Endocrine Abstracts

: A 26 year old 22 weeks pregnant woman was referred to the Endocrine team after she presented with high blood pressure without evidence of proteinuria. She had no past medical history and was newly diagnosed with gestational diabetes. On clinical examination, she had some clinical features consistent with hypercortisolism such as very prominent large purplish striae over her abdomen, bad facial acne, multiple superficial ecchymoses due to easy skin bruisability and excessive weight gain.She had abnormally high 24-hour urinary cortisol (3510nmol/24 hour), undetectable serum ACTH level (<3ng/l) with loss of diurnal variability on cortisol day curve. Her early morning cortisol was inappropriately raised following both a 2mg and 8mg overnight dexamethasone suppression test being above 1000 nmol/l on both instances. Radiologically, she was found to have a left 3.8 x 3.1 x 3.8 cm lesion within the left adrenal gland on an MRI adrenals. She agreed for laparoscopic adrenalectomy at 26/40 gestational week. Histology confirmed adrenal cortical adenoma. She improved clinically after the procedure and was maintained on hydrocortisone replacement therapy until delivery. She gave birth to a healthy baby girl at 34 weeks and was progressively weaned off the hydrocortisone. The initial short Synacthen test post surgery showed inadequate response but improved on subsequent testing. Her hydrocortisone was eventually stopped after 8 months of slow weaning. This case highlights the difficulty in diagnosing Cushing’s syndrome during pregnancy due to overlap of clinical features. Additionally, biochemical results are confounded by changes in the hypothalamic-pituitary-adrenal axis in normal pregnancy requiring careful interpretation of biochemical investigations.