ࠍ࣐ᡞ࢘Քᡞᗵ‫(ܓ‬autosomal recessive)ᒹ༉Ȃ‫ڐ‬ЯҕίΚफԥѳϸϟΚ‫ޠ‬ᐡ ཽᑰொӤኻ‫੿੾ޠ‬Ȃ೼ଊਁᔗӪঢ়឵ᇴ݃Ȅ೼‫ٳ‬ҧ‫ޒ‬သષӬԚ౵ள‫੿ޠ‬΢Ȃ ໍΚؐໍ՘ႇ෪ሗᢅមܺၑᡜ(perchlorate discharge test)ᡘұп࿩ᚕφԥᐡϾ ુട(organification defect)޲ഷ࣐ளُȂՅໍΚؐ஡೼‫ٳ‬࿩ᚕφԥᐡϾુട‫ޠ‬ ੿่І‫ڐ‬ঢ়΢‫ޠ‬DNAձϸφҢ‫ޑ‬Ᏹϸ‫ݚ‬ᡘұӶѯᢋӵୣ୥ᇅԥᐡϾؐ᡾‫ޠ‬ҧ ‫ޒ‬သႇੋϾ㢵(thyroid peroxidase)‫ޠ‬ஆӱᡑ౵Ϝп2268 insTഷளُ (9, 10)Ȅ ӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀ΚစጃຩࡤȂᔗҴ֊๞ϡlevothyroxine၅щ‫ݾ‬ᕜȂ ࡛ឋп10-15 μg/kg/day‫ޠ‬Ꮩ໕໡ۗ(11, 12)Ȃӕᓎ຀Ԓឮ‫ޠ‬ቩߞ‫ٸ‬ᡜ՗‫ޠ‬๗‫ݏ‬። ᐍᏙ໕ȄҦܼؑঐொ‫ޠڌ‬ሰ्໕ϛᅿࣻӤȂ‫ܛ‬пȂӶ‫ݾ‬ᕜ෉໣ᔗۢ෉ଢᙺொ ่Ңߞᇅึ‫ݸޒي‬І՗ఽϜҧ‫ޒ‬သષ‫ڸ‬ҧߵષᐩ࡚Ȃ‫ו‬గ૗ᆱࡼҧ‫ޒ‬သષ ᐩ࡚ӶӤԒឮҔளጓ൝‫ޠ‬αљࢳй‫ڐ‬ҧߵષӶҔளጓ൝ϲ(13)ȄҔԄࠊख़ȂԄ ‫࣐ݏ‬ҧ‫ޒ‬သึ‫ي‬ϛӓ‫ܛ‬य‫ޠ‬Ҙε‫ܓ‬ӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀੿่ȂΚۢሰಥٙ௦ ‫ڨ‬ҧ‫ޒ‬သષ၅щ‫ݾ‬ᕜȂԄ‫ݏ‬Ӥ՞ષ௮ඣ๗‫ݏ‬ҧ‫ޒ‬သӶҔள՞ဋйѵ‫ם‬Ҕள‫ޠ‬ ੿่ȂѠ૗࣐ኸਣ‫ܓ‬ӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀ȂҼѠ૗࣐ҧ‫ޒ‬သષӬԚ౵ள‫ܛ‬य ‫ޠ‬Ҙε‫ܓ‬ӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀Ȃ‫ܛ‬пΚૢ࡛ឋ೼‫่੿ٳ‬ӶήྒѿѢ୅᛿ӕຠ զȂۢ෉ଢᙺ‫ڐ‬ҧ‫ޒ‬သѓ૗Ȃп‫੿ۢ؛‬΢࢑֐ሰಥٙ௦‫ڨ‬ҧ‫ޒ‬သષ၅щ‫ݾ‬ᕜ (11, 12) Ȅ ҦܼӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀ུҢ‫ڌ‬ᑣᔯϏձ‫ޠ‬௱ኅȂ‫ٻ‬ூ೼‫่੿ٳ‬૗Іԟ ௦‫ݾڨ‬ᕜȂ๗‫ݏ‬уউ‫ޠ‬හ୧Ӷ5-7ྒਣᇅҔள‫ޠ่ڌ‬හ୧‫ٯ‬ณᡘ຀ৰր(14, 15)Ȅ Յ਴ᐄѯτᚃଲ‫ޠ‬စᡜȂѯᢋӵୣߩᑣᔯึ౫‫ޠ‬ӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀ொ่‫ޠ‬ ҂ְහ୧࣐78ɲ21(4)ՅུҢ‫ڌ‬ᑣᔯ‫ึܛ‬౫‫ޠ‬ӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀ொ่‫ޠ‬҂ְ හ୧࣐102ɲ18(16)ȄᡘดӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀‫ུޠ‬Ң‫ڌ‬ᑣᔯϏձϑႁ‫्ॷڐژ‬ ҭዀș෶Ўහ૗ሬᛥ‫ึޠ‬ҢȄ ԥΠ೼‫܉྆ٳ‬Ȃ‫ש‬উӕଇ፤ӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀ึҢ౦‫ޠ‬ឋᚡȄ਴ᐄ Нᝧൣܼ֚1970ԒхजђӵୣӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀‫ึޠ‬Ң౦ङ࣐1:4254(17)Ȃ 93

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Յዊࢹӵୣङ࣐1:3801(18)Ȅܼ2007ԒHarrisІPassӔӤึߓߗΡΫԒ‫ٿ‬Ӷज୾ ӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀‫ึޠ‬Ң౦ङቩђΠΚॼ‫ޠ‬ൣ֚(19)Жକ२ຝȄܼዊࢹȃђ ਍τҼึ౫᜹ծ‫ޠ‬௒‫(ם‬20-22)ȄՎܼѯᢋӵୣȂѯτུҢ‫ڌ‬ᑣᔯϜЗ෇ܼ1988 Վ1990Ԓ໣ձႇ።ࢦȂ࿌ਣ‫ޠ‬ः‫ف‬೪ॏ࣐ҧ‫ޒ‬သ‫ޠ‬௮ඣӶҔள՞ဋ޲ְܼή ྒਣ୅᛿Ȃጃ࣐ۢҘε‫ܓ‬ӒЉ‫ܓ‬ҧ‫ޒ‬သ޲Ϙӗ࣐੿΢ȂԄԫ‫ܛ‬௱ᆘя‫ึޠ‬Ң ౦࣐1:5788(8)ȄѫѵȂച஥⢊๊΢਴ᐄ 1997ԒՎ2008Ԓ໣ӓҖୋߴၦਠ৳‫ޠ‬ ኶ᐄ௱ᆘяึҢ౦࣐ؑΚ࿳ӫུҢ‫ڌ‬Ϝԥ5.02ӫொ่(23) (ङ1:1991)ȂՅ୾ୋ ‫׌‬1984ԒՎ2017Ԓ‫ޠ‬ၦਠ(24)ᡘұึҢ౦࣐ؑΚ࿳ӫུҢ‫ڌ‬Ϝԥ6.73ӫொ่(ङ 1:1486)Ȅ‫ڐ‬ϜȂ1988ԒՎ1990Ԓ໣ȂึҢ౦࣐ؑΚ࿳ӫུҢ‫ڌ‬Ϝԥ2.7ӫொ่ (ङ1:3582)Յ1997ԒՎ2008Ԓ໣ȂؑΚ࿳ӫུҢ‫ڌ‬Ϝԥ7.2ӫொ่(ङ1:1379)Ȅ ߗΡΫԒ‫ٿ‬ӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀‫ึޠ‬Ң౦઎‫ޠ‬ቩђΠ༞ȉ‫ٲ‬ᄃαȂࣻᜱНᝧ ၦਠᡘұԫᆎ੾੿ึҢ౦ቩђ‫ߓޠ‬ຬᇅߗԒ‫ٿ‬።७ҧߵષᑣᔯ‫๋؛‬অԥᜱȂ ӱ࣐ԄԫՅӼึ౫ΠӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀‫ޠ‬ঐ਱Ȃϛႇ೼‫ٳ‬ঐ਱Ӽ࣐ሇ઀ொ ‫(ڌ‬20-22)ȄѫΚР८Ȃ୾ϲӓҖୋߴၦਠ৳І୾ୋဎ‫ีܛ‬ᓄ‫ޠ‬ঐ਱єࢃΠࣻ࿌ Щ‫ޠپ‬ኸਣ‫ܓ‬ӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀ொ่Ȃ೼η࢑ആԚึҢ౦ဤৰԄԫτ‫ޠ‬२ ्ӱષ(25)ȄՎܼ७մҧߵષᑣᔯ‫๋؛‬অᗷѠӼึ౫ঐ਱կηቩђΠ኶ॼୄ໩ ‫ܓ‬Յሰ௦‫ڨ‬ϛ्҇ᔯࢦ‫ޠ‬ঐ਱(21)Ȃ‫ܛ‬пᑣᔯ‫๋؛‬অ࢑֐অூ።७Վҭࠊ‫ޠ‬մ অϬԥ‫ލ‬ឋ(26)ȄดՅȂᐋЗԥঐ਱ӱᑣᔯᒹᅔՅึҢහ૗ሬᛥȂ‫ܛ‬пӶ‫ލ‬ឋ ᚅఽࠊȂᔗ၏‫ء‬ԥᑣᔯϜЗඹࠄดӵ።ାᑣᔯ‫๋؛‬অȄ ஠ԥӫມϜऽНᄈྲߓ ӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀

