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Castets S, Albarel F, Bachelot A, Brun G, Bouligand J, Briet C, Bui Quoc E, Cazabat L, Chabbert-Buffet N, Christin-Maitre S, Courtillot C, Cuny T, De Filippo G, Donadille B, Illouz F, Pellegrini I, Reznik Y, Saveanu A, Teissier N, Touraine P, Vantyghem MC, Vergier J, Léger J, Brue T, Reynaud R. Position statement on the diagnosis and management of congenital pituitary deficiency in adults: The French National Diagnosis and Treatment Protocol (NDTP). ANNALES D'ENDOCRINOLOGIE 2024; 85:327-339. [PMID: 38452869 DOI: 10.1016/j.ando.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Pituitary deficiency, or hypopituitarism, is a rare chronic disease. It is defined by insufficient synthesis of one or more pituitary hormones (growth hormone, TSH, ACTH, LH-FSH, prolactin), whether or not associated with arginine vasopressin deficiency (formerly known as diabetes insipidus). In adult patients, it is usually acquired (notably during childhood), but can also be congenital, due to abnormal pituitary development. The present study focuses on congenital pituitary deficiency in adults, from diagnosis to follow-up, including special situations such as pregnancy or the elderly. The clinical presentation is highly variable, ranging from isolated deficit to multiple deficits, which may be part of a syndromic form or not. Diagnosis is based on a combination of clinical, biological (assessment of all hormonal axes), radiological (brain and hypothalamic-pituitary MRI) and genetic factors. Treatment consists in hormonal replacement therapy, adapted according to the period of life and the deficits, which may be progressive. Comorbidities, risk of complications and acute decompensation, and the impact on fertility and quality of life all require adaptative multidisciplinary care and long-term monitoring.
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Affiliation(s)
- Sarah Castets
- Service de pédiatrie multidisciplinaire, centre de référence des maladies rares de l'hypophyse HYPO, hôpital de la Timone Enfants, Assistance publique-Hôpitaux de Marseille (AP-HM), 13005 Marseille, France.
| | - Frédérique Albarel
- Service d'endocrinologie, centre de référence des maladies rares de l'hypophyse HYPO, hôpital de la Conception, Assistance publique-Hôpitaux de Marseille (AP-HM), 13005 Marseille, France
| | - Anne Bachelot
- IE3M, ICAN, Department of Endocrinology and Reproductive Medicine, Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Centre de Référence des Pathologies Gynécologiques Rares, hôpital Pitié-Salpêtrière, AP-HP, Paris, France; Sorbonne université, Paris, France
| | - Gilles Brun
- Aix-Marseille University, Institut National de la Santé et de la Recherche Médicale (INSERM), U1251, Marseille Medical Genetics (MMG), Assistance Publique Hôpitaux de Marseille, Reference Center for Rare Pituitary Diseases HYPO, Assistance-Publique des Hôpitaux de Marseille, Laboratory of Molecular Biology, Conception Hospital, Marseille, France; Hôpital Européen, Pôle imagerie médicale, 13003, Marseille, France
| | - Jérôme Bouligand
- Molecular Genetic, Pharmacogenetic and Hormonology, Kremlin-Bicêtre Hospital, Paris-Saclay University, AP-HP, Le Kremlin-Bicêtre, France
| | - Claire Briet
- Département d'endocrinologie-diabétologie nutrition, Centre de référence des maladies rares de la Thyroïde et des Récepteurs Hormonaux, Endo-ERN centre for rare endocrine diseases, CHU d'Angers, 4, rue larrey, 49100 Angers, France; Laboratoire MITOVASC, UMR CNRS 6015, Inserm 1083, Université d'Angers, rue Roger Amsler, 49100 Angers, France
| | - Emmanuelle Bui Quoc
- Ophthalmology Department, Robert-Debré University Hospital, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Laure Cazabat
- Department of Endocrinology, Diabetology and Nutrition, Ambroise Paré Hospital, AP-HP, UVSQ, Boulogne-Billancourt, France
| | - Nathalie Chabbert-Buffet
- Department of Gynecology and Obstetrics, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 75020 Paris, France
| | - Sophie Christin-Maitre
- Department of Endocrinology, Diabetology and Reproductive Medicine, Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du Développement (CMERC), Centre de Compétence HYPO, Hôpital Saint-Antoine, Sorbonne University, Assistance publique-Hôpitaux de Paris, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
| | - Carine Courtillot
- IE3M, ICAN, Department of Endocrinology and Reproductive Medicine, Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Centre de Référence des Pathologies Gynécologiques Rares, hôpital Pitié-Salpêtrière, AP-HP, Paris, France
| | - Thomas Cuny
- Department of Endocrinology, Diabetology and Reproductive Medicine, Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du Développement (CMERC), Centre de Compétence HYPO, Hôpital Saint-Antoine, Sorbonne University, Assistance publique-Hôpitaux de Paris, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
| | - Gianpaolo De Filippo
- Service d'endocrinologie et diabétologie pédiatrique, centre de référence des maladies endocriniennes de la croissance et du développement, hôpital universitaire Robert-Debré, université Paris Cité, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Bruno Donadille
- Department of Endocrinology, Diabetology and Reproductive Medicine, Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du Développement (CMERC), Centre de Compétence HYPO, Hôpital Saint-Antoine, Sorbonne University, Assistance publique-Hôpitaux de Paris, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
| | - Frédéric Illouz
- Département d'endocrinologie-diabétologie nutrition, Centre de référence des maladies rares de la Thyroïde et des Récepteurs Hormonaux, Endo-ERN centre for rare endocrine diseases, CHU d'Angers, 4, rue larrey, 49100 Angers, France; Laboratoire MITOVASC, UMR CNRS 6015, Inserm 1083, Université d'Angers, rue Roger Amsler, 49100 Angers, France
| | - Isabelle Pellegrini
- Service d'endocrinologie, centre de référence des maladies rares de l'hypophyse HYPO, hôpital de la Conception, Assistance publique-Hôpitaux de Marseille (AP-HM), 13005 Marseille, France
| | - Yves Reznik
- Endocrinology and Diabetes Department, CHU Côte de Nacre and Unicaen, Caen Cedex, France
| | - Alexandru Saveanu
- Aix-Marseille University, Institut National de la Santé et de la Recherche Médicale (INSERM), U1251, Marseille Medical Genetics (MMG), Assistance Publique Hôpitaux de Marseille, Reference Center for Rare Pituitary Diseases HYPO, Assistance-Publique des Hôpitaux de Marseille, Laboratory of Molecular Biology, Conception Hospital, Marseille, France
| | - Natacha Teissier
- Department of Pediatric Otolaryngology, Robert Debré Hospital, AP-HP Nord, Paris, France
| | - Philippe Touraine
- Service d'endocrinologie et médecine de la reproduction, centre de maladies endocrinennes rares de la croissance et du développement, médecine-hôpital Pitié-Salpêtrière, Sorbonne université, Paris, France
| | - Marie-Christine Vantyghem
- Service d'endocrinologie, diabétologie et maladies métaboliques, CHRU de Lille, rue Polonowski, Lille cedex, France
| | - Julia Vergier
- Service de pédiatrie multidisciplinaire, centre de référence des maladies rares de l'hypophyse HYPO, hôpital de la Timone Enfants, Assistance publique-Hôpitaux de Marseille (AP-HM), 13005 Marseille, France
| | - Julianne Léger
- Service d'endocrinologie et diabétologie pédiatrique, centre de référence des maladies endocriniennes de la croissance et du développement, hôpital universitaire Robert-Debré, université Paris Cité, Assistance publique-Hôpitaux de Paris, Paris, France; Université Paris Cité, NeuroDiderot, Institut National de la Santé et de la Recherche Médicale (INSERM) UMR 1141, Paris, France
| | - Thierry Brue
- Service de pédiatrie multidisciplinaire, centre de référence des maladies rares de l'hypophyse HYPO, hôpital de la Timone Enfants, Assistance publique-Hôpitaux de Marseille (AP-HM), 13005 Marseille, France; Aix-Marseille University, Institut National de la Santé et de la Recherche Médicale (INSERM), U1251, Marseille Medical Genetics (MMG), Assistance Publique Hôpitaux de Marseille, Reference Center for Rare Pituitary Diseases HYPO, Assistance-Publique des Hôpitaux de Marseille, Laboratory of Molecular Biology, Conception Hospital, Marseille, France; Inserm, MMG, Laboratory of Molecular Biology, Hospital La Conception, Aix-Marseille University, AP-HM, Marseille, France
| | - Rachel Reynaud
- Service de pédiatrie multidisciplinaire, centre de référence des maladies rares de l'hypophyse HYPO, hôpital de la Timone Enfants, Assistance publique-Hôpitaux de Marseille (AP-HM), 13005 Marseille, France; Aix-Marseille University, Institut National de la Santé et de la Recherche Médicale (INSERM), U1251, Marseille Medical Genetics (MMG), Assistance Publique Hôpitaux de Marseille, Reference Center for Rare Pituitary Diseases HYPO, Assistance-Publique des Hôpitaux de Marseille, Laboratory of Molecular Biology, Conception Hospital, Marseille, France; Inserm, MMG, Laboratory of Molecular Biology, Hospital La Conception, Aix-Marseille University, AP-HM, Marseille, France
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Chen J, Chang JJ, Chung EH, Lathi RB, Aghajanova L, Katznelson L. Fertility issues in hypopituitarism. Rev Endocr Metab Disord 2024; 25:467-477. [PMID: 38095806 DOI: 10.1007/s11154-023-09863-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 06/09/2024]
Abstract
Women with hypopituitarism have lower fertility rates and worse pregnancy outcomes than women with normal pituitary function. These disparities exist despite the use of assisted reproductive technologies and hormone replacement. In women with hypogonadotropic hypogonadism, administration of exogenous gonadotropins can be used to successfully induce ovulation. Growth hormone replacement in the setting of growth hormone deficiency has been suggested to potentiate reproductive function, but its routine use in hypopituitary women remains unclear and warrants further study. In this review, we will discuss the clinical approach to fertility in a woman with hypopituitarism.
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Affiliation(s)
- Julie Chen
- Department of Medicine, Division of Endocrinology, Stanford University Medical Center, 300 Pasteur Drive, Grant-S025, Stanford, Palo Alto, CA, 94305-5103, USA.
| | - Julia J Chang
- Department of Medicine, Division of Endocrinology, Stanford University Medical Center, 300 Pasteur Drive, Grant-S025, Stanford, Palo Alto, CA, 94305-5103, USA
| | - Esther H Chung
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Stanford University, Palo Alto, CA, USA
| | - Ruth B Lathi
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Stanford University, Palo Alto, CA, USA
| | - Lusine Aghajanova
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Stanford University, Palo Alto, CA, USA
| | - Laurence Katznelson
- Department of Medicine, Division of Endocrinology, Stanford University Medical Center, 300 Pasteur Drive, Grant-S025, Stanford, Palo Alto, CA, 94305-5103, USA
- Department of Neurosurgery, Stanford University, Palo Alto, CA, USA
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Lotter LD, Nehls S, Losse E, Dukart J, Chechko N. Temporal dissociation between local and global functional adaptations of the maternal brain to childbirth: a longitudinal assessment. Neuropsychopharmacology 2024:10.1038/s41386-024-01880-9. [PMID: 38769432 DOI: 10.1038/s41386-024-01880-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 04/24/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Abstract
The maternal brain undergoes significant reorganization during birth and the postpartum period. However, the temporal dynamics of these changes remain unclear. Using resting-state functional magnetic resonance imaging, we report on local and global brain function alterations in 75 mothers in their first postpartum week, compared to 23 nulliparous women. In a subsample followed longitudinally for the next six months, we observed a temporal and spatial dissociation between changes observed at baseline (cluster mass permutation: pFWE < 0.05). Local activity and connectivity changes in widespread neocortical regions persisted throughout the studied time period (ANCOVAs vs. controls: pFDR < 0.05), with preliminary evidence linking these alterations to behavioral and psychological adaptations (interaction effect with postpartum time: uncorrected p < 0.05). In contrast, the initially reduced whole-brain connectivity of putamen-centered subcortical areas returned to control levels within six to nine weeks postpartum (linear and quadratic mixed linear models: pFDR < 0.05). The whole-brain spatial colocalization with hormone receptor distributions (Spearman correlations: pFDR < 0.05) and preliminary blood hormone associations (interaction effect with postpartum time: uncorrected p < 0.05) suggested that the postpartum restoration of progesterone levels may underlie this rapid normalization. These observations enhance our understanding of healthy maternal brain function, contributing to the identification of potential markers for pathological postpartum adaptation processes, which in turn could underlie postpartum psychiatric disorders.
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Affiliation(s)
- Leon D Lotter
- Institute of Neuroscience and Medicine, Brain & Behavior (INM-7), Research Centre Jülich, Jülich, Germany.
- Institute of Systems Neuroscience, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
- Max Planck School of Cognition; Stephanstrasse 1A, 04103, Leipzig, Germany.
| | - Susanne Nehls
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, RWTH Aachen, Aachen, Germany
- Institute of Neuroscience and Medicine, JARA-Institute Brain Structure Function Relationship (INM-10), Research Centre Jülich, Jülich, Germany
| | - Elena Losse
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, RWTH Aachen, Aachen, Germany
| | - Juergen Dukart
- Institute of Neuroscience and Medicine, Brain & Behavior (INM-7), Research Centre Jülich, Jülich, Germany
- Institute of Systems Neuroscience, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Natalya Chechko
- Institute of Neuroscience and Medicine, Brain & Behavior (INM-7), Research Centre Jülich, Jülich, Germany.
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, RWTH Aachen, Aachen, Germany.
- Institute of Neuroscience and Medicine, JARA-Institute Brain Structure Function Relationship (INM-10), Research Centre Jülich, Jülich, Germany.
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Maniaci A, La Via L, Pecorino B, Chiofalo B, Scibilia G, Lavalle S, Scollo P. Obstructive Sleep Apnea in Pregnancy: A Comprehensive Review of Maternal and Fetal Implications. Neurol Int 2024; 16:522-532. [PMID: 38804478 PMCID: PMC11130811 DOI: 10.3390/neurolint16030039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/01/2024] [Accepted: 05/02/2024] [Indexed: 05/29/2024] Open
Abstract
Obstructive sleep apnea (OSA) is a prevalent yet underdiagnosed condition in pregnancy, associated with various maternal and fetal complications. This review synthesizes the current evidence on the epidemiology, pathophysiology, and neurological consequences of OSA in pregnancy, along with the potential management strategies. Articles were sourced from the PubMed, EMBASE, and Cochrane databases until 2023. Our comprehensive review highlights that the incidence of OSA increases during pregnancy due to physiological changes such as weight gain and hormonal fluctuations. OSA in pregnancy is linked with gestational hypertension, pre-eclampsia, gestational diabetes, and potential adverse fetal outcomes such as intrauterine growth restriction and preterm birth. Continuous positive airway pressure (CPAP) therapy remains the most effective management strategy for pregnant women with OSA. However, adherence to CPAP therapy is often suboptimal. This comprehensive review underscores the importance of the early recognition, timely diagnosis, and effective management of OSA in pregnancy to improve both maternal and fetal outcomes. Future research should focus on enhancing screening strategies and improving adherence to CPAP therapy in this population.
