Thyroid Disorders In Pregnancy Research Articles

Maternal and fetal outcome in COVID 19 positive pregnant women with thyroid dysfunction

Background: Normally functioning thyroid glands are able to meet the increasing need for hormones during pregnancy and keep thyroid hormone levels within normal limits. However thyroid dysfunction in pregnancy can cause adverse maternal and fetal outcomes like pre-eclampsia and gestational hypertension, antepartum hemorrhage, anemia, preterm delivery, low birth weight and addition of SARS-CoV-19 infection can worsen the perinatal outcome. In present ambispective study, obstetric outcomes of 32 cases of COVID 19 positive pregnant women with thyroid dysfunction (Group A) were compared with 32 cases of COVID 19 negative pregnant women with thyroid dysfunction (Group B). Results: Pregnancy induced hypertension (PIH) was the most common antepartum complication noted in both the groups (28.1% vs 12.5%). Group-A had 40.6% LSCS rate whereas it was 37.5% in group-B. Average period of gestation at delivery was 38 weeks in both the groups. The most common neonatal complication was low birth weight (9.4%) in both the groups. Group A was also associated with meconium aspiration syndrome (MAS) (9.4%), neonatal sepsis (6.2%) and transient tachypnoea of newborn (TTN) (3.1%). NICU admissions were 37.5% in group A while only 6.25% in group B. (p value <0.01). Most common indication for NICU admission was MAS (9.4%) in group A. It was observed that incidence of pregnancy induced hypertension (PIH) and neonatal complications including NICU admissions were increased in presence of both COVID 19 and thyroid disorder as compared to only thyroid disorder in pregnancy. Multi-disciplinary approach with more vigilant monitoring can help reduce perinatal morbidity and mortality.

Study of thyroid disorders in pregnancy and their effects on feto-maternal outcomes

The second most common endocrine disease that occurs during pregnancy is thyroid disease. Overt and subclinical thyroid dysfunction can lead to adverse effects on both the fetus and the mother. Thyroid diseases during pregnancy affect maternal outcomes and neuropsychological development of the fetus. The objectives of this study were to investigate the effects of thyroid disorders on maternal health and its maternal and perinatal outcomes and to formulate a plan for the management of thyroid disorders in pregnancy. This prospective observational study involved 165 pregnant women. They will be assessed using thyroid function tests, and patients with deranged thyroid function will be treated and followed up. Pregnancy and outcomes were recorded. The findings of this research will offer important new information regarding possible side effects linked to thyroid issues in mothers as well as the clear advantages of therapy. Maternal thyroid diseases have several risk factors in addition to clear advantages of treatment.

Updates on thyroid disorders in pregnancy and the postpartum period.

NPs play a pivotal role in caring for pregnant people. This article provides an overview of gestational and postpartum thyroid disorders, including their assessment, management, and indications for referral. The goal of this article is to help providers better assess and manage thyroid disorders during pregnancy and improve patient outcomes.

Association of vitamin A with gestational diabetes and thyroid disorders in pregnancy and their influence on maternal, fetal, and neonatal outcomes.

Gestational diabetes mellitus (GDM) and thyroid disorders during pregnancy pose significant health concerns, impacting a substantial number of mothers globally. Globally, about 14% of pregnant women develop GDM, while thyroid disorders impact approximately 2%-3%. Both conditions contribute to adverse outcomes, including gestational hypertension, excessive fetal growth, and heightened perinatal morbidity. The central focus of this literature review is to examine the relationship between vitamin A, a crucial fat-soluble micronutrient in fetal development, and the occurrence of GDM and thyroid disorders during pregnancy. The primary research question investigates the association between vitamin A, GDM, and thyroid disorders, analyzing their combined impact on maternal, fetal, and neonatal outcomes. The review underscores the potential of vitamin A to modulate the risk and outcomes of GDM and thyroid disorders during gestation, emphasizing its role in GDM development and resolution and its influence on thyroid function in pregnancy.