congenital hypothyroidism

‫๋؛‬অ

FXW R൵ SRLQW

ҧ‫ޒ‬သષӬԚ౵ள

dyshormonogenesis

ԥᐡϾુട

RUJDQL¿FDWLRQ GHIHFW

ႇ෪ሗᢅមܺၑᡜ

perchlorate discharge test

Ҙε‫ܓ‬ӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀

permanent congenital hypothyroidism

ኸਣ‫ܓ‬ӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀

transient congenital hypothyroidism

ҧ‫ޒ‬သึ‫ي‬ϛӓ

thyroid dysgenesis

ҧ‫ޒ‬သึ‫ي‬ϛً

thyroid hypoplasia

ҧ‫ޒ‬သ౵՞

ectopic thyroid

ҧ‫ޒ‬သႇੋϾ㢵

thyroid peroxidase

ᇄᢋӵୣӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀‫ུޠ‬Ң‫ڌ‬ᑣᔯ

94

୥ Մ Нᝧ 1. Tsai WY, Lee JS: Congenital hypothyroidism in Taiwan: experience before mass screening. J Formos Med Assoc 1992; 91:864-866.

2. Morreale de Escobar G, Escobar del Rey F, Ruiz-Marcos A: Thyroid hormone and the developing brain. In: Dussault JH, Walker P eds. Congenital hypothyroidism. New York; Marcel Dekker, Inc. 1983; 85-126.

3. Klein AH, Meltzer S, Kenny FM: Improved prognosis in congenital hypothyroidism treated before age three months. J Pediatr 1972; 81:912-915.

4. Hsiao PH, Chiu YN, Tsai WY, Su SC, Lee JS, Soong WT: Intellectual outcome of patients with congenital hypothyroidism not detected by neonatal screening. J Formos Med Assoc 1999; 98:512-515.

5. Klein AH, Agustin AV, Foley TPJ: Successful laboratory screening for congenital hypothyroidism. Lancet 1974; ii:77-79.

6. Dussault JH, Coulombe P, Laberge C, Letarte J, Guyda H, Khoury K: Preliminary report on a mass screening program for neonatal hypothyroidism, J Pediatr 1975; 86:670-674.

7. Tsai WY, Lee JS, Wang TR, Chen JS, Chuang SM: Clinical characteristics of congenital hypothyroidism detected by neonatal screening. J Formos Med Assoc 1993; 92:20-23.

8. Tsai WY, Lee JS, Chao MC, Chen LY, Lin SJ, Wu KH, Wang TR, Chen JS, Chuang SM: Prevalence of permanent primary congenital hypothyroidism in Taiwan. J Formos Med Assoc 1995; 94:271-273.

9. Niu DM, Hwang B, Chu YK, Liao CJ, Wang PL, Lin CY: High prevalence of a novel mutation (2268 insT) of the thyroid peroxidase gene in Taiwanese patients with total iodide organification defect, and evidence for a founder effect. J Clin Endocrinol Metab 2002; 87;4208-4212.

10. Wu JY, Shu SG, Yang CF, Lee CC, Tsai FJ: Mutation analysis of thyroid peroxidase gene in &KLQHVH SDWLHQWV ZLWK WRWDO LGRGLGH RUJDQL¿FDWLRQ GHIHFW LGHQWL¿FDWLRQ RI ¿YH QRYHO PXWDWLRQV J Endocrinol 2002; 172:627-635.

11. American Academy of Pediatrics, American Thyroid Association, Lawson Wilkins pediatric endocrine society: Update of newborn screening and therapy of congenital hypothyroidism. J Pediatr 2006; 117:2290-2303.

12. Léger J, Olivieri A, Donaldson M, Torresani T, Krude H, Van Vliet G, Polak M, Butler G: European society for paediatric endocrinology consensus guidelines on screening, diagnosis, and management of congenital hypothyroidism. Horm Res Paediatr 2014; 81:80-103.

13. Tsai WY, Lee JS, Chou YH, Yau KIT: Thyroid function in normal neonates and infants. Acta Paed Sin 1994; 35:261-265.

14. Glorieux J, Dussault JH, Morissette J, Desjardins M, Letarte J, Guyda H: Follow-up at ages 5 and 7 years on mental development in children with hypothyroidism detected by Quebec screening program. J Pediatr 1985; 107:913-915.

15. New England congenital hypothyroidism collaborative: Neonatal hypothyroidism screening: status of patients at 6 years of age. J Pediatr 1985; 107:915-919.

16. Hsiao PH, Chiu YN, Tsai WY, Su SC, Lee JS, Soong WT: Intellectual outcome of patients

95

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

with congenital hypothyroidism detected by neonatal screening. J Formos Med Assoc 2001; 100:40-44.

Fisher DA, Dussault JH, Foley TPJ, Klein AH, LaFranchi S, Larsen PR, Mitchell ML, Murphey WH, Walfish PG: Screening for congenital hypopthyroidism: results of screening one million North American infants. J Pediatr 1979; 94:700-705.

Toublanc JE: Comparison of epidemiological data on congenital hypothyroidism in Europe with those of other parts in the world. Horm Res 1992; 38:230-235.

Harris KB, Pass KA: Increase in congenital hypothyroidism in New York State and in the United States. Mol Genet Metab 2007; 91:268-277.

Corbetta C, Weber G, Cortinovis F, Calebiro D, Passoni A, Vigone MC, Beck-Peccoz P, Chiumello G, Persani L: A 7-year experience with low blood TSH cutoff levels for neonatal screening reveals an unsuspected frequency of congenital hypothyroidism (CH). Clin Endocrinol 2009; 71:739-745.

Mengreli C, Kanaka-Gantenbein C, Girginoudis P, Magiakou MA, Christakopoulou I, Giannoulia-Karantana A, Chrousos GP, Dacou-Voutetakis C: Screening for congenital K\SRWK\URLGLVP WKH VLJQL¿FDQFH RI WKUHVKROG OLPLW LQ IDOVH QHJDWLYH UHVXOWV - &OLQ (QGRFULQRO Metab 2010; 95:4283-4290.

Deladoëy J, Ruel J, Giguère Y, Van Vliet G: Is the incidence of congenital hypothyroidism really increasing? A 20-year retrospective population-based study in Québec. J Clin Endocrinol Metab 2011; 96:2422-2429.

Chen CY, Lee KT, Lee CT, Lai WT, Huang YB: Epidemiology and clinical characteristics of congenital hypothyroidism in an Asian population: a nationwide population-based study. J Epidemiol 2013; 23:85-94. ፐҢᆌւഌ୾ҖୋஷဎȈུҢ‫ڌ‬ӒЉ‫ܓ‬хᗃ౵ள੾੿ᑣᔯᐤԒԚ‫ݏ‬Ȅ Parks JS, Lin M, Grosse SD, Hinton CF, Drummond-Borg M, Borgfeld L, Sullivan KM: The impact of transient hypothyroidism on the increasing rate of congenital hypothyroidism in the United States. Pediatr 2010; 125:S54-S63.

Lain S, Trumpff C, Grosse SD, Olivieri A, Van Vliet G: Are lower TSH cutoffs in neonatal screening for congenital hypothyroidism warranted? Eur J Endocrinol 2017; 177:D1-D12.