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Affiliation(s)
- Antonino Maniaci
- Faculty of Medicine and Surgery, University of Enna “Kore”, 94100 Enna, Italy; (A.M.); (B.P.); (B.C.); (S.L.); (P.S.)
| | - Luigi La Via
- Anesthesia and Intensive Care Department, Policlinico “G.Rodolico—San Marco” Hospital, 95123 Catania, Italy
| | - Basilio Pecorino
- Faculty of Medicine and Surgery, University of Enna “Kore”, 94100 Enna, Italy; (A.M.); (B.P.); (B.C.); (S.L.); (P.S.)
| | - Benito Chiofalo
- Faculty of Medicine and Surgery, University of Enna “Kore”, 94100 Enna, Italy; (A.M.); (B.P.); (B.C.); (S.L.); (P.S.)
| | - Giuseppe Scibilia
- Gynecology and Obstetrics Department, Giovanni Paolo II Hospital, ASP 7, 97100 Ragusa, Italy;
| | - Salvatore Lavalle
- Faculty of Medicine and Surgery, University of Enna “Kore”, 94100 Enna, Italy; (A.M.); (B.P.); (B.C.); (S.L.); (P.S.)
| | - Paolo Scollo
- Faculty of Medicine and Surgery, University of Enna “Kore”, 94100 Enna, Italy; (A.M.); (B.P.); (B.C.); (S.L.); (P.S.)
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Dimcea DAM, Petca RC, Dumitrașcu MC, Șandru F, Mehedințu C, Petca A. Postpartum Depression: Etiology, Treatment, and Consequences for Maternal Care. Diagnostics (Basel) 2024; 14:865. [PMID: 38732283 PMCID: PMC11083152 DOI: 10.3390/diagnostics14090865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 03/18/2024] [Accepted: 04/19/2024] [Indexed: 05/13/2024] Open
Abstract
Postpartum depression (PPD) is a disabling condition that has recently shown an increase in prevalence, becoming an essential public health problem. This study is a qualitative review summarizing the most frequent risk factors associated with PPD, evaluating molecular aspects of PPD and current approaches to detect and prevent PPD. The most prevalent risk factors were detected in the areas of economic and social factors, obstetrical history, lifestyle, and history of mental illness. Research on the genetic basis for PPD has taken place in recent years to identify the genes responsible for establishing targeted therapeutic methods and understanding its pathogenesis. The most frequently studied candidate gene was the serotonin transporter gene (SERT) associated with PPD. Among biological studies, antidepressants and psychological interventions provided the most evidence of successful intervention. The obstetrician can serve an essential role in screening for and treating PPD. Postpartum women with risk factors should be screened using the Edinburgh Postnatal Depression Scale (EPDS), but, at the moment, there are no prevention programs in Europe. In conclusion, data from this review increase concerns among this vulnerable population and can be used to design a screening tool for high-risk pregnant women and create a prevention program.
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Affiliation(s)
- Daiana Anne-Marie Dimcea
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (D.A.-M.D.); (M.C.D.); (C.M.); (A.P.)
| | - Răzvan-Cosmin Petca
- Department of Urology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Urology, “Prof. Dr. Th. Burghele” Clinical Hospital, 050659 Bucharest, Romania
| | - Mihai Cristian Dumitrașcu
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (D.A.-M.D.); (M.C.D.); (C.M.); (A.P.)
- Department of Obstetrics and Gynecology, University Emergency Hospital, 050098 Bucharest, Romania
| | - Florica Șandru
- Department of Dermatology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- Department of Dermatology, Elias University Emergency Hospital, 011461 Bucharest, Romania
| | - Claudia Mehedințu
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (D.A.-M.D.); (M.C.D.); (C.M.); (A.P.)
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011171 Bucharest, Romania
| | - Aida Petca
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (D.A.-M.D.); (M.C.D.); (C.M.); (A.P.)
- Department of Obstetrics and Gynecology, Elias University Emergency Hospital, 011461 Bucharest, Romania
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Bernardi S, Tonon F, Barbieri M, Zamagni G, Nuredini R, Perer L, Comar S, Toffoli B, Ronfani L, Ricci G, Fabris B, Stampalija T. A longitudinal study on the effect of obesity upon circulating renin-angiotensin system in normal pregnancy. Nutr Metab Cardiovasc Dis 2024; 34:771-782. [PMID: 38161127 DOI: 10.1016/j.numecd.2023.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 10/08/2023] [Accepted: 10/24/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND AND AIMS Obesity is the most common health issue in women of reproductive age, which profoundly affects maternal-fetal health. Despite progress in understanding key inflammatory and metabolic changes, the pathogenesis of the cardiovascular phenotype of obese pregnant women remains to be fully understood. This study aimed at: (i) evaluating the changes of the renin-angiotensin system (RAS) throughout pregnancy in obese vs normal weight (control) women, and (ii) evaluating the presence of any associations between maternal hemodynamic status and RAS changes. METHODS AND RESULTS Thirty-eight normal weight and nineteen obese pregnant women were included. Clinical assessment, blood samples and maternal hemodynamic evaluation were performed at 12, 20, 30, and 36 weeks, while ultrasound assessment was scheduled at 20, 30, and 36 weeks of gestation. Measurements of sFlt-1, PlGF, Angiotensinogen, Renin, AngII, Ang1-7, ACE and ACE2 were performed by ELISA. Our data show that normotensive obese women had lower placental blood supply, as assessed by UV-Q and UV-Q/EFW, as compared to controls, and significantly higher levels of AngII and AngII/Ang1-7 ratio, which were inversely related to placental blood supply. CONCLUSIONS Our study shows for the first time that normotensive obese women exhibited a significant progressive increase of AngII and AngII/Ang1-7 throughout pregnancy, which were inversely related to placental blood supply as assessed by UV-Q and UV-Q/EFW. Our data shed light on the early changes in pregnant obese women and suggest that RAS dysregulation is a prerequisite rather than a consequence of hypertensive disorders of pregnancy and other maternal neonatal complications.
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Affiliation(s)
- Stella Bernardi
- Department of Medical Surgical and Health Sciences, University of Trieste, 34149, Trieste, Italy; Unit of Endocrinology, ASUGI, Cattinara Teaching Hospital, 34149, Trieste, Italy.
| | - Federica Tonon
- Department of Medical Surgical and Health Sciences, University of Trieste, 34149, Trieste, Italy
| | - Moira Barbieri
- Department of Medical Surgical and Health Sciences, University of Trieste, 34149, Trieste, Italy
| | - Giulia Zamagni
- Clinical Epidemiology and Public Health Research Unit, Institute for Maternal and Child Health IRCCS "Burlo Garofolo", 34147, Trieste, Italy
| | - Roberto Nuredini
- Department of Medical Surgical and Health Sciences, University of Trieste, 34149, Trieste, Italy
| | - Laura Perer
- Department of Medical Surgical and Health Sciences, University of Trieste, 34149, Trieste, Italy
| | - Sarah Comar
- Department of Medical Surgical and Health Sciences, University of Trieste, 34149, Trieste, Italy
| | - Barbara Toffoli
- Department of Medical Surgical and Health Sciences, University of Trieste, 34149, Trieste, Italy
| | - Luca Ronfani
- Clinical Epidemiology and Public Health Research Unit, Institute for Maternal and Child Health IRCCS "Burlo Garofolo", 34147, Trieste, Italy
| | - Giuseppe Ricci
- Department of Medical Surgical and Health Sciences, University of Trieste, 34149, Trieste, Italy; Department of Obstetrics and Gynaecology, Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", 34137, Trieste, Italy
| | - Bruno Fabris
- Department of Medical Surgical and Health Sciences, University of Trieste, 34149, Trieste, Italy; Unit of Endocrinology, ASUGI, Cattinara Teaching Hospital, 34149, Trieste, Italy
| | - Tamara Stampalija
- Department of Medical Surgical and Health Sciences, University of Trieste, 34149, Trieste, Italy; Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health IRCCS Burlo Garofolo, 34137, Trieste, Italy
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7
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Khadir F, Rahimi Z, Vaisi-Raygani A, Shakiba E, Pouramir M, Bahrehmand F. Variants and Haplotypes of SIRT1 (rs7895833, rs7069102, and rs2273773) are Associated with the Risk of Preeclampsia and Affect the Trace Elements and Antioxidant Enzymes Levels. Biochem Genet 2023:10.1007/s10528-023-10548-w. [PMID: 38001390 DOI: 10.1007/s10528-023-10548-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/09/2023] [Indexed: 11/26/2023]
Abstract
Preeclampsia is the most common and serious complication of pregnancy. Variants of Sirtuin-1 (SIRT1) as a key player in the regulation of oxidant/antioxidant signaling pathways might be involved in the pathogenesis of preeclampsia. In the present case-control study 300 women with and without preeclampsia were studied for SIRT1 variants (rs7895833, rs7069102, and rs2273773) and haplotypes. Also, the relationship of glutathione peroxidase (GPx) and superoxide dismutase (SOD) activities and Zn, Cu, and Se levels to the polymorphisms were investigated. The SIRT1 rs7895833 A > G, rs7069102 C > G, and the rs2273773 C > T polymorphisms were associated with the risk of preeclampsia. We found the haplotypes G (rs7895833) C (rs7069102) C (rs2273773), GCC, and ACC compared to the AGT decreased the risk of preeclampsia. The risk haplotype of AGT was associated with higher GPx activity compared to the GCC haplotype. A significantly higher level of Cu and lower levels of Zn and Se in patients with preeclampsia compared to controls were detected. Also, a significantly lower SOD and higher GPx activity in preeclamptic patients compared to controls were found. The three risk genotypes of AA (rs7895833), GG (rs7069102), and TT (rs2273773) significantly decreased the Zn level and SOD activity, and the TT genotype (rs2273773) increased the Cu level in all studied women. The presence of rs7069102 polymorphism was associated with enhanced systolic blood pressure. For the first time, we indicated three SIRT1 polymorphisms and the AGT haplotype are risk factors for preeclampsia development. Also, SIRT1 variants and haplotypes affect the levels of antioxidant enzymes and their cofactors, complicating the pregnancy outcome.
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Affiliation(s)
- Fatemeh Khadir
- Department of Clinical Biochemistry, Medical School, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Zohreh Rahimi
- Department of Clinical Biochemistry, Medical School, Kermanshah University of Medical Sciences, Kermanshah, Iran.
- Medical Biology Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran.
- Medical Biology Research Center, Medical School, Daneshgah Avenue, P.O.Box: 67148-69914, Kermanshah, Iran.
| | - Asad Vaisi-Raygani
- Department of Clinical Biochemistry, Medical School, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Ebrahim Shakiba
- Department of Clinical Biochemistry, Medical School, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mahdi Pouramir
- Cellular and Molecular Biology Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
- Department of Clinical Biochemistry, Faculty of Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Fariborz Bahrehmand
- Department of Clinical Biochemistry, Medical School, Kermanshah University of Medical Sciences, Kermanshah, Iran
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8
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Iioka M, Hayakawa T, Otsuki M, Shimomura I. A Rare Case of Placental Abruption and Postpartum Compression Fractures in Pregnancy With Cushing Syndrome. JCEM CASE REPORTS 2023; 1:luad128. [PMID: 38021078 PMCID: PMC10652248 DOI: 10.1210/jcemcr/luad128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Indexed: 12/01/2023]
Abstract
Cushing syndrome (CS) is a disorder rarely found during pregnancy. Patients with CS usually receive treatment before pregnancy. In addition, hypercortisolism suppresses gonadotropins, leading to amenorrhea or irregular menstruation. Therefore, few reports have described cases of pregnancy with untreated CS. Here, we observed the changes in the cortisol level of a 38-year-old woman with adrenal CS before and throughout pregnancy and delivery. She also had primary aldosteronism, and we were able to follow her plasma aldosterone levels. Her symptoms of CS before pregnancy were submandibular acne and irregular menstruation, but after conception, "moon face" and fatigue appeared. Laboratory tests also revealed impaired glucose tolerance, hypokalemia, lymphocytopenia, and increased urinary free cortisol levels. After administration of metyrapone to ameliorate her general condition, laparoscopic adrenalectomy was performed in the nineteenth week of pregnancy. After the operation, the patient's symptoms improved, and the cortisol level was maintained with hydrocortisone supplementation. The patient's plasma aldosterone level and blood pressure did not deteriorate throughout the course. However, the delivery was complicated by placental abruption. One month after delivery, the mother presented with compression fractures. We review the literature and discuss the treatment and complications of pregnancy with CS.
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Affiliation(s)
- Masahito Iioka
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Tomoaki Hayakawa
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Michio Otsuki
- Department of Endocrinology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo 162-8666, Japan
| | - Iichiro Shimomura
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
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9
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Takeuchi N, Imamura Y, Ishiwata K, Kanesaka M, Goto Y, Sazuka T, Suzuki S, Koide H, Sakamoto S, Ichikawa T. Cushing's syndrome in pregnancy in which laparoscopic adrenalectomy was safely performed by a retroperitoneal approach. IJU Case Rep 2023; 6:415-418. [PMID: 37928280 PMCID: PMC10622216 DOI: 10.1002/iju5.12637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 08/25/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction Laparoscopic adrenalectomy is the standard treatment for adrenal tumors caused by Cushing's syndrome. However, few pregnant women have undergone adrenalectomy because of the risk of general anesthesia and surgery. Case presentation A 28-year-old woman presented with gradually worsening Cushing's signs at around 12 weeks of pregnancy. Magnetic resonance imaging displayed a 38-mm left adrenal tumor, which was the cause of the adrenal Cushing's syndrome. Metyrapone was started, which increased androgen levels. Since the management of Cushing's syndrome by medication alone is challenging, unilateral laparoscopic adrenalectomy by a retroperitoneal approach was performed at 23 weeks of the pregnancy. No perioperative complications were noted. Conclusion Adrenalectomy is considered safe in pregnant women with Cushing's syndrome. Laparoscopic adrenalectomy by retroperitoneal approach should be chosen and performed between 14 and 30 weeks of pregnancy to prevent mother and fetal complications.
