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Stoinis N, Creeper K, Phillips J, Graham D, Lim EM. Diverse presentations of Cushing's syndrome during pregnancy - A case series. Aust N Z J Obstet Gynaecol 2024; 64:314-318. [PMID: 38284434 DOI: 10.1111/ajo.13793] [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: 08/29/2023] [Accepted: 01/11/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND Cushing's syndrome (CS) encompasses various causes of hypercortisolism including adrenocorticotropic hormone (ACTH) secreting pituitary adenoma with or without bilateral adrenal hyperplasia, an adrenal adenoma or carcinoma, ectopic ACTH or corticotrophin-releasing hormone (CRH) secretion by a neoplasm or exogenous corticosteroid therapy. The diagnosis of CS in pregnancy presents a challenge due to overlapping clinical features of pregnancy (weight gain, striae, acne). If untreated, CS in pregnancy is associated with increased risk of maternal and fetal complications. AIMS With fewer than 250 cases currently published, we aim to review the clinical presentations, diagnostic methods, management, and outcomes of patients with CS in pregnancy to help optimise our clinical practice. MATERIALS AND METHODS This is a single-centre, retrospective review of woman with documented hypercortisolism receiving antenatal care at a tertiary maternity hospital in Perth between 2006 to 2022. Data were collated from electronic and chart reviews. OMNI calculator was used for birthweight calculations. Local ethics and patient consent were obtained. RESULTS Five women and seven pregnancies were identified. Four women had a pituitary source of ACTH-dependent CS as confirmed by brain magnetic resonance imaging. One woman had an ectopic source of ACTH. Two women were diagnosed during pregnancy. All pregnancies occurring prior to treatment of the Cushing's disease were complicated by secondary hypertension and diabetes. CONCLUSION CS represents a rare and difficult to diagnose condition in pregnancy. When untreated, maternal and fetal outcomes are compromised. Close monitoring of the associated complications with involvement of a multidisciplinary team are recommended.
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Affiliation(s)
- Natasha Stoinis
- Department of Obstetric Medicine, King Edward Memorial Hospital, Perth, Western Australia, Australia
- Department of General Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Katherine Creeper
- Department of Obstetric Medicine, King Edward Memorial Hospital, Perth, Western Australia, Australia
| | - Jessica Phillips
- Department of Obstetric Medicine, King Edward Memorial Hospital, Perth, Western Australia, Australia
| | - Dorothy Graham
- Department of Obstetric Medicine, King Edward Memorial Hospital, Perth, Western Australia, Australia
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Ee Mun Lim
- Department of Endocrinology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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2
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Zhu C, Cai S, Zhong X, Huang L. Pregnancies complicated with functioning adrenal adenomas causing severe obstetric outcomes: a 20-year experience at a tertiary center. BMC Endocr Disord 2024; 24:122. [PMID: 39044264 PMCID: PMC11267956 DOI: 10.1186/s12902-024-01655-9] [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: 08/03/2023] [Accepted: 07/15/2024] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND Functioning adrenal adenoma during pregnancy is rare, and the diagnosis is challenging owing to unspecific symptoms and restricted investigations. The obstetric outcomes of patients who undergo surgery during pregnancy or who receive only medical treatment are poorly described. OBJECTIVE The aim was to investigate the associations between functioning adrenal adenomas and obstetric outcomes. METHODS A retrospective study was performed in a tertiary center over 20 years. The clinical characteristics, management and obstetric outcomes of the diagnosed pregnant women were reviewed. RESULTS A total of 12 women were diagnosed with functioning adrenal adenomas during pregnancy from January 2002 to September 2022. Eight women had cortisol-secreting adrenal adenomas, two had excessive catecholamine secretion, and two had primary aldosteronism. The initial symptoms of adrenal adenoma during pregnancy included hypertension or preeclampsia, gestational diabetes mellitus or prepregnancy diabetes mellitus, hypokalemia and ecchymosis. Four women underwent adrenalectomy during pregnancy, while 8 women received only medical therapy. Preterm birth occurred in all patients who received medicine, whereas 1 patient who underwent surgery experienced preterm birth. Among the 8 women in the medical treatment group, 3 had neonates who died. CONCLUSIONS Once hypertension, hyperglycemia and hypokalemia occur during the 1st or 2nd trimester, pregnant women with adrenal adenomas should be evaluated via laboratory and imaging examinations. The maternal and fetal outcomes were unpredictable owing to the severity of adrenal adenoma, particularly in patients who received only medical treatment. Adrenalectomy should be recommended during pregnancy.
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Affiliation(s)
- Caixia Zhu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-sen University, Zhongshan er Road, No.58, Guangzhou, 510080, China
| | - Shiqin Cai
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-sen University, Zhongshan er Road, No.58, Guangzhou, 510080, China
| | - Xue Zhong
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-sen University, Zhongshan er Road, No.58, Guangzhou, 510080, China
| | - Linhuan Huang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-sen University, Zhongshan er Road, No.58, Guangzhou, 510080, China.
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3
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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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4
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Zhekov Z, Radeva SY, Yankov YG. Cushing's Syndrome and a Dead Fetus in Pregnancy: A Clinical Case and Behavior Report. Cureus 2024; 16:e56769. [PMID: 38650766 PMCID: PMC11033964 DOI: 10.7759/cureus.56769] [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] [Accepted: 03/23/2024] [Indexed: 04/25/2024] Open
Abstract
Cushing's syndrome is a rare disease that has a different primary etiology, most often due to chronic hypercortisolism. In addition to the defined causes, in contrast to the general population, the observed etiology in pregnant women is a benign adrenocortical adenoma, less often bilateral hyperplasia of the adrenal glands of hypothalamic-pituitary origin or Cushing's disease, and malignant adrenal root adenoma. In this study, we present the case of a 41-year-old pregnant woman experiencing her first pregnancy. Her general diseases from anamnesis were chronic obstructive pyelonephritis, acute rhythm disturbance, somnolence, pituitary adenoidectomy, and adrenalectomy of both adrenal glands. The patient was obese, with a BMI of 31.25 kg/m2. She sought medical help due to fatigue, anuria, vomiting, a fever of up to 38.9°C, and hypertension. In the 18th gestational week, fetal death was diagnosed. The fever persisted for several days, and the patient had a malaise and became intoxicated with evidence of sepsis. She was hospitalized at two medical facilities for clarification. In the Department of Gynecology at the Specialized Hospital for Obstetrics and Gynecology in Varna, Bulgaria, a cesarean section was performed. The patient's condition remained stable after surgery. She was referred to a central intensive care unit for follow-up.
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Affiliation(s)
- Zhivko Zhekov
- Department of Gynecology, Specialized Hospital of Obstetrics and Gynecology for Active Treatment, Varna, BGR
- Department of Obstetrics and Gynecology, Medical University "Prof. Dr. Paraskev Stoyanov", Varna, BGR
| | - Svetlana Y Radeva
- Department of Gynecology, Specialized Hospital of Obstetrics and Gynecology for Active Treatment, Varna, BGR
- Faculty of Public Health, Medical University "Prof. Dr. Paraskev Stoyanov", Varna, BGR
| | - Yanko G Yankov
- Clinic of Maxillofacial Surgery, University Hospital "St. Marina", Varna, BGR
- Department of General and Operative Surgery, Medical University "Prof. Dr. Paraskev Stoyanov", Varna, BGR
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5
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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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6
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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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7
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Melmed S, Kaiser UB, Lopes MB, Bertherat J, Syro LV, Raverot G, Reincke M, Johannsson G, Beckers A, Fleseriu M, Giustina A, Wass JAH, Ho KKY. Clinical Biology of the Pituitary Adenoma. Endocr Rev 2022; 43:1003-1037. [PMID: 35395078 PMCID: PMC9695123 DOI: 10.1210/endrev/bnac010] [Citation(s) in RCA: 91] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Indexed: 02/06/2023]
Abstract
All endocrine glands are susceptible to neoplastic growth, yet the health consequences of these neoplasms differ between endocrine tissues. Pituitary neoplasms are highly prevalent and overwhelmingly benign, exhibiting a spectrum of diverse behaviors and impact on health. To understand the clinical biology of these common yet often innocuous neoplasms, we review pituitary physiology and adenoma epidemiology, pathophysiology, behavior, and clinical consequences. The anterior pituitary develops in response to a range of complex brain signals integrating with intrinsic ectodermal cell transcriptional events that together determine gland growth, cell type differentiation, and hormonal production, in turn maintaining optimal endocrine health. Pituitary adenomas occur in 10% of the population; however, the overwhelming majority remain harmless during life. Triggered by somatic or germline mutations, disease-causing adenomas manifest pathogenic mechanisms that disrupt intrapituitary signaling to promote benign cell proliferation associated with chromosomal instability. Cellular senescence acts as a mechanistic buffer protecting against malignant transformation, an extremely rare event. It is estimated that fewer than one-thousandth of all pituitary adenomas cause clinically significant disease. Adenomas variably and adversely affect morbidity and mortality depending on cell type, hormone secretory activity, and growth behavior. For most clinically apparent adenomas, multimodal therapy controlling hormone secretion and adenoma growth lead to improved quality of life and normalized mortality. The clinical biology of pituitary adenomas, and particularly their benign nature, stands in marked contrast to other tumors of the endocrine system, such as thyroid and neuroendocrine tumors.