ᇄᢋӵୣӒЉ‫ܓ‬ҧ‫ޒ‬သմ૗઀‫ུޠ‬Ң‫ڌ‬ᑣᔯ

96

ׂ৓෉ҧ‫ޒ‬သ੾੿ྲៗ‫ޠ‬ஐ౱ऌᢏᘉ ᇄіߞ۹ख‫܉‬ᚃଲஐ౱ऌ ‫ⷔܜ׉‬ȃࢺ੏‫ڸ‬

ࠊّ ਴ᐄಜॏτङԥ3%‫ޠ‬Ѻஐཽԥҧ‫ޒ‬သѓ૗Ϧໍ‫ܗ‬մί‫ޠ‬ୱᚡ(1)ȂԄ‫ءݏ‬ ԥᎍ࿌‫ݾ‬ᕜ‫ၘޠ‬Ȃ೼‫ٳ‬ஐυཽԥၷା‫ॴޠ‬ᓏя౫ׂ৓‫઀ึڂ‬Іᄈफ‫ུܗڌ‬Ң ‫ڌ‬౱Ңϛًኈ៫(2, 3)ȄӱԫȂஐ౱ऌᚃ৲ᇅϲϸ‫ݫ‬ऌᚃ৲എᔗ၏ᕤ၍೼‫੿੾ٳ‬ ‫ޠ‬२्‫ݾڸܓ‬ᕜ঩ࠍȄ ᓎ຀ᛅѺਣ෉хᗃሰؒ‫ޠ‬ቩђȂҧ‫ޒ‬သҢ౪ηཽԥ‫׾ܛ‬ᡑ(4)Ȅ‫ژڨ‬ሮᐮ ષȞestrogenȟኈ៫Ȃ՗షϜҧ‫ޒ‬သષ๗Ӭ౩೗ҪȞthyroxine-binding globulinȟ‫ޠ‬ҢԚཽቩђȂಒΡѺ෉Ѡႁ‫ژ‬ґᛅѺਣ‫ॼڎޠ‬Ȅ࣐Πᆱࡼ෭ᚕҧ‫ޒ‬သ ષȞfree thyroid hormonesȟ‫ޠ‬ᐩ࡚Ȃҧ‫ޒ‬သષᖃ໕Ȟtotal T3, T4ȟηཽᓎϟα ЁȂӶׂ৓ΡΫ໋ਣႁ‫ژ‬ґᛅѺਣ‫ޠ‬1.5ॼȄԫѵȂफዻฆᎵቺಡबϸ‫ޠݫ‬΢ ᜹๘Ъጱ‫ܓ‬သᐮષȞhuman chorionic gonadotropinȂhCGȟȂҦܼಣԚᄻആ‫ڸ‬ ߵҧ‫ޒ‬သᐮષȞthyroid-stimulating hormone, TSH, or thyrotropinȟࣻծȂѬৰ ΠΚঐԪ൑ϰȂӱԫηཽᇅTSH௦‫ڨ‬Ꮳ๗ӬȂ‫ڏ‬ԥཌྷ৶‫ໍߵޠ‬ҧ‫ޒ‬သષҢԚ ձңȄӶಒΚѺ෉Ȃ՗షϜhCGᐩཽ࡚αЁՎഷାȂҧ‫ޒ‬သષᖃ໕ηཽၮ຀ αЁȇTSHࠍཽί७Վ‫ء‬ԥᛅѺਣ‫ޠ‬ΚљȂ‫ژ‬ಒΡѺ෉ࡤϘᄛᄛӲඉ‫ژ‬ᛅѺ ࠊ‫ޠ‬኶অȄᕤ၍೼‫ٳ‬Ң౪ᡑϾ஡ԥֆܼ‫ש‬উ၍᠟ᛅѺ෉໣ө໷ҧ‫ޒ‬သѓ૗ᔯ ᡜ‫ޠ‬๗‫ݏ‬Ȃп߰๞ϡ੿ொഷᎍ࿌‫៬ྲޠ‬Ȅ American Thyroid Association࡛ឋϛӤ΢πఋထӶϛӤѺ෉Ȃᔗԥࣻᄈᔗ

‫ޠ‬Ҕளҧ‫ޒ‬သᐮષᐩ࡚‫ޠ‬୥Մጓ൝(5)ȄӒࠊϜ୾‫ޠ‬ः‫ࡿف‬яȂᛅѺ7-12໋‫ޠ‬๽ ΢ஐυȂ՗ϜTSHᐩ࡚Ҕளጓ൝‫ޠ‬α४Щ‫ڐ‬уఋထ‫ޠٿ‬ା(6)ȄѠ௕‫࢑ޠ‬Ȃҭࠊ ᗚ‫ء‬ԥѯᢋҐρ‫ޠ‬኶ᐄѠ‫ٽ‬୥ՄȄ ਴ᐄߵҧ‫ޒ‬သષȞTSHȟ‫ڸ‬෭ᚕ࠯ҧ‫ޒ‬သષT4Ȟfree T4ȟ‫ޠ‬ᡑϾȂAmerican College of Obstetricians & Gynecologists஡Ѻ෉ҧ‫ޒ‬သѓ૗౵ள྆ϸ࣐ѳ ᜹ȞߓΚȟȈҧ‫ޒ‬သѓ૗ϦໍȞovert hyperthyroidismȟȃҧ‫ޒ‬သѓ૗մί Ȟovert hypothyroidismȟȃ‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗ϦໍȞsubclinical hyperthyroidismȟ‫ٴڸ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մίȞsubclinical hypothyroidismȟ(7)Ȅ௦ί‫ٿ‬൸ଭ ᄈ೼ං໷Ѻ෉ளُҧ‫ޒ‬သѓ૗౵ள‫ޠ‬ຩᘟ‫ݾڸ‬ᕜ୉ᙐ्‫ޠ‬ϮಞȄ

97

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

ߓΚȃளُѺ෉ҧ‫ޒ‬သѓ૗౵ள՗ఽϜTSH‫ڸ‬free T4অ‫ޠ‬ᡑϾ௒‫ם‬ ҕᡞ‫ݸޒ‬

TSH

Free T4

ҔளᛅѺ

‫ٸ‬Ѻ෉ᡑϾ

‫ء‬ԥ‫׾‬ᡑ

ҧ‫ޒ‬သѓ૗Ϧໍ

७մ

αЁ

‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗Ϧໍ

७մ

‫ء‬ԥ‫׾‬ᡑ

ҧ‫ޒ‬သѓ૗մί

αЁ

७մ

‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մί

αЁ

‫ء‬ԥ‫׾‬ᡑ

‫ڦ‬؆ՍObstet Gynecol 2015; 125:996-1005.

ҧ‫ޒ‬သѓ૗Ϧໍ ᛅѺஐυϜȂτङ 0.4-1.7% ԥҧ‫ޒ‬သѓ૗Ϧໍ‫ޠ‬௒‫( ם‬2, 4)Ȅளُ‫ߓޠ‬ኊ ԥȈҧ‫ޒ‬သလτȃЗ௛ȃฺԯȃᡞ२෶ሇȃฑኍȃಂ࿙ऐя๊​๊Ȃഌϸ઀‫ޒ‬ ߓ౫ᇅᛅѺߒ෉‫ޠ‬ϛᎍ઀‫ޒ‬᜹ծȂӱԫቩђᛅѺߒ෉ਣຩᘟ‫ᜳ֩ޠ‬Ȅׂ৓ ෉ҧ‫ޒ‬သѓ૗Ϧໍ‫ޠ‬ຩᘟл्࢑‫ٸ‬ᐄᖞ‫ߓט‬ኊ‫ڸ‬ҧ‫ޒ‬သѓ૗‫ޠ‬ᔯขȞTSHί ७ȂӬ‫ڂ‬free T4αЁȟȄGravesɅdisease‫ڸ‬ᛅѺߒ෉hCGቩђ‫ܛ‬Ᏻयኸਣ‫ܓ‬ҧ ‫ޒ‬သѓ૗Ϧໍ࢑ഷளُ‫ޠ‬঩ӱȇԄ‫੿ݏ‬΢գᓎಂ੿ᡑІ՗Ϝя౫TSH‫ڨ‬Ꮳ‫׫‬ ᡞȞTSH receptor antibodyȂTRAbȟȂѠᔔֆຩᘟ࣐GravesɅdiseaseȄ‫ڐ‬ᎸЎ ُ‫ޠ‬঩ӱԥҧ‫ޒ‬သ‫ވ‬ȃҧ‫ޒ‬သလድȃဟί࠮ᡞသድȞTSH-producing pituitary adenomaȟȃ֋லҧ‫ޒ‬သድȞstruma ovariiȟȃ‫࢑ܗ‬ฆᎵቺಡब੾੿ȞԄmolar pregnancyȟ๊Ȅ ѺஐԄ‫ݏ‬ԥҧ‫ޒ‬သѓ૗Ϧໍȃέ‫ء‬ԥᎍ࿌‫ݾ‬ᕜ‫ၘޠ‬Ȃཽቩђԟ౱ȃԬ ౱ȃफ‫ڌ‬Ңߞ୒ϊȃφᡫࠊ઀ІЗ૿ᆒ‫ॴޠ‬ᓏȂӱԫᔗ၏๞ϡᑗ྄೏౪ (2, 4, 8)

