Endocrine Abstracts

Here we report the case of a woman with first presentation of Addison disease in pregnancy that went undiagnosed until postpartum period. She gave birth to a healthy child by vaginal delivery at 40 weeks of pregnancy. Our patient is a 31 years pregnant woman with unremarkable medical or familial history. At 8 weeks of pregnancy she was complaining of nausea, vomiting, loss of appetite and fatigue, leading to hospitalization. The physical examination revealed a blood pressure of 80/50 mmHg, a check-up that included blood and urine analyses did not reveal any abnormalities. She received treatment with saline and glucose perfusion, vitamin B and was discharged after one week, with persistent symptoms attributed to hyperemesis gravidarum. At 16 weeks of gestation the patient noticed a bronze appearance of the skin. Her condition was deteriorating, with accentuation of fatigue and 9 kg weight loss, leading to another 2 hospitalizations due to presumed hyperemesis gravidarum. Neverthless at 40 weeks of gestation she gave birth to a healthy child by vaginal delivery. 2 months later she was hospitalized in the endocrinology department due to extreme fatigue and persistent gastrointestinal symptoms. At admission the patient’s blood pressure was 85/55 mmHg, pulse – 88 beats/minute and respiratory rate – 20 breaths/minute. She had tanned skin and hyperpigmented spots on gums, tongue and mucosa of cheeks. Laboratory data showed: ACTH 1006 (0–46 pmol/l), cortisol 2.41 (69–690 nmol/l). A diagnosis of primary adrenal insufficiency was established and intravenous hydrocortisone hemisuccinate was initiated. Thereafter, the patient was transferred to oral cortisone, and discharged on the 5th day. Currently the patient is in good condition, taking tablets of Cortisone 25 mg at 0800 h and 12.5 mg at 1200 h, and is breastfeeding.

Discussion: Addison disease (AD) is a rare condition, usually due to autoimmune destruction of the adrenal cortex. Addison disease complicating pregnancy is even rarer, about 100 pregnancies being reported worldwide. Untreated Addison disease during pregnancy leads to increased maternal mortality and fetal growth retardation. Nausea and vomiting due to adrenal insufficiency may be confused with typical symptoms of pregnancy. Generalized hyperpigmentation – a hallmark of Addison disease may be seen in normal pregnancy, but dark spots on lips and mouth mucosa should prompt adrenal insufficiency evaluation.

Conclusion: First diagnosis of Addison disease during pregnancy may be challenging due to misleading symptoms attributed to normal pregnancy. Differential diagnosis of severe and prolonged hyperemesis gravidarum should include adrenal insufficiency.