Home | About us | Editorial board | Search | Ahead of print | Current issue | Archives | Submit article | Instructions | Subscribe | Contacts | Advertise | Login 
 
Search Article 
  
Advanced search 
  Users Online: 25 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size  

 
Table of Contents
LETTER TO THE EDITOR
Year : 2012  |  Volume : 16  |  Issue : 3  |  Page : 481-482

Unassisted successful pregnancy in a case of Addison's disease with recurrent pregnancy loss


1 Department of Radio Diagnosis, Sher-I-Kashmir Institute of Medical Sciences Soura Srinagar, Jammu and Kashmir, India
2 Department of Internal Medicine and Endocrinology, Sher-I-Kashmir Institute of Medical Sciences Soura Srinagar, Jammu and Kashmir, India
3 Department of Immunology and Molecular Medicine, Sher-I-Kashmir Institute of Medical Sciences Soura Srinagar, Jammu and Kashmir, India

Date of Web Publication5-May-2012

Correspondence Address:
Mohd Ashraf Ganie
Department of Endocrinology, Sher-I- Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir
India
Login to access the Email id


DOI: 10.4103/2230-8210.95747

Get Permissions


How to cite this article:
Ganie MA, Bhat RA, Iu, Dangroo MA, Kotwal S, Bhat MA, Ahmed S, Hassan S, Shah ZA. Unassisted successful pregnancy in a case of Addison's disease with recurrent pregnancy loss. Indian J Endocr Metab 2012;16:481-2

How to cite this URL:
Ganie MA, Bhat RA, Iu, Dangroo MA, Kotwal S, Bhat MA, Ahmed S, Hassan S, Shah ZA. Unassisted successful pregnancy in a case of Addison's disease with recurrent pregnancy loss. Indian J Endocr Metab [serial online] 2012 [cited 2014 Aug 22];16:481-2. Available from: http://www.ijem.in/text.asp?2012/16/3/481/95747

Sir,

Pregnancy itself is a state of physiological hypercortisolism. Due to increased production and secretion, plasma cortisol levels increase progressively starting in the first trimester. The half-life of serum cortisol is prolonged, and by term usually the circulating cortisol levels are 2- to 3-fold higher than those in nonpregnant women. [1] Therefore, recognizing adrenal insufficiency in the pregnant women is not straightforward. Adrenal insufficiency in pregnancy is associated with substantial mortality and morbidity, if not treated and/or diagnosed early in the course of gestation. [2],[3] Fetal growth restriction, oligohydramnios, and fetal distress have all been linked to inadequately treated maternal Addison's disease. [4],[5]

Cortisol secretion and metabolism are decreased in patients with both primary and secondary hypothyroidism. [6] The magnitude of the changes in secretion and metabolism is, however, similar to that of serum cortisol concentrations, but urinary cortisol excretion is normal. [7] Thyroid hormone stimulates the activity of hepatic Δ4 5-steroid reductases, and it decreases the reductase activity of hepatic 11 hydroxysteroid dehydrogenase (11 HSD) type 1, thereby decreasing conversion of cortisone, which is biologically inactive, to cortisol. [8],[9],[10] The activity of 11 HSD type 1 reductase activity is increased in overtly hypothyroid patients causing increased cortisone conversion to cortisol with a consequent decrease in the ratio of tetrahydrocortisone to tetrahydrocortisol in urine. [11] Theoretically, occurrence of hypothyroidism in a case adrenal insufficiency may mask its severity. We report this young lady with clinically overt Addison's disease who carried this pregnancy till 8th month after seven recurrent abortions. She had supervening hypothyroidism this time, which is likely reason for alteration of cortisol metabolism. We could not find any such presentation in the published literature, to the best of our knowledge.

