title: Update on adrenal insufficiency: diagnosis and management in pregnancy.
abstract: OBJECTIVE
  Adrenal insufficiency in pregnancy, although relatively rare, has significant clinical implications on both maternal and fetal outcomes. Hypothalamo-pituitary-adrenal axis dynamics and physiological changes are complex, thus diagnosis and management of adrenal insufficiency in pregnancy remain challenging.
  
  
  RESULTS
  Studies consistently demonstrate a rise in total serum cortisol with pregnancy, but less data are available on free cortisol levels. Salivary cortisol values have been measured in normal pregnancy and in a few studies using healthy nonpregnant women controls. Although this adds to our current knowledge of hypothalamo-pituitary-adrenal axis changes in pregnancy, clear-cut cortisol reference ranges are yet to be established. Serum cortisol and the cosyntropin stimulation test (albeit with higher peak cortisol thresholds) are currently the diagnostic tests of choice. Hydrocortisone is the preferred glucocorticoid replacement in pregnancy as it is inactivated by placental 11-β-hydroxysteroid dehydrogenase 2; dose titration may be required, but should be individualized depending on clinical course and mode of delivery.
  
  
  CONCLUSIONS
  Further studies on the long-term effects of maternal glucocorticoid regimens on the fetus and potential modulators of fetal glucocorticoid sensitivity and placental 11-β-hydroxysteroid dehydrogenase 2 are needed and will be useful in guiding clinical management strategies in pregnant women with adrenal insufficiency.
authors.affiliation: aDivision of Endocrinology, Diabetes and Metabolism, Department of Medicine bDepartment of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA.
authors.forename: Fabienne
authors.initials: F
authors.lastname: Langlois
authors.forename: Dawn S T
authors.initials: DST
authors.lastname: Lim
authors.forename: Maria
authors.initials: M
authors.lastname: Fleseriu
mesh_terms: D000309:Adrenal Insufficiency / Q000097:blood / Q000175:diagnosis* / Q000628:therapy*; D000324:Adrenocorticotropic Hormone / Q000097:blood; D003366:Cosyntropin / Q000008:administration & dosage; D003940:Diagnostic Techniques, Endocrine; D005260:Female; D005938:Glucocorticoids / Q000627:therapeutic use; D020249:Hormone Replacement Therapy; D006801:Humans; D006854:Hydrocortisone / Q000097:blood / Q000627:therapeutic use; D011247:Pregnancy; D011248:Pregnancy Complications / Q000097:blood / Q000175:diagnosis* / Q000628:therapy*
chemical_list: D005938:Glucocorticoids; D003366:Cosyntropin; D000324:Adrenocorticotropic Hormone; D006854:Hydrocortisone