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Affiliation(s)
| | - Ursula B Kaiser
- Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - M Beatriz Lopes
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Jerome Bertherat
- Université de Paris, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Luis V Syro
- Hospital Pablo Tobon Uribe and Clinica Medellin - Grupo Quirónsalud, Medellin, Colombia
| | - Gerald Raverot
- Hospices Civils de Lyon and Lyon 1 University, Lyon, France
| | - Martin Reincke
- University Hospital of LMU, Ludwig-Maximilians-Universität, Munich, Germany
| | - Gudmundur Johannsson
- Sahlgrenska University Hospital & Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | | | - Andrea Giustina
- San Raffaele Vita-Salute University and IRCCS Hospital, Milan, Italy
| | | | - Ken K Y Ho
- The Garvan Institute of Medical Research and St. Vincents Hospital, Sydney, Australia
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8
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Savas M, Mehta S, Agrawal N, van Rossum EFC, Feelders RA. Approach to the Patient: Diagnosis of Cushing Syndrome. J Clin Endocrinol Metab 2022; 107:3162-3174. [PMID: 36036941 PMCID: PMC9681610 DOI: 10.1210/clinem/dgac492] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Indexed: 12/27/2022]
Abstract
Cushing syndrome results from supraphysiological exposure to glucocorticoids and is associated with significant morbidity and mortality. The pathogenesis includes administration of corticosteroids (exogenous Cushing syndrome) or autonomous cortisol overproduction, whether or not ACTH-dependent (endogenous Cushing syndrome). An early diagnosis of Cushing syndrome is warranted; however, in clinical practice, it is very challenging partly because of resemblance with other common conditions (ie, pseudo-Cushing syndrome). Initial workup should start with excluding local and systemic corticosteroid use. First-line screening tests including the 1-mg dexamethasone suppression test, 24-hour urinary free cortisol excretion, and late-night salivary cortisol measurement should be performed to screen for endogenous Cushing syndrome. Scalp-hair cortisol/cortisone analysis helps in the assessment of long-term glucocorticoid exposure as well as in detection of transient periods of hypercortisolism as observed in cyclical Cushing syndrome. Interpretation of results can be difficult because of individual patient characteristics and hence requires awareness of test limitations. Once endogenous Cushing syndrome is established, measurement of plasma ACTH concentrations differentiates between ACTH-dependent (80%-85%) or ACTH-independent (15%-20%) causes. Further assessment with different imaging modalities and dynamic biochemical testing including bilateral inferior petrosal sinus sampling helps further pinpoint the cause of Cushing's syndrome. In this issue of "Approach to the patient," the diagnostic workup of Cushing syndrome is discussed with answering the questions when to screen, how to screen, and how to differentiate the different causes. In this respect, the latest developments in biochemical and imaging techniques are discussed as well.
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Affiliation(s)
| | | | - Nidhi Agrawal
- Division of Endocrinology, NYU Langone Medical Center/ Bellevue Hospital Center, New York, NY
| | - Elisabeth F C van Rossum
- Correspondence: Elisabeth F.C. van Rossum, MD, PhD, Medicine, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.
| | - Richard A Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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9
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Abstract
Primary pigmented nodular adrenocortical disease (PPNAD) is a rare cause of adrenocorticotropin hormone (ACTH)-independent Cushing's syndrome (CS), which mainly occurs in children and young adults. Treatment options with proven clinical efficacy for PPNAD include adrenalectomy (bilateral or unilateral adrenalectomy) and drug treatment to control hypercortisolemia. Previously, the main treatment of PPNAD is bilateral adrenal resection and long-term hormone replacement after surgery. In recent years, cases reports suggest that unilateral or subtotal adrenal resection can also lead to long-term remission in some patients without the need for long-term hormone replacement therapy. Medications for hypercortisolemia, such as Ketoconazole, Metyrapone and Mitotane et.al, have been reported as a preoperative transition for in some patients with severe hypercortisolism. In addition, tryptophan hydroxylase inhibitor, COX2 inhibitor Celecoxib, somatostatin and other drugs targeting the possible pathogenic mechanisms of the disease are under study, which are expected to be applied to the clinical treatment of PPNAD in the future. In this review, we summarize the recent progress on treatment of PPNAD, in which options of surgical methods, research results of drugs acting on possible pathogenic mechanisms, and the management during gestation are described in order to provide new ideas for clinical treatment.
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Affiliation(s)
- Xinming Liu
- Department of Endocrinology and Metabolism, The First Hospital of Jilin
University, Changchun, China
| | - Siwen Zhang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin
University, Changchun, China
| | - Yunran Guo
- Department of Endocrinology and Metabolism, The First Hospital of Jilin
University, Changchun, China
| | - Xiaokun Gang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin
University, Changchun, China
| | - Guixia Wang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin
University, Changchun, China
- Correspondence Dr. Guixia Wang The First Hospital of Jilin
UniversityDepartment of Endocrinology and
MetabolismNO.1 Xinmin
Street130021
ChangchunChina+86 431
8878-2078+86 431 8878-6066
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10
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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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11
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Li M, Wood CE, Keller-Wood M. Chronic maternal hypercortisolemia models stress-induced adverse birth outcome and altered cardiac function in newborn lambs. Am J Physiol Regul Integr Comp Physiol 2022; 323:R193-R203. [PMID: 35670476 PMCID: PMC9291417 DOI: 10.1152/ajpregu.00041.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Maternal stress in pregnancy is thought to be a contributing factor in adverse pregnancy outcome, including stillbirth and prematurity. Previous studies in our laboratory have shown that chronic elevation in maternal cortisol concentration in ewes (by maternal infusion of 1 mg·kg-1·day-1) during the late gestion increased the incidence of stillbirth and altered fetal heart rate and blood pressure at birth. We designed the current study to test the effect of chronically elevated maternal cortisol on fetal cardiac adaption from in utero life to ex utero life. The combined risk of stillbirth or prematurity was significantly greater in the pregnancies with maternal hypercortisolemia: in this cohort, 40% of the lambs of cortisol-infused ewes died in utero or at birth compared to 25% of lambs of control ewes, and 24% of lambs of cortisol-infused ewes were born preterm, whereas no lamb was born preterm in the control group. Compared to control lambs, the lambs of cortisol-infused ewes born at full term exhibited a significant increase in mean aortic pressure just prior to birth, and a significant decrease in mean aortic pressure that was evident during the first 9 hours after birth. The QT interval was decreased prior to birth and increased immediately after birth in the newborns of cortisol-treated ewes compared to control lambs. These findings suggest that an excess in utero corticosteroid exposure adversely affects fetal cardiac adaptation to extrauterine life and that chronic maternal stress or hypersecretion of corticosteroids may contribute to adverse obstetric outcomes.
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Affiliation(s)
- Mengchen Li
- Department of Physiology and Functional Genomics, University of Florida College of Medicine, Gainesville, FL, United States
| | - Charles E Wood
- Department of Physiology and Functional Genomics, University of Florida College of Medicine, Gainesville, FL, United States
| | - Maureen Keller-Wood
- Department of Pharmacodynamics, University of Florida College of Pharmacy, Gainsville, FL, United States
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12
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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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13
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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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14
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Tabarin A, Assié G, Barat P, Bonnet F, Bonneville JF, Borson-Chazot F, Bouligand J, Boulin A, Brue T, Caron P, Castinetti F, Chabre O, Chanson P, Corcuff JB, Cortet C, Coutant R, Dohan A, Drui D, Espiard S, Gaye D, Grunenwald S, Guignat L, Hindie E, Illouz F, Kamenicky P, Lefebvre H, Linglart A, Martinerie L, North MO, Raffin-Samson ML, Raingeard I, Raverot G, Raverot V, Reznik Y, Taieb D, Vezzosi D, Young J, Bertherat J. Consensus statement by the French Society of Endocrinology (SFE) and French Society of Pediatric Endocrinology & Diabetology (SFEDP) on diagnosis of Cushing's syndrome. ANNALES D'ENDOCRINOLOGIE 2022; 83:119-141. [PMID: 35192845 DOI: 10.1016/j.ando.2022.02.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Cushing's syndrome is defined by prolonged exposure to glucocorticoids, leading to excess morbidity and mortality. Diagnosis of this rare pathology is difficult due to the low specificity of the clinical signs, the variable severity of the clinical presentation, and the difficulties of interpretation associated with the diagnostic methods. The present consensus paper by 38 experts of the French Society of Endocrinology and the French Society of Pediatric Endocrinology and Diabetology aimed firstly to detail the circumstances suggesting diagnosis and the biologic diagnosis tools and their interpretation for positive diagnosis and for etiologic diagnosis according to ACTH-independent and -dependent mechanisms. Secondly, situations making diagnosis complex (pregnancy, intense hypercortisolism, fluctuating Cushing's syndrome, pediatric forms and genetically determined forms) were detailed. Lastly, methods of surveillance and diagnosis of recurrence were dealt with in the final section.
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Affiliation(s)
- Antoine Tabarin
- Service Endocrinologie, Diabète et Nutrition, Université, Hôpital Haut-Leveque CHU de Bordeaux, 33604 Pessac, France.