First trimester screening for thyroid disorders in pregnancy

First trimester screening for thyroid disorders in pregnancy

Prevalence of Thyroid Disorders among Pregnant Women at Birat Medical College Teaching Hospital

Background: Thyroid disorders (TD) are the second most common endocrine disorders seen in pregnancy. TD is known to be associated with adverse maternal and fetal outcomes.
 Materials and Methods: This was a hospital based descriptive cross-sectional study. All the pregnant women attending the antenatal clinic at Birat Medical College Teaching Hospital from 1st July 2021 to 30th June 2022 were enrolled in the study, irrespective of their gestational age and gravida status. Pregnant women with diagnosed thyroid disorder and are on medication, multiple gestation, Diabetes mellitus, Hypertension and pregnant women with age more than 35 years were excluded from study. Thyroid function status of pregnant women was assessed by measuring serum levels of thyroid stimulating hormone (TSH) and if the TSH value was deranged then they underwent free T3 and free T4 level. Based on the TFT reports they will be classified as euthyroid, subclinical hypothyroidism and overt hypothyroidism, subclinical hyperthyroidism and overt hyperthyroidism.
 Results: A total of 395 pregnant women were enrolled in this study. The mean age and standard deviation of pregnant women was 25.25± 4.76 years. Among 395 pregnant women 93(23.6%) pregnant women have thyroid disorder. Subclinical hypothyroidism and Overt hypothyroidism were 19% and 1.8% respectively. Subclinical and Overt hyperthyroidism were 1.5% and 1.3% respectively.
 Conclusion: The prevalence of thyroid disorder in pregnancy was 23.6%. The most common thyroid disorder observed was Subclinical hypothyroidism comprising 19% cases followed by overt hypothyroidism comprising 1.8% cases followed by Subclinical and Overt hyperthyroidism 1.5% and 1.3% cases respectively.

Early treatment will prevent feto-maternal complications in thyroid disorders during pregnancy: A prospective study.

Associations between adverse maternal complications and fetal outcomes are known entity in thyroid disorders during pregnancy. Thus, prompt identification of thyroid disorders and timely initiation of treatment is essential. Universal screening and early treatment of pregnant women for thyroid disorder should be considered especially in a resource-limited country like India with a high prevalence of undiagnosed thyroid disorders and adverse feto-maternal outcomes. Early treatment will prevent feto-maternal complications in thyroid disorders in pregnant females visiting outpatient department in tertiary care hospital in rural settings. This study was conducted in a tertiary care rural-based medical college with participation from departments of Obstetrics and Gynaecology, Medicine, and ENT. Expectant mothers in first trimester who had urine pregnancy test positive in outpatient clinic were included after a written informed consent. Detailed history and examination was done. TSH was done if abnormal-FT3 and FT4 were done. All thyroid disorders were treated according to American Thyroid Association (ATA) 2017 guideline. All pregnancies were followed up for maternal complications and fetal outcomes. Data from the performa were entered in Office Excel and analysis was performed using STATA (14.2). Descriptive statistics (mean [standard deviation], Frequency [%], etc.) were used to depict profile of study participants, prevalence of thyroid dysfunction, and outcome measures. Chi-square test was employed to assess the association between thyroid dysfunction and various maternal and fetal outcomes. A P value less than. 05 was considered statistically significant. Of 350 pregnant females, 83 (23.5%) pregnant females had thyroid disorder. Of which, 33 (9.4%) had subclinical hypothyroidism, 37 (10.5%) had overt hypothyroidism, 11 (3.1%) had subclinical hyperthyroidism, and two (0.5%) had hyperthyroidism. The prevalence of hypothyroidism in pregnancy increases with increasing age (P value. 001) and not associated with parity, abortion, and consumption of iodized salt. Total patients with feto-maternal outcome follow-up were 241. Pre-eclampsia (P value. 004) was a significant complication in hypothyroid mothers. There was no significant difference in the rate of cesarean section and preterm delivery in hypothyroid and euthyroid mothers. Neonatal outcomes showed more trends of abortion, fetal demise, and IUFD in the hypothyroid group, although not statistically significant. (P value. 07). Due to the high prevalence of thyroid disorders during pregnancy, universal screening of thyroid disorders should be done in early pregnancy instead of high-risk screening. Early detection and early treatment in the first 10 weeks of pregnancy help to prevent maternal and fetal complications of thyroid disorders in pregnancy. Pre-eclampsia is to be monitored in treated pregnant females with hypothyroidism.