She was a 29-year-old female who presented in the 8th month of pregnancy with history of generalized weakness, easy fatigability, lethargy, asthenia, and progressive discoloration of the skin. Patient had history of seven recurrent first-trimester abortions in the past. Patient noticed progressive dark brown tanning of the skin for the past 9 years. On examination, patient had pallor, puffiness of face, hyperpigmentation over face, knuckles, tongue, and buccal mucosa [Figure 1]. Vitals revealed pulse of 100 beats/minute and blood pressure was 100/60 mm Hg supine and 80/50 mm Hg standing. Patient was clinically hypothyroid with Zulewski score of 8. She had no thyromegaly. She had 32 weeks gravid uterus with cephalic presentation and fetal heart rate of 135 beats/minute. Rest of the general and systemic examination was unremarkable. There were no clinical pointers to any overt cause for bad obstetric history except features of Addison's disease. Investigative workup revealed normal hemogram, kidney function, liver functions, serum calcium, lipid profile, LDH, CPK, and electrolytes. Thyroid function test revealed free T4 of 1.26 ng/dl (normal range 0.7-2.5 ng/dl) and thyroid-stimulating hormone (TSH) of 12.48 mIU/L (normal range 0.4-4.2 mIU/L). Anti-TPO antibodies levels were 600 IU/ml (normal range < 34 IU/ml). Basal cortical level done at 8 AM was 3.78 μg/dl (normal range > 15 μg/dl). Antiphospholipid antibodies were negative. TORCH (toxoplasmosis, rubella, cytomegalovirus virus, herpes virus) screen was also negative.
Figure 1: (a) Clinical photomicrograph showing hyperpigmentation of the face. (b) Clinical photomicrograph showing hyperpigmentation of tongue. (c) Profile photomicrograph showing abdominal protuberance due to gravid uterus. (d) Clinical photomicrograph showing hyperpigmentation and dry rough skin of the hands

Click here to view


Patient was started on oral steroids initially and levothyroxine was added later on once patient became eucortisolemic and repeat TSH was 0.48 mIU/L. Patient was maintained on the same treatment till the time of delivery, when patient was put on IV steroids. Patient delivered by normal vaginal delivery and postpartum period was uneventful though on levothyroxine 100 μg/day and prednisolone 5-7.5 mg/day. Six weeks after delivery, steroids were stopped for 24 hours and 8 AM cortisol was repeated, which was 6.4 μg/dl. Adrenocorticotropic hormone stimulation test showed inadequate response to 250 μg IV subcutaneous dose (maximum response 12.3 μg/dl). Luteinizing hormone, follicle-stimulating hormone, and prolactin levels were normal. Patient was again started on steroids and levothyroxine was continued.

Adrenal glands in pregnancy undergo hypertrophy to meet the extra stress of pregnancy which is important for the continuation of pregnancy. [12],[13] Early diagnosis of any adrenal insufficiency and prompt steroid treatment is important for uneventful fetal and maternal outcome. [14] Early morning plasma cortisol levels of 3.0 μg/dl confirm adrenal insufficiency while a cortisol > 19 μg/dl in the first or early second trimester excludes the diagnosis in a clinically stable patient. [15],[16] Our patient was clinically and biochemically in hypoadrenal state and history was suggestive of a long duration illness. Since common causes of recurrent abortions were ruled out in our patient, the possible cause of recurrent abortions was adrenal insufficiency. The reason for successful pregnancy till 8th month was not clear. One possibility is that the patient was able to carry this pregnancy to near term due to the presence of concomitant hypothyroidism. As already described, serum cortisol concentration in a normal eucortisolemic person does not change with the development of hypothyroidism. [7] However, the effect of hypothyroidism on serum cortisol concentration in a patient with adrenal insufficiency is not known. Thyroxine treatment in a patient with underlying adrenal insufficiency may precipitate adrenal crisis as does a major stress in the form of surgery, sepsis, or pregnancy. [17] Cortisol in physiological doses itself exerts an inhibitory effect on serum TSH levels. [18],[19] Also in supraphysiological doses, it inhibits peripheral conversion of T 4 to T 3 . [20] Glucocorticoid treatment in our patient did not result in normalization of TSH. Patient was therefore started on thyroxine replacement. The other explanation to this success could be enough fetal cortisol production because it may be adequate enough to protect mother from severe adrenal insufficiency until postpartum. [21]

This mechanism was, however, unlikely in our patient, because patient was in hypoadrenal state and previously all the pregnancies were first-trimester abortions.

In conclusion, this patient was documented to have adrenal insufficiency and hypothyroidism both at presentation and after delivery. Despite having recurrent abortions in the past, patient was able to carry this pregnancy to near term. The possible reasons could be (1) a concomitant hypothyroid state, (2) enough fetal cortisol production, or (3) both. We report this patient because of unusual clinical presentation as there is no such presentation reported in the literature till date.

