[CG] Avoidance of adrenal crisis in pregnant women at risk

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Glucocorticoid dependent obstetric patients are not encountered commonly, however appropriate care is crucial to avoid potentially life threatening acute adrenal crisis. In order to avoid a precipitous fall in BP during anaesthesia or in the immediate postoperative period, anaesthetists must know whether a patient is taking or has been taking glucocorticoids. 

Signs of acute adrenal crisis include severe dehydration, pale clammy skin, sweating, rapid and shallow breathing, hypotension, dizziness, vomiting and diarrhoea and severe drowsiness or loss of consciousness.

Women at risk [1]

  1. All women requiring long term glucocorticoid replacement (for example as a result of pituitary disease or congenital adrenal hyperplasia, or women with Addison’s disease). These women will usually be receiving the equivalent of 20-25mg hydrocortisone per day and are likely to be dependent on this replacement.1
  2. Women receiving exogenous glucocorticoid may now be dependent on this and develop adrenal crisis if they are stopped suddenly. This group of women includes:
    1. Patients taking the equivalent of 5mg prednisolone per day for more than FOUR See Appendix 1 for more detail.2
    2. Patients on more than the equivalent of 40mg prednisolone per day for more than 7 days2
    3. Patients on long term high dose inhaled steroids. See Appendix 2 for more detail.2
    4. High doses of topical steroids (e.g. ≥200g per week of potent or very potent steroids). See Appendix 3 for more detail. 2

Mineralocorticoids

Note that women with adrenal disease (e.g. Addisons disease or previous bilateral adrenalectomy) may also be receiving mineralocorticoid replacement, usually in the form of fludrocortisone. This also needs to be considered and likely continued.

Factors which can precipitate Adrenal Crisis

  • Infection.
  • Major surgery (e.g. caesarean section).
  • Malabsorption of oral steroids (e.g. due to vomiting).
  • Major stress (e.g. labour).
  • Discontinuation of glucocorticoids (hydrocortisone, prednisolone, dexamethasone).

Peripartum Steroid Management [4]

Caesarean Section

On day of surgery

  • Normal morning dose of steroid.
  • 100 mg hydrocortisone IV just before anaesthesia. Then:
  • Double oral glucocorticoid dose for 48 hours.

Unless the patient is not tolerating oral intake, or is vomiting or unwell, in which case:

  • 50 mg hydrocortisone IM 6 hours until eating and drinking normally.
  • Once well, return to oral dose as above. After 48 hours:
  • If well, return to patient’s normal dose.

Induction of Labour

  • Continue normal dose of steroid until labour diagnosed.

Labour

When labour is diagnosed:

  • 100 mg hydrocortisone IV at onset of labour.

Then:

  • Commence infusion of hydrocortisone at 200mg IV over 24hr

OR

  • 50mg hydrocortisone every 6hrs IM.

Then:

  • Double oral glucocorticoid dose for 48 hours postpartum.
  • Unless the patient is not tolerating oral intake, or is vomiting or unwell, in which case use the IM route as above.

After 48 hours:

  • If well, return to patient’s normal dose.

Special Points

All women at risk of adrenal crisis should consider carrying a Steroid Emergency Card to alert healthcare professionals.

Women who are deficient in glucocorticoids are also at risk of hypoglycaemia. 

  • Check capillary blood glucose and a formal laboratory glucose when first assessed and if the patient develops any symptoms of hypoglycaemia. 

If patient becomes hypotensive, drowsy or peripherally shut down, give 100mg hydrocortisone IM or

IV immediately. (Intravenous doses should be administered over 10 minutes.) 

IM hydrocortisone is preferable to IV since it has a more sustained release. 

Use hydrocortisone sodium phosphate or hydrocortisone sodium succinate, not hydrocortisone acetate. 

If the patient is unwell postpartum (e.g. vomiting or fever), delay return to normal dose beyond the 48 hour period stated above. If the patient is nil by mouth, ensure adequate intravenous fluid replacement (e.g. 0.9% sodium chloride or Hartmann’s solution). 