Prevalence of Hypothyroidism in Pregnancy in a Tertiary Care Hospital

Introduction: Thyroid disorders are the most common endocrine disorders affecting women of reproductive age. The most frequent thyroid disorder in pregnancy is maternal hypothyroidism. During early pregnancy, the fetus is totally dependent on maternal thyroid hormone supply. Thyroid hormone is critical for fetal brain and intellectual development. Thyroid hormone is also important for some preventable pregnancy complications like anaemia, low birth weight, abruptio placenta, preeclampsia, etc., which pose special risks for the mother and developing fetus. Aim of the study: To assess the prevalence of hypothyroidism in pregnant women and thus ensure appropriate treatment for the wellbeing of the mother and baby. Methods: This prospective obsessional study was conducted on 113 pregnant women at US Bangla Medical College Hospital, Dhaka, Bangladesh, who attended obstetrics outdoors. Women were randomly chosen irrespective of age, parity, residence, and socioeconomic status. Women with multiple pregnancies or having any pre-existing medical disorder were excluded. All women were investigated for TSH along with routine pregnancy tests. All were divided into two groups: normal/euthyroid and abnormal/thyroid disorders, considering their thyroid status. Result: We found the prevalence of thyroid dysfunction in pregnancy was 17.7%, with hypothyroidism being 15.93%, of which 10.62% were subclinical hypothyroidism, 5.31% were cases of overt hypothyroidism, and 1.77% were cases of hyperthyroidism. Conclusion: This study showed an increased prevalence of hypothyroidism in pregnancy, recommending a need for universal screening for all pregnant women in the early weeks of pregnancy. This study aims at validating the efficacy of the above-mentioned screening for a better pregnancy outcome.

Prevalence of thyroid disorders in pregnancy in northern Algeria

Prevalence of thyroid disorders in pregnancy in northern Algeria

Prevalence of Thyroid Disorders in Pregnancy and Associated Maternal and Fetal Outcome

Prevalence of Thyroid Disorders in Pregnancy and Associated Maternal and Fetal Outcome

Thyroid disease in pregnancy

Pregnancy is accompanied by metabolic changes associated with the thyroid gland. It is therefore important to understand the underlying physiological alterations and the management of patients with thyroid disorders in pregnancy. This review focuses on the physiology and the management of hyperthyroidism, hypothyroidism and thyroid nodules in the context of pregnancy.

A Study on Prevalence of Thyroid Disorders in Pregnancy and its Impact on Maternal and Fetal Outcomes in a Tertiary Care Centre in Villupuram

A Study on Prevalence of Thyroid Disorders in Pregnancy and its Impact on Maternal and Fetal Outcomes in a Tertiary Care Centre in Villupuram

Thyroid disorders in pregnancy

ABSTRACT Thyroid disease is the second most common endocrine disorder encountered in pregnant women with substantial maternal and fetal implications. Therefore, assessing thyroid status during pregnancy is essential for initiating treatment in newly diagnosed individuals and adjusting doses for those already under treatment. To initiate proper and timely treatment evidence-based recommendations are required for clinical decisionmaking in managing thyroid disorders in pregnant and postpartum women. Keeping this in mind, task force consisted of experts in the fields of endocrinology and thyroid disease was constituted and various published data and guidelines were explored to address screening, diagnosis, and management of hypothyroidism, thyrotoxicosis, GD, thyroid nodules, and post-partum thyroiditis and their related complications during pregnancy. This document provides much-required insights and useful, practical, and accurate guidance that aids a practicing clinician.

Thyroid Disorders in Pregnancy and Their Maternal and Foetal Outcome in Tertiary Care Centre

