Hydrocortisone Loading Dose for Elective Cesarean Section with Adrenal Insufficiency
For elective cesarean section in patients with adrenal insufficiency, administer hydrocortisone 100 mg IV at induction, followed immediately by a continuous infusion of 200 mg over 24 hours. 1
Intraoperative Protocol
Cesarean section is classified as major surgery and requires the same stress-dose steroid coverage as other major surgical procedures 1
The loading dose consists of hydrocortisone 100 mg IV bolus at surgical induction, which should be given before the procedure begins 1, 2
Immediately after the bolus, initiate a continuous IV infusion of hydrocortisone 200 mg/24 hours (approximately 8.3 mg/hour) 1, 2
This protocol applies to both patients with primary or secondary adrenal insufficiency AND patients on chronic adrenosuppressive doses of steroids (prednisolone equivalent ≥5 mg for 4 weeks or longer) 1
Postoperative Management
Continue the hydrocortisone 200 mg/24h IV infusion while the patient is NPO or experiencing postoperative vomiting 1, 2
An alternative to continuous infusion is hydrocortisone 50 mg IV or IM every 6 hours, though continuous infusion is preferred for maintaining stable cortisol levels 1, 3
Once tolerating oral intake, resume oral glucocorticoid at double the pre-surgical dose for 48 hours if recovery is uncomplicated 1, 2
If complications arise or recovery is prolonged, continue double oral dose for up to one week 1, 2
Evidence Supporting This Approach
Research demonstrates that continuous IV infusion is superior to intermittent bolus administration for maintaining cortisol concentrations in the physiologic stress range, with a 50-100 mg initial bolus followed by 200 mg/24h infusion being optimal 3
Pharmacokinetic studies show that cortisol half-life is prolonged in the postoperative period, suggesting that lower doses than historically used may be adequate, but the 200 mg/24h dose remains the guideline-recommended standard 4
Maternal cortisol levels during elective cesarean section (mean 831-906 nmol/L) are significantly lower than during vaginal delivery (mean 1325-1559 nmol/L), but cesarean section still represents major surgical stress requiring full coverage 5
Critical Pitfalls to Avoid
Never delay steroid administration for diagnostic testing in patients with known or suspected adrenal insufficiency—treat immediately 6
Do not use dexamethasone as the primary agent for patients with adrenal insufficiency, as it lacks mineralocorticoid activity and has a prolonged half-life that makes dose adjustment difficult 6
Ensure patients with primary adrenal insufficiency receive fludrocortisone once oral intake resumes, as they require mineralocorticoid replacement in addition to glucocorticoid coverage 6
Do not abruptly discontinue stress-dose steroids—always taper gradually to maintenance doses over 48 hours to one week depending on recovery 1, 2
Monitor for hypoglycemia in neonates if antenatal corticosteroids were administered, though this is a separate consideration from maternal stress-dose coverage 7