Steroid Management in Pregnant Women with Suspected Adrenal Crisis
Hydrocortisone is the steroid of choice for pregnant women with suspected adrenal crisis, administered as 100 mg IV bolus immediately, followed by either continuous IV infusion of 200 mg over 24 hours or 50 mg IM/IV every 6 hours until stabilized. 1
Why Hydrocortisone is the Preferred Agent
Hydrocortisone does not cross the placenta due to rapid metabolism by placental 11 beta-hydroxy steroid dehydrogenase type 2, making it the safest glucocorticoid for both maternal treatment and fetal protection. 2 This is critical because:
Dexamethasone and betamethasone cross the placenta readily and can cause fetal adrenal suppression, leading to neonatal hypoglycemia, hyponatremia, and prolonged need for replacement therapy (up to 3 months postnatally). 2, 3
Prednisolone and methylprednisolone are also metabolized by placental enzymes but with prolonged high-dose use, enzyme saturation occurs, resulting in fetal exposure and potential adrenal suppression. 3
Hydrocortisone provides essential mineralocorticoid activity at physiologic doses, which is particularly important in primary adrenal insufficiency during pregnancy. 1, 4
Immediate Management Protocol for Suspected Adrenal Crisis
Initial Treatment (Do Not Delay)
Administer hydrocortisone 100 mg IV bolus immediately upon suspicion of adrenal crisis—never delay treatment for diagnostic confirmation. 1, 4
Begin rapid volume resuscitation with isotonic saline simultaneously to correct hypotension and potential hyponatremia. 4
Maintenance Dosing Options
Choose one of the following regimens:
Preferred: Continuous IV infusion of hydrocortisone 200 mg over 24 hours (enhanced safety profile). 1
Alternative: Hydrocortisone 50 mg IM or IV every 6 hours if continuous infusion is unavailable. 1
Transition to Oral Therapy
Once hemodynamically stable and tolerating oral intake, switch to oral hydrocortisone at double the usual maintenance dose (typically 30-40 mg daily in divided doses). 1, 4
Continue doubled oral dose for 24-48 hours postpartum, then taper back to maintenance dosing. 1
Special Considerations During Pregnancy
Third Trimester Adjustments
Glucocorticoid requirements increase during late pregnancy (from 20th week onwards) due to physiologic rises in both total and free cortisol levels. 1
Maintenance hydrocortisone dose may need to increase by 2.5-10 mg daily in the third trimester, though only 41% of women in recent surveys received dose increases. 1, 5, 6
Labor and Delivery Protocol
At onset of active labor (contractions every 5 minutes for 1 hour OR cervical dilation >4 cm): Give hydrocortisone 100 mg IV bolus. 1, 4
Continue with either:
- Continuous IV infusion 200 mg/24 hours, OR
- Hydrocortisone 50 mg IM every 6 hours until after delivery. 1
Mineralocorticoid Management
Fludrocortisone dose may require adjustment during late pregnancy due to progesterone's anti-mineralocorticoid effects. 1
Monitor blood pressure and serum electrolytes rather than plasma renin activity (which physiologically increases in pregnancy). 1
Critical Pitfalls to Avoid
Never Use These Steroids in Pregnancy for Maternal Adrenal Crisis
Dexamethasone is inadequate for primary adrenal insufficiency treatment as it lacks mineralocorticoid activity AND crosses the placenta, risking fetal adrenal suppression. 1, 2, 3
Avoid prednisolone and methylprednisolone for acute crisis management in pregnancy due to potential placental transfer with high doses or prolonged use. 2, 3
Common Management Errors
Delaying treatment while awaiting diagnostic confirmation—treat immediately if clinical suspicion exists; diagnosis can be established later even after treatment initiation. 7, 4
Failing to provide adequate patient education—adrenal crisis occurred in 7-24% of pregnancies in recent surveys, with only 40-47% of affected women carrying steroid emergency cards. 5, 6
Inadequate dose escalation in third trimester—recent data shows only 57% of pregnancies received any glucocorticoid dose increase despite physiologic need. 5, 6
Maternal and Fetal Outcomes
When managed appropriately in specialized endocrine centers:
Maternal mortality is rare but reported (1 death in 101 pregnancies in one series). 6
Adrenal crisis rate: 7-24% of pregnancies, emphasizing need for vigilant monitoring and patient education. 5, 6
Cesarean section rate is elevated at 58-64% compared to general population. 5, 6
Preterm birth rate: 21% and low birth weight (<10th centile): 13%. 6
Fetal complications are uncommon (3%) with appropriate hydrocortisone use. 5
Patient Safety Essentials
All pregnant women with adrenal insufficiency must carry an NHS steroid emergency card and have emergency hydrocortisone injection kit (100 mg) available. 4, 6
Both patient and partner should be trained in hydrocortisone emergency injection techniques. 8
Obstetric staff must receive clear written guidance for hydrocortisone cover during labor and delivery. 8
Multidisciplinary care with endocrinology and obstetrics throughout pregnancy is essential for optimal outcomes. 8, 5, 6