Monitor electrolytes and BP post-partum: 

  • BP every 4 hours.
  • U&Es daily for 2-3 days.

Appendix 1 Long-term oral glucocorticoids (ie 4 weeks or longer)

Long-term oral glucocorticoids (ie 4 weeks or longer) – Taken from Society of Endocrinology, Exogenous steroids treatment in adults2

Medicine Dose (*) 
Beclometasone  625 microgram per day or more 
Betamethasone 750 microgram per day or more 
Budesonide 1.5mg per day or more (***) 
Deflazacort  6mg per day or more 
Dexamethasone  500 microgram per day or more (**)4
Hydrocortisone  15mg per day or more (**)
Methylprednisolone 4mg per day or more 
Prednisone 5mg per day or more 
Prednisolone 5mg per day or more  

(*) dose equivalent from BNF except (**) where dose reflects that described in the guideline by Simpson et al (2020)4 and (***) based on best estimate

Appendix 2 Inhaled glucocorticoid doses

Inhaled glucocorticoid doses - Taken from Society of Endocrinology, Exogenous steroids treatment in adults2

Medicine

Dose (*)5 

Beclometasone          

(as non-proprietary, Clenil, Easihaler, or Soprobec)

More than 1000 microgram per day 

Beclometasone         

(as Qvar, Kelhale or Fostair )       

More than 500 microgram per day

(check if using combination inhaler and MART regimen) 

Budesonide      

More than 1000 microgram per day 

(check if using combination inhaler and MART regimen) 

Ciclesonide                          

More than 480 microgram per day 

Fluticasone propionate  

More than 500 microgram per day 

Fluticasone furoate          

(as Trelegy and Relvar)

More than 200 microgram per day 

Mometasone                     

More than 800 microgram per day 

(*) dose equivalent - NICE Inhaled corticosteroid doses for NICE’s asthma guideline (2018)

Appendix 3 Topical glucocorticoids

Topical glucocorticoids. 2

Topical steroid treatments

Potency of steroid 

Beclometasone dipropionate 0.025%

Potent 

Betamethasone dipropionate 0.05% and higher

Potent 

Betamethasone valerate 0.1% and higher

Potent 

Clobetasol propionate 0.05% and higher

Very potent 

Diflucortolone valerate 0.1%

Potent 

Diflucortolone valerate 0.3%

Very Potent 

Fluocinonide 0.05%

Potent 

Fluocinolone acetonide 0.025%

Potent 

Fluticasone propionate 0.05%

 Potent 

Hydrocortisone butyrate 0.1%

Potent 

Mometasone 0.1%

Potent

Triamcinolone acetonide 0.1%

Potent

All other topical glucocorticoids available in the UK are either mild or moderate potency.

References
  1. Wass JAH, Arlt W. How to Avoid precipitating an acute adrenal crisis. BMJ. 2012; 345: e6333
  2. Erskine D, Simpson H. Exogenous Steroids Treatment in Adults. Adrenal Insufficiency and Adrenal Crisis – Who is at risk and how should they be managed safely. Society for Endocrinology and the British Association of Dermatologists.
  3. Woodcock et al. Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency. Anaesthesia. 2020; 75: 654-663.
  4. Simpson H, Tomlinson J, Wass J, Bean J, Arlt W. Guidance for the prevention and emergency management of adult patients with adrenal insufficiency. Clinical Medicine (London). 2020; 20 (4): 371-378.
  5. Inhaled corticosteroid doses for NICE’s asthma Guideline. July 2018.

Last reviewed: 22 April 2022

Next review: 01 April 2027

Author(s): Dr Andrew Thomson, Consultant Obstetrician & Gynaecologist, RAH; Dr Victoria Watson, ST6 Obstetrics & Gynaecology; Dr Robbie Lindsay, Reader in Diabetes & Endocrinology, University of Glasgow

Version: 2

Approved By: Obstetrics Clinical Governance Group

Document Id: 520