Adrenal insufficiency during pregnancy and lactation
The principles of managing adrenal insufficiency during pregnancy are the same as those for nonpregnant patients. Specialist input is recommended before conception and during pregnancy.
Hydrocortisone is the preferred glucocorticoid in pregnancy, but cortisone acetate and prednisolone (or prednisone) are also suitable; it is not necessary to switch stable treatment to hydrocortisone. Dexamethasone can cross the placenta and suppress fetal adrenal glands, so should not be used in pregnancy.
Most women with pre-existing adrenal insufficiency can continue their usual glucocorticoid and mineralocorticoid replacement doses throughout pregnancy. Some women require a gradual increase of their glucocorticoid dose during the third trimester, particularly those taking a maintenance dose at the lower end of the usual range.
New-onset or previously undiagnosed adrenal insufficiency in a pregnant woman is rare. Diagnosis is difficult—during the first trimester, symptoms of adrenal insufficiency or adrenal crisis (eg vomiting, nausea, fatigue) can be incorrectly attributed to pregnancy. In addition, the plasma total cortisol concentration increases during a healthy pregnancy (related to an increase in corticosteroid binding globulin), so a concentration within the reference range does not exclude adrenal insufficiency during pregnancy. If in doubt, seek advice to interpret the results. More specific symptoms, such as salt craving and hyperpigmentation in skin creases or mucous membranes, can help identify adrenal insufficiency. If adrenal insufficiency is diagnosed during pregnancy, glucocorticoid and mineralocorticoid replacement should be started; seek specialist advice.
Women with persistent vomiting may require parenteral hydrocortisone. Use:
hydrocortisone 100 mg intravenously or intramuscularly, then 50 mg every 6 hours until oral therapy can be tolerated. A higher oral maintenance dose than usual may be required. adrenal insufficiency, persistent vomiting in pregnancy hydrocortisone
If vomiting persists despite parenteral therapy, seek specialist advice.
An increased glucocorticoid dose may also be required during labour.
Glucocorticoid and mineralocorticoid therapy should continue during breastfeeding.