Adrenal Disease and Pregnancy TOG/CPD Flashcards
What causes 70-90% of primary adrenal insufficiency?
Autoimmune atrophy of adrenal gland.
Others: haemorrhage secondary to sepsis, major burns, lymphoma, metastasis and infections like TB
What’s the prevalence of PAI in pregnancy
1/3000 to 5.5/100,000 pregnancies
At what gestation does cortisol levels peak?
On average 26th week of pregnancy
What are the diagnostic features of primary adrenal insufficiency in pregnancy?
!Significant weight loss
!Prolonged vomiting
!Hyperpigmentation of mucous membranes, extensor surfaces and non exposed parts of the body
! Hyponatremia
!hyperkalemia
!hypoglycemia
The production of corticosteroid binding globulin is increased by what hormone in pregnancy ?
Estrogen
What hormone production levels associated with the adrenal gland is increased by the placenta ?
Corticotropin releasing hormone
Adrenocorticotropic hormone (ACTH)
Free and total cortisol levels
Diurnal rhythm of cortisol secretion in pregnancy
Preserved with nadir at bedtime
What is the characteristic of secondary and tertiary adrenal insufficiency in pregnancy
Secondary A.I : ACTH secretion disorder
Tertiary A.I : CRH secretion disorder
What’s the gold standard of diagnosis for adrenal insufficiency in pregnancy
Short synacten stimulation test using 250mcg ACTH with normal response in 30-60 mins being a rise in serum cortisol levels >|= 500-550 nmol/L
What is the glucocorticoid treatment of choice ?
Hydrocortisone: short acting and doesn’t cross placenta
Has mineralocorticoid effect (40mg HC equivalent to 0.1 mg fludrocortisone )
The preferred mineralocorticoid replacement for AI in pregnancy
Fludrocortisone 0.05-1mg per day
What is the common presenting symptom of Addisonian crises (acute AI)
Abdominal pain, vomiting and shock
How to reduce risk of Acute AI in patients on antenatal steroids in pregnancy?
IV hydrocortisone 50-100mg 8 hourly for up to 24 hours intrapartum
What is the IV fluid of choice in resuscitation
2-3 litres of 0.9% saline or 5% dextrose in 0.9% saline
How should IV hydrocortisone be tapered off?
Over 1-3 days( 200<100<50 mg/day) and switches to oral Hydrocot AND fludrocortisone on day 4
What is the general outcome for primary AI in pregnancy
Good. Increased risk of FGR though
Maternal risks of AI in pregnancy
Preterm delivery
CS
Poor wound healing
VTE
Acute adrenal crises
What’s the commonest cause of Cushing syndrome in pregnancy ?
60% Adrenal Adenomas
Outside pregnancy : pituitary dependent Cushing syndrome in 70%
What are the distinguishing clinical features of Cushing syndrome in pregnancy
Proximal myopathy
Easy bruising
Osteopenia/osteoporosis induced fractures
Hirsutism
Early onset hypertension in pregnancy
Red or purple striae
What is the reliable diagnostic test for Cushing syndrome in pregnancy
Salivary cortisol level at night + urinary free cortisol level is diagnostic at > 3* upper limit of normal
Midnight plasma cortisol level as screening test
What is the preferred dexametasone regime for diagnosis of Cushing in pregnancy
High dose(8mg) dexametasone suppression test fails to suppress cortisol levels
( low dose DST has high false positives due to hypercortisolism)
What is pregnancy associated Cushing syndrome
Onset in pregnancy or within 12 months postpartum or miscarriage
What’s the imaging of choice in assessment of suspected pituitary or adrenal Cushing syndrome?
MRI is superior to ultrasound
Gadolinium based MRI is contraindicated
What are the maternal complications of untreated/poorly treated of Cushing syndrome diagnosed in pregnancy
Gestational diabetes
Gestational hypertension
PET
Wound infection
Heart failure
Psychiatric disorders
Maternal death
