Primary Adrenal Insufficiency in Pregnancy: What to Do When Hydrocortisone Has Not Fully Controlled Symptoms

This protocol covers the management of primary adrenal insufficiency (PAI) in pregnant female patients — specifically the structured approach applied when the hydrocortisone regimen used during pregnancy has not adequately met treatment goals, and the patient enters the active phase of labor.

Clinical Scenario

Female patient with primary adrenal insufficiency in pregnancy. Hydrocortisone is the preferred glucocorticoid during pregnancy, selected over cortisone acetate, prednisolone, prednisone, and dexamethasone, with dose adjustments guided by the individual clinical course.

Prior Treatment — Targets Not Met

The pregnancy-phase regimen with Hydrocortisone targets normal weight gain and the absence of fatigue, postural hypotension or hypertension, and hyperglycemia. When these goals are not achieved, or as active labor begins, the following next-line protocol is indicated.

Next-Line Approach: Active Labor

This protocol applies a hydrocortisone stress-dosing strategy timed to the onset of active labor, with a defined approach for the immediate postpartum period. The complete regimen is available in the structured protocol.

Instant Access to Structured Evidence-Based Regimens

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 recommend hydrocortisone stress dosing during the active phase of labor, similar to that used in major surgical stress.
After delivery, hydrocortisone can be quickly tapered back to prepregnancy doses.

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