Adrenalectomy for adrenocortical adenoma causing Cushing's syndrome in pregnancy: a case report and review of literature

Cushing's Syndrome in Pregnancy Secondary to Adrenocortical Adenoma: A Case Series and Review

PURPOSE

To present a case series of Cushing's syndrome (CS) during pregnancy caused by adrenocortical adenomas, highlighting clinical features, hormonal assessments and outcomes.

METHODS

We describe five pregnant women with CS, detailing clinical presentations and laboratory findings.

RESULTS

Common clinical features included a full moon face, buffalo back and severe hypertension. Elevated blood cortisol levels with circadian rhythm disruption and suppressed adrenocorticotrophic hormone (ACTH) levels were observed. Imaging revealed unilateral adrenal tumours. Two cases underwent laparoscopic adrenalectomies during the second trimester, while three had postpartum surgery. All required hormone replacement therapy, with postoperative pathological confirmation of adrenocortical adenomas.

CONCLUSION

Diagnosis of CS during pregnancy is challenging due to overlapping features with normal pregnancy: elevated blood cortisol levels and abnormal diurnal rhythm of blood cortisol, suppressed aid diagnosis. Treatment should be individualised due to a lack of explicit optimum therapeutic approaches. Laparoscopic adrenalectomy may be an optimal choice, along with multidisciplinary management including hormone replacement therapy.

Cushing's syndrome in pregnancy in which laparoscopic adrenalectomy was safely performed by a retroperitoneal approach

Introduction

Laparoscopic adrenalectomy is the standard treatment for adrenal tumors caused by Cushing's syndrome. However, few pregnant women have undergone adrenalectomy because of the risk of general anesthesia and surgery.

Case presentation

A 28-year-old woman presented with gradually worsening Cushing's signs at around 12 weeks of pregnancy. Magnetic resonance imaging displayed a 38-mm left adrenal tumor, which was the cause of the adrenal Cushing's syndrome. Metyrapone was started, which increased androgen levels. Since the management of Cushing's syndrome by medication alone is challenging, unilateral laparoscopic adrenalectomy by a retroperitoneal approach was performed at 23 weeks of the pregnancy. No perioperative complications were noted.

Conclusion

Adrenalectomy is considered safe in pregnant women with Cushing's syndrome. Laparoscopic adrenalectomy by retroperitoneal approach should be chosen and performed between 14 and 30 weeks of pregnancy to prevent mother and fetal complications.

Surgical treatment of adrenal tumors during pregnancy

While most adrenal tumors are identified incidentally and are non-functional, hormone-secreting tumors can cause morbidity and mortality. Hemodynamic lability and hypertension in pregnancy are associated with worse maternal and fetal outcomes. Achieving a diagnosis of hormone excess due to adrenal tumors can be clinically more difficult in the gravid patient due to normal physiologic alterations in hormones and symptoms related to pregnancy. This review focuses on some nuances of the diagnostic work-up, perioperative care, and surgical management of adrenally-mediated cortisol excess, primary aldosteronism, and pheochromocytoma and paraganglioma in the pregnant patient.

The diagnosis and management of Cushing's syndrome in pregnancy

Endogenous Cushing's syndrome (CS) is rarely encountered during pregnancy. Clinical and biochemical changes in healthy pregnancy overlap with those seen in pregnancy complicated by CS; the diagnosis is therefore challenging and can be delayed. During normal gestation, adrenocorticotrophic hormone, corticotrophin-releasing hormone, cortisol, and urinary free cortisol levels rise. Dexamethasone administration fails to fully suppress cortisol in pregnant women without CS. Localisation may be hindered by non-suppressed adrenocorticotrophic hormone levels in a large proportion of those with adrenal CS; smaller corticotroph adenomas may go undetected as a result of a lack of contrast administration or the presence of pituitary hyperplasia; and inferior petrosal sinus sampling is not recommended given the risk of radiation and thrombosis. Yet, diagnosis is essential; active disease is associated with multiple insults to both maternal and foetal health, and those cured may normalise the risk of maternal-foetal complications. The published literature consists mostly of case reports or small case series affected by publication bias, heterogeneous definitions of maternal or foetal outcomes or lack of detail on severity of hypercortisolism. Consequently, conclusive recommendations, or a standardised management approach for all, cannot be made. Management is highly individualised: the decision for surgery, medical control of hypercortisolism or adoption of a conservative approach is dependent on the timing of diagnosis (respective to stage of gestation), the ability to localise the tumour, severity of CS, pre-existing maternal comorbidity, and, ultimately, patient choice. Close communication is a necessity with the patient placed at the centre of all decisions, with risks, benefits, and uncertainties around any investigation and management carefully discussed. Care should be delivered by an experienced, multidisciplinary team, with the resources and expertise available to manage such a rare and challenging condition during pregnancy.

