Endocrine Abstracts

Addison’s disease rarely newly presents during pregnancy. We highlight two cases diagnosed within 3 months. A 41-year-old with mild depression on Sertraline, presented at 11-weeks’ gestation with an 8-week history of fatigue, weight loss, dizziness and vomiting. Persistent hyponatraemia was noted (Na 122–127 mmol/l). Random cortisols were 298–428 nmol/l. Sertraline withdrawal and fluid restriction at another centre did not improve her hyponatraemia, the use of synacthen was deemed contraindicated. On transfer to our service, she had difficulty standing (lying BP 88/53). SST response at 60min showed cortisol 466 nmol/l (trimesteral SST 60-min pass cut-offs are 700, 800 and 900 nmol/l (Lebbe 2013)), ACTH 67.8 (7.2–63.3) and renin 16. Adrenal antibodies were negative. Subclinical hypothyroidism (positive TPO antibodies) was also noted. Marked clinical improvement was seen following in-patient resuscitation. She has subsequently been clinically and biochemically stable on hydrocortisone, fludrocortisone and levothyroxine. Whilst reassessment is planned post-partum, permanent adrenal insufficiency is likely. She has required significant psychological and pharmacological support for her diagnosis acceptance during pregnancy. Separately, a 36-year-old was referred to Bristol Dental Hospital at 8-weeks’ gestation with a sublingual lesion and noted to have buccal pigmentation. Her only symptom was fatigue and she had been receiving compliments for her ‘winter tan’ for months. Her random cortisol was 146 nmol/l. An SST confirmed adrenal insufficiency (60 min cortisol 125 nmol/l), ACTH 1515 and renin 6.9. She is currently progressing well through pregnancy on treatment. These cases highlight the need for a high degree of clinical suspicion to diagnose Addison’s in pregnancy. Trimesteral morning levels <300, <450, <600 nmol/l should alert a possibility of adrenal insufficiency (Lebbe 2013). Synacthen can be used safely but there is a need to appreciate trimester specific cut-offs (increasing CBG driving higher total cortisol levels in pregnancy).