Ȅ‫׫‬ҧ‫ޒ‬သѓ૗Ϧໍ᛿‫ޑ‬Ȟantithyroid drugsȂATDȟ࢑л्‫ݾޠ‬ᕜРԓȇԄ ‫ݏ‬ᄈ᛿‫ޑ‬ႇఄ‫ܗ‬ԥϛًЇᔗਣϘՄኍК೛(5, 7, 9)ȄҦܼफ‫ڌ‬ᄈATDࣻ࿌ఄདȂ ࣐Πᗘռя౫ུҢ‫ڌ‬ҧ‫ޒ‬သလȂࣦՎ࢑ҧ‫ޒ‬သѓ૗մίȂ᛿‫ݾޑ‬ᕜ‫ޠ‬঩ࠍ࢑ ᅿѠ૗‫ٻ‬ңഷմ‫ޠ‬Ꮩ໕Ȃᆱࡼҕᡞሇཌྷ‫ޠ‬ҧ‫ޒ‬သѓ૗ϦໍȂпᗘռႇ࡚‫ݾ‬ ᕜȄΚૢ‫ٿ‬ᇴȂ‫ݾ‬ᕜҭዀ࢑ᆱࡼ՗Ϝfree T4ᐩ࡚Ӷ၏Ѻ෉Ҕளጓ൝‫ޠ‬α४Ȃ ‫࢑ܗ‬౲ାΚ‫(ٳ‬5, 7, 9)Ȅ PropylthiouracilȞPTUȟᇅmethimazoleȞMMIȟ࢑ளң‫ޠ‬ATD᛿‫ޑ‬Ȃᖞ‫ט‬

စᡜᡘұ‫ݾ޲ڎ‬ᕜਞ‫ࣻݏ‬࿌Ȅ‫ٻ‬ңPTU‫ڸ‬MMIਣԥංᘉ‫ٲ‬໷्‫ݨ‬ཏȈಒΚȃ ೼‫ڎ‬ᆎ᛿‫ޑ‬എཽ೾ႇफዻȂԥय࿍फ‫ޠ‬ձң(10-13)ȄಒΚѺ෉࢑फ‫ڌ‬Ꮳۣ‫ם‬Ԛ ‫ޠ‬ᜱᗥ໧ࢳȂӶԫѺ෉‫ٻ‬ңMMIཽቩђӒЉ࿍‫ޠם‬ᐡ౦Ȃ‫پ‬ԄӒЉ‫ܓ‬ҫጴึ

ׂ৓෉ҧ‫ޒ‬သ੾੿ྲៗ‫ޠ‬ஐ౱ऌᢏᘉ

98

‫ي‬ϛӓȃࡤቆЍഗᚈȃ੊ᆔॶၿ㣠ᆔȃᙞᑸяȃ‫ٱ‬ᓟึ‫ي‬ϛӓȃпІึ৥ᒷ ጦ๊Ȟಜᆏ࣐methimazole embryopathyȟ(10, 12, 13)ȄࣻᄈܼMMIȂ݉ңPTU‫ޠ‬Ѻ ஐȂफ‫ึڌ‬ҢӒЉ࿍‫ޠם‬Щ‫پ‬ၷմȃᝓ२࡚ηၷ࣐ሇཌྷȂ‫پ‬ԄՇࠊ㣠ᆔ‫᠅ܗ‬ လȃሇཌྷ๬Ьလ(11-13)ȄӱԫPTU࢑ಒΚѺ෉‫ݾ‬ᕜҧ‫ޒ‬သѓ૗Ϧໍ‫ॷޠ‬ᒶ᛿‫(ޑ‬5, 7, 9) ȄಒΡȃ᛿‫ݾޑ‬ᕜ࡛ឋ‫ޠ‬କۗᏙ໕࣐PTU 50 mg Q8H‫ܗ‬MMI 5-10 mg QDȂ ѠᅛቩՎPTU 150 mg Q8H‫ܗ‬MMI 40 mg QD(7)Ȅᖞ‫ט‬စᡜࡿяȂ300 mg‫ޠ‬PTU τङᇅ10-15 mg‫ޠ‬MMIਞቌࣻ࿌ȄᛅѺ෉໣ᔗؑѳ໋‫ܫ‬՗ᔯᡜTSHȃfree T4ᐩ ࡚ȂᙾඳMMIᇅPTU޲ᔗ‫ܫ໋ڎ‬՗ΚԪȂစ።ᐍ᛿‫ࡤޑ‬Ȃᛨۢࡤӕ‫࣐ؑ׾‬ѳ ໋ΚԪȄಒήȃ2010Ԓ4Уज୾FDAң᛿ԋӓණᒻȂPTU‫ڸ‬MMIഎԥ‫ܓࢴن‬Ȃ ՅйPTU‫ٻ‬ң޲‫ึޠ‬Ң౦ၷାȂ࿌੿΢я౫⭇ЗნӦȃઁॿȃ༂ઇȃ૰Ք‫׎‬ ๊઀‫ޒ‬ਣᔗ୅Ц‫ٻ‬ң᛿‫ޑ‬ȄӱԫȂAmerican Thyroid Association‫ڸ‬American Association of Clinical Endocrinologists࡛ឋȂՍಒΡѺ෉କ஡PTU‫׾‬ԚMMIȂ пᗘռ‫ܓࢴن‬ᄈҕᡞ‫ޠ‬ኈ៫(5, 14)ȄಒѳȃԄ‫ݏ‬Ѻஐ‫ޠ‬ҧ‫ޒ‬သѓ૗ӶPTU 50 mg QD‫ܗ‬MMI 5 mg QD‫ޠ‬Ꮩ໕ίѠпᕖூ௢‫ၘޠښ‬ȂѠпՄኍ୅᛿Ȃথ୅᛿ਣᔗ ໋ؑ‫ܫ‬՗Ȃᛨۢࡤӕ‫࣐ؑ׾‬ѳ໋ΚԪᔯᡜTSHȃfree T4ᐩ࡚(5, 9)Ȅ ݉ңATD᛿‫ޠޑ‬ѺஐȂ࡛ឋӶׂ৓20-24໋໣௦‫ڨ‬ାቺԪົॲ‫ݱ‬ᔯࢦȂຠ զफ‫ڌ‬ᄻആԥณ२τ࿍‫ם‬ϟኍȄѫѵȂη࡛ឋ௦‫قڨ‬ӗ‫ݱॲົޠ‬ᔯࢦȂᆀ௢ फ‫ޠڌ‬Ңߞ௒‫ڸݸ‬ҧ‫ޒ‬သ‫ޠ‬τϊȄҭࠊ‫ٯ‬ϛ࡛ឋ‫ܫ‬फ‫ޠڌ‬ᙞᓘ૖՗‫ٿ‬ᔯขफ ‫ޠڌ‬ҧ‫ޒ‬သѓ૗Ȅ