BACKGROUND
 In pregnant women, thyroid disorders are common endocrine problems and due to non-specific symptoms and hyper-metabolic state of pregnancy they are often neglected. To know the prevalence of thyroid disorders in pregnant women and their maternal and foetal outcome was the purpose of this study.
 METHODS
 This was an observational study which was conducted from 15th November 2021 to 15th May 2022 in the Department of Obstetrics and Gynaecology, Srinivas Medical College, Mukka, (Mangalore). Registration of one fifty pregnant women attending antenatal clinic in first trimester was done. Detailed history and examination was done. Thyroid stimulating hormone (TSH), free triiodothyronine (FT3) and free thyroxine (FT4) level evaluation was done apart from routine antenatal investigations.
 RESULTS
 Among 150 pregnant women, the prevalence of thyroid disorders is 14 (9.31 %). Subclinical hypothyroidism 9 (6 %) was the most common thyroid disorder observed. Maternal anaemia and eclampsia was most common complication 3 each (33.33 %). 1 (11 %) was antepartum haemorrhage. Thyroid disorder occurred during the 2nd trimester 58.33 %; 25 % and 16.66 % in 1st and 3rd trimester. Most commonly observed foetal birth weight in this study were between 2 - 2.5 kgs 7 (77.77 %). Most common foetal complication observed were foetal growth restriction (five) with spontaneous abortion and intra uterine foetal demise (IUFD) (one each) was noted. Out of all thyroid disorders associated with pregnancy, subclinical hypothyroidism is the most frequently noted. Patients with subclinical hypothyroidism remain asymptomatic when not treated, but had bad obstetric and neonatal outcome, although less severe than overt hypothyroidism cases.
 CONCLUSIONS
 Timely screening of pregnant women is required during pregnancy for the prevention of pregnancy which helps in the early diagnosis and management of complications related to maternal and foetus due to thyroid disorders.

Bangladesh Endocrine Society Guidelines for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum

Background: In Bangladesh, patients with thyroid disorders are managed in accordance with the recognized guidelines and based on expert experience, as comprehensive national guidelines are currently lacking. The Bangladesh Endocrine Society (BES), as a professional body, has been working to develop guidelines for the last couple of years. Most recently, BES formulated practical recommendations for the management of thyroid disorders during pregnancy, which will be termed the “Guideline on Thyroid Disorders in Pregnancy in Bangladesh 2022,” Methods: The BES formed a task force comprising experts in this field to formulate the practical recommendations for the management of thyroid disorders during pregnancy under several sections. The members of this task force comprehensively reviewed the available evidence for the specific conditions. Three well-known databases (Google Scholar, PubMed, and Scopus) were searched to determine the evidence. The task force members were well trained on reviewing the documents and methods of evidence synthesis. Each section of the recommendation was drafted by one member and subsequently reviewed. There was no barrier to the date or type of article published in the aforementioned databases except for articles published other than English. Due to the scarcity of intervention studies, ideas and findings of observational studies, case studies and expert recommendations were considered during the formulation of the guidelines. All members and affiliated persons declared no competing interest, and it was managed and communicated by the President of the BES. Results: The current guidelines for the management of thyroid disease in pregnancy include recommendations about the screening of thyroid function in pregnancy, planning pregnancy in women with thyroid disorders, interpretation of thyroid function tests, management of hypothyroidism and hyperthyroidism in pregnancy, management of thyroid nodules and thyroid emergencies throughout pregnancy, postpartum care, and directions of future research. Conclusions: Our utmost efforts were centered on developing evidence-based recommendations to inform all the levels of clinicians of Bangladesh for the easy understanding and decision-making processes in the management of thyroid disorders in pregnancy and afterward. While we care most to prepare the guideline, all recommendations are the opinion of society and admit the scope of making individualized decisions for the optimal care of patients.

Prevalence and Complications of Subclinical and Overt Hypothyroidism in Pregnancy at North Indian Tertiary Care Center.

Thyroid disorders are one of the commonest endocrine problems among pregnant women. It is often argued that it is not only overt, but subclinical thyroid dysfunction also has similar adverse effects on maternal and fetal outcomes. There is a huge deficiency of data from the Indian population to assess the prevalence of thyroid dysfunction in pregnancy. This study aimed to determine the prevalence of thyroid disorders in pregnancy and their impact on obstetrical outcomes in the Indian population. The study also had the objective of finding a correlation between maternal and fetal thyroid-stimulating hormone (TSH) levels in hypothyroid pregnancies. Around 1055 pregnant women in the first and second trimesters were enrolled in the study. A detailed history was noted and general examinations were done. Apart from routine obstetrical investigations, TSH level estimation was done. If the TSH level was deranged, then free T4 (fT4) and free T3 (fT3) levels were also estimated. Furthermore, 50 hypothyroid and euthyroid pregnant women from the same cohort were followed till delivery. Their obstetrical and perinatal outcomes were noted. The prevalence of thyroid dysfunction was 36.5% in this study, which was quite high in the population. Moreover, hypothyroid groups were prone to have pregnancy-induced hypertension (P = 0.03), intrauterine growth restriction (P = 0.05), and preterm delivery (P = 0.04) as compared to control. Cesarean section rate for fetal distress was significantly higher among pregnant hypothyroid women (P = 0.05). Neonatal respiratory distress and low appearance, pulse, grimace, activity, and respiration (APGAR) () scores were significantly more in the hyperthyroidism group (P = 0.04 and P = 0.02, respectively). Maternal TSH was significantly correlated with hemoglobin levels, HbA1c, and systolic blood pressure. Significant adverse effects on maternal and fetal outcomes were seen emphasizing the importance of routine antenatal thyroid screening.