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Affiliation(s)
- Nobuyoshi Takeuchi
- Department of UrologyChiba University Graduate School of MedicineChibaJapan
| | - Yusuke Imamura
- Department of UrologyChiba University Graduate School of MedicineChibaJapan
| | - Kazuki Ishiwata
- Department of Clinical Cell BiologyChiba University Graduate School of MedicineChibaJapan
| | - Manato Kanesaka
- Department of UrologyChiba University Graduate School of MedicineChibaJapan
| | - Yusuke Goto
- Department of UrologyChiba University Graduate School of MedicineChibaJapan
| | - Tomokazu Sazuka
- Department of UrologyChiba University Graduate School of MedicineChibaJapan
| | - Sawako Suzuki
- Department of Clinical Cell BiologyChiba University Graduate School of MedicineChibaJapan
| | - Hisashi Koide
- Department of Clinical Cell BiologyChiba University Graduate School of MedicineChibaJapan
| | - Shinichi Sakamoto
- Department of UrologyChiba University Graduate School of MedicineChibaJapan
| | - Tomohiko Ichikawa
- Department of UrologyChiba University Graduate School of MedicineChibaJapan
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10
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Hansel MC, Murphy HR, Brunner J, Wang C, Miller RK, O'Connor TG, Barrett ES, Rivera-Núñez Z. Associations between neighborhood stress and maternal sex steroid hormones in pregnancy. BMC Pregnancy Childbirth 2023; 23:730. [PMID: 37845614 PMCID: PMC10577914 DOI: 10.1186/s12884-023-06043-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 10/03/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND Neighborhood stressors (e.g., crime and deprivation) have been associated with adverse pregnancy outcomes including preterm birth and low birth weight. A potential mechanism is disruption of maternal endocrine pathways. While stress hormones (e.g., cortisol) have received much attention, other relevant hormones, including sex steroids, have been overlooked. METHODS Pregnant women in the Understanding Pregnancy Signals and Infant Development (UPSIDE) study contributed biospecimens, questionnaires, and medical record data (n = 262). In each trimester, maternal serum total testosterone [TT], estrone, estradiol, and estriol were measured using LC/MS-MS and serum free testosterone was measured by equilibrium dialysis. In the third trimester, participants reported on neighborhood stress over the last year through the validated City Stress Inventory. We examined two subscales: 11-item neighborhood disorder (e.g., vacant buildings, crime) and 7-item exposure to violence (personal experiences of violence). Composite scores were calculated and examined categorically (quartile (Q) for neighborhood disorder and any/none for exposure to violence). We fitted linear mixed models examining associations between neighborhood stressors and sex steroid hormones across pregnancy as well as trimester-specific linear regression models, all adjusting for confounders. Secondarily, we stratified by fetal sex. Results are presented as percentage change (∆%) and 95% confidence interval (CI) in hormones. RESULTS Most participants (73%) reported one or more exposures to neighborhood disorder; 22% reported any exposure to violence. In adjusted models, neighborhood disorder was associated with higher TT across pregnancy (Q2: %∆= 37.3, 95%CI: 13.2, 66.5; Q3: %∆= 22.2, 95%CI: 1.2, 47.5; and Q4: %∆= 25.7, 95%CI: 1.6, 55.3), with the strongest associations observed in the third trimester (Q2: %∆= 38.0, 95%CI: 10.6, 72.1; Q3: %∆= 29.2, 95%CI: 4.4, 59.9; and Q4: %∆=33.4, 95%CI: 4.9, 69.6). In stratified models, neighborhood disorder was associated with higher TT among women carrying male fetuses (%∆ range: 48.2-84.8). Exposure to violence was not associated with any hormones. CONCLUSION Neighborhood disorder is associated with higher maternal testosterone levels, which may have implications for maternal and child health. Additional research is needed to understand the mechanisms by which neighborhood stress impacts endocrine physiology.
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Affiliation(s)
- Megan C Hansel
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Hannah R Murphy
- Department of Obstetrics and Gynecology, University of Rochester, Rochester, NY, USA
| | - Jessica Brunner
- Department of Obstetrics and Gynecology, University of Rochester, Rochester, NY, USA
| | - Christina Wang
- Clinical and Translational Science Institute, The Lundquist Institute at Harbor -UCLA Medical Center, Torrance, CA, USA
| | - Richard K Miller
- Department of Obstetrics and Gynecology, University of Rochester, Rochester, NY, USA
| | - Thomas G O'Connor
- Departments of Psychiatry, Psychology, Neuroscience, University of Rochester, Rochester, NY, USA
| | - Emily S Barrett
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Zorimar Rivera-Núñez
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA.
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11
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Kanazawa K, Inaba T, Koga S, Kuwabara K. Clinical insights of pregnancy management, adrenal insufficiency as a possible cause of elevated TSH: a pilot study of case series. BMC Pregnancy Childbirth 2023; 23:711. [PMID: 37794329 PMCID: PMC10552194 DOI: 10.1186/s12884-023-06015-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 09/20/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND The upper limit for thyroid-stimulating hormone has been strictly defined for pregnancy management, at which point levothyroxine replacement therapy will been initiated. However, it is essential to exclude adrenal insufficiency, including subclinical adrenal insufficiency, when initiating levothyroxine replacement therapy. However, in pregnancy management, it has rarely reported the incidence, clinical course, and characteristics of adrenal insufficiency as a possible cause of elevated thyroid-stimulating hormone. METHODS This case series study included pregnant patients undergoing thyroid-stimulating hormone management in a single-center diabetes endocrinology department between 2017 and 2020. The primary study outcome was the incidence of newly diagnosed adrenal insufficiency. We reported the clinical course and assessed the adrenal insufficiency characteristics at baseline and delivery and compared them with those of hypothyroidism. RESULT Fifteen pregnant women were included for thyroid-stimulating hormone management; and nine were below the basal serum cortisol level, and four were newly diagnosed as having adrenal insufficiency (26.7%) with the endocrinological stimulation test. Among them, two cases exhibited nausea and hypoglycemic symptoms after the start of levothyroxine replacement therapy. In cases of adrenal insufficiency, the patients were successfully treated with appropriate steroid coverage. CONCLUSIONS In the management of elevated thyroid-stimulating hormone levels during pregnancy, the frequency of adrenal insufficiency suspecting hypothyroidism may be higher than expected; therefore, we must be careful about starting levothyroxine replacement therapy for hypothyroidism. These clinical insights can have a significant impact on the pregnancy outcomes.
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Affiliation(s)
- Ken Kanazawa
- Department of Diabetes, Metabolism, and Endocrinology, Labor Health and Safety Organization, Tokyo Rosai Hospital, 4-13-21 Omoriminami, Ota-ku, 143- 0013, Tokyo, Japan.
| | - Tatsuro Inaba
- Department of Diabetes, Metabolism, and Endocrinology, Labor Health and Safety Organization, Tokyo Rosai Hospital, 4-13-21 Omoriminami, Ota-ku, 143- 0013, Tokyo, Japan
| | - Shinichiro Koga
- Department of Diabetes, Metabolism, and Endocrinology, Labor Health and Safety Organization, Tokyo Rosai Hospital, 4-13-21 Omoriminami, Ota-ku, 143- 0013, Tokyo, Japan
| | - Koichiro Kuwabara
- Department of Diabetes, Metabolism, and Endocrinology, Labor Health and Safety Organization, Tokyo Rosai Hospital, 4-13-21 Omoriminami, Ota-ku, 143- 0013, Tokyo, Japan
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12
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Findling JW, Raff H. Recognition of Nonneoplastic Hypercortisolism in the Evaluation of Patients With Cushing Syndrome. J Endocr Soc 2023; 7:bvad087. [PMID: 37440963 PMCID: PMC10334485 DOI: 10.1210/jendso/bvad087] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Indexed: 07/15/2023] Open
Abstract
The evaluation of suspected hypercortisolism is one of the most challenging problems in medicine. The signs and symptoms described by Dr Harvey Cushing are common and often create diagnostic confusion to even experienced endocrinologists. Cushing syndrome is classically defined as neoplastic hypercortisolism resulting from an ACTH-secreting tumor or from autonomous secretion of excess cortisol associated with benign or malignant adrenal neoplasia. The increasing recognition of the negative cardiometabolic effects of mild cortisol excess without overt physical signs of Cushing syndrome has led to more screening for endogenous hypercortisolism in patients with adrenal nodular disease, osteoporosis, and the metabolic syndrome. However, sustained or intermittent activation of the dynamic hypothalamic-pituitary-adrenal axis caused by chemical (alcohol), inflammatory (chronic kidney disease), psychologic (major depression), and physical (starvation/chronic intense exercise) stimuli can result in clinical and/or biochemical features indistinguishable from neoplastic hypercortisolism. Nonneoplastic hypercortisolism (formerly known as pseudo-Cushing syndrome) has been recognized for more than 50 years and often causes diagnostic uncertainty. This expert consultation describes two patients with features of Cushing syndrome who were referred for inferior petrosal sinus sampling for the differential diagnosis of ACTH-dependent hypercortisolism. Both patients were discovered to have nonneoplastic hypercortisolism: one from a covert alcohol use disorder and the other to chronic kidney disease. This consultation emphasizes the value of a good history and physical examination, appropriate laboratory testing, and the desmopressin acetate stimulation test to aid in distinguishing neoplastic from nonneoplastic hypercortisolism.
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Affiliation(s)
- James W Findling
- Department of Medicine (Endocrinology and Molecular Medicine), Medical College of Wisconsin, Milwaukee, WI 53226, USA
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Hershel Raff
- Correspondence: Hershel Raff, PhD, Endocrinology Research HRC4150, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226, USA.
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13
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Gumpp AM, Behnke A, Ramo-Fernández L, Radermacher P, Gündel H, Ziegenhain U, Karabatsiakis A, Kolassa IT. Investigating mitochondrial bioenergetics in peripheral blood mononuclear cells of women with childhood maltreatment from post-parturition period to one-year follow-up. Psychol Med 2023; 53:3793-3804. [PMID: 35311632 PMCID: PMC10317795 DOI: 10.1017/s0033291722000411] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 12/27/2021] [Accepted: 02/04/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Childhood maltreatment (CM) exerts various long-lasting psychological and biological changes in affected individuals, with inflammation being an interconnecting element. Besides chronic low-grade inflammation, CM might also affect the energy production of cells by altering the function and density of mitochondria, i.e. the body's main energy suppliers. Here, we compared mitochondrial respiration and density in intact peripheral blood mononuclear cells (PBMC), from women with and without CM between two time points, i.e. at the highly inflammatory phase within 1 week after parturition (t0) and again after 1 year (t2). METHODS CM exposure was assessed with the Childhood Trauma Questionnaire. Whole blood was collected from n = 52 healthy women within the study 'My Childhood - Your Childhood' at both time points to isolate and cryopreserve PBMC. Thawed PBMC were used to measure mitochondrial respiration and density by high-resolution respirometry followed by spectrophotometric analyses of citrate-synthase activity. RESULTS Over time, quantitative respiratory parameters increased, while qualitative flux control ratios decreased, independently of CM. Women with CM showed higher mitochondrial respiration and density at t0, but not at t2. We found significant CM group × time interaction effects for ATP-turnover-related respiration and mitochondrial density. CONCLUSIONS This is the first study to longitudinally investigate mitochondrial bioenergetics in postpartum women with and without CM. Our results indicate that CM-related mitochondrial alterations reflect allostatic load, probably due to higher inflammatory states during parturition, which normalize later. However, later inflammatory states might moderate the vulnerability for a second-hit on the level of mitochondrial bioenergetics, at least in immune cells.
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Affiliation(s)
- Anja M. Gumpp
- Clinical & Biological Psychology, Institute of Psychology and Education, Ulm University, Ulm, Germany
| | - Alexander Behnke
- Clinical & Biological Psychology, Institute of Psychology and Education, Ulm University, Ulm, Germany
| | - Laura Ramo-Fernández
- Clinical & Biological Psychology, Institute of Psychology and Education, Ulm University, Ulm, Germany
| | - Peter Radermacher
- Institute of Anesthesiological Pathophysiology and Process Engineering, University Hospital Ulm, Ulm, Germany
| | - Harald Gündel
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Ulm, Ulm, Germany
| | - Ute Ziegenhain
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital Ulm, Ulm, Germany
| | - Alexander Karabatsiakis
- Clinical & Biological Psychology, Institute of Psychology and Education, Ulm University, Ulm, Germany
- Clinical Psychology, Institute of Psychology, University of Innsbruck, Innsbruck, Austria
| | - Iris-Tatjana Kolassa
- Clinical & Biological Psychology, Institute of Psychology and Education, Ulm University, Ulm, Germany
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14
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Xu S, Liu M, Xu J, Che B, Zhang W, Li W, Huang T, Yu Y, Zha C, Peng Z, Huang K, Tang K. Pregnancy complicated with adrenal adenoma causing ACTH-independent Cushing's syndrome, accompanied by obstetric antiphospholipid syndrome and severe pre-eclampsia: case report and literature review. Front Endocrinol (Lausanne) 2023; 14:1147316. [PMID: 37274343 PMCID: PMC10235702 DOI: 10.3389/fendo.2023.1147316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 05/02/2023] [Indexed: 06/06/2023] Open
Abstract
This case report shares the management experience of a patient with pregnancy combined with adrenal adenoma causing ACTH-independent Cushing's syndrome (CS), accompanied by obstetric antiphospholipid syndrome (OAPS) and severe pre-eclampsia. The case was a 26-year-old that presented with typical clinical symptoms and signs of CS. The patient had a history of 4 spontaneous abortions in the last 4 years. The 24-hour urinary free cortisol was significantly increased, an abnormal cortisol circadian rhythm was demonstrated by a high late-night salivary cortisol, blood ACTH was suppressed (< 1ng/dL), anticardiolipin antibody was positive, and imaging examination showed an adrenal tumor. The patient underwent laparoscopic adrenal tumor resection under general anesthesia at 23 weeks of gestation. The tumor was pathologically confirmed to be an adrenocortical adenoma. The patient underwent a cesarean section at 39 weeks of gestation to give birth to a healthy baby girl with an Apgar score of 10. Pregnancy complicated by CS is clinically rare, easily masked by normal physiological changes of pregnancy, and is difficult to diagnose. The determination of 24-hour urinary free cortisol, the circadian rhythm of serum cortisol, ultrasound, and MRI can be helpful in the diagnosis of CS during pregnancy. Surgery is the first choice for the treatment of CS during pregnancy. As a subtype of antiphospholipid syndrome, patients with OAPS are prone to thrombotic events and recurrent miscarriages if not treated accordingly. To our knowledge no cases of CS with OAPS and severe pre-eclampsia have been reported. We summarize the experience of the treatment of this patient and review the literature to improve clinicians' awareness of this disease.