ҧ‫ޒ‬သѓ૗մί ҧ‫ޒ‬သѓ૗մί‫ޠ‬ஐυ঩Ґ൸ӱ௷֋౵ளՅϛৡܿᛅѺ‫ܗ‬Ӷׂ৓ԟ෉ я౫Սึ‫ࢻܓ‬౱ȂӱԫᛅѺஐυϜȂτङѬԥ 0.3% ‫ޠ‬΢ொԥҧ‫ޒ‬သѓ૗մ ί‫ޠ‬௒‫(ם‬3)ȄӶϑ໡ึ୾ঢ়Ϝഷளُ‫ޠ‬঩ӱ࢑ᐞҐЫҧ‫ޒ‬သ‫(ވ‬HashimotoɅs thyroiditis)ȂՅӶᕋᎵુн‫ޠ‬ӵୣࠍ࢑ુ࿩‫ޠ‬๗‫(ݏ‬3)Ȅளُ‫ޒ઀ޠ‬ԥઁॿȃܑ տȃ߰બȃᡞ२αЁȂկ࢑೩Ӽ੿΢‫ءٯ‬ԥ݃ᡘ઀‫ޒ‬Ȅׂ৓ҧ‫ޒ‬သѓ૗մί ‫ޠ‬ຩᘟ࢑Ꭽ‫ܫ‬՗ᔯᡜᜍᄃTSHঅαЁȂӬ‫ڂ‬free T4অί७ȄՅѺஐԄ‫ݏ‬ԥҧ ‫ޒ‬သѓ૗մίȃέ‫ء‬ԥᎍ࿌‫ݾ‬ᕜ‫ၘޠ‬Ȃཽቩђφᡫࠊ઀ȃफዻԟ෉দᚕȃफ ‫ڌ‬ๅय़ȃԟ౱ȃմяҢᡞ२ȃ౱ࡤτя՗‫ॴޠ‬ᓏȂпІኈ៫ུҢ‫ޠڌ‬ઢစึ ৥‫ڸ‬ᇰ‫ޤ‬ѓ૗๊​๊(3, 15, 16)Ȅ30-60%‫ޠ‬ҧ‫ޒ‬သѓ૗մί‫੿ޠ‬΢ཽԥanti-thyroid peroxidase antibody (anti-TPO‫׫‬ᡞ)Ȃ೼᜹੿ொӶѺ෉໣౱Ң‫ޠ઀ึڂ‬ᐡ౦ཽ Щ‫ء‬ԥanti-TPO‫׫‬ᡞ‫ޠ‬΢‫ٿ‬ூ‫؂‬ା(15)Ȅ ᛅѺ෉໣ུຩᘟ‫ޠ‬ҧ‫ޒ‬သѓ૗մίȂ‫ݾ‬ᕜ঩ࠍሰ୥Մ՗ϜTSHঅȈTSH ାܼ4 mU/L޲ȂѠп௄ାᏙ໕levothyroxineȞ1.6 mcg/kg/dayȟ໡ۗȇTSHϮ 99

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

ܼҔளঅα४Վ2.5 mU/L޲ȂसӤਣԥanti-TPO‫׫‬ᡞІӒࠊ‫ޠ‬Ї᙮ࢻ౱੿ѭȂ ࠍ݉ңմᏙ໕‫ޠ‬levothyroxineȞ50 mcg/dayȟ(5, 9, 17)Ȅ᛿‫ݾޑ‬ᕜ‫ޠ‬ҭዀ࢑ᆱࡼ TSHӶ၏Ѻ෉Ҕளঅ‫ܗ‬մܼ2.5 mU/LȄᛅѺࠊΡΫ໋ᔗؑѳ໋‫ܫ‬՗ΚԪȂ። ᐍ᛿‫ޑ‬Ꮩ໕ȂႇΠᛅѺΡΫ໋ࡤѠпؑѺ෉‫ܫ‬՗ΚԪ֊ѠȄ౱ࡤѳ‫ژ‬ϳ໋ਣ ‫ܫ‬՗ᔯᡜȂ‫्֐࢑ۢ؛‬ӕ᝸៊݉᛿Ȅ ঩Ґ൸ԥҧ‫ޒ‬သѓ૗մί‫੿ޠ‬΢ȂᛅѺਣ‫ޠ‬ሰؒᏙ໕ཽЩѺࠊቩђङ 30%

(18)

ȄѠпӒ௄໋ؑᒶ‫ڎ‬Љȃӭᚗॼ‫ޠ‬᛿‫ޑ‬Ꮩ໕໡ۗȂดࡤؑ2-4໋‫ܫ‬՗ᔯ ᡜȂ።ᐍ᛿‫ޑ‬Ꮩ໕(5, 9, 17)Ȅ౱ࠊ‫ޠ‬ᒛၛࣻ࿌२्ȂTSHঅसାႁ4-10 mU/LȂࢻ

౱‫ޠ‬ᐡ౦ཽቩђ(19)Ȃ࡛ឋ஡TSHঅ௢‫ښ‬Ӷ2.5 mU/LпίȄ౱ࡤࠍѠпӲඉ࣐ ঩Ґ‫ޠ‬Ꮩ໕ȂѠӶ౱ࡤѳ‫ژ‬ϳ໋ਣ‫ܫ‬՗ᔯᡜȂ‫्֐࢑ۢ؛‬ӕ።ᐍȄ

‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗Ϧໍ‫ܗ‬մί ‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗ϦໍτङխᛅѺஐυ‫ޠ‬1.7%Ȃۢဏ࣐free T4অҔளȂ կTSHঅմܼ၏Ѻ෉‫ޠ‬Ҕளጓ൝(20)Ȅ೼᜹੿΢೾ளϛཽԥҧ‫ޒ‬သѓ૗Ϧໍ‫ޠ‬ ઀‫ޒ‬Ȃҭࠊ‫ޠ‬ः‫ف‬η‫ء‬ԥึ౫ཽቩђׂ৓‫ॴޠ઀ึڂ‬ᓏ‫ܗ‬ኈ៫ུҢ‫ڌ‬ႲࡤȂ ӱԫ‫ء‬ԥᜍᐄМࡼᄈ೼᜹Ѻஐ्๞ϡ᛿‫ݾޑ‬ᕜ(5, 7, 9, 20)ȄՄኍ‫ژ‬ഌϸஐυСࡤ ཽໍ৥Ԛҧ‫ޒ‬သѓ૗Ϧໍ‫ޠ‬Ѡ૗Ȃ࡛ឋѳՎϳ໋‫ܫ‬՗ᔯᡜTSH‫ڸ‬free T4অ‫ٿ‬ ଢᙺȄ ‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մίτङխᛅѺஐυ‫ޠ‬2.5%Ȃۢဏ࣐free T4অҔளȂ կTSHঅାܼ၏Ѻ෉Ҕளጓ൝(16, 21, 22)Ȅࣻၷܼҧ‫ޒ‬သѓ૗Ҕள‫ޠ‬ѺஐȂӲ྘ ‫ܓ‬ȃᢏᄇ࠯ः‫ึف‬౫Ȃ‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մί‫ޠ‬Ѻஐཽԥၷା‫ޠ‬ᐡཽя౫φ ᡫࠊ઀‫ึܗ‬Ңԟ౱Ȃ‫ٯ‬йѠ૗ኈ៫ུҢ‫ޠڌ‬ઢစᇰ‫ึޤ‬৥(23, 24)ȄดՅȂτ೤ ዂࠊᙂ‫ܓ‬ȃᓎᐡȃᚗ‫ޠޢ‬ᖞ‫ט‬ၑᡜ๗‫ࠔݏ‬ᡘұȂ‫ٴ‬ᖞ‫ט‬ҧ‫ޒ‬သѓ૗մί‫ޠ‬ஐ υȂᛅѺ໣ԥ‫ء‬ԥ݉ңlevothyroxine‫ݾ‬ᕜȂҕᡞ‫ུڸ‬Ң‫ڌ‬Ⴒࡤ‫ءٯ‬ԥৰ౵(25, 26) Ȅҭࠊө஠ऌᏱཽᄈ೼᜹Ѻஐ‫ݾޠ‬ᕜРԓᗚ‫ء‬ԥۢ፤ȈEndocrine Society‫ڸ‬ European Thyroid Association࡛ឋ्၅щlevothyroxine(9, 17)ȇAmerican Thyroid Association࡛ឋanti-TPO ‫׫‬ᡞ֖໩‫ܓ‬Їᔗ‫ޠ‬Ѻஐ्၅щlevothyroxineȂՎܼ anti-TPO ‫׫‬ᡞ֖ജ‫ܓ‬Їᔗ‫ޠ‬Ѻஐࠍϛ࡛ឋηϛЇᄈ๞ϡ‫ݾ‬ᕜ(5)ȇAmerican College of Obstetricians & Gynecologistsࠍ࢑ϛᆔanti-TPO ‫׫‬ᡞᔯᡜ๗‫ݏ‬ԄեȂഎ

