Endocrine Abstracts

Mrs XY, 28 years. primigravida was seen for PV bleed. Ultrasonogram confirmed live intrauterine foetus of 8 weeks gestation with no obvious cause for PV bleeding. An OGTT at 21 weeks suggested gestational diabetes. She was referred to Diabetes Nurse led clinic and treated with metformin. Hypertension was recorded and controlled with labetalol and amlodipine. Mrs XY had recurrent admissions for PV bleeds and some polycythaemia. She was seen by the haematologist and a diagnosis of transient polycythaemia was made. Mrs XY then presented with pre-eclampsia at 36 weeks resulting in emergency LSCS and healthy baby. Six months postpartum she was referred to endocrine clinic for persisting hypertension and facial swelling. O/e she had proximal myopathy, easy bruising and purplish abdominal striae. BP was controlled on labetalol 200 mg bid, BMI: 21.2, HbA1c 31 mmol/mol, 24 h. urinary catecholamine’s and androgen profile were normal. 24 h urinary free cortisol was elevated with 1 mg overnight dexamethasone suppression test and a low dose dexamethasone suppression test not suppressing. 0900 h ACTH levels were suppressed and a diagnosis of ACTH independent Cushing’s syndrome was made. CT scans confirmed right adrenal adenoma. Ketoconazole was started for inhibition of steroidogenesis. Mrs XY underwent laparoscopic right adrenalectomy with histology confirming adrenocortical adenoma. Post-surgery her blood pressure normalised.

Discussion: Cushing’s syndrome is a rare diagnosis in pregnancy which can result in significant maternal and foetal morbidity. Adrenal adenomas comprise most of Cushing’s seen in pregnancy as was in our patient. The signs and symptoms of hypercortisolemia overlap with normal pregnancy making it difficult to diagnose. In normal pregnancy the diurnal rhythm of cortisol secretion is preserved but there is increase in ACTH, total cortisol as well as free plasma cortisol making biochemical diagnosis difficult. UFC >1 times upper limit of normal in 1st trimester and UFC >3 times upper limit of normal in 2nd or 3rd trimester along with demonstration of loss of diurnal rhythm preferably by salivary cortisol can aid diagnosis of Cushing’s syndrome. A high index of suspicion is necessary to consider Cushing’s in pregnancy especially if there is excessive weight gain, and a combination of gestational diabetes and hypertension.