What is the management of a 24-week pregnant woman in adrenal crisis with hypokalemia, hypotension, and a suspected pulmonary embolism (PE) with a D-dimer level of 0.95 and a lower lobe infiltrate on chest X-ray?

From the Guidelines

For a 24-week pregnant patient in adrenal crisis with low potassium and low blood pressure, immediate administration of hydrocortisone 100mg IV, followed by 50-100mg every 6-8 hours, and IV fluids (normal saline) to restore blood volume is crucial. Correct potassium with IV or oral supplementation based on severity. Monitor vital signs, electrolytes, and fetal heart rate continuously. Consult endocrinology and maternal-fetal medicine specialists urgently 1.

Regarding the patient's condition, it is essential to address both the adrenal crisis and the potential pulmonary embolism (PE). The signs of PE would include:

• Sudden shortness of breath
• Chest pain worsening with breathing
• Rapid heart rate
• Cough (possibly with blood)
• Anxiety The D-dimer of 0.95 is mildly elevated but may be normal in pregnancy 1. The lower lobe infiltrate on chest X-ray suggests possible pneumonia rather than PE, but doesn't rule out PE.

To diagnose PE, consider CT pulmonary angiogram with abdominal shielding or ventilation-perfusion scan, as untreated PE carries high mortality risk in pregnancy 1. Empiric anticoagulation with low molecular weight heparin (LMWH) may be appropriate while awaiting definitive diagnosis if clinical suspicion remains high 1. LMWH is the treatment of choice for PE during pregnancy, with a predictable pharmacokinetic profile and no risk of fetal hemorrhage or teratogenicity 1.

The management of labor and delivery requires particular attention, with strong consideration 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 1. Anticoagulant treatment should be administered for more than 6 weeks after delivery and with a minimum overall treatment duration of 3 months 1.

Both adrenal crisis and potential PE require immediate hospitalization in a high-risk obstetric unit. It is crucial to prioritize the patient's morbidity, mortality, and quality of life, and to make decisions based on the most recent and highest-quality evidence available 1.

From the Research

Adrenal Crisis Management

• Adrenal crisis is a life-threatening emergency that requires prompt recognition and treatment 2
• Patients with adrenal crisis present with nonspecific signs and symptoms, and the incidence is estimated to be 8 per 100 patient years in patients with adrenal insufficiency 2
• The emergency treatment involves administration of parenteral hydrocortisone, rehydration, and management of electrolyte abnormalities, such as low potassium 2
• Continuous intravenous hydrocortisone infusion is recommended over intermittent bolus administration in the prevention and treatment of adrenal crisis during major stress 3

Low Potassium and Low Blood Pressure

• Low potassium (hypokalemia) can exacerbate adrenal crisis, and potassium repletion is essential in the management of adrenal crisis 2
• Low blood pressure (hypotension) can also occur in adrenal crisis, and fluid hydration is necessary to manage hypotension 2

Pregnancy Considerations

• Adrenal crisis can occur in pregnant women, and it is essential to manage the condition promptly to prevent maternal and fetal complications
• The management of adrenal crisis in pregnancy involves the same principles as in non-pregnant women, including administration of parenteral hydrocortisone and management of electrolyte abnormalities

Pulmonary Embolism (PE) Signs and Symptoms

• Signs and symptoms of PE include shortness of breath, chest pain, and cough 4
• A D-dimer level of 0.95 is not significantly elevated, but it does not rule out PE entirely 4
• A lower lobe infiltrate on chest X-ray can be seen in PE, but it is not specific for the condition 4
• Further evaluation, such as CT pulmonary angiography, may be necessary to rule out PE 4

Ruling Out PE

• A combination of clinical evaluation, laboratory tests, and imaging studies is necessary to rule out PE 4
• The Wells score or the Geneva score can be used to estimate the probability of PE, and further testing can be guided by these scores 4
• In pregnant women, the diagnosis of PE can be challenging due to the physiological changes of pregnancy, and a high index of suspicion is necessary to make the diagnosis 4