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Affiliation(s)
- Shenghan Xu
- Department of Urology and Andrology, the First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, China
- The Clinical Medical College of Guizhou Medical University, Guiyang, China
| | - Miao Liu
- The Clinical Medical College of Guizhou Medical University, Guiyang, China
| | - Jiamu Xu
- The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Bangwei Che
- The Clinical Medical College of Guizhou Medical University, Guiyang, China
| | - Wenjun Zhang
- The Clinical Medical College of Guizhou Medical University, Guiyang, China
| | - Wei Li
- The Clinical Medical College of Guizhou Medical University, Guiyang, China
| | - Tao Huang
- The Clinical Medical College of Guizhou Medical University, Guiyang, China
| | - Ying Yu
- The Clinical Medical College of Guizhou Medical University, Guiyang, China
| | - Cheng Zha
- The Clinical Medical College of Guizhou Medical University, Guiyang, China
| | - Zheng Peng
- The Clinical Medical College of Guizhou Medical University, Guiyang, China
| | - Kunyuan Huang
- The Clinical Medical College of Guizhou Medical University, Guiyang, China
| | - Kaifa Tang
- Department of Urology and Andrology, the First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, China
- The Clinical Medical College of Guizhou Medical University, Guiyang, China
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15
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Al-Ghotani B, Alabdallah E, Shaaban V, Nemer F, Alsneeh A, Sharif FAL, Dalati H, Mansour M. Adrenocortical carcinoma in a 10-month-old infant: A literature review and a rare case report. Ann Med Surg (Lond) 2023; 85:1197-1205. [PMID: 37113825 PMCID: PMC10129272 DOI: 10.1097/ms9.0000000000000447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 03/16/2023] [Indexed: 04/29/2023] Open
Abstract
Adrenocortical carcinoma (ACC) in children is a rare condition. The annual incidence of ACC is extremely low, with only 0.2-0.3 cases per million children. The clinical presentations of ACC are numerous, such as terminal hair appearance, pubertal progress, hypercortisolism, enlarged clitoris, acne, systemic arterial hypertension, weight gain, and voice change. Case presentation A 10-month-old female infant presented by her parents to the Department of Endocrinology with a mass on the right adrenal gland and Cushing's syndrome symptoms. Surgery was performed. The death occurred after two times resuscitation due to sudden cardiac arrest. Clinical discussion The adrenal gland consists of two distinct parts. Different types of tumors arise from each part of the adrenal gland. The most common tumor in adrenomedullary tumors was neuroblastoma which accounted for 60.4% of adrenal tumors. ACC in children is a rare condition. The etiology of ACTs is unclear. Conclusion This case emphasizes that early diagnosis has a considerable role in preventing major complications. Also to advise considering ACC as a differential diagnosis when similar symptoms are found in an infant.
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Affiliation(s)
- Basel Al-Ghotani
- Faculty of Medicine
- Stemosis for Scientific Research
- Corresponding author. Address: Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic. E-mail address: (B. Al-Ghotani)
| | | | | | - Farah Nemer
- Faculty of Medicine
- Department of Anesthesia, Resuscitation and Intensive Care Unit, Faculty of Medicine, Damascus University
| | | | - Fawaz AL Sharif
- Faculty of Medicine
- Department of Pediatric Surgery, Children’s University Hospital, Damascus
| | - Husam Dalati
- Faculty of Medicine
- Department of Pediatric Surgery, Children’s University Hospital, Damascus
| | - Marah Mansour
- Faculty of Medicine, Tartous University, Tartous, Syrian Arab Republic
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16
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Lee JH, Torpy DJ. Adrenal insufficiency in pregnancy: Physiology, diagnosis, management and areas for future research. Rev Endocr Metab Disord 2023; 24:57-69. [PMID: 35816262 DOI: 10.1007/s11154-022-09745-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2022] [Indexed: 02/01/2023]
Abstract
Adrenal insufficiency requires prompt diagnosis in pregnancy, as untreated, it can lead to serious consequences such as adrenal crisis, intrauterine growth restriction and even foetal demise. Similarities between symptoms of adrenal insufficiency and those of normal pregnancy can complicate diagnosis. Previously diagnosed adrenal insufficiency needs monitoring and, often, adjustment of adrenal hormone replacement. Many physiological changes occur to the hypothalamic-pituitary-adrenal (HPA) axis during pregnancy, often making diagnosis and management of adrenal insufficiency challenging. Pregnancy is a state of sustained physiologic hypercortisolaemia; there are multiple contributing factors including high plasma concentrations of placental derived corticotropin-releasing hormone (CRH), adrenocorticotropin (ACTH) and increased adrenal responsiveness to ACTH. Despite increased circulating concentrations of CRH-binding protein (CRH-BP) and the major cortisol binding protein, corticosteroid binding globulin (CBG), free concentrations of both hormones are increased progressively in pregnancy. In addition, pregnancy leads to activation of the renin-angiotensin-aldosterone system. Most adrenocortical hormone diagnostic thresholds are not applicable or validated in pregnancy. The management of adrenal insufficiency also needs to reflect the physiologic changes of pregnancy, often requiring increased doses of glucocorticoid and at times mineralocorticoid replacement, especially in the last trimester. In this review, we describe pregnancy induced changes in adrenal function, the diagnosis and management of adrenal insufficiency in pregnancy and areas requiring further research.
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Affiliation(s)
- Jessica H Lee
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia.
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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17
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Puglisi S, Basile V, Sperone P, Terzolo M. Pregnancy in patients with adrenocortical carcinoma: a case-based discussion. Rev Endocr Metab Disord 2023; 24:85-96. [PMID: 36414840 DOI: 10.1007/s11154-022-09769-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2022] [Indexed: 11/24/2022]
Abstract
Although adrenocortical carcinoma (ACC) during pregnancy is rare, a retrospective review of a case series at our hospital revealed that almost one third of our patients were women in childbearing age. Given that the age of maternity is increasing, dealing with a tumor diagnosis during pregnancy and the need for fertility planning in cancer survivors is likely to become more frequent.We thus carried out a case-based discussion regarding: i) diagnosing and treating an ACC during pregnancy; ii) patients conceiving while on mitotane; iii) ACC survivors with a maternal desire.In each of these cases, it is important to provide patients with sufficient information, to offer medical advice and psychological support, to personalize treatments in accordance with the wishes of the patient and her relatives, and to collaborate with other specialists since a multidisciplinary expert team is required to manage each case individually.
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Affiliation(s)
- Soraya Puglisi
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy
| | - Vittoria Basile
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy
| | - Paola Sperone
- Medical Oncology, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Massimo Terzolo
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy.
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18
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Younes N, St-Jean M, Bourdeau I, Lacroix A. Endogenous Cushing's syndrome during pregnancy. Rev Endocr Metab Disord 2023; 24:23-38. [PMID: 35670990 DOI: 10.1007/s11154-022-09731-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2022] [Indexed: 02/01/2023]
Abstract
Endogenous Cushing's syndrome (CS) is rare during pregnancy, probably because hypercortisolism induces anovulation and infertility. To date, slightly above 200 cases have been reported in the literature. The most frequent etiology of CS diagnosed during gestation is from primary adrenal causes, namely adrenal adenomas and an entity called pregnancy-induced CS. The latter can be secondary to the aberrant adrenal expression of luteinizing hormone/human chorionic gonadotropin receptor (LHCGR) in the adrenal lesions. Diagnosis of CS during pregnancy is extremely challenging, as a consequence of the physiologic hypercortisolism normally present during pregnancy. Assessment of excess cortisol production tests should be interpreted cautiously using adapted upper limits of normal criteria for pregnant patients and a high index of suspicion is required for diagnosis. Imaging is also limited due to high risk of radiation exposure with computed tomography and teratogenicity with contrast agents. The optimal treatment strategy is surgical resection of adrenal adenoma or pituitary adenoma, ideally before 24 weeks of gestation to reduce the risk of maternal and fetal complications. In mild cases, surgery can be postponed until after delivery and treatment should focus on controlling metabolic complications of hypercortisolism, such as hypertension and dysglycemia. Maternal and fetal outcomes of excess cortisol exposure, except fetal loss, are not readily improved by successful treatment of hypercortisolism.
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Affiliation(s)
- Nada Younes
- Division of Endocrinology, Department of Medicine Research Center, Centre hospitalier de l'Université de Montréal (CHUM), CHUM 900 Saint-Denis Street, H2X 0A9, Montréal, Québec, Canada
| | - Matthieu St-Jean
- Division of Endocrinology, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine Research Center, Centre hospitalier de l'Université de Montréal (CHUM), CHUM 900 Saint-Denis Street, H2X 0A9, Montréal, Québec, Canada
| | - André Lacroix
- Division of Endocrinology, Department of Medicine Research Center, Centre hospitalier de l'Université de Montréal (CHUM), CHUM 900 Saint-Denis Street, H2X 0A9, Montréal, Québec, Canada.
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Watt M, Mohammadzadeh P, Pinsinski E, Hollinshead FK, Bouma GJ. Corticotropin releasing hormone is present in the feline placenta and maternal serum. Front Endocrinol (Lausanne) 2023; 14:1132743. [PMID: 37124751 PMCID: PMC10140359 DOI: 10.3389/fendo.2023.1132743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 03/22/2023] [Indexed: 05/02/2023] Open
Abstract
Background In women, placental corticotropin releasing hormone (CRH) can be detected in maternal blood throughout pregnancy and is important in the regulation of the timing of parturition. However, its role in other mammalian species is unclear. In fact, very little is known about the presence and localization of CRH in placentas other than human. In this study we report for the first time the presence of CRH in feline placenta and maternal serum. Methods Presence of CRH mRNA and protein was assessed using RT-PCR and Western blot, respectively, in at term domestic cat placentas opportunistically obtained at a local animal shelter and spay clinic. In addition, CRH localization within the placenta was demonstrated via immunohistochemistry. Finally, presence of CRH in maternal blood from early (¾21 days) and mid (25-35 days) stages of pregnancy was investigated by ELISA. Results CRH mRNA and protein were detected in feline placentas, and localized to larger decidual cells and fetal trophoblast cells, including the binucleate cells. CRH was detectable in maternal blood collected from early-stage pregnancies, and amounts significantly increased in mid-gestation samples. Conclusion This is the first report on the presence and localization of CRH in the feline placenta, and its increase in maternal serum during the first half of pregnancy. These data lay the foundation for future studies to determine if CRH can be used as potential novel marker for early pregnancy diagnosis, determination, and monitoring in felids, and could greatly increase efficiency and success in zoo breeding programs utilizing artificial reproductive technologies for endangered feline species.
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Affiliation(s)
- Madison Watt
- Department of Biomedical Sciences, Colorado State University, Fort Collins, CO, United States
| | - Pardis Mohammadzadeh
- Department of Biomedical Sciences, Colorado State University, Fort Collins, CO, United States
| | - Emma Pinsinski
- Department of Biomedical Sciences, Colorado State University, Fort Collins, CO, United States
| | - Fiona K. Hollinshead
- Department of Clinical Sciences, Colorado State University, Fort Collins, CO, United States
- *Correspondence: Fiona K. Hollinshead,
| | - Gerrit J. Bouma
- Department of Biomedical Sciences, Colorado State University, Fort Collins, CO, United States
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Eskandari D, Ziaee A, Samadanifard SH, Tavangar SM, Tirkan A, ZaeimYekeh MA. A Case Report of Cushing's Disease Presenting With Psychosis and Muscle Weakness Postpartum. J Investig Med High Impact Case Rep 2023; 11:23247096231204732. [PMID: 37799021 PMCID: PMC10559700 DOI: 10.1177/23247096231204732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 08/09/2023] [Accepted: 08/19/2023] [Indexed: 10/07/2023] Open
Abstract
Cushing's syndrome is a condition leading to overproducing of cortisol by the adrenal glands. If the pituitary gland overproduces cortisol, it is called Cushing's disease. Cushing's syndrome and even Cushing's disease during and after pregnancy are rare events. There is not enough literature and guidance for managing and treating these patients. The diagnosis of Cushing's syndrome in pregnancy is often delayed because the symptoms overlap. We presented a thin 31-year-old woman, admitted 2 months after a normal-term delivery, with an atypical presentation of Cushing's disease, unusual clinical features, and a challenging clinical course. She had no clinical discriminatory features of Cushing's syndrome. Given that the patient only presented with psychosis and proximal myopathy and had an uncomplicated pregnancy, our case was considered unusual. The patients also had hyperpigmentation and severe muscle weakness which are among the less common presentations of Cushing's syndrome. Our findings suggest that an early diagnosis of Cushing's disease is important in pregnancy period for its prevalent fetal and maternal complications, and it should be treated early to optimize fetal and maternal outcomes as there is an increasing trend toward live births in treated participants.
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Affiliation(s)
- Delaram Eskandari
- Assistant Professor of Endocrinology, Rasool Akram Medical Complex, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Amir Ziaee
- Professor of Endocrinology, Rasool Akram Medical Complex, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Hossein Samadanifard
- Assistant Professor of Endocrinology, Rasool Akram Medical Complex, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammad Tavangar
- Professor of Pathology, Department of Pathology, Endocrine Population Sciences Institute, Endocrinology & Metabolism Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Atefe Tirkan
- Department of Internal Medicine, Rasool Akram Medical Complex, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Amin ZaeimYekeh
- Department of Internal Medicine, Rasool Akram Medical Complex, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
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21
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Lousada LM, Tapia MJB, Cescato VAS, da Silva GO, Musolino NRC, Fragoso MCBV, Bronstein MD, Machado MC. Pregnancy after pituitary surgery does not influence the recurrence of Cushing's disease. Endocrine 2022; 78:552-558. [PMID: 35930216 DOI: 10.1007/s12020-022-03151-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 07/18/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Pregnancy is associated with the activation of the hypothalamus-pituitary-adrenal axis, which can cause a misdiagnosis of Cushing's syndrome. The aim of this study is to evaluate the impact of pregnancy after pituitary surgery on the recurrence rate in Cushing's disease (CD) patients. METHODS This was a retrospective study in a tertiary center. Between 1990 and 2020, 355 CD patients underwent pituitary surgery. Of those, we included 113 female patients who were ≤ 45 years old (median age of 32 years, 14-45), PS remission, a follow-up of ≥6 months (median of 122 months, 6-402) and an available obstetric history. Recurrence was defined as the diagnosis of Cushing's syndrome via at least two altered first-line methods. The patients were divided into two subgroups according to pregnancy: no pregnancy or pregnancy prior to CD diagnosis (NP/PP) and pregnancy after CD pituitary surgery (PA). RESULTS Overall, recurrence occurred in 43 out of 113 patients (38%). A higher recurrence rate was seen in the PA subgroup (11/22, 50%), but there was no significant difference between the NP/PP subgroup (32/91, 35%). No difference in survival-free recurrence (SFR) was found between NP/PP and PA subgroups. The lower SFR was related to a higher PS plasma ACTH and normal pituitary at pathological analyses. CONCLUSIONS There was no difference in the recurrence rate in patients according to pregnancy history. Other studies with higher numbers of patients are needed to confirm these data.