| | - Guillaume Assié
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Pascal Barat
- Unité d'Endocrinologie-Diabétologie-Gynécologie-Obésité Pédiatrique, Hôpital des Enfants CHU Bordeaux, Bordeaux, France
| | - Fidéline Bonnet
- UF d'Hormonologie Hôpital Cochin, Université de Paris, Institut Cochin Inserm U1016, CNRS UMR8104, Paris, France
| | | | - Françoise Borson-Chazot
- Fédération d'Endocrinologie, Hôpital Louis-Pradel, Hospices Civils de Lyon, INSERM U1290, Université Lyon1, 69002 Lyon, France
| | - Jérôme Bouligand
- Faculté de Médecine Paris-Saclay, Unité Inserm UMRS1185 Physiologie et Physiopathologie Endocriniennes, Paris, France
| | - Anne Boulin
- Service de Neuroradiologie, Hôpital Foch, 92151 Suresnes, France
| | - Thierry Brue
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Philippe Caron
- Service d'Endocrinologie et Maladies Métaboliques, Pôle Cardiovasculaire et Métabolique, CHU Larrey, 24, chemin de Pouvourville, TSA 30030, 31059 Toulouse cedex, France
| | - Frédéric Castinetti
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Olivier Chabre
- Université Grenoble Alpes, UMR 1292 INSERM-CEA-UGA, Endocrinologie, CHU Grenoble Alpes, 38000 Grenoble, France
| | - Philippe Chanson
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse HYPO, Le Kremlin-Bicêtre, France
| | - Jean Benoit Corcuff
- Laboratoire d'Hormonologie, Service de Médecine Nucléaire, CHU Bordeaux, Laboratoire NutriNeuro, UMR 1286 INRAE, Université de Bordeaux, Bordeaux, France
| | - Christine Cortet
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, CHU de Lille, Lille, France
| | - Régis Coutant
- Service d'Endocrinologie Pédiatrique, CHU Angers, Centre de Référence, Centre Constitutif des Maladies Rares de l'Hypophyse, CHU Angers, Angers, France
| | - Anthony Dohan
- Department of Radiology A, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Delphine Drui
- Service Endocrinologie-Diabétologie et Nutrition, l'institut du Thorax, CHU Nantes, 44092 Nantes cedex, France
| | - Stéphanie Espiard
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, INSERM U1190, Laboratoire de Recherche Translationnelle sur le Diabète, 59000 Lille, France
| | - Delphine Gaye
- Service de Radiologie, Hôpital Haut-Lêveque, CHU de Bordeaux, 33604 Pessac, France
| | - Solenge Grunenwald
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Laurence Guignat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Elif Hindie
- Service de Médecine Nucléaire, CHU de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Frédéric Illouz
- Centre de Référence Maladies Rares de la Thyroïde et des Récepteurs Hormonaux, Service Endocrinologie-Diabétologie-Nutrition, CHU Angers, 49933 Angers cedex 9, France
| | - Peter Kamenicky
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Hervé Lefebvre
- Service d'Endocrinologie, Diabète et Maladies Métaboliques, CHU de Rouen, Rouen, France
| | - Agnès Linglart
- Paris-Saclay University, AP-HP, Endocrinology and Diabetes for Children, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Filière OSCAR, and Platform of Expertise for Rare Disorders, INSERM, Physiologie et Physiopathologie Endocriniennes, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Laetitia Martinerie
- Service d'Endocrinologie Pédiatrique, CHU Robert-Debré, AP-HP, Paris, France; Université de Paris, Paris, France
| | - Marie Odile North
- Service de Génétique et Biologie Moléculaire, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Marie Laure Raffin-Samson
- Service d'Endocrinologie Nutrition, Hôpital Ambroise-Paré, GHU Paris-Saclay, AP-HP Boulogne, EA4340, Université de Versailles-Saint-Quentin, Paris, France
| | - Isabelle Raingeard
- Maladies Endocriniennes, Hôpital Lapeyronie, CHU Montpellier, Montpellier, France
| | - Gérald Raverot
- Fédération d'Endocrinologie, Centre de Référence Maladies Rares Hypophysaires, "Groupement Hospitalier Est", Hospices Civils de Lyon, Lyon, France
| | - Véronique Raverot
- Hospices Civils de Lyon, LBMMS, Centre de Biologie Est, Service de Biochimie et Biologie Moléculaire, 69677 Bron cedex, France
| | - Yves Reznik
- Department of Endocrinology and Diabetology, CHU Côte-de-Nacre, 14033 Caen cedex, France; University of Caen Basse-Normandie, Medical School, 14032 Caen cedex, France
| | - David Taieb
- Aix-Marseille Université, CHU La Timone, AP-HM, Marseille, France
| | - Delphine Vezzosi
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Jacques Young
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Jérôme Bertherat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
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15
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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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16
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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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Abstract
Cushing's disease (CD) is the most prevalent cause of endogenous hypercortisolism. CD is responsible for multiple co-morbidities and increased mortality. Accurate and prompt diagnosis and optimal treatment are essential to improve the prognosis of CD. However, the diagnosis of CD is probably one of the most difficult in endocrinology and, therefore, diagnostic workup should be performed in an experienced center. Transsphenoidal surgery performed by an expert surgeon is the only therapeutic option that can offer definitive cure and remains the first-line treatment in most patients. Second-line treatments include pharmacotherapy, pituitary radiotherapy and bilateral adrenalectomy. The second-line therapeutic strategy is complex, must be individualized and performed in a multidisciplinary expert center. Symptomatic treatments of persisting co-morbidities after remission, which are responsible for increased mortality and impaired quality of life is an important part of medical management.
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Affiliation(s)
- Amandine Ferriere
- Department of Endocrinology, Diabetes and Nutrition, University Hospital (CHU) of Bordeaux and University of Bordeaux, France
| | - Antoine Tabarin
- Department of Endocrinology, Diabetes and Nutrition, University Hospital (CHU) of Bordeaux and University of Bordeaux, France; INSERM U1215, NeuroCentre Magendie, University of Bordeaux, France.
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18
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Bass IR, Leiter A, Pozharny Y, Shrivastava R, Shah NA. Cushing Disease Treated Successfully With Metyrapone During Pregnancy. AACE Clin Case Rep 2021; 8:78-81. [PMID: 35415226 PMCID: PMC8984512 DOI: 10.1016/j.aace.2021.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 09/19/2021] [Accepted: 10/17/2021] [Indexed: 11/29/2022] Open
Abstract
Background Case Report Discussion Conclusion
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Affiliation(s)
- Ilana Ramer Bass
- Division of Endocrinology, Diabetes and Bone Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Amanda Leiter
- Division of Endocrinology, Diabetes and Bone Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Yevgeniya Pozharny
- Department of Obstetrics and Gynecology, New York Presbyterian Brooklyn Hospital, New York, New York
| | - Raj Shrivastava
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nirali A. Shah
- Division of Endocrinology, Diabetes and Bone Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Address correspondence to Dr Nirali A. Shah, Division of Endocrinology, Diabetes and Bone Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, 5 East, 98th Street, 3rd Floor, New York, NY 10029.
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19
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Sridharan K, Sahoo J, Palui R, Patil M, Kamalanathan S, Ramesh AS, Kubera NS. Diagnosis and treatment outcomes of Cushing's disease during pregnancy. Pituitary 2021; 24:670-680. [PMID: 33779937 DOI: 10.1007/s11102-021-01142-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE We report a case of a pregnant woman with Cushing's disease (CD) and performed a systematic review of literature on diagnosis, treatment, maternal and fetal outcomes of CD in pregnancy. METHODS A PubMed search was performed for manuscripts in English language from inception till June 2020. Cases of CD with hypercortisolism during pregnancy were included and categorized into three groups based on treatment received. Data on diagnostic modalities, CD remission, materno-fetal outcomes were analysed. RESULTS Fifty-five patients of CD with 62 pregnancies were analysed. 24-h urinary free cortisol(UFC) was elevated by a mean of 5.4 ± 4.2 fold upper limit of normal non-pregnant level. 12/19 (63.1%) CD patients had more than threefold elevation of UFC measured during pregnancy. Mean midnight serum cortisol was 753.7 ± 270.5 nmol/l. At a midnight serum cortisol cut off of 440 nmol/l, 15/16 patients were correctly identified as CD. 23.2% underwent trans-sphenoidal surgery (group 1), 16.1% received only medical treatment (group 2) while 60.7% received no treatment (group 3) during pregnancy. Remission rates for CD in groups 1 and 2 were 76.9% and 77.8%, respectively. Adverse maternal and fetal outcomes were seen in 53.9% and 59.3% of the patients, respectively and were not significantly different between groups, although, lesser live births and greater pregnancy losses were seen in group 3. CONCLUSION Midnight serum cortisol had better sensitivity than UFC for diagnosing hypercortisolism due to CD during pregnancy. In general, CD should be treated during pregnancy in order to optimize maternal and fetal outcomes as a trend towards increased live births is seen in treated subjects.
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Affiliation(s)
- Kalyani Sridharan
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India.
| | - Jayaprakash Sahoo
- Department of Endocrinology and Metabolism, Jawaharlal Institute of Post Graduate Medical Education and Research, Dhanvanthri Nagar, Puducherry, India
| | - Rajan Palui
- Consultant Endocrinologist, The Mission Hospital, Durgapur, West Bengal, India
| | - Milind Patil
- Consultant Endocrinologist, Inlaks Budhrani Hospital, Pune, India
| | - Sadishkumar Kamalanathan
- Department of Endocrinology and Metabolism, Jawaharlal Institute of Post Graduate Medical Education and Research, Dhanvanthri Nagar, Puducherry, India
| | - A S Ramesh
- Department of Neurosurgery, Jawaharlal Institute of Post Graduate Medical Education and Research, Dhanvanthri Nagar, Puducherry, India
| | - N S Kubera
- Department of Obstetrics and Gynecology, Jawaharlal Institute of Post Graduate Medical Education and Research, Dhanvanthri Nagar, Puducherry, India
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20
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Impact of Environmental and Lifestyle Use of Chromium on Male Fertility: Focus on Antioxidant Activity and Oxidative Stress. Antioxidants (Basel) 2021; 10:antiox10091365. [PMID: 34572997 PMCID: PMC8468676 DOI: 10.3390/antiox10091365] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 02/07/2023] Open
Abstract
Male reproductive tissues are strongly susceptible to several environmental and lifestyle stressors. In general, male reproductive health is highly sensitive to oxidative stress, which results in reversible and/or irreversible changes in testosterone-producing cells, spermatogenesis, and sperm quality. Chromium compounds are widely used in the +3 and +6 valence states, as food supplements, and in the industrial field, respectively. Chromium (III) compounds, i.e., Cr(III)-tris-picolinate, [Cr(pic)3], known as chromium picolinate, are used as nutritional supplements for the control of diabetes, body weight, and muscular growth. However, previous studies showed that animal models exposed to chromium picolinate experienced degenerative changes in spermatogenesis. Contradictory results are documented in the literature and deserve discussion. Furthermore, the long-term effects of chromium picolinate on the antioxidant system of treated subjects have not been properly studied. Comprehensive studies on the role of this compound will help to establish the safe and useful use of chromium supplementation. On the other hand, chromium (VI) compounds are widely used in several industries, despite being well-known environmental pollutants (i.e., welding fumes). Chromium (VI) is known for its deleterious effects on male reproductive health as toxic, carcinogenic, and mutagenic. Previous studies have demonstrated severe lesions to mouse spermatogenesis after exposure to chromium (VI). However, workers worldwide are still exposed to hexavalent chromium, particularly in electronics and military industries. Data from the literature pinpoints mechanisms of oxidative stress induced by chromium compounds in somatic and germ cells that lead to apoptosis, thus underlining the impairment of fertility potential. In this review, we analyze the benefits and risks of chromium compounds on male fertility, as well as the mechanisms underlying (in)fertility outcomes. Although supplements with antioxidant properties may maximize male fertility, adverse effects need to be investigated and discussed.
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21
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Cherian KE, Kapoor N, Paul TV, Asha HS. Functioning Endocrine Tumors in Pregnancy: Diagnostic and Therapeutic Challenges. Indian J Endocrinol Metab 2021; 25:299-304. [PMID: 35136736 PMCID: PMC8793957 DOI: 10.4103/ijem.ijem_310_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/25/2021] [Accepted: 09/08/2021] [Indexed: 11/18/2022] Open
Abstract
The occurrence of endocrine tumors in pregnancy poses several diagnostic and therapeutic challenges. Although rare, functioning tumors involving the pituitary, thyroid, adrenal, and pancreas are reported in the literature. Timely diagnosis and management of these tumors are essential as they might lead to adverse maternal and fetal outcomes if left untreated. This review is an attempt to characterize various functioning tumors that could occur in pregnancy, their clinical features, diagnosis, and management.
