Background 

Hypothyroidism, a common endocrine disorder in women of reproductive age, can cause serious maternal and fetal complications if not diagnosed and managed early. Pregnancy increases thyroid hormone demand, potentially destabilizing some patients. Primary care physicians play a key role in screening and follow-up.Aim: This study aimed to assess the knowledge, attitudes, and practices of primary care physicians in the Kairouan region regarding hypothyroidism management during pregnancy, to identify gaps and propose recommendations for improved maternal–fetal outcomes.

Materials and Methods:

A cross-sectional study was conducted among primary care physicians working in the Kairouan region. Participants completed a questionnaire assessing their knowledge of gestational hypothyroidism, their attitudes toward screening and management, and their self-reported clinical practices. The survey assessed participants’ sociodemographic characteristics, knowledge, attitudes, and clinical practices regarding hypothyroidism in pregnancy. Data were analyzed descriptively using SPSS 25, and ethical principles, including anonymity and informed consent, were strictly followed.

Results:

The sample was predominantly female (64%), with a mean age of 47.8 years. Knowledge about the role of thyroid hormones and the complications of hypothyroidism during pregnancy was generally satisfactory (69% and 63% correct answers, respectively). Most physicians (96%) were aware that screening should be targeted; however, only 64% knew the recommended first-trimester TSH target value, 35% followed the recommended monthly monitoring frequency, and only 17% knew that levothyroxine dosage should be increased once pregnancy is confirmed. While a majority (85%) recognized their essential role in management, fewer than 60% felt competent in doing so. In practice, 49% preferred to refer patients to a specialist rather than initiate treatment themselves. The availability of standardized protocols and documentation of therapeutic adjustments remained insufficient.

Conclusion:

Although primary care physicians in Kairouan are generally aware of the importance of gestational hypothyroidism, significant gaps persist in several key aspects of diagnosis and therapeutic follow-up. Strengthening continuous medical education, disseminating clear local guidelines, and improving physicians’ autonomy are essential steps to optimize management and reduce maternal and fetal risks.

Hypothyroidism, a common endocrine disorder primarily affecting women of reproductive age, results from insufficient production of thyroid hormones (T3 and T4), which are essential for metabolism and fetal development [1]. During pregnancy, hormonal demands increase, making screening and monitoring particularly crucial, especially in women with pre-existing thyroid disease [2]. If left untreated, hypothyroidism may lead to miscarriage, preeclampsia, intrauterine growth restriction, or fetal neurological impairment [3,4].

Despite international recommendations, a persistent lack of awareness and specific data regarding the management of hypothyroidism during pregnancy is observed among primary care physicians, particularly in resource-limited settings such as Tunisia [5,6]. Nevertheless, primary care physicians play a critical role in screening, follow-up, and patient education. Assessing their knowledge, attitudes, and practices is therefore essential to identify gaps, improve management, and reduce maternal and fetal morbidity.

In this context, evaluating the knowledge, attitudes, and practices of primary care physicians concerning pregnancy in hypothyroid women is crucial. Such an assessment can help identify gaps in continuing education, provide context-specific recommendations for Tunisia, and strengthen management protocols based on the latest scientific evidence. This study aims to contribute to improving best practices in primary care gynecology.

This was a descriptive cross-sectional study conducted among primary care physicians in the Kairouan health region, including basic health centers, regional and local hospitals, as well as the Ibn El Jazzar University Hospital. Data collection was carried out over a two-month period, from April to May 2025, using a self-administered digital questionnaire (Appendix N°1) distributed through electronic platforms (email, professional social networks, and medical What Sapp groups). The questionnaire consisted of four sections: sociodemographic and professional characteristics of participants, knowledge regarding hypothyroidism and its obstetrical implications, attitudes toward the management of pregnancies complicated by hypothyroidism, and reported clinical practices related to screening, follow-up, and treatment. Data were entered and analyzed using SPSS software version 25.0, with descriptive analysis calculating frequencies, percentages, and means of the studied variables. Ethical principles were strictly observed throughout the study, ensuring the anonymity and confidentiality of responses, as well as obtaining free, informed, and voluntary consent from all participants.

The target population included all primary care physicians (general practitioners or equivalent) practicing in the Kairouan governorate, estimated at a total of 75 practitioners. At the end of the data collection period, 50 complete and usable questionnaires were returned, representing a response rate of 66.7%.