The effect of Cushing's syndrome on pregnancy complication rates: analysis of more than 9 million deliveries

PURPOSE

The purpose of this study to evaluate the risk of Cushing's syndrome (CS) and maternal and fetal complications using the American Nationwide Inpatient Sample database.

MATERIALS AND METHODS

This is a retrospective study using the Health Care Cost and Utilization Project-Nationwide Inpatient Sample database from 2004 to 2014. We compared pregnancies with CS versus non-CS regarding pregnancy, delivery, and neonatal outcomes using multivariate logistic regression.

RESULTS

We identified 9,096,788 pregnancies during the study period. Cushing's syndrome complicated 135 pregnancies at a rate of 1-2 cases per 100,000 births. Cushing's syndrome subjects were more likely to be older, obese, have private insurance, chronic hypertension, and pre-gestational diabetes (p<.001). The maternal mortality rate was 0.7 and 0.007% in Cushing's syndrome and control groups, respectively, although due to small numbers of cases, this should be interpreted with caution. Preeclampsia was higher in CS compared to controls after controlling for confounding variables, aOR 2.20. Operative vaginal delivery and blood transfusion rates were higher in CS patients than controls after controlling for confounding factors, aOR 6.49 and 3.09, respectively. The rates of preterm delivery (8.9 versus 7.2%) and gestational diabetes (8.1 versus 5.8%) were not statistically different between CS and control groups.

CONCLUSION

Cushing's syndrome patients begin pregnancies often with maladies making them more at risk for complications including, preeclampsia, blood transfusion, and operative vaginal delivery. These patients might benefit from prevention methods for preeclampsia, and increased surveillance to decrease maternal morbidity and mortality. However, the nature of the database and its limitations, including the lack of information about CS activity and treatments received by patients, warrant careful interpretation of these results.

Cushing syndrome in pregnancy, diagnosed after delivery

Cushing syndrome (CS) is rare in pregnancy, and few cases have been reported to date. Women with untreated CS rarely become pregnant because of the ovulatory dysfunction induced by hypercortisolism. It is difficult to diagnose CS in pregnancy because of its very low incidence, the overlap between the clinical signs of hypercortisolism and the physiological changes that occur during pregnancy and the changes in hypothalamus-pituitary-adrenal axis activity that occur during pregnancy and limit the value of standard diagnostic testing. However, CS in pregnancy is associated with poor maternal and fetal outcomes; therefore, its early diagnosis and treatment are important. Here, we report two patients with CS that was not diagnosed during pregnancy, in whom maternal and fetal morbidity developed because of hypercortisolism.

Surgical indications for pituitary tumors during pregnancy: a literature review

PURPOSE

Surgical indications for pituitary tumors during pregnancy are rare, and are derived from a balance between expected benefits, particularly for maternal benefits, and anesthetic/surgical risks.

METHODS

A literature review was performed to define the optimal surgical indications for pituitary adenomas (PA) and other pituitary tumors during pregnancy.

RESULTS

Main benefits are expected in case of critical visual impairment and/or life-threatening endocrine disturbances. Multidisciplinary patient management is systematically required although nonobstetric surgery presents a reasonable risk during pregnancy. The risks of congenital malformation during the first trimester and those of premature birth during the third trimester make the second trimester the optimal period for surgery. In prolactin-secreting, nonsecreting, GH- and TSH-secreting PAs, transsphenoidal surgery (TS) is recommended in cases involving severe visual impairment, characterized by severe visual field deficit, visual acuity impairment, and abnormal optical coherence tomography findings, and when no other medical alternatives are possible and/or sufficient. Uncontrolled and severe Cushing's disease (CD) during pregnancy increases both maternal and fetal morbimortality, thus justifying TS or sometimes dopamine agonist therapy as a safer alternative. Finally, metyrapone, ketoconazole, or bilateral adrenalectomy could be recommended in certain cases after the failure of medical therapies and/or TS. Surgery is also required for suprasellar meningiomas, craniopharyngiomas, and pituitary cysts in the case of severe visual deficit.

