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MRCOG PART 2 > Adrenal Disease and Pregnancy TOG/CPD > Flashcards

Adrenal Disease and Pregnancy TOG/CPD Flashcards

1
Q

What causes 70-90% of primary adrenal insufficiency?

A

Autoimmune atrophy of adrenal gland.
Others: haemorrhage secondary to sepsis, major burns, lymphoma, metastasis and infections like TB

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2
Q

What’s the prevalence of PAI in pregnancy

A

1/3000 to 5.5/100,000 pregnancies

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3
Q

At what gestation does cortisol levels peak?

A

On average 26th week of pregnancy

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4
Q

What are the diagnostic features of primary adrenal insufficiency in pregnancy?

A

!Significant weight loss
!Prolonged vomiting
!Hyperpigmentation of mucous membranes, extensor surfaces and non exposed parts of the body
! Hyponatremia
!hyperkalemia
!hypoglycemia

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5
Q

The production of corticosteroid binding globulin is increased by what hormone in pregnancy ?

A

Estrogen

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6
Q

What hormone production levels associated with the adrenal gland is increased by the placenta ?

A

Corticotropin releasing hormone

Adrenocorticotropic hormone (ACTH)

Free and total cortisol levels

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7
Q

Diurnal rhythm of cortisol secretion in pregnancy

A

Preserved with nadir at bedtime

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8
Q

What is the characteristic of secondary and tertiary adrenal insufficiency in pregnancy

A

Secondary A.I : ACTH secretion disorder
Tertiary A.I : CRH secretion disorder

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9
Q

What’s the gold standard of diagnosis for adrenal insufficiency in pregnancy

A

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

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10
Q

What is the glucocorticoid treatment of choice ?

A

Hydrocortisone: short acting and doesn’t cross placenta
Has mineralocorticoid effect (40mg HC equivalent to 0.1 mg fludrocortisone )

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11
Q

The preferred mineralocorticoid replacement for AI in pregnancy

A

Fludrocortisone 0.05-1mg per day

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12
Q

What is the common presenting symptom of Addisonian crises (acute AI)

A

Abdominal pain, vomiting and shock

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13
Q

How to reduce risk of Acute AI in patients on antenatal steroids in pregnancy?

A

IV hydrocortisone 50-100mg 8 hourly for up to 24 hours intrapartum

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14
Q

What is the IV fluid of choice in resuscitation

A

2-3 litres of 0.9% saline or 5% dextrose in 0.9% saline

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15
Q

How should IV hydrocortisone be tapered off?

A

Over 1-3 days( 200<100<50 mg/day) and switches to oral Hydrocot AND fludrocortisone on day 4

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16
Q

What is the general outcome for primary AI in pregnancy

A

Good. Increased risk of FGR though

17
Q

Maternal risks of AI in pregnancy

A

Preterm delivery
CS
Poor wound healing
VTE
Acute adrenal crises

18
Q

What’s the commonest cause of Cushing syndrome in pregnancy ?

A

60% Adrenal Adenomas
Outside pregnancy : pituitary dependent Cushing syndrome in 70%

19
Q

What are the distinguishing clinical features of Cushing syndrome in pregnancy

A

Proximal myopathy
Easy bruising
Osteopenia/osteoporosis induced fractures
Hirsutism
Early onset hypertension in pregnancy
Red or purple striae

20
Q

What is the reliable diagnostic test for Cushing syndrome in pregnancy

A

Salivary cortisol level at night + urinary free cortisol level is diagnostic at > 3* upper limit of normal

Midnight plasma cortisol level as screening test

21
Q

What is the preferred dexametasone regime for diagnosis of Cushing in pregnancy

A

High dose(8mg) dexametasone suppression test fails to suppress cortisol levels
( low dose DST has high false positives due to hypercortisolism)

22
Q

What is pregnancy associated Cushing syndrome

A

Onset in pregnancy or within 12 months postpartum or miscarriage

23
Q

What’s the imaging of choice in assessment of suspected pituitary or adrenal Cushing syndrome?

A

MRI is superior to ultrasound

Gadolinium based MRI is contraindicated

24
Q

What are the maternal complications of untreated/poorly treated of Cushing syndrome diagnosed in pregnancy

A

Gestational diabetes
Gestational hypertension
PET
Wound infection
Heart failure
Psychiatric disorders
Maternal death

25
Q

How are fetal cortisol levels related to maternal levels?

A

Lower fetal levels due to breakdown by 11-B-hydroxysteroid dehydrogenase type 2

26
Q

What are the fetal complications of Cushing syndrome

A

Miscarriage
FGR
Preterm delivery
Stillbirth
Neonatal Adrenal Insufficiency

27
Q

What is the treatment option of first choice for both pituitary and adrenal Cushing

A

Surgical treatment : laparoscopic unilateral/bilateral adrenelectony
Trans-sphenoidal surgery

28
Q

What alternative medical treatment for patient unfit for surgery

A

Metyrapone
Cabergoline as second choice in pituitary Cushings.

MRCOG PART 2 (8 decks)

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