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Affiliation(s)
- Lia Mesquita Lousada
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | - Mariuxi Jacqueline Borja Tapia
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | | | | | | | | | - Marcello Delano Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
- Laboratory of Cellular and Molecular Endocrinology LIM-25, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | - Marcio Carlos Machado
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil.
- Laboratory of Cellular and Molecular Endocrinology LIM-25, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil.
- Endocrinology Service, AC Camargo Cancer Center, Sao Paulo, SP, Brazil.
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Rathi A, Khapre S, Chavada J, Gupta S, Singla T. Postpartum Depression and Its Biological Biomarkers. Cureus 2022; 14:e31124. [DOI: 10.7759/cureus.31124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/05/2022] [Indexed: 11/08/2022] Open
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23
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Gardella B, Gritti A, Scatigno AL, Gallotti AMC, Perotti F, Dominoni M. Adrenal crisis during pregnancy: Case report and obstetric perspective. Front Med (Lausanne) 2022; 9:891101. [PMID: 36186806 PMCID: PMC9521595 DOI: 10.3389/fmed.2022.891101] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
Adrenal dysfunction (AD) and, in particular, adrenal crisis are uncommon events in pregnant women, but associated with significant maternal and fetal morbidity and mortality if untreated or undiagnosed. Adrenal crisis may be confused with the common symptoms of pregnancy: the obstetricians should be able to promptly diagnose and treat it in order to avoid the adverse outcomes regarding the mother and the fetus. For this reason, AD must be treated by an expert multidisciplinary team. We presented a case report of a young pregnant woman with adrenal crisis due to tuberculosis, cocaine abuse, and massive bilateral hemorrhage with symptoms of emesis, hypotension, sudden abdominal pain, and leukocytosis. The most common issues of diagnosis and treatment are discussed and analyzed. Finally, we performed a review of the literature regarding adrenal crisis and adrenal insufficiency (AI) in pregnancy in order to clarify the management of these diseases in obstetrics setting.
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Affiliation(s)
- Barbara Gardella
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- Department Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Andrea Gritti
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- Department Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- *Correspondence: Andrea Gritti,
| | - Annachiara Licia Scatigno
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- Department Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Francesca Perotti
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- Department Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Mattia Dominoni
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- Department Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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24
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Persistent vs Recurrent Cushing’s Disease Diagnosed Four Weeks Postpartum. Case Rep Endocrinol 2022; 2022:9236711. [PMID: 35996523 PMCID: PMC9392589 DOI: 10.1155/2022/9236711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 07/22/2022] [Indexed: 11/18/2022] Open
Abstract
Background Cushing's disease (CD) recurrence in pregnancy is thought to be associated with estradiol fluctuations during gestation. CD recurrence in the immediate postpartum period in a patient with a documented dormant disease during pregnancy has never been reported. Case Report. A 30-year-old woman with CD had improvement of her symptoms after transsphenoidal resection (TSA) of her pituitary lesion. She conceived unexpectedly 3 months postsurgery and had no symptoms or biochemical evidence of recurrence during pregnancy. After delivering a healthy boy, she developed CD 4 weeks postpartum and underwent a repeat TSA. Despite repeat TSA, she continued to have elevated cortisol levels that were not well controlled with medical management. She eventually had a bilateral adrenalectomy. Discussion. CD recurrence may be higher in the peripartum period, but the link between pregnancy and CD recurrence and/or persistence is not well studied. Potential mechanisms of CD recurrence in the postpartum period are discussed below. Conclusion We describe the first report of recurrent CD that was quiescent during pregnancy and diagnosed in the immediate postpartum period. Understanding the risk and mechanisms of CD recurrence in pregnancy allows us to counsel these otherwise healthy, reproductive-age women in the context of additional family planning.
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25
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The Efficacy of Digital Cognitive–Behavioral Interventions in Supporting the Psychological Adjustment and Sleep Quality of Pregnant Women with Sub-Clinical Symptoms: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159549. [PMID: 35954901 PMCID: PMC9368246 DOI: 10.3390/ijerph19159549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/25/2022] [Accepted: 07/29/2022] [Indexed: 12/10/2022]
Abstract
The present meta-analysis investigated the overall and differential efficacy of digital cognitive–behavioral therapies (CBTs) vs. third-generation CBTs deployed to pregnant women in reducing sub-clinical depression, anxiety, and stress symptoms while fostering sleep quality and quality of life. A PRISMA-guided systematic search was used, including randomized controlled trials (RCTs) evaluating the above-mentioned interventions. Data were pooled using either the mean difference (MD) or standardized MD (SMD). Sub-group analyses were carried out when appropriate. The primary outcomes were depression, anxiety, and stress symptoms, as well as sleep quality and quality of life. The interventions’ acceptability was evaluated through the odds ratio (OR) of drop-out rates. Seven RCTs were included, comprising 1873 pregnant women. The results showed the interventions’ efficacy in terms of reducing depression symptoms (SMD = −0.36, CI = 0.61, −0.11, k = 9) at the endpoint, although it was not maintained at follow-up during the postpartum period. The interventions’ efficacy in terms of reducing anxiety symptoms (SMD = 1.96, CI = −2.72, −1.21, k = 3) at the endpoint was also significant, while having no effect on sleep quality. The interventions were well accepted (OR = 1.68; 95% CI = 0.84, 3.35; k = 7). Although no sound conclusions can be drawn concerning the joint or differential efficacy of the considered interventions, this study was useful in highlighting the need to develop evidence-based digital prevention programs for pregnant women with sub-clinical symptoms.
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26
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Hamblin R, Coulden A, Fountas A, Karavitaki N. The diagnosis and management of Cushing's syndrome in pregnancy. J Neuroendocrinol 2022; 34:e13118. [PMID: 35491087 PMCID: PMC9541401 DOI: 10.1111/jne.13118] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/01/2022] [Accepted: 03/05/2022] [Indexed: 11/28/2022]
Abstract
Endogenous Cushing's syndrome (CS) is rarely encountered during pregnancy. Clinical and biochemical changes in healthy pregnancy overlap with those seen in pregnancy complicated by CS; the diagnosis is therefore challenging and can be delayed. During normal gestation, adrenocorticotrophic hormone, corticotrophin-releasing hormone, cortisol, and urinary free cortisol levels rise. Dexamethasone administration fails to fully suppress cortisol in pregnant women without CS. Localisation may be hindered by non-suppressed adrenocorticotrophic hormone levels in a large proportion of those with adrenal CS; smaller corticotroph adenomas may go undetected as a result of a lack of contrast administration or the presence of pituitary hyperplasia; and inferior petrosal sinus sampling is not recommended given the risk of radiation and thrombosis. Yet, diagnosis is essential; active disease is associated with multiple insults to both maternal and foetal health, and those cured may normalise the risk of maternal-foetal complications. The published literature consists mostly of case reports or small case series affected by publication bias, heterogeneous definitions of maternal or foetal outcomes or lack of detail on severity of hypercortisolism. Consequently, conclusive recommendations, or a standardised management approach for all, cannot be made. Management is highly individualised: the decision for surgery, medical control of hypercortisolism or adoption of a conservative approach is dependent on the timing of diagnosis (respective to stage of gestation), the ability to localise the tumour, severity of CS, pre-existing maternal comorbidity, and, ultimately, patient choice. Close communication is a necessity with the patient placed at the centre of all decisions, with risks, benefits, and uncertainties around any investigation and management carefully discussed. Care should be delivered by an experienced, multidisciplinary team, with the resources and expertise available to manage such a rare and challenging condition during pregnancy.
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Affiliation(s)
- Ross Hamblin
- Institute of Metabolism and Systems Research, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
- Centre for Endocrinology, Diabetes and MetabolismBirmingham Health PartnersBirminghamUK
- Department of Endocrinology, Queen Elizabeth HospitalUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Amy Coulden
- Institute of Metabolism and Systems Research, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
- Centre for Endocrinology, Diabetes and MetabolismBirmingham Health PartnersBirminghamUK
- Department of Endocrinology, Queen Elizabeth HospitalUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Athanasios Fountas
- Institute of Metabolism and Systems Research, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
- Centre for Endocrinology, Diabetes and MetabolismBirmingham Health PartnersBirminghamUK
- Department of Endocrinology, Queen Elizabeth HospitalUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
- Centre for Endocrinology, Diabetes and MetabolismBirmingham Health PartnersBirminghamUK
- Department of Endocrinology, Queen Elizabeth HospitalUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
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27
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Ramos IF, Ross KM, Rinne GR, Somers JA, Mancuso RA, Hobel CJ, Coussons-Read M, Dunkel Schetter C. Pregnancy anxiety, placental corticotropin-releasing hormone and length of gestation. Biol Psychol 2022; 172:108376. [PMID: 35667479 PMCID: PMC10022399 DOI: 10.1016/j.biopsycho.2022.108376] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 05/29/2022] [Accepted: 05/31/2022] [Indexed: 12/20/2022]
Abstract
OBJECTIVE High pregnancy anxiety is a consistent predictor of earlier labor and delivery. Placental corticotropin-releasing hormone (pCRH) predicts earlier delivery consistently and it has been identified as a biological mediator of the association between pregnancy anxiety and gestational length. However, studies have not examined whether changes in pregnancy anxiety are associated with earlier birth as mediated by changes in pCRH during pregnancy. Accordingly, this study tests whether linear changes in pregnancy anxiety are associated with length of gestation indirectly through nonlinear increases in pCRH over pregnancy. METHODS A sample of pregnant women (n=233) completed prenatal assessments in early pregnancy, second trimester, and third trimester that included a 4-item assessment of pregnancy anxiety and collection of blood samples assayed for pCRH using radioimmunoassay. Length of gestation was abstracted from medical records after birth. RESULTS Increases in pregnancy anxiety from early pregnancy to third trimester predicted shorted length of gestation, as did nonlinear increases in pCRH over pregnancy. However, there was no evidence of an indirect effect of changes in pregnancy anxiety on length of gestation via changes in pCRH. CONCLUSIONS These results indicate that linear changes in pregnancy anxiety and nonlinear changes in pCRH during pregnancy are independent risk factors for shortened gestational length. This study adds to a small but growing body of work on biopsychological processes in pregnancy and length of gestation. Modeling changes in psychological and biological processes during pregnancy could provide more insight into understanding risk for adverse pregnancy outcomes.
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28
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Semrl N, Obermayer-Pietsch B, Feigl S, Ragossnig M, Wölfler M, Taumberger N, Kirchhoff E, Hochstätter R, Kurleto M, Kollmann M. Cushing Syndrom in der Schwangerschaft, eine diagnostische Herausforderung – Case Report. Geburtshilfe Frauenheilkd 2022. [DOI: 10.1055/s-0042-1750254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Affiliation(s)
- N Semrl
- Schwerpunkt für gynäkologische Endokrinologie und Fortpflanzungsmedizin, Universitätsklinik für Frauenheilkunde und Geburtshilfe, Medizinische Universität Graz
| | - B Obermayer-Pietsch
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz
- Forschungseinheit Frühe Programmierung, Universitätsklinik für Frauenheilkunde und Geburtshilfe, Medizinische Universität Graz
| | - S Feigl
- Schwerpunkt für gynäkologische Endokrinologie und Fortpflanzungsmedizin, Universitätsklinik für Frauenheilkunde und Geburtshilfe, Medizinische Universität Graz
| | - M Ragossnig
- Schwerpunkt für gynäkologische Endokrinologie und Fortpflanzungsmedizin, Universitätsklinik für Frauenheilkunde und Geburtshilfe, Medizinische Universität Graz
| | - M Wölfler
- Schwerpunkt für gynäkologische Endokrinologie und Fortpflanzungsmedizin, Universitätsklinik für Frauenheilkunde und Geburtshilfe, Medizinische Universität Graz
| | - N Taumberger
- Schwerpunkt für gynäkologische Endokrinologie und Fortpflanzungsmedizin, Universitätsklinik für Frauenheilkunde und Geburtshilfe, Medizinische Universität Graz
| | - E Kirchhoff
- Schwerpunkt für gynäkologische Endokrinologie und Fortpflanzungsmedizin, Universitätsklinik für Frauenheilkunde und Geburtshilfe, Medizinische Universität Graz
| | - R Hochstätter
- Schwerpunkt für gynäkologische Endokrinologie und Fortpflanzungsmedizin, Universitätsklinik für Frauenheilkunde und Geburtshilfe, Medizinische Universität Graz
| | - M Kurleto
- Schwerpunkt für gynäkologische Endokrinologie und Fortpflanzungsmedizin, Universitätsklinik für Frauenheilkunde und Geburtshilfe, Medizinische Universität Graz
| | - M Kollmann
- Schwerpunkt für gynäkologische Endokrinologie und Fortpflanzungsmedizin, Universitätsklinik für Frauenheilkunde und Geburtshilfe, Medizinische Universität Graz
- Forschungseinheit Frühe Programmierung, Universitätsklinik für Frauenheilkunde und Geburtshilfe, Medizinische Universität Graz
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Abstract
Adrenal insufficiency (AI), first described by Thomas Addison in 1855, is characterised by inadequate hormonal production by the adrenal gland, which could either be primary, due to destruction of the adrenal cortex, or secondary/tertiary, due to lack of adrenocorticotropic hormone or its stimulation by corticotropin-releasing hormone. This was an invariably fatal condition in Addison's days with most patients dying within a few years of diagnosis. However, discovery of cortisone in the 1940s not only improved the life expectancy of these patients but also had a dramatic effect on their overall quality of life. The diagnosis, easily confirmed by demonstrating inappropriately low cortisol secretion, is often delayed by months, and many patients present with acute adrenal crisis. Sudden withdrawal from chronic glucocorticoid therapy is the most common cause of AI. Currently, there remains a wide variation in the management of this condition across Europe. As primary AI is a relatively rare condition, most medical specialists will only manage a handful of these patients in their career. Despite many advances in recent years, there is currently no curative option, and modern cortisol replacement regimens fail to adequately mimic physiological cortisol rhythm. A number of new approaches including allograft of adrenocortical tissue and stem cell therapy are being tried but remain largely experimental.