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Affiliation(s)
- Kripa E. Cherian
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamilnadu, India
| | - Nitin Kapoor
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamilnadu, India
| | - Thomas V. Paul
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamilnadu, India
| | - Hesarghatta S. Asha
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamilnadu, India
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22
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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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23
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Pituitary disease and pregnancy. ENDOCRINOL DIAB NUTR 2021; 68:184-195. [PMID: 34167698 DOI: 10.1016/j.endien.2020.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/07/2020] [Indexed: 11/22/2022]
Abstract
Pregnancy results in a significant change in both pituitary gland size and function. Due to this physiological adaptation, the diagnosis and management of pituitary diseases during pregnancy represents a particularly complex challenge. The presence of a functioning pituitary adenoma may be harmful to the health of the mother and fetus, and scientific evidence regarding the safety of drugs normally used to control hormone excess during pregnancy is scarce. In addition, pregnancy may be associated with the risk of the growth of a pre-existing pituitary adenoma. This review focuses on the diagnostic challenges in pregnant women with adenomas secreting prolactin, growth hormone, or adrenocorticotropic hormone. Some evidence-based recommendations for the treatment of these conditions during pregnancy are provided, and algorithms that could help monitor a pituitary adenoma during pregnancy are examined. Mention is also made of how hormone replacement therapy can be optimised in pregnant women with hypopituitarism. Finally, differential diagnosis between Sheehan's syndrome and lymphocytic hypophysitis, two pituitary disorders that may occur during pregnancy or delivery, is discussed.
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24
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Risk of miscarriage in women with chronic diseases in Norway: A registry linkage study. PLoS Med 2021; 18:e1003603. [PMID: 33970911 PMCID: PMC8143388 DOI: 10.1371/journal.pmed.1003603] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 05/24/2021] [Accepted: 04/01/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Increased risk of miscarriage has been reported for women with specific chronic health conditions. A broader investigation of chronic diseases and miscarriage risk may uncover patterns across categories of illness. The objective of this study was to study the risk of miscarriage according to various preexisting chronic diseases. METHODS AND FINDINGS We conducted a registry-based study. Registered pregnancies (n = 593,009) in Norway between 2010 and 2016 were identified through 3 national health registries (birth register, general practitioner data, and patient registries). Six broad categories of illness were identified, comprising 25 chronic diseases defined by diagnostic codes used in general practitioner and patient registries. We required that the diseases were diagnosed before the pregnancy of interest. Miscarriage risk according to underlying chronic diseases was estimated as odds ratios (ORs) using generalized estimating equations adjusting for woman's age. The mean age of women at the start of pregnancy was 29.7 years (SD 5.6 years). We observed an increased risk of miscarriage among women with cardiometabolic diseases (OR 1.25, 95% CI 1.20 to 1.31; p-value <0.001). Within this category, risks were elevated for all conditions: atherosclerosis (2.22; 1.42 to 3.49; p-value <0.001), hypertensive disorders (1.19; 1.13 to 1.26; p-value <0.001), and type 2 diabetes (1.38; 1.26 to 1.51; p-value <0.001). Among other categories of disease, risks were elevated for hypoparathyroidism (2.58; 1.35 to 4.92; p-value 0.004), Cushing syndrome (1.97; 1.06 to 3.65; p-value 0.03), Crohn's disease (OR 1.31; 95% CI: 1.18 to 1.45; p-value 0.001), and endometriosis (1.22; 1.15 to 1.29; p-value <0.001). Findings were largely unchanged after mutual adjustment. Limitations of this study include our inability to adjust for measures of socioeconomic position or lifestyle characteristics, in addition to the rareness of some of the conditions providing limited power. CONCLUSIONS In this registry study, we found that, although risk of miscarriage was largely unaffected by maternal chronic diseases, risk of miscarriage was associated with conditions related to cardiometabolic health. This finding is consistent with emerging evidence linking cardiovascular risk factors to pregnancy complications.
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Zoli M, Guaraldi F, Zoia C, La Corte E, Asioli S, Bongetta D, Rustici A, Mazzatenta D. Management of sellar and parasellar tumors becoming symptomatic during pregnancy: a practical algorithm based on multi-center experience and systematic literature review. Pituitary 2021; 24:269-283. [PMID: 33200305 PMCID: PMC7966198 DOI: 10.1007/s11102-020-01107-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Sellar/parasellar tumors (SPTs) very rarely become symptomatic during pregnancy. No specific guidelines exist for their management, that is extremely challenging as mother and fetus health can be jeopardized. MATERIALS AND METHODS Data of patients with SPTs becoming symptomatic during pregnancy treated at two Italian referral Centers were retrospectively collected. Systematic literature review was also performed. RESULTS Our series consisted of 6 cases, 3 meningiomas, 1 ACTH-secreting adenoma, 1 pituicytoma and 1 craniopharyngioma. Mean age at presentation was 33.6 ± 6.0 years. Five patients complained of visual disturbances, associated with headache in one case, that occurred between gestation week (GW) 22 and 34. In 5 cases, pregnancy was uneventful with the delivery of a healthy baby between GW 33 and 35, followed by endoscopic surgical tumor exeresis (n = 4) or proton bean therapy (n = 1). Another patient presented with stigmata typical of Cushing's syndrome and rapidly worsening pre-eclampsia, that required pregnancy interruption and adenomectomy. Based on personal and literature cases, a practical algorithm was proposed to help clinicians dealing with these patients. CONCLUSIONS SPTs becoming symptomatic in pregnancy deserve careful monitoring and multidisciplinary management. Overall, wait-and-see approach is suggested, reserving surgery to patients with rapidly progressive/life-threatening situations, significant risk of permanent neurological impairment or malignant lesions.
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Affiliation(s)
- Matteo Zoli
- Pituitary Unit, IRCCS Istituto Delle Scienze Neurologiche di Bologna, Via Altura, 3, 40139, Bologna, Italy.
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.
| | - Federica Guaraldi
- Pituitary Unit, IRCCS Istituto Delle Scienze Neurologiche di Bologna, Via Altura, 3, 40139, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Cesare Zoia
- Neurosurgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Emanuele La Corte
- Pituitary Unit, IRCCS Istituto Delle Scienze Neurologiche di Bologna, Via Altura, 3, 40139, Bologna, Italy
| | - Sofia Asioli
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
- Unit of Anatomic Pathology 'M. Malpighi', Bellaria Hospital, Azienda USL Bologna, Bologna, Italy
| | | | - Arianna Rustici
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
| | - Diego Mazzatenta
- Pituitary Unit, IRCCS Istituto Delle Scienze Neurologiche di Bologna, Via Altura, 3, 40139, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
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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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Pituitary disease and pregnancy. ACTA ACUST UNITED AC 2021; 68:184-195. [PMID: 33358152 DOI: 10.1016/j.endinu.2020.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/19/2020] [Accepted: 07/07/2020] [Indexed: 12/30/2022]
Abstract
Pregnancy results in a significant change in both pituitary gland size and function. Due to this physiological adaptation, the diagnosis and management of pituitary diseases during pregnancy represents a particularly complex challenge. The presence of a functioning pituitary adenoma may be harmful to the health of the mother and fetus, and scientific evidence regarding the safety of drugs normally used to control hormone excess during pregnancy is scarce. In addition, pregnancy may be associated with the risk of the growth of a pre-existing pituitary adenoma. This review focuses on the diagnostic challenges in pregnant women with adenomas secreting prolactin, growth hormone, or adrenocorticotropic hormone. Some evidence-based recommendations for the treatment of these conditions during pregnancy are provided, and algorithms that could help monitor a pituitary adenoma during pregnancy are examined. Mention is also made of how hormone replacement therapy can be optimised in pregnant women with hypopituitarism. Finally, differential diagnosis between Sheehan's syndrome and lymphocytic hypophysitis, two pituitary disorders that may occur during pregnancy or delivery, is discussed.
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Azzola A, Eastabrook G, Matsui D, Berberich A, Tirona RG, Gray D, Gallego P, Van Uum S. Adrenal Cushing Syndrome Diagnosed During Pregnancy: Successful Medical Management With Metyrapone. J Endocr Soc 2020; 5:bvaa167. [PMID: 33305159 PMCID: PMC7712789 DOI: 10.1210/jendso/bvaa167] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Indexed: 11/19/2022] Open
Abstract
Adrenal Cushing syndrome during pregnancy is rare, and there is limited information on the effect and safety of metyrapone treatment both for mother and fetus. We present a 24-year-old woman diagnosed with adrenal Cushing syndrome at the end of the second trimester. We elected treatment with metyrapone titrated to 250 mg 3 times daily, resulting in good clinical response and maternal serum and saliva cortisol levels in the upper half of the normal pregnancy range. A healthy male infant was born at 35 weeks’ gestation, with no clinical signs of adrenal insufficiency, this despite a low cortisol of 5 nmol/L on the first day of life. We measured metyrapone in maternal and umbilical cord blood samples, demonstrating fetal venous metyrapone levels similar to maternal venous concentration, and a fetal arterial cord concentration at about 60% of the fetal venous cord concentration. This case demonstrates that salivary cortisol levels may be used to monitor the effect of metyrapone on adrenal Cushing syndrome during pregnancy. We show, for the first time in humans, that metyrapone does cross the placenta and may suppress fetal cortisol production without necessarily causing clinical signs of adrenal insufficiency.
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Affiliation(s)
- Alescia Azzola
- Department of Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Genevieve Eastabrook
- Obstetrics and Gynaecology, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Doreen Matsui
- Paediatrics, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Amanda Berberich
- Department of Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Rommel G Tirona
- Physiology and Pharmacology, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Daryl Gray
- Surgery, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Patricia Gallego
- Paediatrics, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Stan Van Uum
- Department of Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada
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29
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Wen L, Li R, Wang J, Yi J. The reproductive stress hypothesis. Reproduction 2020; 158:R209-R218. [PMID: 31677601 PMCID: PMC6892456 DOI: 10.1530/rep-18-0592] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 07/23/2019] [Indexed: 12/16/2022]
Abstract
In this paper, we propose the reproductive stress hypothesis that describes the pregnant females response to reproductive events based upon the activation of the hypothalamic–pituitary–adrenal axis and sympathetic adrenomedullary system. The main components of the reproductive stress hypothesis can be summarized as follows: (1) events unique to reproduction including empathema, pregnancy, parturition and lactation cause non-specific responses in females, called active reproductive stress; (2) the fetus is a special stressor for pregnant females where endocrine hormones, including corticotropin-releasing hormones and fetal glucocorticoids secreted by the fetus and placenta, enter the maternal circulatory system, leading to another stress response referred to as passive reproductive stress and (3) response to uterine tension and intrauterine infection is the third type of stress, called fetal intrauterine stress. Appropriate reproductive stress is a crucial prerequisite in normal reproductive processes. By contrast, excessive or inappropriate reproductive stress may result in dysfunctions of the reproductive system, such as compromised immune function, leading to susceptibility to disease. The novel insights of the reproductive stress hypothesis have important implications for deciphering the pathogenesis of certain diseases in pregnant animals, including humans, which in turn may be applied to preventing and treating their occurrence.
