What is the management of a 24-week pregnant woman in adrenal crisis with hypokalemia, hypotension, and suspected pulmonary embolism (PE) with a D-dimer level of 0.95 and a lower lobe infiltrate on chest X-ray, and which imaging modality, ventilation-perfusion (V/Q) scan or computed tomography (CT) angiography, is less harmful to the fetus?

From the Guidelines

For a 24-week pregnant patient in adrenal crisis with low potassium and hypotension, immediate medical intervention is essential, prioritizing the administration of IV hydrocortisone and correction of potassium levels to prevent morbidity and mortality. Administer IV hydrocortisone 100mg immediately followed by 50-100mg every 6-8 hours, along with IV fluids (normal saline) to restore blood pressure, as recommended by general medical guidelines for adrenal crisis management 1. Correct potassium with IV or oral supplementation based on severity, monitoring fetal heart rate and maternal vital signs continuously.

Suspected Pulmonary Embolism (PE) Management

For suspected PE, look for signs such as dyspnea, chest pain, tachycardia, hypoxemia, and hemoptysis. With a D-dimer of 0.95 and lower lobe infiltrate, further imaging is warranted.

• CT pulmonary angiography (CTPA) is the preferred imaging modality over V/Q scanning during pregnancy, as it provides better diagnostic accuracy for PE and can help evaluate alternative diagnoses like pneumonia, which could explain the infiltrate 1.
• The radiation exposure to the fetus from CTPA is relatively low (0.1-0.4 mGy), and while V/Q scanning also has low radiation exposure (0.1-0.5 mGy), CTPA's diagnostic benefits make it the preferred choice in this context.
• According to the American Society of Hematology 2018 guidelines, both V/Q scanning and CT pulmonary angiography have low frequencies of false-negative results when used to evaluate suspected PE during pregnancy, but CTPA offers more definitive diagnostic information 1.

Multidisciplinary Approach

Involve obstetrics, endocrinology, and critical care teams immediately to manage the patient's adrenal crisis and suspected PE. Continue stress-dose steroids until the crisis resolves, then transition to maintenance therapy. The patient will need close monitoring throughout pregnancy with regular assessment of adrenal function and electrolytes. Delivery planning should involve a multidisciplinary approach to manage potential complications during labor, prioritizing both maternal and fetal well-being 1.

From the Research

Adrenal Crisis in Pregnancy

• Adrenal crisis in pregnancy is a life-threatening emergency that requires prompt diagnosis and treatment 2, 3, 4, 5.
• The symptoms of adrenal crisis can be similar to those of normal pregnancy, making diagnosis challenging 4, 5.
• Adrenal insufficiency in pregnancy can lead to serious consequences such as adrenal crisis, intrauterine growth restriction, and fetal demise if left untreated 2, 4.

Management of Adrenal Crisis in Pregnancy

• The management of adrenal crisis in pregnancy involves prompt recognition and administration of parenteral hydrocortisone, rehydration, and management of electrolyte abnormalities 6.
• Patient education is crucial in preventing adrenal crisis, and patients should be educated on stress dosing and parenteral glucocorticoid administration 6.
• A multidisciplinary team of experts should be involved in the management of adrenal crisis in pregnancy 5.

Low Potassium and Low Blood Pressure in Pregnancy

• Low potassium (hypokalemia) and low blood pressure (hypotension) can be symptoms of adrenal crisis in pregnancy 5.
• These symptoms should be promptly evaluated and treated to prevent serious consequences 6.

Pulmonary Embolism (PE) in Pregnancy

• The symptoms of PE in pregnancy can include sudden onset of shortness of breath, chest pain, and cough 5.
• A D-dimer test can be used to rule out PE, but a negative result does not completely rule out the condition 5.
• Imaging tests such as a VQ scan or CT angiogram can be used to diagnose PE, but the choice of test should be made on a case-by-case basis, taking into account the risks and benefits to the mother and fetus 5.

Imaging Tests in Pregnancy

• The choice of imaging test in pregnancy should be made on a case-by-case basis, taking into account the risks and benefits to the mother and fetus 5.
• A VQ scan may be preferred over a CT angiogram in some cases due to the lower radiation exposure, but the decision should be made in consultation with a radiologist and other experts 5.
• The benefits of diagnosing PE should be weighed against the risks of radiation exposure to the fetus 5.