Screening and Management of Subclinical Hypothyroidism in Pregnancy: A Nationwide Survey of Physicians in Saudi Arabia

Background Subclinical hypothyroidism (SCH) in pregnancy poses serious maternal and fetal risks, including miscarriage, gestational diabetes, and neurodevelopmental impairment. Despite clear international guidelines like those from the American Thyroid Association (ATA), global practice remains inconsistent. In Saudi Arabia, where SCH prevalence among pregnant women is notably high (13%), there is limited national data on how closely physicians follow these guidelines. This study aimed to evaluate current clinical practices, adherence to ATA recommendations, and influencing factors across medical specialties. Methods A descriptive cross-sectional study was conducted from January to April 2025 using a nationwide online survey targeting licensed physicians involved in obstetric care. The structured questionnaire, adapted from a validated US-based tool, collected data on the SCH screening methods, diagnostic thresholds, use of anti-TPO antibodies, levothyroxine (LT4) prescribing patterns, and guideline familiarity. Adherence scores were computed based on alignment with key ATA recommendations. Statistical analyses, including Chi-square tests, t-tests, and analysis of variance (ANOVA), were performed to assess associations between adherence and physician-related variables. Results A total of 280 physicians participated, with most practicing in government hospitals (188, 67.1%) and in the Central Region (220, 78.6%). Although all participants (280, 100.0%) reported screening based on risk factors or symptoms, only 65 (23.2%) had reviewed the ATA guidelines, and 12 (4.3%) applied the recommended TSH cutoff of >2.5 mIU/L in the first trimester. Routine anti-TPO testing was reported by 99 (35.4%) participants, and only nine (3.2%) adhered to the four-week TSH monitoring interval. The mean adherence score was 6.17 (SD = 3.84), significantly associated with physician confidence (r = 0.310, p < .001) and experience (r = 0.323, p < .001). Endocrinologists and academic physicians demonstrated the highest adherence, while general practitioners and physicians from the Western Region showed the lowest. Clinical decision-making was primarily influenced by TSH levels (32, 11.4%), symptoms (18, 6.4%), and guideline awareness (14, 5.0%). Most respondents (208 (74.3%) prescribed LT4 monotherapy, often initiating fixed low doses. Conclusion The study revealed substantial variability and low overall adherence to the ATA guidelines among physicians in Saudi Arabia managing SCH during pregnancy. Gaps were most evident in the TSH cutoff application, antibody testing, and postpartum management. These findings highlight the need for targeted education, national consensus protocols, and specialty-specific training to standardize care and improve maternal-fetal outcomes.