Management of Congenital Adrenal Hyperplasia in Pregnancy
The key feature of pregnancy care for this patient is that her prednisolone dose should be increased during pregnancy, particularly in the third trimester, and she will require stress-dose glucocorticoids during labor and delivery. However, none of the provided answer choices accurately reflect evidence-based management of CAH in pregnancy.
Analysis of the Answer Choices
Choice A: Dexamethasone 20 mg before week 10
This option confuses maternal CAH management with prenatal treatment of an at-risk fetus. Dexamethasone is used for prenatal treatment of affected female fetuses to prevent virilization, not for maternal CAH management 1, 2. The dose mentioned (20 mg) is incorrect, and this treatment would only be considered if the fetus is at risk for CAH and the goal is to prevent genital ambiguity in an affected female fetus 2. This patient already has CAH herself and is on prednisolone for her own condition.
Choice B: Increase prednisolone immediately by 10 mg
While glucocorticoid dose adjustment is necessary during pregnancy, the recommendation is to increase hydrocortisone by 2.5-10 mg/day in the third trimester, not immediately at 6 weeks 1. The timing and magnitude of this increase are incorrect. Additionally, the increase should be based on clinical symptoms and overall health, not a blanket 10 mg increase at 6 weeks gestation 1.
Choice C & D: Estrogen or progesterone supplementation
There is no evidence supporting routine estrogen or progesterone supplementation for pregnant women with CAH 1, 3. In fact, estrogens can decrease hepatic metabolism of corticosteroids, potentially increasing their effect 4.
Choice E: Female child requiring reconstructive therapy
This statement is misleading. A female child born to a mother with CAH will not require reconstructive therapy unless the child herself has CAH 5. The mother's CAH does not directly cause genital abnormalities in offspring; only if the child inherits two mutated genes and develops CAH would virilization occur 3, 6.
Correct Management Approach
Glucocorticoid Adjustment
- Increase hydrocortisone equivalent dose by 2.5-10 mg/day in the third trimester due to estrogen-stimulated increases in corticosteroid-binding globulin 1
- Adjust based on clinical symptoms, blood pressure, and electrolyte monitoring rather than fixed protocols 1
Labor and Delivery Management
- Administer 100 mg hydrocortisone (Solu-Cortef) IV or IM during labor, repeated every 6 hours if necessary 1
- Double the oral dose for 24-48 hours after delivery 1
Mineralocorticoid Considerations
- Fludrocortisone dose may need increase in later pregnancy due to progesterone's anti-mineralocorticoid effect 1
- Monitor through salt cravings, blood pressure, and serum electrolytes rather than plasma renin activity 1
Monitoring Requirements
- Regular assessment of blood pressure, electrolyte levels, and clinical symptoms throughout pregnancy 1
- Patient education on signs of adrenal crisis and emergency self-administration of hydrocortisone 1
Critical Pitfall
The most dangerous error would be failing to provide stress-dose glucocorticoids during labor and delivery, which could precipitate life-threatening adrenal crisis 1. This patient requires careful endocrine monitoring throughout pregnancy and appropriate glucocorticoid coverage during the physiologic stress of delivery 3, 6.