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Affiliation(s)
- Lixin Wen
- Department of Clinical Veterinary Medicine, College of Veterinary Medicine, Hunan Agricultural University, Changsha, People's Republic of China.,Hunan Collaborative Innovation Center of Animal Production Safety, Changsha, People's Republic of China
| | - Rongfang Li
- Department of Clinical Veterinary Medicine, College of Veterinary Medicine, Hunan Agricultural University, Changsha, People's Republic of China.,Hunan Collaborative Innovation Center of Animal Production Safety, Changsha, People's Republic of China
| | - Ji Wang
- Department of Clinical Veterinary Medicine, College of Veterinary Medicine, Hunan Agricultural University, Changsha, People's Republic of China.,Hunan Collaborative Innovation Center of Animal Production Safety, Changsha, People's Republic of China
| | - Jine Yi
- Department of Clinical Veterinary Medicine, College of Veterinary Medicine, Hunan Agricultural University, Changsha, People's Republic of China.,Hunan Collaborative Innovation Center of Animal Production Safety, Changsha, People's Republic of China
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30
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Kersten M, Hancke K, Janni W, Kraft K. Pregnancy induced Cushing's syndrome and primary aldosteronism: a case report. BMC Pregnancy Childbirth 2020; 20:421. [PMID: 32711486 PMCID: PMC7382848 DOI: 10.1186/s12884-020-03117-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 07/16/2020] [Indexed: 11/10/2022] Open
Abstract
Background First manifestation of Cushing’s syndrome during pregnancy is rare. The diagnosis of both Cushing’s and primary aldosteronism within a pregnancy has not been previously documented. Diagnosis is especially challenging due to the normal physiological changes that occur during pregnancy. Consequently, many tests that are normally used for diagnosis are not reliable. Tumor based etiologies can be surgically removed. Etiologies that are not tumor based are challenging to treat during pregnancy. Case presentation A 25 year old G1P0 was admitted in the 22 5/7 week of pregnancy with elevated blood pressure (200/100 mm Hg), acne, moon facies, abdominal striae and hirsutism. With five antihypertensive medications her blood pressure remained 190/100 mm Hg. The patient was admitted to the ICU for intravenous medications and monitoring. She was diagnosed with Cushing’s syndrome and primary aldosteronism. In spite of therapy with spironolactone and metyrapone she developed preeclampsia and was delivered in the 26 0/7 week of pregnancy. At her follow up visit eight weeks postpartum she had blood pressure within normal limits, no clinical signs or symptoms, and all medications had been discontinued. Conclusions Early diagnosis of pregnancy induced Cushing’s syndrome and primary aldosteronism requires an interdisciplinary approach. Late detection has been associated with increased perinatal morbidity and mortality including but not limited to placental abruption and intrauterine demise. Collaboration is essential in the optimization of maternal and fetal outcomes.
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Affiliation(s)
- Maria Kersten
- Department of Obstetrics and Gynecology, University of Ulm (Universitätsklinikum Ulm), Ulm, Germany
| | - Katharina Hancke
- Department of Obstetrics and Gynecology, University of Ulm (Universitätsklinikum Ulm), Ulm, Germany
| | - Wolfgang Janni
- Department of Obstetrics and Gynecology, University of Ulm (Universitätsklinikum Ulm), Ulm, Germany
| | - Katrina Kraft
- Department of Obstetrics and Gynecology, Munich Klinik Harlaching (München Klinik Harlaching), Munich, Germany.
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31
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Joseph S, Sharma A, Horne LP, Wood CE, Langaee T, James MO, Stacpoole PW, Keller-Wood M. Pharmacokinetic and Biochemical Profiling of Sodium Dichloroacetate in Pregnant Ewes and Fetuses. Drug Metab Dispos 2020; 49:451-458. [PMID: 33811107 PMCID: PMC11019763 DOI: 10.1124/dmd.120.000330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/16/2021] [Indexed: 11/22/2022] Open
Abstract
Sodium dichloroacetate (DCA) is an investigational drug that shows promise in the treatment of acquired and congenital mitochondrial diseases, including myocardial ischemia and failure. DCA increases glucose utilization and decreases lactate production, so it may also have clinical utility in reducing lactic acidosis during labor. In the current study, we tested the ability of DCA to cross the placenta and be measured in fetal blood after intravenous administration to pregnant ewes during late gestation and labor. Sustained administration of DCA to the mother over 72 hours achieved pharmacologically active levels of DCA in the fetus and decreased fetal plasma lactate concentrations. Multicompartmental pharmacokinetics modeling indicated that drug metabolism in the fetal and maternal compartments is best described by the DCA inhibiting lactate production in both compartments, consistent with our finding that the hepatic expression of the DCA-metabolizing enzyme glutathione transferase zeta1 was decreased in the ewes and their fetuses exposed to the drug. We provide the first evidence that DCA can cross the placental compartment to enter the fetal circulation and inhibit its own hepatic metabolism in the fetus, leading to increased DCA concentrations and decreased fetal plasma lactate concentrations during its parenteral administration to the mother. SIGNIFICANCE STATEMENT: This study was the first to administer sodium dichloroacetate (DCA) to pregnant animals (sheep). It showed that DCA administered to the mother can cross the placental barrier and achieve concentrations in fetus sufficient to decrease fetal lactate concentrations. Consistent with findings reported in other species, DCA-mediated inhibition of glutathione transferase zeta1 was also observed in ewes, resulting in reduced metabolism of DCA after prolonged administration.
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Affiliation(s)
- Serene Joseph
- Departments of Pharmacodynamics (S.J., M.K.-W.), Pharmaceutics (A.S.), Medicinal Chemistry (M.O.J.), Pharmacotherapy and Translational Research (T.L.), Center for Pharmacogenomics and Precision Medicine (T.L.), and Departments of Medicine and Biochemistry and Molecular Biology (L.P.H., P.W.S.), Physiology and Functional Genomics (C.E.W.), University of Florida, Gainesville, Florida
| | - Abhisheak Sharma
- Departments of Pharmacodynamics (S.J., M.K.-W.), Pharmaceutics (A.S.), Medicinal Chemistry (M.O.J.), Pharmacotherapy and Translational Research (T.L.), Center for Pharmacogenomics and Precision Medicine (T.L.), and Departments of Medicine and Biochemistry and Molecular Biology (L.P.H., P.W.S.), Physiology and Functional Genomics (C.E.W.), University of Florida, Gainesville, Florida
| | - Lloyd P Horne
- Departments of Pharmacodynamics (S.J., M.K.-W.), Pharmaceutics (A.S.), Medicinal Chemistry (M.O.J.), Pharmacotherapy and Translational Research (T.L.), Center for Pharmacogenomics and Precision Medicine (T.L.), and Departments of Medicine and Biochemistry and Molecular Biology (L.P.H., P.W.S.), Physiology and Functional Genomics (C.E.W.), University of Florida, Gainesville, Florida
| | - Charles E Wood
- Departments of Pharmacodynamics (S.J., M.K.-W.), Pharmaceutics (A.S.), Medicinal Chemistry (M.O.J.), Pharmacotherapy and Translational Research (T.L.), Center for Pharmacogenomics and Precision Medicine (T.L.), and Departments of Medicine and Biochemistry and Molecular Biology (L.P.H., P.W.S.), Physiology and Functional Genomics (C.E.W.), University of Florida, Gainesville, Florida
| | - Taimour Langaee
- Departments of Pharmacodynamics (S.J., M.K.-W.), Pharmaceutics (A.S.), Medicinal Chemistry (M.O.J.), Pharmacotherapy and Translational Research (T.L.), Center for Pharmacogenomics and Precision Medicine (T.L.), and Departments of Medicine and Biochemistry and Molecular Biology (L.P.H., P.W.S.), Physiology and Functional Genomics (C.E.W.), University of Florida, Gainesville, Florida
| | - Margaret O James
- Departments of Pharmacodynamics (S.J., M.K.-W.), Pharmaceutics (A.S.), Medicinal Chemistry (M.O.J.), Pharmacotherapy and Translational Research (T.L.), Center for Pharmacogenomics and Precision Medicine (T.L.), and Departments of Medicine and Biochemistry and Molecular Biology (L.P.H., P.W.S.), Physiology and Functional Genomics (C.E.W.), University of Florida, Gainesville, Florida
| | - Peter W Stacpoole
- Departments of Pharmacodynamics (S.J., M.K.-W.), Pharmaceutics (A.S.), Medicinal Chemistry (M.O.J.), Pharmacotherapy and Translational Research (T.L.), Center for Pharmacogenomics and Precision Medicine (T.L.), and Departments of Medicine and Biochemistry and Molecular Biology (L.P.H., P.W.S.), Physiology and Functional Genomics (C.E.W.), University of Florida, Gainesville, Florida
| | - Maureen Keller-Wood
- Departments of Pharmacodynamics (S.J., M.K.-W.), Pharmaceutics (A.S.), Medicinal Chemistry (M.O.J.), Pharmacotherapy and Translational Research (T.L.), Center for Pharmacogenomics and Precision Medicine (T.L.), and Departments of Medicine and Biochemistry and Molecular Biology (L.P.H., P.W.S.), Physiology and Functional Genomics (C.E.W.), University of Florida, Gainesville, Florida
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Araujo-Castro M, Berrocal VR, Pascual-Corrales E. Pituitary tumors: epidemiology and clinical presentation spectrum. Hormones (Athens) 2020; 19:145-155. [PMID: 31933100 DOI: 10.1007/s42000-019-00168-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/16/2019] [Indexed: 02/07/2023]
Abstract
Pituitary tumors (PTs) are a heterogeneous group of lesions of the central nervous system that are usually benign. Most of them occur sporadically, but 5% can do so within family syndromes, usually at a young age. There are differences by sex, age, race, and genetic factors in the prevalence of different tumor cell types and clinical presentation. Functioning-PTs (FPTs) are usually diagnosed earlier than non-functioning PTs (NFPTs). However, this depends on the PT type. Headaches and visual disturbances are the most frequent mass-effect symptoms, but seizures or hydrocephalus may also occur. Pituitary apoplexy is another possible mode of presentation, and it requires special attention because of its potential severity. PTs in pregnancy, childhood, and old age present a series of clinical peculiarities that must be taken into account when evaluating these patients. Ectopic PTs (EPTs) are uncommon and share the same clinical-epidemiological data as eutopic PTs, but, depending on their location, other types of clinical manifestations may appear. Silent PTs are often detected as an incidentaloma or due to neurologic symptoms related to mass-effect. Aggressive PTs and pituitary carcinomas (PCs), which are very rare, are characterized by multiple local recurrences and metastases, respectively. This review addresses the epidemiology and clinical presentation of PTs, from the classical hormonal and mass-effect symptoms to the different rare presentations, such as pituitary apoplexy, hydrocephalus, or diabetes insipidus. Moreover, special situations of the presentation of PTs are discussed, namely, PTs in pregnancy, childhood, and the elderly, EPTs, silent and aggressive PTs, and PCs.
