Adrenal Disease and Pregnancy

This blogpost is about the Adrenal Disease and Pregnancy. The points have been taken from a TOG article which was published in October 2021. The article covers this topic quite comprehensively. It is recommended to read the original article for complete understanding of this important exam topic. I hope you find this post helpful. 

To download the original article: Click Here

To access ALL TOGs List: Click Here

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Introduction

• Adrenal disease in pregnancy is rare
• Challenging to diagnose
• Associated with ↑ adverse outcomes for both mother & fetus
• Timely diagnosis & MDT involvement are essential to manage these high risk pregnancies

Major Adrenal Disorders

• Primary Adrenocortical Insufficiency (Addisons’s Disease)
• Cushing’s Syndrome
• Primary Aldosteronism (PA)
• Congenital Hyperplasia (CAH)
• Pheochromocytoma & Paraganglioma (PPGL)

Primary Adrenocortical Insufficiency (Addisons’s Disease)

Adrenal insufficiency (AI) classified → primary, secondary & tertiary

Primary Insufficiency in Pregnancy

• Uncommon 1 in 3000 to 5.5 in 100 000 pregnancies
• Results due to adrenocortical disease
• Both Glucocorticoid (GC) & Mineralocorticoid (MC) deficiency 
• 70-90% due to autoimmune atrophy of adrenal gland

Secondary Insufficiency  associated with ACTH secretion disorders mainly cortisol deficiency 

Tertiary Insufficiency  associated with CRH secretion disorders mainly cortisol deficiency 

Cortisol during pregnancy 

• ↑ Levels Both free & total cortisol
• Peaks at 26th weeks
• Diurnal rhythmic variation is maintained

Ref: TOG

Diagnosis

• Females with Primary AI → lower fertility rates
• Most diagnosed before pregnancy & are already on GC & MC
• Challenging to diagnose for the 1st time in pregnancy as overlap of physiological symptoms of pregnancy 
• Highly Suggestive Features → hyperpigmentation on mucous membranes, extensor surfaces & non exposed regions

Short Synacthen stimulation Test

• Non-pregnant → diagnosis likely if morning cortisol <140 nmol/L along with ↑ ACTH
• Pregnant → this cut-off not reliable as most women have values >555 nmol/L in 2nd /3rd tri
• Offer treatment if indeterminate SST & retest after delivery

Salivary free cortisol 

In pregnancy → consistent, generalisable & rationale measure of adrenal function

Consent Advice: Risk Figures Compilation

This post is the collection of all RCOG Consent Advice Papers. These papers are very important from an exam point of view and these numbers are to be memorized by heart. As these questions are very straightforward forward and it is easy to score. The only way to memorize these is to revise as much as possible.

• To date, RCOG has published 14 consent advice papers. To download papers: Click Here 
• All RCOG consent advice papers follow a standard for presenting information on risk, which is given below
• For most of the procedures, Consent Form 1 is used except for Amniocentesis for which Consent Form 3 is used
• Before taking consent, it is a good idea to be familiar with the basics of Consent. This blog post Medical Law & Ethics might be helpful in this regard.
• I have compiled this information in the form of tables and tried to give risks in different forms (percentages/fractions) as the same fact can be tested in different ways
• I hope you find this post helpful. Suggestions to improve future posts are welcome

Thanks

Presenting Information on risk

Term	Equivalent numerical ratio	Colloquial equivalent
Very common	1/1 to 1/10	A person in family
Common	1/10 to 1/100	A person in street
Uncommon	1/100 to 1/1000	A person in village
Rare	1/1000 to 1/10 000	A person in small town
Very rare	Less than 1/10 000	A person in large town

Consent Advice #1 Diagnostic Hysteroscopy Under GA 

Serious Risks
Overall	2:1000 or 1:500 or 0.2% (uncommon)
Damage to uterus	Uncommon
Damage to bowel, bladder or major blood vessels	Rare
Failure to gain entry	Uncommon
Infertility	Rare
Death	3-8/100 000 Very rare
Frequent Risks	Infection Bleeding

Consent Advice #2 Diagnostic Laparoscopy