ϛ࡛ឋ‫ݾ‬ᕜ(7)Ȅ

ሰ्Ӷׂ৓ԟ෉ᄈ‫ܛ‬ԥѺஐໍ՘ӓ८‫ܓ‬ҧ‫ޒ‬သѓ૗ᑣᔯ༞ȉ ࠊ८ණႇȂѺஐԄ‫ݏ‬ԥҧ‫ޒ‬သѓ૗Ϧໍ‫ܗ‬մίȃέ‫ء‬ԥᎍ࿌‫ݾ‬ᕜ‫ၘޠ‬Ȃ ཽԥၷା‫ॴޠ‬ᓏя౫ׂ৓‫઀ึڂ‬Іᄈफ‫ུܗڌ‬Ң‫ڌ‬౱Ңϛًኈ៫Ȅ٦ቅ࢑ϛ

ׂ৓෉ҧ‫ޒ‬သ੾੿ྲៗ‫ޠ‬ஐ౱ऌᢏᘉ

100

࢑၏Ӷׂ৓ԟ෉ᄈ‫ܛ‬ԥѺஐໍ՘ӓ८‫ܓ‬ҧ‫ޒ‬သѓ૗ᑣᔯ‫׳ٿ‬яᑰ੿‫ޠ‬ѺஐȂ ๞ϡ‫ݾ‬ᕜȂ‫ٿ‬ᗘռϛً‫ڻޠ‬౱෉Ⴒࡤ‫ں‬ȉNegro๊΢ໍ՘ΠΚ໷ᓎᐡϸಣᖞ ‫ט‬ၑᡜȂЩၷ௦‫ڨ‬ӓ८‫ܓ‬ᑣᔯȞᔯᡜTSHȃfree T4‫ڸ‬anti-TPO antibodyȟ‫ڸ‬ᒶ ᐆ‫ܓ‬ᑣᔯȞη൸࢑Ѭଭᄈԥίӗӡᓏӱφ‫ޠ‬Ѻஐໍ՘ᑣᔯȂєࢃȈԥՍᡞռ ࣬‫ܓ‬ҧ‫ޒ‬သ੾੿ঢ়ఋѭȃҧ‫ޒ‬သလτȃҧ‫ޒ‬သѓ૗౵ளᖞ‫ޒ઀ט‬ȃಒΚ࠯ᑦ ‫ڐܗ੿׎‬уՍᡞռ࣬੾੿ȃӒࠊᓜഌ௦‫ڨ‬ႇܺৣ‫ݾ‬ᕜȃӒࠊԥࢻ౱‫ܗ‬ԟ౱੿ ѭ๊ȟѺஐ‫ڻޠ‬౱෉Ⴒࡤ(1)Ȅ๗‫ึݏ‬౫Ȃ‫ڎ‬ಣѺஐϟ໣ө໷‫ڻ‬౱෉Ⴒࡤࡿዀ ‫ءٯ‬ԥৰ౵Ȅଭᄈ೼ঐឋᚡȂϛӤ‫ޠ‬஠ऌᏱཽη൸ԥϛӤ‫࡛ޠ‬ឋȈ American College of Obstetricians & Gynecologists࡛ឋଭᄈԥ઀‫ܗޒ‬Սᡞռ࣬੾੿‫ޠ‬Ѻ ஐໍ՘ҧ‫ޒ‬သѓ૗ᔯข(7)ȇEndocrine Societyࠍ࡛ឋᄈԥίӗӡᓏӱφ‫ޠ‬Ѻஐ ໍ՘ᑣᔯȈ30ྒпαȃԥҧ‫ޒ‬သ੾੿ঢ়ఋѭȃҧ‫ޒ‬သѓ૗౵ளᖞ‫ޒ઀ט‬ȃ෇ ԥҧ‫ޒ‬သ੾੿‫ܗ‬К೛ȃӒࠊᓟᓜഌ௦‫ڨ‬ႇܺৣ‫ݾ‬ᕜȃanti-TPO antibody໩‫ܓ‬ ЇᔗȃಒΚ࠯ᑦ‫ڐܗ੿׎‬уՍᡞռ࣬੾੿ȃϛѺȃӒࠊԥࢻ౱‫ܗ‬ԟ౱੿ѭȃ ‫۩ܗ‬՟Ӷ࿩ુнୣ஀๊(9)ȄAmerican Thyroid Association঩ࠍα௵‫ڸڦ‬Endocrine SocietyΚኻ‫ޠ‬ᑣᔯ఩ӈȂᗚѫѵӼΠήঐӡᓏӱφȈ޴णȞBMI>40 kg/ m2ȟȃ෇݉ңamiodarone‫ܗ‬lithiumȃ‫ܗ‬ഷߗ௦‫ڨ‬ႇ֥࿩‫ޠ‬ᡘኈᏙ(5)Ȅ

঴‫ޠ෉ٱ‬Մ໕ ౫ϭჃᓿҕ‫࣐ٱ‬лࢻᢏ‫܉‬Ȃԥҧ‫ޒ‬သ੾੿‫ޠ‬ஐυȂԥѠ૗७մ‫ٱݫڐ‬ѓ ૗ȂկӶᎍ࿌‫ݾ‬ᕜίѠࡼ៊঴ᗾҕ‫ٱ‬ȄAmerican Thyroid AssociationࡿЖ࡛ ឋȈҧ‫ޒ‬သѓ૗Ϧໍ‫ޠ‬ஐυȂԄ‫ݏ‬MMIؑСᏙ໕Ӷ20 mgпίȂ‫ܗ‬PTUؑСᏙ ໕Ӷ450 mgпίȂѠࡼ៊ᗾҕ‫(ٱ‬5)Ȅ࣐Πᗘռ‫ึޠܓࢴن‬ҢȂ࡛ឋᓻӒՄኍ ‫ٻ‬ңMMI‫ݾ‬ᕜȄ݉ңATD‫ޠ‬঴‫ٱ‬ҕᒒȂҕ‫ٱ‬Ϝ᛿‫ޠޑ‬ᐩ࡚ࣻ࿌մȂ‫ٯ‬ϛཽᄈ ུҢ‫ޠڌ‬ҧ‫ޒ‬သѓ૗‫ܗ‬Ңߞึ‫ي‬ആԚϛًኈ៫(27)ȄՎܼҧ‫ޒ‬သѓ૗մί‫ޠ‬঴ ‫ٱ‬ҕᒒȂ‫ٻ‬ңlevothyroxine‫ݾ‬ᕜ‫ٯ‬ϛཽᄈུҢ‫ޠڌ‬ҧ‫ޒ‬သѓ૗ആԚኈ៫Ȅ

ҧ‫ޒ‬သᕝ ᛅѺ෉໣‫ܗ‬౱ࡤึ౫‫ޠ‬ҧ‫ޒ‬သᕝȂ‫ڐ‬ႲࡤᇅΚૢఋထ‫ٯ‬ณৰ౵(28)ȄτӼ ኶‫ޠ‬ҧ‫ޒ‬သᕝ࢑឵ܼϸϾًԂ࠯Ȟwell-differentiated carcinomaȟȂҦܼໍ৥ ጦᄛȂ࡛ឋѠᢏᄇՎ౱ࡤӕК೛Ȃ‫ڐ‬ඉึᐡ౦‫ڸ‬ႲࡤഎᇅᛅѺ෉໣К೛‫ء‬ԥ ৰ౵ȄՅЎ኶ԚߞٟഁȃလድႇτആԚᔇय़ȃϸϾϛً࠯ȃգᓎᙾಌ‫ޠ‬ҧ‫ޒ‬ သᕝȂࠍሰӶᛅѺ෉໣Ꮢ‫ץ‬೏౪ȇಒΡѺ෉࢑ࣻᄈᛨۢѠ௦‫ߩڨ‬౱ऌК೛‫ޠ‬ ਣᐡȄՎܼҧ‫ޒ‬သᕝ೛ࡤ‫ޠ‬ஐυȂ࡛ឋӶК೛ࡤ‫ܗ‬К೛ђܺৣ࿩‫ݾ‬ᕜࡤϳঐ УӕᛅѺȄसᗚԥ෥੽‫ޠ‬ᕝಡबȂ࡛ឋπ݉levothyroxineᔇ‫׼‬လድԚߞȂҭዀ ࢑஡TSHঅᆱࡼՎ0.3-2 mU/Lϟ໣Ȅ 101