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Affiliation(s)
- Marta Araujo-Castro
- Neuroendocrinology Unit, Endocrinology Department, Ramón y Cajal University Hospital, Madrid, Spain.
| | | | - Eider Pascual-Corrales
- Neuroendocrinology Unit, Endocrinology Department, Ramón y Cajal University Hospital, Madrid, Spain
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33
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Kim HB, Kim MK, Kim E, Ahn KS, Kim HS, Kim NK. Cushing syndrome in pregnancy, diagnosed after delivery. Yeungnam Univ J Med 2020; 38:60-64. [PMID: 32438534 PMCID: PMC7787896 DOI: 10.12701/yujm.2020.00290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/12/2020] [Indexed: 11/04/2022] Open
Abstract
Cushing syndrome (CS) is rare in pregnancy, and few cases have been reported to date. Women with untreated CS rarely become pregnant because of the ovulatory dysfunction induced by hypercortisolism. It is difficult to diagnose CS in pregnancy because of its very low incidence, the overlap between the clinical signs of hypercortisolism and the physiological changes that occur during pregnancy and the changes in hypothalamus-pituitary-adrenal axis activity that occur during pregnancy and limit the value of standard diagnostic testing. However, CS in pregnancy is associated with poor maternal and fetal outcomes; therefore, its early diagnosis and treatment are important. Here, we report two patients with CS that was not diagnosed during pregnancy, in whom maternal and fetal morbidity developed because of hypercortisolism.
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Affiliation(s)
- Han Byul Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Raphael Hospital, Daegu, Korea
| | - Mi Kyung Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Korea
| | - El Kim
- Department of Neurosurgery, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Keun Soo Ahn
- Department of Surgery, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Hye Soon Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Nam Kyung Kim
- Park Kyung Dae Clinic of Internal Medicine, Gyeongju, Korea
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Li S, Yang C, Fan J, Yao Y, Lv X, Guo Y, Zhang S. Pregnancy-induced Cushing's syndrome with an adrenocortical adenoma overexpressing LH/hCG receptors: a case report. BMC Endocr Disord 2020; 20:62. [PMID: 32393232 PMCID: PMC7216527 DOI: 10.1186/s12902-020-0539-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 04/27/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Pregnancy-induced Cushing's syndrome (CS) with an adrenocortical adenoma overexpressing luteinizing hormone (LH)/human choriogonadotropin (hCG) receptors (LHCGR) has been rarely reported in the literatures. This peculiar condition challenges the canonical diagnosis and management of CS. CASE PRESENTATION A 27-year-old woman (G2P0A1) presented at 20 weeks gestational age (GA) with overt Cushingoid clinical features. Adrenocorticotropic hormone (ACTH)-independent CS was diagnosed based on undetectable ACTH and unsuppressed cortisol levels by dexamethasone. Magnetic resonance imaging (MRI) scanning without contrast revealed a left adrenal nodule while pituitary MRI scanning was normal. A conservative treatment strategy of controlling Cushingoid comorbidities was conducted. At 36 weeks GA, a caesarean operation was performed and a live female infant was delivered. At 8 weeks after parturition, our patient achieved normalization of blood pressure, blood glucose, serum potassium, and urinary cortisol level spontaneously. During non-pregnancy period, stimulation testing with exogenous hCG significantly evoked a cortisol increase. The woman underwent resection of the adrenal tumor at 6 months after parturition. Immunohistochemistry (IHC) showed the tumor tissue that stained positive for luteinizing hormone (LH)/human choriogonadotropin (hCG) receptor (LHCGR), whereas negative for both melanocortin 2 receptor (MC2R) and G protein-coupled receptor-1 (GPER-1). CONCLUSIONS Stimulation test with exogenous hCG after parturition is necessary for the diagnosis of pregnancy-induced CS. LHCGR plays an essential role in the pathogenesis of this rare condition.
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Affiliation(s)
- Shaohua Li
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, 510120, China
| | - Chen Yang
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, 510120, China
| | - Jing Fan
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, 510120, China
| | - Yao Yao
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, 510120, China
| | - Xiaomei Lv
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, 510120, China
| | - Ying Guo
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, 510120, China
| | - Shaoling Zhang
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, 510120, China.
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Ildefonso-Najarro SP, Plasencia-Dueñas EA, Benites-Moya CJ, Carrion-Rojas J, Concepción-Zavaleta MJ. Pregnancy during the course of Cushing's syndrome: a case report and literature review. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200022. [PMID: 32478666 PMCID: PMC7159255 DOI: 10.1530/edm-20-0022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 03/23/2020] [Indexed: 02/05/2023] Open
Abstract
SUMMARY Cushing's syndrome is an endocrine disorder that causes anovulatory infertility secondary to hypercortisolism; therefore, pregnancy rarely occurs during its course. We present the case of a 24-year-old, 16-week pregnant female with a 10-month history of unintentional weight gain, dorsal gibbus, nonpruritic comedones, hirsutism and hair loss. Initial biochemical, hormonal and ultrasound investigations revealed hypokalemia, increased nocturnal cortisolemia and a right adrenal mass. The patient had persistent high blood pressure, hyperglycemia and hypercortisolemia. She was initially treated with antihypertensive medications and insulin therapy. Endogenous Cushing's syndrome was confirmed by an abdominal MRI that demonstrated a right adrenal adenoma. The patient underwent right laparoscopic adrenalectomy and anatomopathological examination revealed an adrenal adenoma with areas of oncocytic changes. Finally, antihypertensive medication was progressively reduced and glycemic control and hypokalemia reversal were achieved. Long-term therapy consisted of low-dose daily prednisone. During follow-up, despite favorable outcomes regarding the patient's Cushing's syndrome, stillbirth was confirmed at 28 weeks of pregnancy. We discuss the importance of early diagnosis and treatment of Cushing's syndrome to prevent severe maternal and fetal complications. LEARNING POINTS Pregnancy can occur, though rarely, during the course of Cushing's syndrome. Pregnancy is a transient physiological state of hypercortisolism and it must be differentiated from Cushing's syndrome based on clinical manifestations and laboratory tests. The diagnosis of Cushing's syndrome during pregnancy may be challenging, particularly in the second and third trimesters because of the changes in the maternal hypothalamic-pituitary-adrenal axis. Pregnancy during the course of Cushing's syndrome is associated with severe maternal and fetal complications; therefore, its early diagnosis and treatment is critical.
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Affiliation(s)
| | | | | | - Jose Carrion-Rojas
- Metabolism and Reproduction Unit, Division of Endocrinology, Guillermo Almenara Irigoyen National Hospital, Lima, Peru
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Graillon T, Cuny T, Castinetti F, Courbière B, Cousin M, Albarel F, Morange I, Bruder N, Brue T, Dufour H. Surgical indications for pituitary tumors during pregnancy: a literature review. Pituitary 2020; 23:189-199. [PMID: 31691893 DOI: 10.1007/s11102-019-01004-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE Surgical indications for pituitary tumors during pregnancy are rare, and are derived from a balance between expected benefits, particularly for maternal benefits, and anesthetic/surgical risks. METHODS A literature review was performed to define the optimal surgical indications for pituitary adenomas (PA) and other pituitary tumors during pregnancy. RESULTS Main benefits are expected in case of critical visual impairment and/or life-threatening endocrine disturbances. Multidisciplinary patient management is systematically required although nonobstetric surgery presents a reasonable risk during pregnancy. The risks of congenital malformation during the first trimester and those of premature birth during the third trimester make the second trimester the optimal period for surgery. In prolactin-secreting, nonsecreting, GH- and TSH-secreting PAs, transsphenoidal surgery (TS) is recommended in cases involving severe visual impairment, characterized by severe visual field deficit, visual acuity impairment, and abnormal optical coherence tomography findings, and when no other medical alternatives are possible and/or sufficient. Uncontrolled and severe Cushing's disease (CD) during pregnancy increases both maternal and fetal morbimortality, thus justifying TS or sometimes dopamine agonist therapy as a safer alternative. Finally, metyrapone, ketoconazole, or bilateral adrenalectomy could be recommended in certain cases after the failure of medical therapies and/or TS. Surgery is also required for suprasellar meningiomas, craniopharyngiomas, and pituitary cysts in the case of severe visual deficit. CONCLUSION Surgical indications for pituitary tumors are rare during pregnancy; therefore, surgery should be avoided when possible. Further, the second trimester should be considered as the optimal surgical period. Severe visual disturbance and uncontrolled CD are the main surgical indications during pregnancy.
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Affiliation(s)
- Thomas Graillon
- Neurosurgery Department, Aix-Marseille Univ, APHM, CHU Timone, La Timone Hospital, 264 rue Saint-Pierre, 13005, Marseille, France.
