What is the management of a 24-week pregnant woman in adrenal crisis with hypokalemia and hypotension, and how to diagnose and rule out pulmonary embolism (PE)?

From the Guidelines

For a 24-week pregnant patient in adrenal crisis, immediate medical intervention is essential, starting with IV hydrocortisone 100mg bolus followed by 50-100mg every 6-8 hours, along with aggressive IV fluid resuscitation using normal saline to address hypotension, as recommended by general medical guidelines 1.

Adrenal Crisis Management

To manage the adrenal crisis, it is crucial to:

• Administer IV hydrocortisone as mentioned
• Monitor potassium levels closely and replace as needed with IV or oral potassium supplements, aiming for levels above 3.5 mEq/L
• Provide continuous maternal and fetal monitoring, with fetal heart rate tracking and consideration of antenatal corticosteroids for fetal lung maturity if delivery seems imminent

Pulmonary Embolism (PE) Diagnosis

For suspected PE, watch for symptoms including:

• Sudden dyspnea
• Chest pain
• Tachycardia
• Hypoxemia
• Unilateral leg swelling To rule out PE, perform initial assessment with:
• D-dimer testing, though pregnancy often elevates baseline levels
• Chest X-ray with abdominal shielding to identify alternative diagnoses
• Compression ultrasonography of the legs to detect deep vein thrombosis If suspicion remains high, consider:
• V/Q scanning
• CT pulmonary angiography with appropriate radiation shielding for the fetus, as the risks and benefits of these tests must be carefully weighed, considering the guidelines from the European Heart Journal 1

Treatment of PE in Pregnancy

Low Molecular Weight Heparin (LMWH) is the treatment of choice for PE during pregnancy, due to its predictable pharmacokinetics and favorable risk profile, as stated in the 2019 ESC guidelines 1. LMWH does not cross the placenta and thus does not confer a risk of fetal hemorrhage or teratogenicity. The optimal dose of LMWH for the treatment of PE during pregnancy is similar to that in non-pregnant patients, either with once-daily or twice-daily regimens based on early pregnancy weight.

Management of Labor and Delivery

In women receiving therapeutic LMWH, strong consideration should be given to planned delivery in collaboration with the multidisciplinary team to avoid the risk of spontaneous labor while fully anticoagulated. If regional analgesia is considered for a woman receiving therapeutic LMWH, more than 24 hours should have elapsed since the last LMWH dose before insertion of a spinal or epidural needle, assuming normal renal function and including risk assessment at extremes of body weight.

Post-partum Care

Anticoagulant treatment should be administered for at least 6 weeks after delivery and with a minimum overall treatment duration of 3 months. LMWH and warfarin can be given to breastfeeding mothers; the use of NOACs is not recommended, as per the guidelines from the European Heart Journal 1.

From the Research

Adrenal Crisis in Pregnancy

• Adrenal crisis is a life-threatening emergency that can occur in patients with adrenal insufficiency, including those who are pregnant 2.
• The incidence of adrenal crisis is estimated to be 8 per 100 patient years in patients with adrenal insufficiency 2.
• Infections, physical stress, forgetting or discontinuing glucocorticoid therapy, pronounced physical activity, and psychological stress are common precipitating factors for adrenal crisis 2.

Diagnosis and Management of Adrenal Insufficiency in Pregnancy

• Adrenal insufficiency in pregnancy is relatively rare, but has significant clinical implications on both maternal and fetal outcomes 3.
• Diagnosis of adrenal insufficiency in pregnancy can be challenging due to the complex hypothalamo-pituitary-adrenal axis dynamics and physiological changes during pregnancy 3.
• Hydrocortisone is the preferred glucocorticoid replacement in pregnancy, and dose titration may be required depending on clinical course and mode of delivery 3.

Management of Adrenal Crisis in Pregnancy

• Emergency treatment of adrenal crisis involves prompt recognition and administration of parenteral hydrocortisone, rehydration, and management of electrolyte abnormalities 2.
• Continuous intravenous hydrocortisone infusion is recommended for maintaining cortisol concentrations in the required range during major stress, including adrenal crisis 4.
• Patient education on stress dosing and parenteral glucocorticoid administration is crucial in preventing adrenal crisis 2.

Low Potassium and Low Blood Pressure in Pregnancy

• Low potassium (hypokalemia) and low blood pressure (hypotension) can be symptoms of adrenal insufficiency, including adrenal crisis 5, 6.
• Management of hypokalemia and hypotension in pregnancy requires careful consideration of the underlying cause, including adrenal insufficiency, and may involve glucocorticoid replacement and other supportive measures 5, 6.

Signs of Pulmonary Embolism (PE) in Pregnancy

• Signs of PE in pregnancy may include sudden onset of shortness of breath, chest pain, and cough 5, 6.
• Diagnosis of PE in pregnancy requires imaging studies, such as computed tomography (CT) scan or ventilation-perfusion scan, and may involve other diagnostic tests, such as D-dimer assay 5, 6.
• Management of PE in pregnancy involves anticoagulation therapy and other supportive measures, and may require hospitalization and close monitoring 5, 6.

Ruling Out PE in Pregnancy

• Ruling out PE in pregnancy requires a thorough medical history, physical examination, and diagnostic tests, including imaging studies and laboratory tests 5, 6.
• A low probability of PE, based on clinical assessment and diagnostic tests, can help rule out the diagnosis 5, 6.
• However, a high index of suspicion for PE is necessary in pregnancy, due to the increased risk of thromboembolic events during this period 5, 6.