What is the management for a 24-week pregnant woman in adrenal crisis with hypokalemia and hypotension?

From the Guidelines

Seek immediate emergency medical care for a 24-week pregnant woman in adrenal crisis, as this is a life-threatening emergency requiring hospital treatment with IV hydrocortisone, IV fluids, and potassium replacement. According to the guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency 1, the incidence of adrenal crisis in patients with primary and secondary adrenal insufficiency is significant, and prompt treatment is crucial to prevent morbidity and mortality.

The patient's low potassium and blood pressure indicate severe hormonal imbalance affecting kidney function and cardiovascular stability. In the hospital, doctors will monitor fetal health while stabilizing the mother's condition. After stabilization, maintenance therapy typically includes oral hydrocortisone and fludrocortisone, with close monitoring throughout the remainder of pregnancy.

Some key points to consider in the management of this patient include:

• The importance of not interrupting physiological replacement therapy and increasing the daily dose at times of physiological stress, such as pregnancy 1
• The need for close monitoring of fetal health and maternal condition throughout the remainder of pregnancy
• The potential for increased steroid doses as pregnancy progresses due to physiological changes affecting hormone metabolism
• The importance of specialized care to protect both mother and fetus, as adrenal crisis during pregnancy can cause dangerously low blood pressure, electrolyte imbalances, and can be fatal if untreated

In terms of specific treatment, the guidelines recommend IV hydrocortisone 100 mg at the start of treatment, followed by an infusion of 200 mg/24 h 1. Additionally, IV fluids and potassium replacement should be administered as needed to manage the patient's low blood pressure and electrolyte imbalances.

It is essential to prioritize the patient's morbidity, mortality, and quality of life in the management of this condition, and to seek immediate emergency medical care if symptoms persist or worsen. The patient's condition should be managed in a hospital setting, with close monitoring and specialized care to ensure the best possible outcomes for both mother and fetus.

From the FDA Drug Label

Corticosteroids have been shown to be teratogenic in many species when given in doses equivalent to the human dose Animal studies in which corticosteroids have been given to pregnant mice, rats, and rabbits have yielded an increased incidence of cleft palate in the offspring. There are no adequate and well-controlled studies in pregnant women. Corticosteroids should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus Infants born to mothers who have received corticosteroids during pregnancy should be carefully observed for signs of hypoadrenalism.

The management of a 24-week pregnancy in adrenal crisis, with low potassium and low pressures, is not directly addressed in the provided drug label. However, it is stated that corticosteroids should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

• The potential benefits and risks of using corticosteroids, such as hydrocortisone, in this situation should be carefully considered.
• Low potassium levels may be a concern, as corticosteroids can increase the risk of hypokalemia, particularly when used with digitalis glycosides.
• The label does not provide specific guidance on the management of adrenal crisis in pregnancy, and the decision to use corticosteroids should be made on a case-by-case basis, taking into account the potential risks and benefits 2.

From the Research

Adrenal Crisis in Pregnancy

• Adrenal insufficiency in pregnancy is a rare condition that can have significant clinical implications on both maternal and fetal outcomes 3.
• The diagnosis of adrenal insufficiency in pregnancy can be challenging due to the similarities between symptoms of adrenal insufficiency and those of normal pregnancy 4.
• A high index of suspicion must be maintained to diagnose adrenal disorders in pregnancy, as they can go unrecognised and untreated 5.

Management of Adrenal Insufficiency in Pregnancy

• Hydrocortisone is the preferred glucocorticoid replacement in pregnancy, and dose titration may be required depending on clinical course and mode of delivery 3.
• The management of adrenal insufficiency in pregnancy needs to reflect the physiologic changes of pregnancy, often requiring increased doses of glucocorticoid and at times mineralocorticoid replacement, especially in the last trimester 4.
• Adrenal crisis in pregnancy can present with symptoms similar to severe nausea and vomiting of pregnancy or hyperemesis gravidarum, and empiric treatment with glucocorticoid therapy may be necessary 6.

Low Potassium and Low Blood Pressure in Adrenal Crisis

• Hypotension and hyponatremia can be symptoms of adrenal crisis in pregnancy 6.
• Low potassium levels can also occur in adrenal insufficiency, and may require treatment with mineralocorticoid replacement 7.
• The renin-angiotensin-aldosterone system is activated during pregnancy, which can lead to changes in blood pressure and electrolyte levels 4.

Specific Considerations for a 24-Week Pregnancy

• At 24 weeks of gestation, the pregnancy is considered to be in the second trimester, and the management of adrenal insufficiency should take into account the physiologic changes that occur during this period 4.
• The diagnosis and management of adrenal insufficiency in pregnancy require a multidisciplinary approach, involving obstetricians, endocrinologists, and other healthcare professionals 7.
• Close monitoring of the mother and fetus is necessary to prevent complications and ensure the best possible outcomes 5.