Gestational TSH Levels and Their Association with Obstetric and Neonatal Outcomes in Lebanon: A National Observational Retrospective Study

Objectives: Gestational hypothyroidism is associated with obstetric complications and disturbances in the offspring development; however, it remains easy to treat. The objective of the study was to describe thyroid-stimulating hormone (TSH) levels in pregnant women and analyze their association with pregnancy course and outcome. Design: This national, observational, retrospective study analyzed data on Lebanese pregnant women visiting their obstetrician as part of their routine follow up. Participants, Setting and Methods: Enrolled subjects were all pregnant women who visited the obstetrics clinic from 01 September 2017 until 31 August 2018, as part of their routine follow up and have a TSH level record. In 2020, during their routine follow-up visit, the participants signed an informed consent to allow the investigator to access the data retrospectively and enter them into his database. Relevant participant characteristics and outcome data were collected from clinic files of the private clinic of Dr Abi Tayeh, at the Department of Obstetrics and Gynecology, H?tel-Dieu de France University Hospital, Beirut, Lebanon. Results: A total of 419 women were enrolled, 11.5% of them reported at least one comorbidity prior to pregnancy, most often the antiphospholipid syndrome, followed by thrombophilia and hypothyroidism. At least one complication was reported for 18.4% of participants. Around 87.6% of participants delivered a full-term baby with normal birth weight for most. The average TSH value for all participants was within the normal range at all time-points. Highest TSH values were recorded during the first trimester. As treatment was immediately initiated in women with abnormal TSH levels, no correlation was observed between TSH levels and pregnancy outcomes or pregnancy complications at any time-point. Conclusions: This study highlights satisfactory routine practice in the management of thyroid disorders in pregnancy and underscores the need for routine TSH screening for all pregnant women.

Prevalence of thyroid dysfunction in pregnancy and its association with feto-maternal outcomes: A prospective observational study from a tertiary care institute in Northern India

BackgroundThyroid dysfunction in pregnancy is one of the most prominent endocrinological disorders. Physiological changes in thyroid status and non-adaptation to these changes during pregnancy lead to thyroid dysfunction resulting in feto-maternal complications. In this context, we undertook this study to estimate the prevalence of thyroid disorders in pregnant women and their association with feto-maternal outcomes. MethodsThis prospective observational study was carried out in a tertiary care institute in Punjab, North India. We recruited 347 pregnant women who visited the OPD (Out Patient Department) through consecutive sampling, out of which 300 were included in our final analysis. A detailed history and clinical examination were made. Apart from routine ante-natal investigations, we estimated the TSH levels. In case of abnormal TSH values, free T4 and T3 levels were assessed. Study participants were followed till 12 weeks post-delivery to observe their obstetrical and perinatal outcomes. ResultsOverall prevalence of thyroid disorders in pregnancy was 33.9%, with hypothyroidism (31.6%) being more common than hyperthyroidism (2.3%). A significant association was found between thyroid disorders and feto-maternal complications (p value < 0.001). Adverse maternal effects observed in the hypothyroid group as compared to the euthyroid group were preeclampsia (14.7% vs. 5.6%), anemia (7.4% vs. 6.1%), abortion (7.4% vs. 0.5%) and meconium-stained liquor (5.3% vs. 2.5%). Abortion (71.4%) was the main complication in the hyperthyroid group. Adverse neonatal outcomes were low and very low birth weight, low Apgar scores, respiratory distress syndrome, and meconium aspiration syndrome. ConclusionWe observed a high prevalence of thyroid disorders and their relative adverse effects. Universal screening of all women in the pre-conception period or as early as pregnancy is diagnosed, is recommended to reduce subsequent feto-maternal morbidity and mortality.