The most represented age group among participating physicians was 40–50 years (46%, n=34), followed by those under 40 years (38%, n=28). Together, these two groups accounted for 84% of the total study population. Female physicians were predominant, representing 64% (n=32/50), with a sex ratio of 1.78. In terms of professional experience, 76% (n=57) of participants had less than 10 years of experience, including 42% (n=31) with fewer than 5 years.

Regarding the knowledge assessment, 69% (n=52) of physicians correctly recognized that thyroid hormones play an essential role in fetal neurological development. The maternal and fetal complications associated with untreated hypothyroidism were well identified by 84% (n=63) of respondents (Table I).

Table I: Distribution of respondents’ answers regarding the risks associated with untreated hypothyroidism

Concerning screening practices, 96% (n=72) believed that systematic screening for thyroid dysfunction is not recommended for all pregnant women. When asked about the target TSH value during the first trimester, 64% (n=48) correctly cited a value below 2.5 mIU, in line with current recommendations.

For therapeutic management, the vast majority (85%, n=64) identified levothyroxine sodium as the reference treatment for hypothyroidism during pregnancy. Regarding biological monitoring, only 35% (n=26) of physicians reported performing monthly hormonal follow-up as recommended, while 57% (n=43) indicated a quarterly monitoring schedule.

Concerning the role of primary care physicians, a large majority of participants (85.3%, n=64) recognized that their involvement is essential in the follow-up of hypothyroidism during pregnancy. 

Table II summarizes their attitudes and perceptions. 64% (n=48) strongly agreed that thyroid function screening should be systematic at the beginning of pregnancy, while 24% (n=18) agreed and only 4% disagreed. Regarding professional competence, 56% (n=42) of physicians felt adequately trained to manage hypothyroidism during pregnancy, whereas 24% (n=18) expressed uncertainty or disagreement. In terms of continuous education, 73% (n=55) reported that they regularly update their knowledge of gynecological recommendations. Moreover, 73.3% (n=55) believed that hypothyroid pregnant women should be systematically referred to a specialist, reflecting a tendency toward specialist reliance. Finally, the vast majority affirmed that the role of primary care physicians is crucial in the thyroid follow-up of pregnant women, emphasizing their importance in early detection, management, and coordination of care.

Table II: Distribution of Respondents’ Answers Regarding the Role of Primary Care Physicians in the Management of Hypothyroidism During Pregnancy

Regarding the management of a TSH elevation (>4 mIU/L) at the beginning of pregnancy, nearly half of the physicians (49%, n=37) reported referring patients to an endocrinologist. Only 19% (n=14) initiated levothyroxine therapy themselves, while 28% (n=21) opted for observation without treatment. A small proportion (4%, n=3) chose other approaches, such as repeating the assessment (Table III).

Table III: Distribution of Respondents’ Answers Regarding Their Management Approach to Elevated TSH (>4 mIU/L) in Early Pregnancy

Following their reported management approaches to elevated TSH in early pregnancy (Table III), it is also important to examine how primary care physicians monitor hypothyroid patients throughout pregnancy and educate them about potential risks. Regarding the frequency of TSH monitoring, results showed considerable variability: 48% (n=36) of physicians reported monthly checks, in line with recommendations, while 14% (n=10) were unsure about the appropriate interval.

In terms of institutional guidance, 15% (n=11) of respondents indicated not having access to a written or institutional protocol for managing these patients. Concerning patient education, 68% (n=51) of physicians always or often inform patients about the fetal risks associated with hypothyroidism, whereas about one-third do so irregularly or not at all.

Regarding documentation practices, only 17% (n=13) of physicians record levothyroxine dose adjustments in the obstetric follow-up booklet. Finally, approximately one-third of respondents reported having encountered complications in pregnant women with hypothyroidism, underscoring the clinical importance of careful monitoring, patient education, and adherence to recommended management protocols.

