Diagnosing and managing adrenal crisis in pregnancy: A case report

BACKGROUND: The diagnosis of adrenal insufficiency in pregnancy is relatively rare. Further, making this diagnosis can be challenging as many of the symptoms overlap with normal symptoms of pregnancy. Given the potential for severe maternal and fetal morbidity and mortality, early recognition and prompt comprehensive treatment are critical. CASE: A 24-year-old woman, G3 P2002, at 17 + 1 weeks of gestation with unremarkable prenatal course was admitted to hospital for hyperemesis gravidarum in the setting of parainfluenza with a notable blood glucose of 20 mg/dL. On hospital day two, she was transferred to intensive care after developing significant hypotension, hyponatremia, and a new finding of hypothyroidism. During her evaluation in the ICU, she was diagnosed with adrenal crisis and she showed significant improvement with glucocorticoid therapy. CONCLUSIONS: There is a paucity of literature regarding diagnosing adrenal insufficiency in pregnancy. Adrenal crisis in pregnancy can present with symptoms similar to severe nausea and vomiting of pregnancy or hyperemesis gravidarum. Additionally, several critical laboratory tests to support the proper diagnosis require time that acute patients cannot always afford. In this patient's case, the diagnosis was made empirically with improvement after glucocorticoid administration, and was later confirmed by laboratory testing. This case highlights the importance of including adrenal insufficiency in the differential diagnosis of hyperemesis patients in order to quickly manage and treat these often acutely and severely ill patients.