Prevalence of overt and subclinical thyroid dysfunction in pregnant women and outcome in a tertiary care centre

Aim: To know the prevalence of overt and subclinical thyroid disorders in Indian pregnant women and to know the effect of overt and subclinical thyroid dysfunction on maternal and fetal outcome.&#x0D; Materials and methods: This study was conducted at the Government Maternity Hospital, sultan bazaar, Osmania medical college, Hyderabad over a period of 15 months from august 2016 to October 2017. 1000 pregnant women who attended the antenatal clinic were screened for the thyroid dysfunction. Serum TSH level estimated. fT3, fT4 and anti TPO Ab levels were estimated if the TSH level was abnormal. Patients were managed accordingly and followed till the delivery. Maternal and fetal outcome recorded.&#x0D; Results: It was a prospective study done on 1000 antenatal women. Prevalence of thyroid disorder in this study was 11.3%. Prevalence of subclinical, overt hypothyroidism, subclinical and overt hyperthyroidism was 9.4%, 1.4%, 0.4% and 0.1% respectively. Subclinical hypothyroidism was associated with complications like preeclampsia (13.8%), Anaemia (15.95%), preterm delivery (6.38%), Intrauterine growth restriction (4.25%), low birth weight (12.76%) and Intrauterine fetal death)(2.12%). Overt hypothyroidism was associated with complications like Preeclampsia (14.28%), anaemia (21.4%), Preterm delivery (14.28%), intrauterine growth restriction (14.28%), low birth weight (21.4%) and Intrauterine fetal death (7.14%). Incidence of CD was 18.05% in women with hypothyroidism. Subclinical hyperthyroidism was associated with complications like Preeclampsia, Preterm delivery, Intrauterine growth restriction, Intrauterine fetal death.&#x0D; Conclusion: Thyroid disorders in pregnancy are significantly associated with both maternal and fetal complications and adversely affect the outcome of pregnancy. Hence, early identification of thyroid disorders and timely initiation of treatment is essential

Accurate interpretation of thyroid dysfunction during pregnancy: should we continue to use published guidelines instead of population-based gestation-specific reference intervals for the thyroid-stimulating hormone (TSH)?

BackgroundConsidering the changes in thyroid physiology associated with pregnancy and poor outcomes related to abnormal maternal thyroid function, international guidelines recommend using population-based trimester-specific reference intervals (RIs) for thyroid testing. If these RIs are not available in the laboratory, implementing recommended fixed cut-off values globally is still controversial. To address this issue, we aimed to establish appropriate RI of thyroid-stimulating hormone (TSH) in pregnant Turkish women for our laboratory and compare the prevalence of thyroid dysfunction based on the established and recommended criteria.MethodsOf 2638 pregnant women, 1777 women followed in the obstetric outpatient were enrolled in the reference interval study after applying exclusion criteria related to medical and prenatal history. A retrospective study was conducted by collecting data from July 2016 to March 2019. Serum TSH was measured by UniCel DxI 800 Immunoassay System (Beckman Coulter Inc., Brea, CA, USA). The study design relied on two approaches in order to classify pregnant women: trimester-specific and subgroup-specific; the latter involved dividing each trimester into two subgroups: T1a, T1b, T2a, T2b, T3a, T3b. The lower and upper limits of the RIs were derived by the parametric method after normalizing the data distribution using the modified Box-Cox power transformation method.ResultsThe lowest TSH value was detected at 8-12 weeks in early pregnancy, and the median value of TSH in the T1b subgroup was significantly lower than the T1a subgroup (P < 0.05). TSH levels showed a gradual trend of increase along with the pregnancy and increased significantly in the T2a, T2b, and T3b subgroups compared to the preceding subgroups (P < 0.05). Compared to the diagnostic criteria recommended by American Thyroid Association (ATA), the prevalence of thyroid dysfunction was significantly different from the established trimester- and subgroup-specific RIs throughout the pregnancy (P < 0.001).ConclusionsWe conclude that establishing gestation- and laboratory-specific RIs, especially for TSH, is essential for diagnosing thyroid disorders in pregnancy, and the recommended universal cut-off values, which may contribute to the risk of a misdiagnosis or a missed diagnosis, should be taken with caution in the clinical setting. However, regarding the fluctuation of thyroid function tests throughout pregnancy, trimester-specific RIs are insufficient, and implementing split phases is required.