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Affiliation(s)
- Rajeev Kumar
- Diabetes and Endocrinology, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
| | - W S Wassif
- Clinical Biochemistry, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
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30
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Castinetti F, Brue T. L’impact du syndrome de Cushing sur la fertilité et la grossesse. ANNALES D'ENDOCRINOLOGIE 2022; 83:188-190. [DOI: 10.1016/j.ando.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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31
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Characterization of Depressive Symptom Trajectories in Women between Childbirth and Diagnosis. J Pers Med 2022; 12:jpm12040538. [PMID: 35455653 PMCID: PMC9030055 DOI: 10.3390/jpm12040538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/18/2022] [Accepted: 03/23/2022] [Indexed: 12/03/2022] Open
Abstract
The inhomogeneity of postpartum mood and mother–child attachment was estimated from immediately after childbirth to 12 weeks postpartum in a cohort of 598 young mothers. At 3-week intervals, depressed mood and mother–child attachment were assessed using the EPDS and the MPAS, respectively. The diagnosis was based on clinical interviews at the end of the 12-week follow-up. The latent class mixed model estimated multiple distinct patterns in depressed mood and mother–child attachment. The baseline EPDS cluster contained 72% of the study population and showed low EPDS values during the follow-up period, while the five remaining clusters showed either deterioration or improvement of the EPDS levels. The majority of women with postpartum depression showed deteriorating, and the majority of adjustment disorder cases improving, behavior. While the cases with more pronounced EPDS values were found to constitute more homogeneous clusters in terms of diagnosis, subclinical or only temporarily increased EPDS levels represented less homogeneous clusters. Higher EPDS levels correlated with the higher risk factor profiles. The four MPAS/EPDS clusters demonstrated that higher EPDS lead to lower mother–child attachment, and vice versa.
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32
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Morton A, Teasdale S. Physiological changes in pregnancy and their influence on the endocrine investigation. Clin Endocrinol (Oxf) 2022; 96:3-11. [PMID: 34724247 DOI: 10.1111/cen.14624] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 10/05/2021] [Accepted: 10/18/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Physiological changes in pregnancy may result in significant alterations in endocrine hormone profiles, serum and urine electrolytes and endocrine gland morphology on imaging. Pregnancy-specific pathophysiological processes may also affect the results for endocrine tests. Investigation of endocrine disorders in pregnancy requires knowledge of these changes and awareness of the safety of dynamic hormone testing and imaging for the mother and foetus. OBJECTIVE This review seeks to outline the important physiological changes in pregnancy affecting reference intervals of basal and dynamic endocrine tests in pregnancy and the scenarios in which these changes are clinically significant, the pregnancy-specific disorders that may affect the investigation of endocrine disorders, and the safety of dynamic testing and imaging. CONCLUSION Awareness of the effect of physiological changes, and the potential impact of pregnancy-specific disorders of endocrine tests, and the safety of imaging is crucial to the management of endocrine disorders in pregnancy.
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Affiliation(s)
- Adam Morton
- Departments of Endocrinology and Obstetric Medicine, Mater Health, Brisbane, Queensland, Australia
| | - Stephanie Teasdale
- Departments of Endocrinology and Obstetric Medicine, Mater Health, Brisbane, Queensland, Australia
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A Rare Occurrence of Premature Birth and Recurrent Acute Pulmonary Oedema in the Mother due to Cushing's Syndrome: A Case Report. J ASEAN Fed Endocr Soc 2021; 36:200-204. [PMID: 34966205 PMCID: PMC8666499 DOI: 10.15605/jafes.036.02.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/18/2021] [Indexed: 11/17/2022] Open
Abstract
Presentation of Cushing's syndrome during pregnancy is extremely rare. We report a 21-year-old female with Cushing's syndrome diagnosed at 23 weeks of gestation and had recurrent acute pulmonary oedema during the antepartum and postpartum period. She delivered prematurely via emergency caesarean section at 28 weeks of gestation. This case highlights the rare occurrence of recurrent acute pulmonary oedema during pregnancy and consequential premature birth in a patient with adrenal Cushing's. She was diagnosed with adrenal Cushing's during the postpartum period based on unsuppressed serum cortisol after overnight and low-dose dexamethasone suppression test with a suppressed ACTH. CT scan of the adrenal glands revealed a right adrenal cortical adenoma. The risk of complications in infants and mothers who suffer from Cushing's syndrome needs to be handled carefully. The diagnosis of Cushing's syndrome in pregnant women often overlaps and is difficult to establish in early pregnancy.
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Clinical Characteristics of Pregnancy-Associated Central Serous Chorioretinopathy in the Chinese Population. J Ophthalmol 2021; 2021:5580075. [PMID: 34956667 PMCID: PMC8702364 DOI: 10.1155/2021/5580075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 11/19/2021] [Accepted: 11/26/2021] [Indexed: 01/24/2023] Open
Abstract
Purpose To investigate the clinical characteristics of pregnancy-associated central serous chorioretinopathy (CSC) in the Chinese population. Methods The medical records of patients diagnosed with pregnancy-associated CSC from February 2012 to October 2019 were retrospectively reviewed. Best-corrected visual acuity (BCVA), symptom duration, pregnancy-related medical information, and optical coherence tomography (OCT) images were collected. Results Nine patients (11 eyes) were included. Five women were in their first pregnancy and four were in their second pregnancy, two of whom experienced CSC in their first pregnancy as well. The mean age was 35.00 ± 3.97 years. The mean symptom duration at the initial visit was 19.73 ± 13.65 days. The mean gestational age at the time of development of CSC was 27.11 ± 2.09 weeks. The mean BCVA (logarithm of the minimum angle of resolution (logMAR)) at the initial visit was 0.36 ± 0.18 (Snellen 20/45, range 20/100–20/25). All eyes showed subretinal hyperreflective fibrin on OCT images at the initial visit. Four patients (4 eyes) were lost to follow-up before fluid resolution. The mean BCVA at the final visit was logMAR 0.10 ± 0.15 (Snellen 20/25, range 20/50–20/20)). One eye in the oldest patient had persistent subretinal fluid at 26 months postpartum. The subretinal fluid resolved completely after half-dose photodynamic therapy (PDT); however, the ellipsoid zone at the fovea remained discontinuous at 30 months after half-dose PDT. The remaining six eyes all showed spontaneous resolution of subretinal fluid around delivery and regained intact ellipsoid zone. Conclusions Pregnancy-associated CSC in Chinese developed mostly in the third trimester and usually recovered spontaneously around delivery with good final visual acuity. However, patients might require long-term follow-up until complete resolution of subretinal fluid and to detect recurrences. Half-dose PDT can be administered early if there is little reduction in the amount of subretinal fluid after delivery.
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Chechko N, Dukart J, Tchaikovski S, Enzensberger C, Neuner I, Stickel S. The Expectant Brain-Pregnancy Leads to Changes in Brain Morphology in the Early Postpartum Period. Cereb Cortex 2021; 32:4025-4038. [PMID: 34942007 PMCID: PMC9476604 DOI: 10.1093/cercor/bhab463] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/12/2021] [Accepted: 11/15/2021] [Indexed: 11/15/2022] Open
Abstract
There is growing evidence that pregnancy may have a significant impact on the maternal brain, causing changes in its structure. To investigate the patterns of these changes, we compared nulliparous women (n = 40) with a group of primiparous women (n = 40) and multiparous mothers (n = 37) within 1–4 days postpartum, using voxel-based and surface-based morphometry (SBM). Compared with the nulliparous women, the young mothers showed decreases in gray matter volume in the bilateral hippocampus/amygdala, the orbitofrontal/subgenual prefrontal area, the right superior temporal gyrus and insula, and the cerebellum. These pregnancy-related changes in brain structure did not predict the quality of mother–infant attachment at either 3 or 12 weeks postpartum nor were they more pronounced among the multiparous women. SBM analyses showed significant cortical thinning especially in the frontal and parietal cortices, with the parietal cortical thinning likely potentiated by multiple pregnancies. We conclude that, compared with the brain of nulliparous women, the maternal brain shows widespread morphological changes shortly after childbirth. Also, the experience of pregnancy alone may not be the underlying cause of the adaptations for mothering. As regards the exact biological function of the changes in brain morphology, longitudinal research will be needed to draw any definitive conclusions.
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Affiliation(s)
- Natalia Chechko
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, RWTH Aachen, Aachen 52074, Germany.,Institute of Neuroscience and Medicine, JARA-Institute Brain Structure Function Relationship (INM 10), Research Center Jülich, Jülich 52428, Germany.,Institute of Neuroscience and Medicine, Brain & Behavior (INM-7), Research Center Jülich, Jülich 52428, Germany
| | - Jürgen Dukart
- Institute of Neuroscience and Medicine, Brain & Behavior (INM-7), Research Center Jülich, Jülich 52428, Germany.,Institute of Systems Neuroscience, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf 40225, Germany
| | - Svetlana Tchaikovski
- Department of Gynecology and Obstetrics, Medical Faculty, RWTH Aachen, Aachen 52074, Germany
| | - Christian Enzensberger
- Department of Gynecology and Obstetrics, Medical Faculty, RWTH Aachen, Aachen 52074, Germany
| | - Irene Neuner
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, RWTH Aachen, Aachen 52074, Germany.,Institute of Neuroscience and Medicine, JARA-Institute Brain Structure Function Relationship (INM 10), Research Center Jülich, Jülich 52428, Germany
| | - Susanne Stickel
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, RWTH Aachen, Aachen 52074, Germany.,Institute of Neuroscience and Medicine, JARA-Institute Brain Structure Function Relationship (INM 10), Research Center Jülich, Jülich 52428, Germany
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Parksook WW, Porntharukchareon T, Sunthornyothin S. Desmopressin Stimulation Test in a Pregnant Patient with Cushing’s Disease. AACE Clin Case Rep 2021; 8:105-108. [PMID: 35602876 PMCID: PMC9123553 DOI: 10.1016/j.aace.2021.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 11/15/2021] [Accepted: 11/22/2021] [Indexed: 11/26/2022] Open
Abstract
Objective Hypothalamic-pituitary-adrenal axis stimulation during pregnancy complicates the investigation of Cushing's syndrome (CS). Our objective was to present the case of a pregnant patient with CS caused by a pituitary tumor in whom the desmopressin stimulation test helped in the diagnosis and led to appropriate management. Case Report A 27-year-old woman with 9-week gestation presented with a 2-month history of proximal myopathy. She had high blood pressure, wide purplish striae, and a 1-year history of hypertension and dysglycemia. The 8 am cortisol level was 32.4 μg/dL (normal, 5-18 μg/dL), late-night salivary cortisol level was 0.7 μg/dL (11 pm, normal, <0.4 μg/dL), 24-hour urinary free cortisol levels were 237.6 μg/d (normal, 21.0-143.0 μg/d), and adrenocorticotropic hormone (ACTH) levels were 44.0 pg/mL (8 am, normal, 0-46.0 pg/mL). Nongadolinium-enhanced pituitary magnetic resonance imaging revealed no obvious lesion. The desmopressin stimulation test showed a 70% increase in ACTH levels from baseline after desmopressin administration. Pituitary magnetic resonance imaging with gadolinium revealed an 8 × 8 × 7-mm3 pituitary adenoma. Transsphenoidal surgery was performed, which revealed the presence of ACTH-positive tumor cells. After tumor removal, the patient carried on pregnancy uneventfully. Discussion During pregnancy, ACTH levels may not be an accurate marker to help in the differential diagnosis of CS. Moreover, nongadolinium pituitary imaging might not detect small pituitary lesions. Conclusion In the present case, the desmopressin stimulation test suggested the diagnosis of Cushing's disease, which subsequently led to successful treatment. This suggests that the desmopressin test serves as a useful test for diagnosing Cushing's disease in pregnant individuals.
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Affiliation(s)
- Wasita Warachit Parksook
- Division of General Internal Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Division of Endocrinology and Metabolism, Department of Medicine, and Hormonal and Metabolic Research Unit, Excellence Center in Diabetes, Hormone and Metabolism, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Thachanun Porntharukchareon
- Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Sarat Sunthornyothin
- Division of Endocrinology and Metabolism, Department of Medicine, and Hormonal and Metabolic Research Unit, Excellence Center in Diabetes, Hormone and Metabolism, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Address correspondence to Dr Sarat Sunthornyothin, Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Patumwan, Bangkok 10330, Thailand.
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Sundararajan A, Vora K, Saiyed S, Natesan S. Comparative Profiling of Salivary Cortisol and Salivary DHEA-S Among Healthy Pregnant and Non-Pregnant Women. Horm Metab Res 2021; 53:602-607. [PMID: 34496410 DOI: 10.1055/a-1551-3722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
During pregnancy, circulatory cortisol levels increase, remaining steady over the second-third trimester. In contrast, profile of salivary cortisol during pregnancy is debatable, more influenced by factors like time of sample collection in the day. Circulatory DHEA-S decrease by at least 50% over the second-third trimester of pregnancy. However, profile of salivary DHEA-S is unclear. Objective was to determine changes in salivary cortisol and DHEA-S in healthy pregnant women, compared to non-pregnant women during late morning-early afternoon sampling to avoid fluctuations associated with other times. Pregnant women in their second-third trimester prospectively (n=500) and non-pregnant women (n=133) were enrolled in study with informed consent. Live birth outcome with no pregnancy complications and≥2.5 Kg infant birth weight were included. Concentrations of salivary cortisol and DHEA-S were determined through ELISA assays. Compared to non-pregnant women, pregnant women demonstrated significant increases in salivary cortisol [median (interquartile range)=4.2 (5.1) nmol/l vs. 17.2 (13.9) nmol/l, p<0.001] and salivary DHEA-S median (interquartile range)=2.7 (2.9) nmol/l vs. 3.8 (3.2) nmol/l, p<0.001). Consistently, quartile scores representing higher levels of salivary cortisol and DHEA-S concentrations demonstrated significant association with pregnancy. Quartile scores representing higher salivary cortisol/DHEA-S ratio demonstrated significant association with pregnancy. Study suggests the indicated time range of saliva sampling might best parallel the established profile of circulatory cortisol in pregnant women. However, unlike cortisol, study indicates that the salivary DHEA-S profile is distinct from the well-known profile of circulatory DHEA-S during pregnancy. A combinatorial approach involving both salivary and circulatory compartments could provide comprehensive picture of DHEA-S and hypothalamus-pituitary-adrenal axis during pregnancy.