- Aix-Marseille Univ, INSERM, MMG, Marseille, France.
| | - Thomas Cuny
- Aix-Marseille Univ, INSERM, MMG, Marseille, France
- Endocrinology Department, Aix-Marseille Univ, APHM, CHU Conception, Marseille, France
| | - Frédéric Castinetti
- Aix-Marseille Univ, INSERM, MMG, Marseille, France
- Endocrinology Department, Aix-Marseille Univ, APHM, CHU Conception, Marseille, France
| | - Blandine Courbière
- Centre Clinico-Biologique d'AMP, Pôle Femmes-Parents-Enfants, Hôpital de La Conception, AP-HM, Marseille/Aix Marseille Univ, Avignon Univ, CNRS, IRD, IBME, Marseille, France
| | - Marie Cousin
- Cabinet d'Ophtalmologie, Saint-Rémy de Provence, France
| | - Frédérique Albarel
- Endocrinology Department, Aix-Marseille Univ, APHM, CHU Conception, Marseille, France
| | - Isabelle Morange
- Endocrinology Department, Aix-Marseille Univ, APHM, CHU Conception, Marseille, France
| | - Nicolas Bruder
- Anesthesiology-Intensive Care Department, Aix-Marseille Univ, APHM, CHU Timone, Marseille, France
| | - Thierry Brue
- Aix-Marseille Univ, INSERM, MMG, Marseille, France
- Endocrinology Department, Aix-Marseille Univ, APHM, CHU Conception, Marseille, France
| | - Henry Dufour
- Neurosurgery Department, Aix-Marseille Univ, APHM, CHU Timone, La Timone Hospital, 264 rue Saint-Pierre, 13005, Marseille, France
- Aix-Marseille Univ, INSERM, MMG, Marseille, France
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Umemiya M, Chigusa Y, Minamiguchi S, Horie A, Mandai M, Kondoh E. Cushing’s syndrome during pregnancy with different clinical courses: Two case reports. HYPERTENSION RESEARCH IN PREGNANCY 2020. [DOI: 10.14390/jsshp.hrp2019-019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Maki Umemiya
- Department of Gynecology and Obstetrics, Kyoto University
| | | | | | - Akihito Horie
- Department of Gynecology and Obstetrics, Kyoto University
| | - Masaki Mandai
- Department of Gynecology and Obstetrics, Kyoto University
| | - Eiji Kondoh
- Department of Gynecology and Obstetrics, Kyoto University
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Abstract
Hypertension is a common and morbid complication of pregnancy. While endocrine causes of secondary hypertension are not rare, women with these conditions do not often conceive, and even less commonly are these disorders diagnosed during pregnancy. This review will consider conditions of adrenal hormone excess that cause secondary hypertension: primary aldosteronism (PA), Cushing syndrome (CS), and pheochromocytoma/paraganglioma. We emphasize that pregnancy itself elicits changes in the regulation of aldosterone and cortisol production and standard endocrine testing algorithms. Furthermore, conventional imaging modalities and pharmacotherapies are often contraindicated in pregnancy, which complicates diagnosis and management. Nevertheless, surgical management in the second trimester is the preferred treatment strategy for most of these rare cases when feasible. This article will discuss the approach to patients with endocrine causes of hypertension during pregnancy with emphasis on those aspects that deviate from the assessment and treatment of non-pregnant patients.
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Affiliation(s)
- Alison H Affinati
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Department of Pharmacology, University of Michigan, Ann Arbor, MI, USA
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Zhang Y, Yuan Z, Qiu C, Li S, Zhang S, Fang Y. The diagnosis and treatment of adrenocortical carcinoma in pregnancy: a case report. BMC Pregnancy Childbirth 2020; 20:50. [PMID: 31964355 PMCID: PMC6975082 DOI: 10.1186/s12884-020-2737-1] [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: 10/17/2019] [Accepted: 01/13/2020] [Indexed: 12/02/2022] Open
Abstract
Background Pregnancy complicated with adrenocortical carcinoma (ACC) is a sporadic syndrome that is characterized by hypertension, uncontrolled hypokalemia, severe heart failure, premature delivery and other adverse effects. The clinical presentation of adrenocortical carcinoma is vague and nonspecific, it is challenging to identify complications of pregnancy with adrenocortical carcinoma. Here we present a case of adrenocortical carcinoma during pregnancy. We describe how to distinguish secondary hypertension from other conditions and the importance of timely detection and treatment of such patients. Case presentation A 22-year-old woman 30 weeks pregnant was hospitalized with uncontrolled hypertension and hypokalemia. An ultrasound examination of the right adrenal gland revealed a large mass. She underwent transabdominal adrenalectomy, and histopathology from the sample removed revealed an adrenocortical carcinoma. Five days after surgery, the patient had a premature rupture of the fetal membranes and gave birth to a newborn girl via vaginal delivery at 32 weeks of gestation. The newborn was transferred to the neonatal pediatrics ward, and the woman started receiving chemotherapy. Conclusions Pregnancy with adrenocortical carcinoma is a rare condition. This case alerts the obstetricians that analysis of hypertension, hypokalemia, the plasma level and circadian rhythm of plasma cortisol provides a strategy to diagnose adrenocortical carcinoma during pregnancy.
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Affiliation(s)
- Yuanli Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, 107 Wenhuaxi Road, Ji'nan, Shandong, 250012, People's Republic of China
| | - Zeng Yuan
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, 107 Wenhuaxi Road, Ji'nan, Shandong, 250012, People's Republic of China
| | - Chunping Qiu
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, 107 Wenhuaxi Road, Ji'nan, Shandong, 250012, People's Republic of China
| | - Shuyi Li
- Radiology Departments, Qilu Hospital, Shandong University, 107 Wenhuaxi Road, Ji'nan, Shandong, 250012, People's Republic of China
| | - Shiqian Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, 107 Wenhuaxi Road, Ji'nan, Shandong, 250012, People's Republic of China.
| | - Yan Fang
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, 107 Wenhuaxi Road, Ji'nan, Shandong, 250012, People's Republic of China.
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Ralser DJ, Strizek B, Kupczyk P, Stoffel-Wagner B, Altengarten J, Müller A, Woelfle J, Gembruch U, Klingmueller D, Merz WM, Paschkowiak-Christes A. Obstetric and Neonatal Outcome of Pregnancy in Carney Complex: A Case Report. Front Endocrinol (Lausanne) 2020; 11:296. [PMID: 32457700 PMCID: PMC7225262 DOI: 10.3389/fendo.2020.00296] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 04/20/2020] [Indexed: 01/12/2023] Open
Abstract
Background: Carney complex (CNC) is a rare multiple endocrine neoplasia syndrome with autosomal dominant inheritance. Affected individuals present with mucocutaneous lentigines/blue nevi, cardiac and noncardiac myxomatous tumors, and multiple endocrine tumors. Mutations in PRKAR1A have been identified as genetic cause of the disease. Here, we report on pregnancy, delivery and puerperium in a woman with genetically confirmed CNC and her newborn. Case: The 31 year-old gravida 5 para 1 with CNC was referred at 26 weeks of gestation. Adrenocorticotropin-independent hypercortisolism, hyperglycemia, hypertension, low serum potassium, and osteoporotic fractures were present. Treatment with metyrapone, a reversible 11-beta-hydroxylase inhibitor, was initiated. The maternal condition improved, and a 5 weeks' pregnancy prolongation could be achieved. Elective repeat cesarean section was performed at 31 weeks of gestation for recurrent vaginal bleeding. The neonate developed transient hyponatremia necessitating hydrocortisone substitution for 2 weeks. Conclusion: In our case, treatment of CNC-associated hypercortisolism in pregnancy with metyrapone was effective. Maternal side effects did not occur. The newborn presented with transient hypocortisolism most likely due to transplacental drug effect. Our case illustrates that the treatment of rare diseases in pregnancy represents a challenge requiring interdisciplinary team work.
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Affiliation(s)
- Damian J. Ralser
- Department of Obstetrics and Gynecology, University Bonn Medical School, Bonn, Germany
- *Correspondence: Damian J. Ralser
| | - Brigitte Strizek
- Department of Obstetrics and Gynecology, University Bonn Medical School, Bonn, Germany
| | - Patrick Kupczyk
- Department of Radiology, University Bonn Medical School, Bonn, Germany
| | - Birgit Stoffel-Wagner
- Institute of Clinical Chemistry and Clinical Pharmacology, University Bonn Medical School, Bonn, Germany
| | - Julia Altengarten
- Department of Dermatology, University Bonn Medical School, Bonn, Germany
| | - Andreas Müller
- Department of Neonatology and Pediatric Critical Care Medicine, University Bonn Medical School, Bonn, Germany
| | - Joachim Woelfle
- Pediatric Endocrinology and Diabetology Division, Children's Hospital, University Bonn Medical School, Bonn, Germany
| | - Ulrich Gembruch
- Department of Obstetrics and Gynecology, University Bonn Medical School, Bonn, Germany
| | - Dietrich Klingmueller
- Division of Endocrinology and Diabetes, Department of Medicine I, University Bonn Medical School, Bonn, Germany
| | - Waltraut M. Merz
- Department of Obstetrics and Gynecology, University Bonn Medical School, Bonn, Germany
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Tang K, Lu L, Feng M, Zhang H, Chen K, Sun X, Zhu H, Wang R, Lu Z. The Incidence of Pregnancy-Associated Cushing's Disease and Its Relation to Pregnancy: A Retrospective Study. Front Endocrinol (Lausanne) 2020; 11:305. [PMID: 32547488 PMCID: PMC7272570 DOI: 10.3389/fendo.2020.00305] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 04/22/2020] [Indexed: 12/26/2022] Open
Abstract
Purpose: Cushing's disease (CD) is one of the most severe endocrine disorders and primarily affects women of reproductive age. The peripartum period has been observed to be a common time to develop CD. This study aims to retrospectively analyze the clinical characteristics of CD potentially associated with pregnancy and to evaluate relevant pregnancy outcomes. Methods: Patients who underwent surgery from January 2010 to May 2019 at Peking Union Medical College Hospital (PUMCH) with biochemically and pathologically confirmed CD were retrospectively analyzed. Pregnancy-associated CD was defined as CD onset during gestation or within 12 months after delivery or abortion. Data including demographics, biochemical tests, magnetic resonance imaging (MRI) findings, and disease outcomes were obtained from all patients by reviewing their medical records. Information regarding pregnancy was collected through a supplementary online questionnaire. Results: In a series of female patients (n = 70) of reproductive age with childbearing desire, 27.1% (n = 19) met the criteria for pregnancy-associated CD. The timing of diagnosis of pregnancy-associated CD was 2.7 ± 3.4 years after symptom onset, and the overall remission rate for these women was 89.5%. Three patients with pregnancy-associated CD developed hypertension during pregnancy, two of whom had new-onset hypertension at 16 weeks of gestation and one of whom had a complication of severe diabetes. The rates of spontaneous abortion and preterm birth among the women with pregnancy-associated CD were 26.3 and 28.6%, respectively. The proportions of all low-birth-weight (LBW) newborns (p = 0.002) and term LBW newborns (p = 0.033) were significantly higher in the pregnancy-associated CD group than in the non-pregnancy-associated CD group. Conclusions: In this study, a total of 27.1% of women of reproductive age with CD had pregnancy-associated CD, which might be induced by the hormonal milieu of pregnancy. An increased risk of having a LBW newborn was observed among mothers with pregnancy-associated CD. A high degree of clinical suspicion for CD may be warranted in the peripartum period. Patients with symptoms suspicious for CD throughout pregnancy and after childbirth, such as early-onset hypertension, severe hyperglycemia, and persistent weight gain, should be carefully diagnosed and closely monitored by clinicians.
