Document Detail

What is the best diagnostic and therapeutic management strategy for an Addison patient during pregnancy?
MedLine Citation:
PMID:  23153216     Owner:  NLM     Status:  MEDLINE    
A new diagnosis of primary adrenal insufficiency (PAI) during pregnancy is extremely rare and difficult to recognize as signs and symptoms such as nausea, fatigue and hypotension may resemble features of normal pregnancy. However, if the diagnosis is overlooked and steroid replacement delayed, subsequent adrenal crisis triggered by hyperemesis gravidarum, fever or delivery can cause severe maternal and foetal morbidity and even mortality. In case of clinical suspicion of PAI, we recommend to measure paired samples of cortisol and ACTH and, if clinically feasible, a short synacthen test. We propose trimester-specific pass cut-offs for the short synacthen test that take into account the rise of total and also free cortisol during pregnancy. Empirical hydrocortisone treatment should never be delayed if the clinical suspicion is high. All pregnant women with PAI should be monitored by a team of endocrine and obstetric specialists. The third trimester is physiologically associated with a rise not only in total but also free cortisol and thus requires regular adjustment of the glucocorticoid dose. Mineralocorticoid requirements may change during pregnancy due to the anti-mineralocorticoid properties of progesterone. As plasma renin physiologically increases in pregnancy, monitoring is limited to clinical assessment including blood pressure and serum electrolytes. It is crucial that a pregnant woman with PAI and her partner are well educated regarding the adjustment of glucocorticoid dose in intercurrent illness and that both are trained in hydrocortisone emergency injection techniques. The obstetric staff should be provided with clear and written guidance for hydrocortisone cover during labour and delivery. With the appropriate replacement therapy, PAI patients can expect to have an uneventful pregnancy and deliver a healthy infant.
Marie Lebbe; Wiebke Arlt
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Clinical endocrinology     Volume:  78     ISSN:  1365-2265     ISO Abbreviation:  Clin. Endocrinol. (Oxf)     Publication Date:  2013 Apr 
Date Detail:
Created Date:  2013-03-15     Completed Date:  2013-09-12     Revised Date:  2014-02-20    
Medline Journal Info:
Nlm Unique ID:  0346653     Medline TA:  Clin Endocrinol (Oxf)     Country:  England    
Other Details:
Languages:  eng     Pagination:  497-502     Citation Subset:  IM    
Copyright Information:
© 2012 Blackwell Publishing Ltd.
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MeSH Terms
Addison Disease / diagnosis*,  epidemiology,  therapy*
Glucocorticoids / metabolism
Mineralocorticoids / metabolism
Models, Biological
Pregnancy Complications / diagnosis*,  epidemiology,  therapy*
Professional Practice
Grant Support
G0900567//Medical Research Council; MR/J011592/1//Medical Research Council
Reg. No./Substance:
0/Glucocorticoids; 0/Mineralocorticoids

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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