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь

๗ᇮ 1. ङԥ3%‫ޠ‬Ѻஐԥҧ‫ޒ‬သѓ૗Ϧໍ‫ܗ‬մί‫ޠ‬ୱᚡȄ‫ء‬ԥᎍ࿌‫ݾ‬ᕜ‫ၘޠ‬Ȃ

ཽԥၷା‫ॴޠ‬ᓏя౫ׂ৓‫઀ึڂ‬Іᄈफ‫ུܗڌ‬Ң‫ڌ‬౱Ңϛًኈ៫Ȅ 2. ᑰொҧ‫ޒ‬သѓ૗Ϧໍ‫ޠ‬ஐυȂӶᛅѺߒ෉࡛ឋ‫ٻ‬ңPTU‫ݾ‬ᕜȂӱ࣐ԥ

ၷմ‫ڸ‬ၷሇཌྷ‫ޠ‬य࿍फձңȄᛅѺϜȃࡤ෉ࠍ࡛ឋ‫ٻ‬ңMMIȂӱ࣐ԥ ၷմ‫نޠ‬᠛ࢴ‫ܓ‬୚ձңȄ࡛ឋؑ4-6໋ᔯขҧ‫ޒ‬သѓ૗Ȃ௢‫ښ‬free T4ᐩ ࡚ӶҔளঅα४‫ܗ‬౲ାܼҔளঅȄ 3. ᄈҧ‫ޒ‬သѓ૗մί‫ޠ‬Ѻஐᔗ๞ϡlevothyroxine‫ݾ‬ᕜȂؑ4-6໋ᔯขҧ‫ޒ‬

သѓ૗Ȃ௢‫ښ‬TSHᐩ࡚մܼ2.5 mIU/LȄ 4. American College of Obstetricians & Gynecologistҭࠊ‫ٯ‬ϛ࡛ឋᄈ‫ٴ‬ᖞ‫ט‬

ҧ‫ޒ‬သѓ૗Ϧໍ‫ܗ‬մί‫ޠ‬Ѻஐ๞ϡ᛿‫ݾޑ‬ᕜȄ 5. ࣻᄈܼ‫ܗޒ઀ٸ‬ӡᓏӱφໍ՘ᒶᐆ‫ܓ‬ᑣᔯȂҭࠊϬณ٘஋ᜍᐄᡘұᄈ

Ѻஐໍ՘ӓ८‫ޠܓ‬ҧ‫ޒ‬သѓ૗ᑣᔯѠпԥ‫؂‬Ԃ‫ڻޠ‬౱෉ႲࡤȄ 6. ѯᢋᔗᏒ‫ໍץ‬՘Ѻ෉Ӭ‫ڂ‬ҧ‫ޒ‬သ੾੿‫ࣻޠ‬ᜱः‫ف‬ȂєࢃѺ෉࿩‫ڦឹޠ‬

໕௒‫ם‬ȃѺ෉ҧ‫ޒ‬သѓ૗Ϧໍ‫ܗ‬մί‫ޠ‬౿՘౦ȃпІୋߴ‫࡚ښ‬ίഷᎍ ࿌‫ޠ‬ᑣᔯР‫๊​๊ݳ‬ȂҐρၦਠ஡ԥֆܼᖞ‫ט‬೏ဋᇅ੿ொᒛ୧Ȅ

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6. Li C, Shan Z, Mao J, Wang W, Xie X, Zhou W, et al. Assessment of thyroid function during first-trimester pregnancy: what is the rational upper limit of serum TSH during the first trimester in Chinese pregnant women? J Clin Endocrinol Metab. 2014;99:73-9.

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8. A n d e r s e n S L, O l s e n J, Wu C S, L a u r b e rg P. S p o n t a n e o u s a b o r t i o n, s t i l l b i r t h a n d hyperthyroidism: a danish population-based study. Eur Thyroid J. 2014;3:164-72. ׂ৓෉ҧ‫ޒ‬သ੾੿ྲៗ‫ޠ‬ஐ౱ऌᢏᘉ

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9. De Groot L, Abalovich M, Alexander EK, Amino N, Barbour L, Cobin RH, et al. Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012;97:2543-65.

10. Yoshihara A, Noh J, Yamaguchi T, Ohye H, Sato S, Sekiya K, et al. Treatment of graves' disease with antithyroid drugs in the first trimester of pregnancy and the prevalence of congenital malformation. J Clin Endocrinol Metab. 2012;97:2396-403.

11. Andersen SL, Olsen J, Wu CS, Laurberg P. Severity of birth defects after propylthiouracil exposure in early pregnancy. Thyroid. 2014;24:1533-40.

12. Andersen SL, Olsen J, Wu CS, Laurberg P. Birth defects after early pregnancy use of antithyroid drugs: a Danish nationwide study. J Clin Endocrinol Metab. 2013;98:4373-81.

13. Song R, Lin H, Chen Y, Zhang X, Feng W. Effects of methimazole and propylthiouracil exposure during pregnancy on the risk of neonatal congenital malformations: A meta-analysis.

PLoS One. 2017;12:e0180108.

14. Bahn RS, Burch HB, Cooper DS, Garber JR, Greenlee MC, Klein I, et al. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Endocr Pract. 2011;17:456-520.

15. Allan WC, Haddow JE, Palomaki GE, Williams JR, Mitchell ML, Hermos RJ, et al. Maternal WK\URLG GH¿FLHQF\ DQG SUHJQDQF\ FRPSOLFDWLRQV LPSOLFDWLRQV IRU SRSXODWLRQ VFUHHQLQJ - 0HG Screen. 2000;7:127-30.

16. Abalovich M, Gutierrez S, Alcaraz G, Maccallini G, Garcia A, Levalle O. Overt and subclinical hypothyroidism complicating pregnancy. Thyroid. 2002;12:63-8.

17. Lazarus J, Brown RS, Daumerie C, Hubalewska-Dydejczyk A, Negro R, Vaidya B. 2014 European thyroid association guidelines for the management of subclinical hypothyroidism in pregnancy and in children. Eur Thyroid J. 2014;3:76-94.

18. Alexander EK, Marqusee E, Lawrence J, Jarolim P, Fischer GA, Larsen PR. Timing and magnitude of increases in levothyroxine requirements during pregnancy in women with hypothyroidism. N Engl J Med. 2004;351:241-9.

19. Benhadi N, Wiersinga WM, Reitsma JB, Vrijkotte TG, Bonsel GJ. Higher maternal TSH levels in pregnancy are associated with increased risk for miscarriage, fetal or neonatal death. Eur J Endocrinol. 2009;160:985-91.

20. Casey BM, Dashe JS, Wells CE, McIntire DD, Leveno KJ, Cunningham FG. Subclinical hyperthyroidism and pregnancy outcomes. Obstet Gynecol. 2006;107:337-41.

21. Casey B, de Veciana M. Thyroid screening in pregnancy. Am J Obstet Gynecol. 2014;211:3513 e1.

22. Negro R, Schwartz A, Gismondi R, Tinelli A, Mangieri T, Stagnaro-Green A. Increased pregnancy loss rate in thyroid antibody negative women with TSH levels between 2.5 and 5.0 LQ WKH ¿UVW WULPHVWHU RI SUHJQDQF\ - &OLQ (QGRFULQRO 0HWDE ( 23. Haddow JE, Palomaki GE, Allan WC, Williams JR, Knight GJ, Gagnon J, et al. Maternal thyroid deficiency during pregnancy and subsequent neuropsychological development of the child. N Engl J Med. 1999;341:549-55.

24. Pop VJ, Kuijpens JL, van Baar AL, Verkerk G, van Son MM, de Vijlder JJ, et al. Low maternal free thyroxine concentrations during early pregnancy are associated with impaired psychomotor development in infancy. Clin Endocrinol (Oxf). 1999;50:149-55.