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Affiliation(s)
- Keyun Tang
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- Eight-Year Program of Clinical Medicine, Peking Union Medical College, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Lin Lu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- *Correspondence: Lin Lu
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- Ming Feng
| | - Hanlin Zhang
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- Eight-Year Program of Clinical Medicine, Peking Union Medical College, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Kang Chen
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- Eight-Year Program of Clinical Medicine, Peking Union Medical College, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xu Sun
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Huijuan Zhu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhaolin Lu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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42
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Bellizzi S, Nivoli A, Salaris P, Ronzoni AR, Pichierri G, Palestra F, Wazwaz O, Luque-Fernandez MA. Sexual violence and eclampsia: analysis of data from Demographic and Health Surveys from seven low- and middle-income countries. J Glob Health 2019; 9:020434. [PMID: 31777658 PMCID: PMC6858987 DOI: 10.7189/jogh.09.020434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Scientific literature has provided clear evidence of the profound impact of sexual violence on women’s health, such as somatic disorders and mental adverse outcomes. However, consequences related to obstetric complications are not yet completely clarified. This study aimed to assess the association of lifetime exposure to intimate partner sexual violence with eclampsia. Methods We considered all the seven Demographic and Health Surveys (DHS) that included data on sexual violence and on signs and symptoms suggestive of eclampsia for women of reproductive age (15-49 years). We computed unadjusted and adjusted odds ratios (OR) to evaluate the risk of suggestive eclampsia by ever subjected to sexual violence. A sensitivity analysis was conducted restricting the study population to women who had their last live birth over the 12 months before the interview. Results Self-reported experience of sexual violence ranged from 3.7% in Mali to 9.2% in India while prevalence of women reporting signs and symptoms compatible with eclampsia ranged from 14.3% in Afghanistan to 0.7% in the Philippines. Reported sexual violence was associated with a 2-fold increased odd of signs and symptoms suggestive of eclampsia in the pooled analysis. The sensitivity analysis confirmed the strength of the association between sexual violence and eclampsia in Afghanistan and in India. Conclusions Women and girls in low-and-middle-income countries are at high risk of sexual violence, which may represent a risk factor for hypertensive obstetric complication. Accurate counseling by health care providers during antenatal care consultations may represent an important opportunity to prevent adverse outcomes during pregnancy.
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Affiliation(s)
- Saverio Bellizzi
- Partnership for Maternal, Newborn & Child Health, Geneva, Switzerland
| | - Alessandra Nivoli
- Department of Neuroscience, Institute of Psychiatry, University of Sassari, Sassari, Italy
| | - Paola Salaris
- Department of Endocrinology, Mater Olbia Hospital, Olbia, Italy
| | | | - Giuseppe Pichierri
- Kingston Hospital NHS Foundation Trust, Galsworthy Road, Kingston upon Thames, UK
| | | | - Ola Wazwaz
- Partnership for Maternal, Newborn & Child Health, Geneva, Switzerland
| | - Miguel Angel Luque-Fernandez
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Biomedical Research Institute of Granada, Non-Communicable and Cancer Epidemiology Group (ibs.Granada), Andalusian School of Public Health, Granada, University of Granada, Spain
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Abstract
Pituitary adenomas are common. The impact of pituitary tumors on fertility are mainly caused by oversecretion and/or undersecretion of pituitary hormones or compression of pituitary stalk and normal pituitary tissue by the tumor. Diagnosing and managing pituitary tumors during pregnancy involve many challenges, including the effect of hormone excess or deficiency on pregnancy outcome, changes in the pituitary or pituitary-related hormones, changes in tumor size, and the impact of various treatments of pituitary tumors on maternal and fetal outcomes. This article discusses the diagnosis and treatment of patients with prolactinomas, acromegaly, Cushing disease, and other pituitary tumors during pregnancy.
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Affiliation(s)
- Wenyu Huang
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 North Michigan Avenue, Suite 530, Chicago, IL 60611, USA
| | - Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 North Michigan Avenue, Suite 530, Chicago, IL 60611, USA.
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44
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Lin W, Huang HB, Wen JP, Wang NY, Wang SY, Wang C, Chen G. Approach to Cushing's syndrome in pregnancy: two cases of Cushing's syndrome in pregnancy and a review of the literature. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:490. [PMID: 31700926 DOI: 10.21037/atm.2019.07.94] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Cushing's syndrome (CS) rarely occurs during pregnancy. The primary aim of this article is to propose a therapeutic approach to CS in pregnancy. Here, we present two cases of CS in pregnancy and a literature review. This article proposes the early diagnostic points, especially the clinical approach to this medical condition, mainly for pregnant women without a previous diagnosis of CS. More importantly, we present therapeutic strategies for CS during pregnancy, especially glucocorticoid replacement for perioperative, postoperative, and perinatal periods in pregnant women with CS in order to minimize complications for both mother and fetus. At the same time, we also assess the anxiety status of patients. This article summarizes the approach to CS in pregnancy, not only with a physiological assessment but with a psychological assessment as well.
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Affiliation(s)
- Wei Lin
- Department of Endocrinology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou 350001, China
| | - Hui-Bin Huang
- Department of Endocrinology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou 350001, China
| | - Jun-Ping Wen
- Department of Endocrinology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou 350001, China
| | - Neng-Ying Wang
- Department of Endocrinology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou 350001, China
| | - Shuang-Yu Wang
- Department of Imaging, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou 350001, China
| | - Chen Wang
- Department of Pathology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou 350001, China
| | - Gang Chen
- Department of Endocrinology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou 350001, China
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45
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Manoharan M, Sinha P, Sibtain S. Adrenal disorders in pregnancy, labour and postpartum - an overview. J OBSTET GYNAECOL 2019; 40:749-758. [PMID: 31469031 DOI: 10.1080/01443615.2019.1648395] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Adrenal disorders may manifest during pregnancy for the first time, or present from before pregnancy as either undiagnosed or diagnosed and treated. They may present as hormonal hypofunction or hyperfunction, or with mass effects or other non-endocrine effects. Adrenal disorders such as Cushing's syndrome, Addison's disease, pheochromocytoma, primary hyper-aldosteronism and adreno-cortical carcinoma are rare in pregnancy. Pregnancy presents special problems in the evaluation of the hypothalamic-pituitary-adrenal and renin-angiotensin-aldosterone axis as these undergoe major changes during pregnancy. Diagnosis is challenging as symptoms associated with pregnancy are also seen in adrenal diseases. A timely diagnosis and treatment is critical as these disorders can cause maternal and foetal morbidity and mortality. A high index of suspicion must be maintained as they can go unrecognised and untreated. An early diagnosis and treatment often improves outcomes. The aim of this article is to review the patho-physiology, clinical manifestation, diagnosis and management of various adrenal disorders during pregnancy.
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Affiliation(s)
| | - Prabha Sinha
- Department of Obstetrics and Gynaecology, Oman Medical College, Muscat, Oman
| | - Shabnum Sibtain
- Department of Obstetrics and Gynaecology, Azra Naheed Medical College, Lahore, Pakistan
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46
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Pofi R, Tomlinson JW. Glucocorticoids in pregnancy. Obstet Med 2019; 13:62-69. [PMID: 32714437 DOI: 10.1177/1753495x19847832] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 04/08/2019] [Indexed: 12/18/2022] Open
Abstract
The physiological changes that occur during pregnancy include altered regulation of the hypothalamo-pituitary-adrenal axis. The fetoplacental unit plays a major role in this, together with alteration of circulating cortisol-binding globulin levels, with a net effect to increase both total and free cortisol levels. Importantly, there are several pathological conditions that require steroid treatment or replacement during pregnancy, and optimizing therapy is clearly crucial. The potential for acute and chronic adverse effects that can impact upon both the mother and the fetus makes the decision of how and when to instigate steroid therapy particularly challenging. In this review, we describe the physio-pathological changes to the hypothalamo-pituitary-adrenal axis that occur during pregnancy, tools to assess endogenous glucocorticoid reserve as well as discuss treatment strategies and the potential for the development of adverse events.
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Affiliation(s)
- Riccardo Pofi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.,Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK
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A successful pregnancy in a patient with secondary hypertension caused by adrenal adenoma: a case report. BMC Pregnancy Childbirth 2019; 19:116. [PMID: 30943935 PMCID: PMC6448298 DOI: 10.1186/s12884-019-2262-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 03/25/2019] [Indexed: 02/06/2023] Open
Abstract
Background Secondary hypertension is a rare complication in pregnancy that causes poor outcomes, such as preeclampsia, premature delivery, intrauterine growth retardation, stillbirths, spontaneous abortion or intrauterine death. Cushing’s disease caused by an adrenal adenoma is rare during pregnancy and may be overlooked by obstetricians and physicians, but can lead to hypertension, diabetes mellitus and an increased risk of fetal and maternal morbidity. Approximately 200 cases have been reported in the literature. Here, we report the successful management of a pregnant patient with Cushing’s syndrome due to an adrenal adenoma. Case presentation The 35-year-old Chinese female had no individual or family medical history of hypertension, and did not exhibit chronic kidney disease, diabetes mellitus, autoimmune and common endocrine diseases. Her blood pressure was elevated from the 16th week of gestation and was not controlled by 30 mg nifedipine twice a day. Examination in our department revealed her 24 h urinary free cortisol (24 h UFC) level was 1684.3 μg/24 h (normal range: 20.26–127.55 μg/24 h) and plasma adrenocorticotropic hormone was < 1.00 ng/L in three independent measurements (normal range: 5–78 ng/L). Ultrasonography demonstrated a mass (2.9 cm × 2.8 cm) in the right side of the adrenal gland. Magnetic resonance imaging without contrast showed a 3.2 cm diameter mass in the right-side of the adrenal gland. Other medical tests were normal. Laparoscopic adrenalectomy was performed at the 26th week of gestation by a urological surgeon in the West China Hospital. Histopathology revealed an adrenocortical adenoma. After surgery, the patient accepted glucocorticoid replacement therapy. The remaining trimester continued without complication and her blood pressure was normal at the 32nd week of gestation without antihypertensive therapy. The patient gave birth to a healthy boy at the 40th week of gestation. Conclusions Cushing’s syndrome caused by adrenal adenoma is rare during pregnancy. This unique case suggested that analysis of the UFC level and circadian rhythm of plasma cortisol provides a suitable strategy to diagnose Cushing’s syndrome during pregnancy. Laparoscopic surgical resection in the second trimester provides a reasonable approach to treat pregnant patients exhibiting Cushing’s syndrome caused by an adrenal adenoma.
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