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Affiliation(s)
| | - Kranti Vora
- Indian Institute of Public Health Gandhinagar, Lekawada, Gandhinagar, India
- University of Canberra, Bruce, Australia
| | - Shahin Saiyed
- Indian Institute of Public Health Gandhinagar, Lekawada, Gandhinagar, India
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Baghlaf HA, Badeghiesh AM, Suarthana E, Dahan MH. The effect of Cushing's syndrome on pregnancy complication rates: analysis of more than 9 million deliveries. J Matern Fetal Neonatal Med 2021; 35:6236-6242. [PMID: 34459316 DOI: 10.1080/14767058.2021.1910658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE The purpose of this study to evaluate the risk of Cushing's syndrome (CS) and maternal and fetal complications using the American Nationwide Inpatient Sample database. MATERIALS AND METHODS This is a retrospective study using the Health Care Cost and Utilization Project-Nationwide Inpatient Sample database from 2004 to 2014. We compared pregnancies with CS versus non-CS regarding pregnancy, delivery, and neonatal outcomes using multivariate logistic regression. RESULTS We identified 9,096,788 pregnancies during the study period. Cushing's syndrome complicated 135 pregnancies at a rate of 1-2 cases per 100,000 births. Cushing's syndrome subjects were more likely to be older, obese, have private insurance, chronic hypertension, and pre-gestational diabetes (p<.001). The maternal mortality rate was 0.7 and 0.007% in Cushing's syndrome and control groups, respectively, although due to small numbers of cases, this should be interpreted with caution. Preeclampsia was higher in CS compared to controls after controlling for confounding variables, aOR 2.20. Operative vaginal delivery and blood transfusion rates were higher in CS patients than controls after controlling for confounding factors, aOR 6.49 and 3.09, respectively. The rates of preterm delivery (8.9 versus 7.2%) and gestational diabetes (8.1 versus 5.8%) were not statistically different between CS and control groups. CONCLUSION Cushing's syndrome patients begin pregnancies often with maladies making them more at risk for complications including, preeclampsia, blood transfusion, and operative vaginal delivery. These patients might benefit from prevention methods for preeclampsia, and increased surveillance to decrease maternal morbidity and mortality. However, the nature of the database and its limitations, including the lack of information about CS activity and treatments received by patients, warrant careful interpretation of these results.
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Affiliation(s)
- Haitham A Baghlaf
- Obstetrics & Gynecology Department, Division of Maternal-Fetal Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ahmad M Badeghiesh
- Department of Obstetrics & Gynecology, McGill University, Montreal, Quebec, Canada
| | - Eva Suarthana
- Department of Obstetrics & Gynecology, McGill University, Montreal, Quebec, Canada
| | - Michael H Dahan
- Division of Reproductive Endocrinology and Infertility, MUHC Reproductive Center, McGill University, Montreal, Quebec, Canada
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Castinetti F, Nieman LK, Reincke M, Newell-Price J. Approach to the Patient Treated with Steroidogenesis Inhibitors. J Clin Endocrinol Metab 2021; 106:2114-2123. [PMID: 33675650 PMCID: PMC8427736 DOI: 10.1210/clinem/dgab122] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Indexed: 12/24/2022]
Abstract
Steroidogenesis inhibitors can be given to control the hypercortisolism of Cushing's syndrome in various situations: when surgery has been unsuccessful or not possible; in metastatic adrenocorticotropin hormone (ACTH) or cortisol-secreting tumors; when waiting for the maximal efficacy of radiation techniques; for rapid treatment of severe hypercortisolism in patients with occult ACTH-producing tumors; or as a presurgical treatment in patients with severe comorbidities. Whilst biochemical "control" can be achieved in more than 50% of cases, daily management of such drugs can be challenging. Indeed, with a "dose-titration" or a "block and replace" approach, defining eucortisolism is usually difficult, requiring the measurement of several biological markers. Moreover, each drug has its own side effects, which must be monitored closely. The aim of this "approach to the patient" is to shed light on the management of hypercortisolism with 4 steroidogenesis inhibitors (ketoconazole, levoketoconazole, metyrapone, osilodrostat) to help endocrinologists dealing with patients with Cushing's syndrome. Various points will be discussed, such as initial dose of treatment, dose schedule, monitoring of efficacy, and side effects of monotherapy. The combination of steroidogenesis inhibitors will also be discussed.
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Affiliation(s)
- Frederic Castinetti
- Aix Marseille University, Marseille Medical Genetics, INSERM U1251 and Assistance Publique Hopitaux de Marseille, La Conception Hospital, Department of Endocrinology, Marseille 13005, France
- Correspondence: Frederic Castinetti, MD, PhD, Department of Endocrinology, La Conception Hospital, 147 Boulevard Baille, 13385 Marseille Cedex 05, France. E-mail:
| | - Lynnette K Nieman
- Diabetes, Endocrinology and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich 80336, Germany
| | - John Newell-Price
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, S10 2TN, UK
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Deutschbein T, Jaursch-Hancke C, Knappe UJ, Saeger W, Flitsch J, Bojunga J, Buchfelder M, Ditzen B, Gerlach R, Gertzen E, Honegger J, Horstmann GA, Koch A, Kreitschmann-Andermahr I, Kunz M, Lagrèze WA, Nicolay NH, Paulus W, Reincke M, Schmidt MA, Weber MM, Wilhelm H, Fassnacht M. First German Guideline on Diagnostics and Therapy of Clinically Non-Functioning Pituitary Tumors. Exp Clin Endocrinol Diabetes 2021; 129:250-264. [PMID: 33690872 DOI: 10.1055/a-1373-4087] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Although non-functioning pituitary tumors are frequent, diagnostic and therapeutic concepts are not well standardized. We here present the first German multidisciplinary guideline on this topic. The single most important message is to manage the patients by a multidisciplinary team (consisting at least of an endocrinologist, a neurosurgeon, and a (neuro-) radiologist). The initial diagnostic work-up comprises a detailed characterization of both biochemical (focusing on hormonal excess or deficiency states) and morphological aspects (with magnetic resonance imaging of the sellar region). An ophthalmological examination is only needed in presence of symptoms or large tumors affecting the visual system. Asymptomatic, hormonally inactive tumors allow for a 'wait and scan' strategy. In contrast, surgical treatment by an experienced pituitary surgeon is standard of care in case of (impending) visual impairment. Therapeutic options for incompletely resected or recurrent tumors include re-operation, radiotherapy, and observation; the individual treatment plan should be developed multidisciplinary. Irrespective of the therapeutic approach applied, patients require long-term follow-up. Patient with larger pituitary tumors or former surgery/radiotherapy should be regularly counseled regarding potential symptoms of hormonal deficiency states.
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Affiliation(s)
- Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Würzburg, Germany.,Medicover Oldenburg MVZ, Oldenburg, Germany
| | | | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Hospital, University Hospital of the Ruhr-University Bochum, Minden, Germany
| | - Wolfgang Saeger
- Institute for Neuropathology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Bojunga
- Department of Internal Medicine I, Division of Endocrinology, Goethe-University Hospital, Frankfurt, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, University Hospital Erlangen, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | - Beate Ditzen
- Institute of Medical Psychology, Center for Psychosocial Medicine, University Hospital Heidelberg, Ruprecht-Karls University Heidelberg, Heidelberg, Germany
| | - Rüdiger Gerlach
- Department of Neurosurgery, Helios Klinikum Erfurt, Erfurt, Germany
| | | | - Jürgen Honegger
- Department of Neurosurgery, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Germany
| | | | - Arend Koch
- Department of Neuropathology, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Ilonka Kreitschmann-Andermahr
- Department of Neurosurgery and Spine Surgery, University Medicine Essen, University of Duisburg-Essen, Essen, Germany
| | - Mirjam Kunz
- Schwerpunktpraxis für Diabetologie und Endokrinologie, Ludwigshafen, Germany
| | - Wolf A Lagrèze
- Eye Center, Medical Center, Medical Faculty, University of Freiburg, Germany
| | - Nils H Nicolay
- Department of Radiation Oncology, University of Freiburg - Medical Center, Freiburg, Germany
| | - Werner Paulus
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, München, Germany
| | - Manuel A Schmidt
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Matthias M Weber
- Department of Endocrinology and Metabolism, I Medical Clinic, University Hospital, Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Helmut Wilhelm
- Centre for Ophthalmology, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
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Extracellular and Intracellular Magnesium Deficiency Found in Pregnant Women with Preeclampsia and Gestational Diabetes Is Associated with Overexpression of Notch Proteins, Cytokines, p53, NF-kB and Proto-Oncogenes: Potential Importance in Growth Retardation, Stillbirths, Fetal Mutations and Increased Cardiovascular Risks and Stroke with Advancing Age in Pregnant Women. HEARTS 2021. [DOI: 10.3390/hearts2010011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
In 1983, three of us reported in “Science” that umbilical-placental arteries and veins, obtained from normal pregnant women at term delivery, when exposed in vitro to low concentrations of Mg2+ went into vasospasm; the lower the Mg2+, the greater the contractile force developed. These blood vessels also demonstrated amplified contractile force development when challenged with circulating amines and peptides (e.g., norepinephrine, 5-HT, angiotensin II, etc.). We suggested that severe Mg deficiency during pregnancy could in part be responsible for spontaneous abortions, loss of fetuses, stillbirths, and developmental alterations in infants. Using short-term dietary Mg deficient animals, we have noted a great many molecular and biochemical alterations in ventricular, atrial and somatic vascular smooth muscle alterations including DNA methylation and histone changes leading us to speculate that Mg deficiency may represent a genotoxin promoting mutations and causing epigenetic changes. Over the last 35 years, we have new data on severely preeclamptic and gestational diabetic pregnant women that gives credence to our original hypothesis and demonstrates that recently- discovered developmental proteins, originally found 100 years ago in Drosophila fruit flies termed the “Notch pathway”, due to effects on its wings, appears to be important in development of the umbilical-placental blood vessels in pregnant women. Along with the developmental molecule, p53, these Notch proteins clearly alter the behavior of the umbilical-placental vessels. We believe these new findings probably help to explain many of the genetic-toxicity effects seen in women later in life who develop strokes and cardiovascular diseases. Notch alterations could also play an important role in babies born with cardiac defects.
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Stickel S, Eickhoff SB, Habel U, Stickeler E, Goecke TW, Lang J, Chechko N. Endocrine stress response in pregnancy and 12 weeks postpartum - Exploring risk factors for postpartum depression. Psychoneuroendocrinology 2021; 125:105122. [PMID: 33421704 DOI: 10.1016/j.psyneuen.2020.105122] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/13/2020] [Accepted: 12/21/2020] [Indexed: 01/21/2023]
Abstract
Pregnancy and the postpartum period are characterized by physiological alterations in cortisol and cortisone levels. In the present study, we sought to explore the risk factors for postpartum depression (PPD) and self-remitting postpartum adjustment disorder (AD) and whether cortisol/cortisone metabolism might have any bearing on them. Hair samples from 196 participants (mean age = 31.44, SD = 4.71) were collected at two time points (1-6 days after childbirth and 12 weeks postpartum) to determine the cumulative hair cortisol (HCC) and hair cortisone (HCNC) exposure in the third trimester and during the 12 weeks postpartum. Compared to the non-depressed group (ND, n = 141), more women in the AD (n = 28) and PPD (n = 27) groups had a personal or family history of depression and more stressful life events. Compared to ND and PPD, more women in the AD group had birth-related complications with their children being more often transferred to a pediatric ward. The factors associated with PPD were found to include being unmarried and having a lower household income, less support at home, more subjectively perceived stress after childbirth and lower maternal sensitivity. The natural decrease in HCC concentration from the third trimester to 12 weeks postpartum was significant only in the ND and AD groups, but not in PPD. In summary, prolonged subjectively perceived postpartum stress associated with living situations may contribute to the development of PPD while birth- and child-related complications are likely to trigger brief episodes of AD. Only in ND and AD, the pregnancy-related physiological changes in glucocorticoid levels return to the pre-pregnancy baseline after 12 weeks. Our observations point to the difference between the ND and PPD groups in glucocorticoid metabolism-related postpartum adjustment, which may be a factor in the development of PPD.
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Affiliation(s)
- S Stickel
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; Institute of Neuroscience and Medicine, JARA-Institute Brain Structure Function Relationship (INM 10), Research Center Jülich, Wilhelm-Johnen-Strasse, 52428 Jülich, Germany.
| | - S B Eickhoff
- Institute of Systems Neuroscience, Medical Faculty, Heinrich Heine University Düsseldorf, Universitätsstraße 1, 40225 Düsseldorf, Germany; Institute of Neuroscience and Medicine, Brain & Behaviour (INM-7), Research Centre Jülich, Wilhelm-Johnen-Strasse, 52428 Jülich, Germany
| | - U Habel
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; Institute of Neuroscience and Medicine, JARA-Institute Brain Structure Function Relationship (INM 10), Research Center Jülich, Wilhelm-Johnen-Strasse, 52428 Jülich, Germany
| | - E Stickeler
- Department of Gynecology and Obstetrics, Medical Faculty, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - T W Goecke
- Department of Gynecology and Obstetrics, Medical Faculty, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; RoMed Hospital Rosenheim, Department of Obstetrics, Pettenkoferstraße 10, 83022 Rosenheim, Germany
| | - J Lang
- Institute for Occupational, Social and Environmental Medicine, Medical Faculty, Uniklinik RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany
| | - N Chechko
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; Institute of Neuroscience and Medicine, JARA-Institute Brain Structure Function Relationship (INM 10), Research Center Jülich, Wilhelm-Johnen-Strasse, 52428 Jülich, Germany; Institute of Neuroscience and Medicine, Brain & Behaviour (INM-7), Research Centre Jülich, Wilhelm-Johnen-Strasse, 52428 Jülich, Germany.
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Benothman W, Saad G, Kacem M, Ach K. Three Successful Pregnancies in a Patient with Recurrent Cushing's Disease. Case Rep Endocrinol 2021; 2021:5517303. [PMID: 33628528 PMCID: PMC7899752 DOI: 10.1155/2021/5517303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 01/19/2021] [Accepted: 01/23/2021] [Indexed: 11/30/2022] Open
Abstract
The association of pregnancy and Cushing's disease (CD) is rare. A 28-year-old woman was admitted for clinical suspicion of Cushing's syndrome. The investigations confirmed the diagnosis of CD with secondary hypogonadotropic hypogonadism due to an invasive pituitary macroadenoma. The patient underwent transsphenoidal adenomectomy, and histopathology showed an adrenocorticotropic hormone pituitary adenoma. Initial remission of CD ensued, and fertility was restored as the patient had 2 uncomplicated pregnancies. Five years and 10 months after surgery, a third spontaneous pregnancy was confirmed with underlying recurrent CD. Having mild hypercortisolism, CD was managed expectantly. The outcome was a healthy full-term neonate with no maternal complications during pregnancy or labor. Our case highlights the challenge faced by physicians of choosing the optimal approach to active CD in pregnancy. In cases where maternal and fetal complications are mild, conservative approach may be used and specific treatment can be postponed until after delivery.