CONCLUSION

Surgical indications for pituitary tumors are rare during pregnancy; therefore, surgery should be avoided when possible. Further, the second trimester should be considered as the optimal surgical period. Severe visual disturbance and uncontrolled CD are the main surgical indications during pregnancy.

Endocrine causes of hypertension in pregnancy

Hypertension is a common and morbid complication of pregnancy. While endocrine causes of secondary hypertension are not rare, women with these conditions do not often conceive, and even less commonly are these disorders diagnosed during pregnancy. This review will consider conditions of adrenal hormone excess that cause secondary hypertension: primary aldosteronism (PA), Cushing syndrome (CS), and pheochromocytoma/paraganglioma. We emphasize that pregnancy itself elicits changes in the regulation of aldosterone and cortisol production and standard endocrine testing algorithms. Furthermore, conventional imaging modalities and pharmacotherapies are often contraindicated in pregnancy, which complicates diagnosis and management. Nevertheless, surgical management in the second trimester is the preferred treatment strategy for most of these rare cases when feasible. This article will discuss the approach to patients with endocrine causes of hypertension during pregnancy with emphasis on those aspects that deviate from the assessment and treatment of non-pregnant patients.

Approach to Cushing's syndrome in pregnancy: two cases of Cushing's syndrome in pregnancy and a review of the literature

Cushing's syndrome (CS) rarely occurs during pregnancy. The primary aim of this article is to propose a therapeutic approach to CS in pregnancy. Here, we present two cases of CS in pregnancy and a literature review. This article proposes the early diagnostic points, especially the clinical approach to this medical condition, mainly for pregnant women without a previous diagnosis of CS. More importantly, we present therapeutic strategies for CS during pregnancy, especially glucocorticoid replacement for perioperative, postoperative, and perinatal periods in pregnant women with CS in order to minimize complications for both mother and fetus. At the same time, we also assess the anxiety status of patients. This article summarizes the approach to CS in pregnancy, not only with a physiological assessment but with a psychological assessment as well.

Adrenal disorders in pregnancy, labour and postpartum - an overview

Adrenal disorders may manifest during pregnancy for the first time, or present from before pregnancy as either undiagnosed or diagnosed and treated. They may present as hormonal hypofunction or hyperfunction, or with mass effects or other non-endocrine effects. Adrenal disorders such as Cushing's syndrome, Addison's disease, pheochromocytoma, primary hyper-aldosteronism and adreno-cortical carcinoma are rare in pregnancy. Pregnancy presents special problems in the evaluation of the hypothalamic-pituitary-adrenal and renin-angiotensin-aldosterone axis as these undergoe major changes during pregnancy. Diagnosis is challenging as symptoms associated with pregnancy are also seen in adrenal diseases. A timely diagnosis and treatment is critical as these disorders can cause maternal and foetal morbidity and mortality. A high index of suspicion must be maintained as they can go unrecognised and untreated. An early diagnosis and treatment often improves outcomes. The aim of this article is to review the patho-physiology, clinical manifestation, diagnosis and management of various adrenal disorders during pregnancy.

Cushing disease: highlighting the importance of early diagnosis for both de novo and recurrent disease in light of evolving treatment patterns

OBJECTIVE

To highlight and summarize current literature on Cushing disease (CD)-related morbidity and mortality, focusing on residual complications after "cure" and the changing role of pharmacologic therapy in CD.

METHODS

Current journal articles on the consequences of untreated or undertreated CD, CD recurrence, and recent trends in CD treatment were collected from PubMed searches and analyzed in combination in view of the authors' clinical experience.

RESULTS

Timely recognition and treatment of de novo and recurrent CD remains a singular clinical challenge. Chronic excess cortisol exposure leads to potentially irreversible sequelae and death, stressing the importance of early diagnosis and treatment. Disease relapse after primary pituitary adenomectomy is prevalent and recurrence may manifest decades after initial surgery. Increased risk for mortality and hypercortisolism-related complications in postsurgical CD patients may indicate persistent subclinical disease and further underscores the need for cautious, ongoing observation and testing. Potential long-term pharmacologic treatment options (e.g., pasireotide, mifepristone) have recently emerged that may provide biochemical and symptomatic remission for those with refractory CD, or those for whom surgery is contraindicated.