25. Lazarus JH, Bestwick JP, Channon S, Paradice R, Maina A, Rees R, et al. Antenatal thyroid

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screening and childhood cognitive function. N Engl J Med. 2012;366:493-501.

26. Casey BM, Thom EA, Peaceman AM, Varner MW, Sorokin Y, Hirtz DG, et al. Treatment of Subclinical Hypothyroidism or Hypothyroxinemia in Pregnancy. N Engl J Med. 2017;376:815-25.

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2000;85:3233-8.

28. Yasmeen S, Cress R, Romano PS, Xing G, Berger-Chen S, Danielsen B, et al. Thyroid cancer in pregnancy. Int J Gynaecol Obstet. 2005;91:15-20.

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ጢࡤᇮ ᝸џԒԒཽਣя‫ޏ‬ȶҧ‫ޒ‬သ๗࿾ІϸϾ࠯ᕝᖞ‫ט‬КьȷࡤȂϲϸ‫ݫ‬Ᏹཽ બਫ೏ᓎ֊᝱ࡧ຀КίΚҐ‫ޠ‬ё‫ޑ‬ȂӶං՞ձ޲‫࡛ޠ‬ឋίȂᛅѺਣҧ‫ޒ‬သ੾ ੿‫ޠ‬೏ဋ֊ਜ਼αᘩ८Ȃ௦຀Ҧ෇߈।౪‫ߞٲ‬Іചࡧႁл‫ې‬Ӥཏໍ՘ࡤȂ‫ש‬উ ॐίпज୾ҧ‫ޒ‬သᏱཽ2017Ԓя‫ࡿޠޏ‬Ж࣐୥ՄȂ୉࣐ಒΡҐя‫ޏ‬ё‫ޠޑ‬Р ӪȄ ෇౪‫ߞٲ‬Ӊϲߩள२ຝ‫ܧ‬ᔦԒሇᚃ৲я‫ٿ‬ᅌᗀȂϛ፤Ԓཽ‫ܗ‬ऎཽ۠‫ޠ‬ൣ ֚‫پ੿ܗ‬ଇ፤ཽ‫ޠ‬ൣࣲ֚ԄԫȂӱԫ೼Ґȶׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬ Кьȷη࢑ᗝ፝ϲϸ‫ݫ‬ϜҢх‫ޠ‬ᚃ৲‫॓ٿ‬ೱጢቹȂӶᗝङ‫ޠ‬ႇโ࿌ϜȂᡲ‫ש‬ ౐౐ད‫ژ‬Ԓሇ‫ޠ‬ϲϸ‫ݫ‬ᚃ৲઎‫࢑ޠ‬ঐঐዦ՗‫ݵ‬ឣȃዦЗϵઊȂӫ൑ᗷϸයѯ ᢋө೏ᚃଲȂԞ‫߭ژ‬ӈࡤؑঐ΢എҴ֊Ӳ᙮ӤཏȂ‫࢑؂‬ᡲ‫ש‬ད୞࿳ϸȄ ҐКь‫ޠ‬ኦቹੀԓ࢑п2017ԒATA guideline‫ޠ‬ୱᇅ๏࣐ᙣҐȂөঐത࿾ пज୾‫࡛ޠ‬ឋᒋӬѯᢋᖞ‫ޠט‬౫‫ٯݸ‬ђпಜᐍȂηᎍਣᏳΤѯᢋҐρึߓ‫ޠ‬ ၦਠ୉࣐‫ུ؂‬Ȃؑ጖Нതഎစႇϲϸ‫ݫ‬Ᏹཽ‫ޠ‬౪ᆀ‫ٲ‬Ճ৲উਯᎨࡤණ‫ٽ‬Ᏻ ᠟ȄӤਣӶ11ঐത࿾ѵȂѫѵᗝ፝Πϊ‫ڌ‬ऌጿНЅᚃ৲Іஐ౱ऌࢺ੏‫ڸ‬ᚃ৲ ණ‫ٽ‬஠ঢ়ཏُȄ‫ᜳ؂‬ூ‫࢑ޠ‬஼Љ໚Ճ৲ᔔ‫ש‬উ‫ࡍޠ‬८໕ٙॐ୉ණ‫ٽ‬Πу‫ޠ‬ฬ ձȂ૗ᡲτঢ়਍‫ژ‬ΚҐ፭Зਈҭ‫ޠ‬КьȄ ᙛណӫມ‫ޠ‬ಜΚϬ࢑೼Ԫጢᒯႅ‫ژ‬Ӥኻ‫ޠ‬ୱᚡȂ‫ש‬উ࢑਴ᐄҖ୾87Ԓ୾ Ҵጢណᓣጢॐ‫ޠ‬ȶϲϸ‫ݫ‬Ᏹӫມȷ࣐ྦȂկ࿧‫ޠུژ‬Ԇཋ‫्ܗ‬ಓӬ౫х‫ޠ‬ᇴ ‫ݳ‬ᗚ࢑ԥ‫ٳ‬ཌྷ።ȄӶԫ‫ו‬గ‫ש‬উ‫ཽޠ‬সউϛ֌๞ϡ೼ҐКьჃᓿᇅଠ៫Ȃη ૗஋စளණ‫்ٽ‬উ‫ޠ‬ཏُІሰؒϡᏱཽȂᡲ‫ש‬উѠпጢᒯя‫؂ޏ‬ӼϛӤ᜹࠯ ‫ޠ‬ё‫ޑ‬Ȅ ަყ‫ݳ‬΢Ϝ๽Җ୾ϲϸ‫ݫ‬Ᏹཽબਫߞ!

105

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь ጢࡤᇮ

ቔቄ࣏

MEMO

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MEMO

107

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MEMO

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୾ঢ়შਫᓣя‫ࠣޏ‬Ⴒ՘ጢҭ (CIP) ၦਠ ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь .

2019 / ަყ‫ݳ‬΢Ϝ๽Җ୾ϲϸ‫ݫ‬Ᏹཽጢ຀ . -- ߒ‫ ޏ‬-ᇄіҀȈϲϸ‫ݫ‬Ᏹཽ ,2019.03 ८ȇ 18.2 x 25.7 ϵϸ ISBN 978-986-97559-0-0( ҂၇ ) 1. ҧ‫ޒ‬သ੾੿ 415.662

108002817

ׂ৓ᇅ౱ࡤҧ‫ޒ‬သ੾੿ᖞ‫ט‬ຩ‫ݾ‬Кь ጢ຀Ȉަყ‫ݳ‬΢Ϝ๽Җ୾ϲϸ‫ݫ‬Ᏹཽ ຀ձଓ౱᠍΢Ȉަყ‫ݳ‬΢Ϝ๽Җ୾ϲϸ‫ݫ‬Ᏹཽхߓ΢ ෇߈। ϏձϊಣȈе๳቉ȃ֗Ϯ๽ȃ‫ⷔܜ׉‬ȃ؄ԈⰩȃ؄ਥᄹȃ‫ڻ‬ਐസȃ ‫ݔ‬ᐚᆌȃ࠻‫ְڸ‬ȃࢋ๣ᇉȃࢺ੏‫ڸ‬ȃ༂֘ᆃȃ༂ೈෙȃ ቔ‫ݙ‬ᑹȃጿНЅ ( ‫ۘٸ‬Ы์ฬ௷ӗ ) ᖃጢᒯȈ෇߈।ȃചࡧႁ உ՘ጢᒯȈቔቄ࣏ я‫ึޏ‬՘Ȉަ ყ ‫ ݳ‬΢ Ϝ ๽ Җ ୾ ϲ ϸ ‫ ݫ‬Ᏹ ཽ ӵ ֮ȈѯіҀϜҔୣ‫ׄ܇‬՚ၰΚࢳ 50 ဵ 17 ዃϟ 11 Ⴌ ၘȈ02-2312-3718 ༉ ઎Ȉ02-2312-3712 ᆪ ֮Ȉwww.endo-dm.org.tw/endo/ E-mailȈtaiwan.endocrine.society@gmail.com я‫ޏ‬С෉Ȉ2019 Ԓ 3 У ߒ‫ޏ‬

‫ܛ᠍ޏ‬ԥȅᙛӠ҇‫ف‬

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