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Affiliation(s)
- W. Benothman
- Endocrinology Unit, Department of Endocrinology, Farhat Hached University Hospital, Avenue Ibn El Jazzar, Sousse 4000, Tunisia
| | - G. Saad
- Endocrinology Unit, Department of Endocrinology, Farhat Hached University Hospital, Avenue Ibn El Jazzar, Sousse 4000, Tunisia
| | - M. Kacem
- Endocrinology Unit, Department of Endocrinology, Farhat Hached University Hospital, Avenue Ibn El Jazzar, Sousse 4000, Tunisia
| | - K. Ach
- Endocrinology Unit, Department of Endocrinology, Farhat Hached University Hospital, Avenue Ibn El Jazzar, Sousse 4000, Tunisia
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Vlisides-Henry RD, Deboeck PR, Grill-Velasquez W, Mackey S, Ramadurai DKA, Urry JO, Neff D, Terrell S, Gao MM, Thomas LR, Conradt E, Crowell SE. Behavioral and physiological stress responses: Within-person concordance during pregnancy. Biol Psychol 2021; 159:108027. [PMID: 33476701 DOI: 10.1016/j.biopsycho.2021.108027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 12/17/2022]
Abstract
During pregnancy, a woman's emotions can have longstanding implications for both her own and her child's health. Within-person emotional concordance refers to the simultaneous measurement of emotional responses across multiple levels of analysis. This method may provide insight into how pregnant women experience emotions in response to stress. We enrolled 162 pregnant women and assessed concordance through autonomic physiology (electrodermal activity [EDA], respiratory sinus arrhythmia [RSA]), and coded behavior (Prosocial, Flight, Displacement) during the Trier Social Stress Test-Speech. We used multilevel models to examine behavioral-physiological concordance and whether self-reported emotion dysregulation moderated these effects. Participants exhibited EDA-Prosocial concordance, suggesting that prosocial behavior may be a marker of stress. Emotion dysregulation did not moderate concordance. These findings provide novel information about behavioral coping to stress in pregnancy. Given the importance of observed behavior in the maintenance and treatment of psychopathology, these findings may provide a launchpad for future perinatal intervention research.
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Affiliation(s)
- Robert D Vlisides-Henry
- 380 S 1530 E, Room 502, Dept. of Psychology, University of Utah, Salt Lake City, UT 84112, USA.
| | - Pascal R Deboeck
- 380 S 1530 E, Room 502, Dept. of Psychology, University of Utah, Salt Lake City, UT 84112, USA
| | - Wendy Grill-Velasquez
- 380 S 1530 E, Room 502, Dept. of Psychology, University of Utah, Salt Lake City, UT 84112, USA
| | - Shantavia Mackey
- 380 S 1530 E, Room 502, Dept. of Psychology, University of Utah, Salt Lake City, UT 84112, USA
| | - Dinesh K A Ramadurai
- 380 S 1530 E, Room 502, Dept. of Psychology, University of Utah, Salt Lake City, UT 84112, USA
| | - Joshua O Urry
- 380 S 1530 E, Room 502, Dept. of Psychology, University of Utah, Salt Lake City, UT 84112, USA
| | - Dylan Neff
- 380 S 1530 E, Room 502, Dept. of Psychology, University of Utah, Salt Lake City, UT 84112, USA
| | - Sarah Terrell
- 115 Health and Human Development Building, Dept. of Human Development and Family Studies, Pennsylvania State University, State College, PA 16802, USA
| | - Mengyu Miranda Gao
- 380 S 1530 E, Room 502, Dept. of Psychology, University of Utah, Salt Lake City, UT 84112, USA
| | - Leah R Thomas
- 380 S 1530 E, Room 502, Dept. of Psychology, University of Utah, Salt Lake City, UT 84112, USA
| | - Elisabeth Conradt
- 380 S 1530 E, Room 502, Dept. of Psychology, University of Utah, Salt Lake City, UT 84112, USA; 30 N 1900 E, Dept. of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT 84132, USA; 295 Chipeta Way, Dept. of Pediatrics, University of Utah, Salt Lake City, UT 84108, USA
| | - Sheila E Crowell
- 380 S 1530 E, Room 502, Dept. of Psychology, University of Utah, Salt Lake City, UT 84112, USA; 501 Chipeta Way, Dept. of Psychiatry, University of Utah, Salt Lake City, UT 84108, USA; 30 N 1900 E, Dept. of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT 84132, USA.
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MacKinnon R, Eubanks A, Shay K, Belson B. Diagnosing and managing adrenal crisis in pregnancy: A case report. Case Rep Womens Health 2021; 29:e00278. [PMID: 33376678 PMCID: PMC7758514 DOI: 10.1016/j.crwh.2020.e00278] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 11/28/2020] [Accepted: 12/07/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The diagnosis of adrenal insufficiency in pregnancy is relatively rare. Further, making this diagnosis can be challenging as many of the symptoms overlap with normal symptoms of pregnancy. Given the potential for severe maternal and fetal morbidity and mortality, early recognition and prompt comprehensive treatment are critical. CASE A 24-year-old woman, G3 P2002, at 17 + 1 weeks of gestation with unremarkable prenatal course was admitted to hospital for hyperemesis gravidarum in the setting of parainfluenza with a notable blood glucose of 20 mg/dL. On hospital day two, she was transferred to intensive care after developing significant hypotension, hyponatremia, and a new finding of hypothyroidism. During her evaluation in the ICU, she was diagnosed with adrenal crisis and she showed significant improvement with glucocorticoid therapy. CONCLUSIONS There is a paucity of literature regarding diagnosing adrenal insufficiency in pregnancy. Adrenal crisis in pregnancy can present with symptoms similar to severe nausea and vomiting of pregnancy or hyperemesis gravidarum. Additionally, several critical laboratory tests to support the proper diagnosis require time that acute patients cannot always afford. In this patient's case, the diagnosis was made empirically with improvement after glucocorticoid administration, and was later confirmed by laboratory testing. This case highlights the importance of including adrenal insufficiency in the differential diagnosis of hyperemesis patients in order to quickly manage and treat these often acutely and severely ill patients.
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Affiliation(s)
- Rene MacKinnon
- Walter Reed National Military Medical Center, Department of Obstetrics & Gynecology, United States of America
- Naval Medical Center San Diego, Department of Obstetrics & Gynecology, United States of America
| | - Allison Eubanks
- Walter Reed National Military Medical Center, Department of Obstetrics & Gynecology, United States of America
| | - Kelly Shay
- Walter Reed National Military Medical Center, Department of Obstetrics & Gynecology, United States of America
| | - Brian Belson
- Walter Reed National Military Medical Center, Department of Obstetrics & Gynecology, United States of America
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Bensing S, Giordano R, Falorni A. Fertility and pregnancy in women with primary adrenal insufficiency. Endocrine 2020; 70:211-217. [PMID: 32472424 DOI: 10.1007/s12020-020-02343-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 05/06/2020] [Indexed: 12/17/2022]
Abstract
Primary adrenal insufficiency (PAI) occurs in ~1/5000-1/7000 individuals and is in most cases caused by autoimmune Addison's disease (AAD). Around 10-20% of women with AAD develop premature ovarian insufficiency (POI) before the age of 40 years. 21-Hydroxylase autoantibodies (21OHAb) are the best single immune marker to classify AAD among PAI patients and autoimmune POI in hypergonadotropic hypogonadic women. In AAD, detection of steroid-cell autoantibodies (StCA) predicts future development of POI. AAD-related autoimmune POI is characterized by a selective destruction of theca cells with preservation of primary follicles and granulosa cells of secondary and tertiary follicles. Women with AAD show reduced fertility and parity. Patients with well-managed disease are generally expected to have uneventful pregnancies with favorable outcome, but increased risk of maternal and neonatal complications has been reported. Hence, AAD pregnant women must be carefully monitored by skilled staff which is familiar with the disorder and specific attention must be given to the substitutive therapy.
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Affiliation(s)
- Sophie Bensing
- Department of Endocrinology, Inflammation & Infection Theme, Karolinska University Hospital, 171 77 Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Roberta Giordano
- Department of Clinical and Biological Sciences and Division of Endocrinology, Diabetes and Metabolism-Department of Medical Sciences, University of Turin, 10123, Turin, Italy
| | - Alberto Falorni
- Section of Internal Medicine and Endocrinological and Metabolic Sciences, Department of Medicine, University of Perugia, 06129, Perugia, Italy.
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Estrogen receptor α plays an important role in Cushing’s syndrome during pregnancy. Med Hypotheses 2020; 143:109817. [DOI: 10.1016/j.mehy.2020.109817] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 04/22/2020] [Accepted: 05/05/2020] [Indexed: 11/18/2022]
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Jairaj C, O'Leary N, Doolin K, Farrell C, McCarthy A, McAuliffe FM, O'Grady-Walshe A, Sheehan J, O'Keane V. The hypothalamic-pituitary-adrenal axis in the perinatal period: Its relationship with major depressive disorder and early life adversity. World J Biol Psychiatry 2020; 21:552-563. [PMID: 32216569 DOI: 10.1080/15622975.2020.1740318] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objectives: Effects of major depressive disorder and early life adversity (ELA) on the maternal HPA axis in the perinatal period were examined.Methods: Four groups of women (n = 127) were recruited, with the perinatal groups being compared during pregnancy (Preg) and at two months postpartum (PP) - [1] Depressed during pregnancy (Depressed-Preg/PP), [2] Prior history of depression but euthymic during pregnancy (History-Preg/PP), [3] Healthy pregnant women (Control-Preg/PP), and [4] Healthy non-pregnant women (Non-pregnant Control). Serial saliva samples were collected over the course of a day and waking and evening cortisol, total cortisol output and the cortisol awakening response were examined.Results: There were no HPA axis differences among the three groups during pregnancy. A history of ELA, regardless of comorbid depression, was associated with higher evening cortisol levels during pregnancy (p = 0.015). Women in the Depressed-PP group had had higher evening cortisol levels compared to the History-PP group (p < 0.017).Conclusions: Evening cortisol measures are a potential marker for both ELA and depression, with higher levels during pregnancy being associated with ELA and higher levels postpartum being associated with antenatal depression.
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Affiliation(s)
- Chaitra Jairaj
- Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland
| | - Niamh O'Leary
- Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland
| | - Kelly Doolin
- Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland
| | - Chloe Farrell
- Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland
| | - Anthony McCarthy
- Perinatal Mental Health Service, National Maternity Hospital, Dublin, Ireland
| | - Fionnuala M McAuliffe
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Ann O'Grady-Walshe
- Perinatal Mental Health Service, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - John Sheehan
- Perinatal Mental Health Service, Rotunda Hospital, Dublin, Ireland
| | - Veronica O'Keane
- Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland.,Trinity Centre for Health Sciences, Tallaght Hospital, Dublin, Ireland
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Singh M, Sinha A, Singh T. Idiopathic unilateral adrenal hemorrhage in a term pregnant primigravida female. Radiol Case Rep 2020; 15:1541-1544. [PMID: 32670457 PMCID: PMC7338627 DOI: 10.1016/j.radcr.2020.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 05/31/2020] [Accepted: 06/01/2020] [Indexed: 11/20/2022] Open
Abstract
Idiopathic or spontaneous adrenal hemorrhage is a rare entity and a serious medical condition which is usually underestimated but can result in multiorgan failure, hemodynamic instability and death. It is usually diagnosed postmortem, as it has a nonspecific presentation in view of some other concurrent illness. Pregnancy-induced adrenal hemorrhage in itself is quite rare and a poorly understood disorder. We report here a case of 24-year-old primigravida female at 38 + 6 weeks of gestation who presented with right loin pain associated with fever and chills. Abdominal ultrasound and magnetic resonance imaging were performed which revealed presence of hematoma in right suprarenal location. A diagnosis of idiopathic right adrenal hemorrhage was made. The patient was managed conservatively and was stable post delivery. As this condition can have complications which can potentially be life-threatening, clinicians should keep a high suspicion for this disease when a pregnant female presents with acute abdominal pain.
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Affiliation(s)
- Mandeep Singh
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
| | | | - Tulika Singh
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
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High binding site occupancy of corticosteroid-binding globulin by progesterone increases fetal free cortisol concentrations. Eur J Obstet Gynecol Reprod Biol 2020; 251:129-135. [PMID: 32502768 DOI: 10.1016/j.ejogrb.2020.05.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 02/25/2020] [Accepted: 05/15/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Corticosteroid-binding globulin (CBG) binds and transports cortisol in the circulation in high cortisol-binding affinity (haCBG) and low affinity (laCBG) forms, the latter resulting from enzyme cleavage to target cortisol delivery at sites of inflammation. CBG also has substantial progesterone binding affinity, 3-fold less than cortisol. Progesterone and cortisol are important in the maintenance of pregnancy and in fetal development, respectively. The interactions of cortisol, progesterone and CBG affinity forms have not been studied together. We examined the interaction between progesterone and cortisol with CBG during fetal development. STUDY DESIGN A retrospective cohort analysis of 351 neonates born between January and December 2012 at the Women's and Children's Hospital, Adelaide, South Australia. Cord blood serum samples were collected immediately following delivery. Clinical data was provided by hospital records. Total cortisol, free cortisol, total progesterone, total CBG and haCBG were measured by immunoassay. RESULTS Cord blood total and free cortisol, and progesterone concentrations increased with gestational age. Cord blood progesterone concentrations were 100-fold luteal and 10-fold those in late pregnancy maternal circulation. The proportion of haCBG to total CBG was similar to that in healthy non-pregnant adults. However, free cortisol comprised approximately 15% of total cortisol, 3-fold higher than that in adults. CONCLUSION In a manner unique to fetal life, very high progesterone concentrations are capable of elevating free cortisol concentrations through competition with cortisol at CBG's hormone binding site, without altered binding affinity through CBG cleavage or altered CBG hormone-binding affinity. High circulating fetal progesterone concentrations compete for CBG binding with cortisol, leading to a 3-fold increase in the free cortisol fraction in cord blood. Higher free-to-bound cortisol may alter fetal cortisol distribution facilitating cortisol's roles such as neurodevelopment in concert with dehydroepiandrosterone (sulfate) and lung maturation, or support cortisol action at times of low ambient cortisol. This mechanism may underlie the known association between cortisol, progesterone and CBG, and be relevant principally in the fetal circulation due to the high progesterone concentrations encountered.
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