Primary adrenal insufficiency (PAI) in pregnant female patients requires a tailored management approach, as pregnancy alters the physiological context in ways that directly affect glucocorticoid replacement decisions.
Clinical Scenario
This protocol covers female patients with primary adrenal insufficiency who are pregnant. Pregnancy introduces physiological changes that affect both agent selection and dosing strategy, making standard non-pregnant management insufficient for this population.
Treatment Approach
Management involves glucocorticoid replacement with a preferred agent specifically indicated in the pregnant setting, where dose adjustments based on the individual clinical course become particularly relevant as pregnancy progresses. The complete structured regimen is available below.
References
DOI: 10.1210/jc.2015-1710
In pregnant women with PAI, we suggest using hydrocortisone over cortisone acetate, prednisolone, or prednisone and recommend against using dexamethasone because it is not inactivated in the placenta.
We suggest that, based on the individual clinical course, an increase in hydrocortisone dose should be implemented, in particular during the third trimester.
Although little evidence exists on the exact regimen of optimized glucocorticoid replacement in pregnancy, one common approach is to increase hydrocortisone dose by 20-40% from the 24th week onward to reflect the physiological increase in free cortisol.
We suggest that pregnant patients with PAI be monitored for clinical symptoms and signs of glucocorticoid over- and under-replacement (eg, normal weight gain, fatigue, postural hypotension or hypertension, hyperglycemia), with at least one review per trimester.
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