Endocrine Abstracts

Mrs XY, 29 years. (gravida: 3 and para 2) was admitted under the obstetricians with severe hyperemesis gravidarum (HG). An ultrasonogram revealed single live foetus of 8 weeks gestation. Her two previous pregnancies were normal with no history of HG. Mrs XY was on levothyroxine 150 μg OD for autoimmune primary hypothyroidism with TPO antibodies of 259 kU/l (0–5.6). She was also taking sertraline 200 mg OD for depression. The hyperemesis settled with i.v. fluids as well as antiemetic and she was discharged home.

Subsequently, Mrs XY had a further four admissions of varying duration to hospital for severe HG. At the last admission she was upset and expressed a desire to terminate her pregnancy. An endocrine consult was requested by the obstetricians for deranged thyroid function test. At the Endocrine consult, Mrs XY was noted to be hyperpigmented especially in elbows and buccal mucosa with a blood pressure of 100/59 mm Hg. Blood investigations revealed Na 136 mmol/l (133–146), K 3.8 mmol/l (3.5–5.3), urea 0.5 mmol/l (2.5–5.8), glucose 7.9 mmol/l (3–6), Hb 10.4 g/l (115–148), MCV 87fL (84–99), and eosinophil’s were normal. TSH of 0.24 mU/l (0.35–4.94) with a free T4 of 15.8 pmol/l (9–19.1). A random cortisol level was <20 nmol/l with a Short Synacthen test both basal as well as 30 min undetectable at <20 nmol/l. ACTH levels were elevated at >1250 ng/l. Adrenal antibodies were positive. Miss XY was treated as Addisonian crisis with i.v. hydrocortisone as well as i.v. fluids. She felt much better and later discharged with oral hydrocortisone and fludrocortisone. There were no further admissions with HG during the pregnancy and she delivered a healthy baby at 38 weeks gestation.

Discussion: A new diagnosis of primary adrenal insufficiency during pregnancy is rare but could become rapidly fatal if untreated. A high index of suspicion is necessary especially in patients with other autoimmune disorders like primary hypothyroidism. The hyperpigmentation of pregnancy ‘chloasma’ can cause diagnostic confusion but it usually occurs in sun exposed areas while the hyperpigmentation of Addison’s occur in areas of mechanical friction as well as the mucosae. Recurrent severe vomiting, fatigue as well as a low blood pressure in the presence of hyperpigmentation should prompt investigations for an adrenal insufficiency in pregnancy.