Hypothyroidism is a common endocrine disorder in women of reproductive age, which, if undiagnosed or inadequately managed, can adversely affect pregnancy outcomes and fetal neurodevelopment [1,2,3,4]. During pregnancy, the demand for thyroid hormones increases significantly, making even previously well-controlled women susceptible to hormonal imbalance. Management of gestational hypothyroidism is guided by well-established recommendations regarding target TSH levels, frequency of monitoring, and levothyroxine dose adjustments. Primary care physicians play a crucial role in the screening, diagnosis, and therapeutic follow-up of this condition [5,6].

Assessing the knowledge, attitudes, and practices of primary care physicians is essential, as highlighted by this study in the Kairouan region. Overall, the results indicate a satisfactory level of awareness, although gaps remain, particularly in clinical decision-making and the updating of practical knowledge. The majority of participants were female (64%), reflecting the increasing feminization of primary care, particularly in rural and semi-urban areas [7]. 

Most physicians recognized the importance of maternal thyroid hormones for fetal neurological development (69%), though awareness could be improved compared with data from other countries [9]. The majority correctly identified major maternal-fetal complications of hypothyroidism, such as preeclampsia, prematurity, intrauterine growth restriction, and neurodevelopmental disorders (63%) [10]. A large proportion understood that systematic thyroid screening is not recommended for all pregnant women but only for high-risk cases (96%) (11,12). However, fewer physicians knew the precise TSH target in the first trimester (<2.5 mIU/L, 64%), highlighting a critical knowledge gap even for a central monitoring parameter [13,14].

Encouragingly, most respondents correctly identified levothyroxine as the treatment of choice for overt hypothyroidism (85%) [15]. However, adherence to recommended monitoring frequency was suboptimal, with only 35% performing monthly TSH checks, while 57% monitored quarterly, which may delay dose adjustments [16]. Awareness of the need to increase levothyroxine dosage early in pregnancy was particularly low (17%), posing risks for both maternal and fetal thyroid imbalance [11]. Knowledge regarding subclinical hypothyroidism (75%) and the role of iodine deficiency (71%) was satisfactory but could be further strengthened, especially given local dietary and regional considerations [17,18,19].

Attitudes toward screening and management were generally positive, with most physicians feeling responsible for patient care (85.3%) [20]. Yet, only slightly more than half felt fully competent (56.7%), indicating the need for targeted continuous education programs [21]. Referral practices showed a tendency toward cautious behavior, with many physicians preferring to refer patients rather than initiate treatment directly (49%), which may delay early therapeutic intervention [22]. Furthermore, access to standardized protocols was limited (30%), patient education was not always consistent (68%), and documentation of levothyroxine dose adjustments was often lacking (17%), potentially compromising continuity of care [24,25,26].

Building on the findings regarding physicians’ knowledge and attitudes, it is evident that while awareness of the critical role of thyroid hormones and the risks of untreated hypothyroidism is generally satisfactory, significant gaps remain in practical management. Indeed, although most participants recognized levothyroxine as the treatment of choice and acknowledged their responsibility in patient follow-up, however, adherence to recommended monitoring frequencies and timely dose adjustments was suboptimal. Moreover, knowledge about specific parameters, such as the target TSH in the first trimester and the need for early dose escalation, was insufficient, highlighting areas where continuous education is urgently needed. Furthermore, while patient education was relatively well addressed, the lack of standardized protocols and incomplete documentation of therapeutic adjustments may compromise care continuity. Therefore, these results underscore the necessity of implementing structured interventions, including standardized regional guidelines, targeted training programs, and improved follow-up systems, in order to optimize maternal and fetal outcomes in pregnancies complicated by hypothyroidism.

This study has some limitations. It relied on a self-administered questionnaire, which may introduce reporting bias, and included a relatively small sample of primary care physicians from a single region, limiting generalizability. Its cross-sectional design captures practices at one point in time, and clinical behaviors were self-reported rather than objectively measured. Additionally, the questionnaire was not a previously validated instrument, which may affect comparability with other studies.

Despite relying on self-reported practices, the study highlights areas for improvement, including the development of standardized regional protocols, targeted continuing medical education, integration of electronic reminders for follow-up, and reinforcement of patient education strategies. Overall, these findings emphasize both the awareness and the gaps in practice among primary care physicians in managing gestational hypothyroidism, underscoring the need for structured interventions to optimize maternal and fetal outcomes. These measures are essential to improve the quality of care, reduce maternal and fetal complications, and ensure optimal follow-up of pregnant women in our region.