 
   References Top

1.Trainer PJ. Corticosteroids and pregnancy. Semin Reprod Med 2002;20:375-80.  Back to cited text no. 1
    
2.Ambrosi B, Barbetta L, Morricone L. Diagnosis and management of Addison's disease during pregnancy. J Endocrinol Invest 2003;26:698-702.  Back to cited text no. 2
    
3.Minneci PC, Deans KJ, Banks SM, Eichacker PQ, Natanson C. Meta-analysis: the effect of steroids on survival and shock during sepsis depends on the dose. Ann Intern Med 2004;141:47-56.  Back to cited text no. 3
    
4.O'Shaughnessy RW, Hackett KJ. Maternal Addison's disease and fetal growth retardation. A case report. J Reprod Med 1984;29:752-6.  Back to cited text no. 4
    
5.Osler M. Addison's disease and pregnancy. Acta Endocrinol (Copenh) 1962;41:67-78.  Back to cited text no. 5
    
6.Gordon GG, Southern AL. Thyroid-hormone effects on steroid hormone metabolism. Bull N Y Acad Med 1977;53:241-59.  Back to cited text no. 6
    
7.Iranmanesh A, Lizarralde G, Johnson ML, Veldhuis JD. Dynamics of 24-hour endogenous cortisol secretion and clearance in primary hypothyroidism assessed before and after partial thyroid hormone replacement. J Clin Endocrinol Metab 1990;70:155.  Back to cited text no. 7
    
8.Tomlinson JW, Walker EA, Bujalska IJ, Draper N, Lavery GG, Cooper MS, et al. Hydroxysteroid Dehydrogenase Type 1: A Tissue-Specific Regulator of Glucocorticoid Response. Endocr Rev 2004;25:831-66.  Back to cited text no. 8
    
9.Whorwood CB, Sheppard MC, Stewar PM. Tissue specific effects of thyroid hormone on 11β-hydroxysteroid dehydrogenase gene expression. J Steroid Biochem Mol Biol 1993;46:539-47.  Back to cited text no. 9
    
10.Inagaki K, Otsuka F, Otani H, Sato C, Miyoshi T, Ogura T, et al. Apparent Mineralocorticoid Excess Manifested in An Elderly Patient with Hypothyroidism. Am J Hypertens 2007;20:104-7.  Back to cited text no. 10
    
11.Ichikawa Y, Yoshida K, Kawagoe M, Saito E, Abe Y, Arikawa K, et al. Altered equilibrium between cortisol and cortisone in plasma in thyroid dysfunction and inflammatory diseases. Metabolism 1977;26:989.  Back to cited text no. 11
    
12.Mastorakos G, Ilias I. Maternal hypothalamic-pituitary-adrenal axis in pregnancy and the postpartum period. Postpartum-related disorders. Ann N Y Acad Sci 2000;900:95-106.  Back to cited text no. 12
    
13.Campbell S, Bain C, Dewhurst CJ, Fotherby K. The 30-minute Synacthen test in pregnancy and labour. J Obstet Gynaecol Br Commonw 1970;77:620-4.  Back to cited text no. 13
    
14.Lindsay JR, Nieman LK. The hypothalamic-pituitary-adrenal axis in pregnancy: Challenges in disease detection and treatment. Endocr Rev 2005;26:775-99.  Back to cited text no. 14
    
15.McKenna DS, Wittber GM, Nagaraja HN, Samuels P. The effects of repeat doses of antenatal corticosteroids on maternal adrenal function. Am J Obstet Gynecol 2000;183:669.  Back to cited text no. 15
    
16.Grinspoon SK, Biller BM. Clinical review 62: Laboratory assessment of adrenal insufficiency. J Clin Endocrinol Metab 1994;79:923.  Back to cited text no. 16
    
17.Means JH, Hertz S, Lerman J. The pituitary type of myxedema or Simmonds' disease masquerading as myxedema. Trans Assoc Am Physicians 1940;55:32.  Back to cited text no. 17
    
18.Topliss DJ, White EL, Stockigt JR. Significance of thyrotropin excess in untreated primary adrenal insufficiency. J Clin Endocrinol Metab 1980;50:52-6.  Back to cited text no. 18
    
19.Barnett AH, Donald RA, Espiner EA. High concentrations of thyroid stimulating hormone in untreated glucocorticoid deficiency: Indication of primary hypothyroidism? Br Med J (Clin Res Ed) 1982;285:172-3.  Back to cited text no. 19
    
20.Chopra IJ, Williams DE, Orgiazzi J, Solomon DH. Opposite effects of dexamethasone on serum concentrations of 3,3¢,5¢- triiodothyronine (reverse T3) and 3,5,3¢-triiodothyronine (T3). J Clin Endocrinol Metab 1975;41:911.  Back to cited text no. 20
    
21.Drucker D, Shumak S, Angel A. Schmidt's syndrome presenting with intrauterine growth retardation and postpartum Addisonian crisis. Am J Obstet Gynecol 1984;149:229.  Back to cited text no. 21
    


    Figures

  [Figure 1]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    References
    Article Figures

 Article Access Statistics
    Viewed1237    
    Printed24    
    Emailed0    
    PDF Downloaded130    
    Comments [Add]    

Recommend this journal