What are the considerations for using hydrocortisone (cortisol) in a pregnant female, particularly one with a history of or at risk for Pregnancy-Induced Hypertension (PIH)?

Hydrocortisone Use in Pregnancy

Hydrocortisone is safe and necessary during pregnancy for women with primary adrenal insufficiency, requiring dose adjustments in the third trimester and during delivery, but it should not be used to treat pregnancy-induced hypertension itself. 1

For Women with Adrenal Insufficiency

Dose Adjustments During Pregnancy

• Increase hydrocortisone by 2.5-10 mg daily during the third trimester due to physiologic increases in corticosteroid-binding globulin and free cortisol levels 1
• Fludrocortisone dose often needs to be increased during late pregnancy due to progesterone's anti-mineralocorticoid effects 1
• Monitor using salt cravings, blood pressure, and serum electrolytes rather than plasma renin activity, which normally increases during pregnancy 1

Delivery Management

• Administer 100 mg hydrocortisone (Solu-Cortef) IV as a bolus at delivery, repeated every 6 hours if necessary 1
• Double the oral dose for 24-48 hours postpartum 1

Fetal Considerations

• Infants born to mothers receiving corticosteroids during pregnancy should be carefully observed for signs of hypoadrenalism 2
• Animal studies show increased incidence of cleft palate with corticosteroid exposure, though only 10% of maternal non-fluorinated corticosteroid dose reaches the fetus 3, 2
• The FDA label states corticosteroids should be used during pregnancy only if potential benefit justifies potential risk to the fetus 2

Regarding Pregnancy-Induced Hypertension

Corticosteroids Are NOT Indicated for PIH Treatment

• Corticosteroids are not recommended for treating pregnancy-induced hypertension or preeclampsia itself - the hypertension guidelines make no mention of corticosteroids as antihypertensive therapy 1
• Methyldopa, labetalol, and nifedipine are the preferred antihypertensive agents during pregnancy 1
• For severe hypertension (≥170/110 mmHg), use IV labetalol, oral methyldopa, or oral nifedipine - not corticosteroids 1

Exception: Antenatal Corticosteroids for Fetal Lung Maturation

• Betamethasone (not hydrocortisone) is indicated between 24+0 and 33+6 weeks when preterm delivery is anticipated within 7 days, even in women with severe preeclampsia 3
• Historical concerns about corticosteroid use in preeclampsia have been addressed - when continuous fetal heart rate monitoring is used, corticosteroids for fetal lung maturity can be considered even with severe preeclampsia 4
• Do NOT use corticosteroids for HELLP syndrome specifically - six guidelines explicitly recommend against this 3

Monitoring Requirements in Pregnancy

For Women on Chronic Hydrocortisone

• Monitor blood pressure closely, as corticosteroids can cause hypertension and increase preeclampsia risk 3
• Screen for gestational diabetes - corticosteroids increase blood glucose concentrations and may require antidiabetic dose adjustments 2
• Watch for peripheral edema and adjust fludrocortisone accordingly 1

Drug Interactions to Avoid

• Avoid NSAIDs - increased gastrointestinal side effects when combined with corticosteroids 2
• Avoid liquorice and grapefruit juice - they potentiate mineralocorticoid effects 1
• Estrogens (including oral contraceptives) decrease hepatic metabolism of corticosteroids, increasing their effect 2

Breastfeeding Considerations

• Systemically administered corticosteroids appear in human milk and could suppress infant growth or interfere with endogenous corticosteroid production 2
• Prednisone or non-fluorinated steroids <20 mg per day are considered compatible with breastfeeding 3
• Very little of the maternal corticosteroid dose enters breast milk 3

Critical Pitfall to Avoid

Do not confuse the indication for hydrocortisone replacement in adrenal insufficiency with treatment of PIH - these are entirely separate clinical scenarios. Women with adrenal insufficiency who develop PIH need both their replacement hydrocortisone (adjusted as above) AND appropriate antihypertensive therapy with methyldopa, labetalol, or nifedipine 1.