CONCLUSION

Delays in CD diagnosis, management, and follow-up are common and lead to increased adverse metabolic complications and mortality. Rapid recognition and treatment as well as vigilant monitoring are therefore essential. After surgical treatment, some patients may suffer from persistent subclinical CD that remains difficult to detect with routine testing. Although long-term pharmacologic treatment has historically been limited by adverse reactions or escape from response, new treatments may offer more options for patients with refractory disease.

A successful pregnancy in a patient with secondary hypertension caused by adrenal adenoma: a case report

Background

Secondary hypertension is a rare complication in pregnancy that causes poor outcomes, such as preeclampsia, premature delivery, intrauterine growth retardation, stillbirths, spontaneous abortion or intrauterine death. Cushing’s disease caused by an adrenal adenoma is rare during pregnancy and may be overlooked by obstetricians and physicians, but can lead to hypertension, diabetes mellitus and an increased risk of fetal and maternal morbidity. Approximately 200 cases have been reported in the literature. Here, we report the successful management of a pregnant patient with Cushing’s syndrome due to an adrenal adenoma.

Case presentation

The 35-year-old Chinese female had no individual or family medical history of hypertension, and did not exhibit chronic kidney disease, diabetes mellitus, autoimmune and common endocrine diseases. Her blood pressure was elevated from the 16th week of gestation and was not controlled by 30 mg nifedipine twice a day. Examination in our department revealed her 24 h urinary free cortisol (24 h UFC) level was 1684.3 μg/24 h (normal range: 20.26–127.55 μg/24 h) and plasma adrenocorticotropic hormone was < 1.00 ng/L in three independent measurements (normal range: 5–78 ng/L). Ultrasonography demonstrated a mass (2.9 cm × 2.8 cm) in the right side of the adrenal gland. Magnetic resonance imaging without contrast showed a 3.2 cm diameter mass in the right-side of the adrenal gland. Other medical tests were normal. Laparoscopic adrenalectomy was performed at the 26th week of gestation by a urological surgeon in the West China Hospital. Histopathology revealed an adrenocortical adenoma. After surgery, the patient accepted glucocorticoid replacement therapy. The remaining trimester continued without complication and her blood pressure was normal at the 32nd week of gestation without antihypertensive therapy. The patient gave birth to a healthy boy at the 40th week of gestation.

Conclusions

Cushing’s syndrome caused by adrenal adenoma is rare during pregnancy. This unique case suggested that analysis of the UFC level and circadian rhythm of plasma cortisol provides a suitable strategy to diagnose Cushing’s syndrome during pregnancy. Laparoscopic surgical resection in the second trimester provides a reasonable approach to treat pregnant patients exhibiting Cushing’s syndrome caused by an adrenal adenoma.

MANAGEMENT OF ENDOCRINE DISEASE: Management of Cushing's syndrome during pregnancy: solved and unsolved questions

With fewer than 200 reported cases, Cushing's syndrome (CS) in pregnancy remains a diagnostic and therapeutic challenge. In normal pregnancies, misleading signs may be observed such as striae or hypokalemia, while plasma cortisol and urinary free cortisol may rise up to 2- to 3-fold. While the dexamethasone suppression test is difficult to use, reference values for salivary cortisol appear valid. Apart from gestational hypertension, differential diagnosis includes pheochromocytoma and primary aldosteronism. The predominant cause is adrenal adenoma (sometimes without decreased ACTH), rather than Cushing's disease. There are considerable imaging pitfalls in Cushing's disease. Aberrant receptors may, in rare cases, lead to increased cortisol production during pregnancy in response to HCG, LHRH, glucagon, vasopressin or after a meal. Adrenocortical carcinoma (ACC) is rare and has poor prognosis. Active CS during pregnancy is associated with a high rate of maternal complications: hypertension or preeclampsia, diabetes, fractures; more rarely, cardiac failure, psychiatric disorders, infection and maternal death. Increased fetal morbidity includes prematurity, intrauterine growth retardation and less prevalently stillbirth, spontaneous abortion, intrauterine death and hypoadrenalism. Therapy is also challenging. Milder cases can be managed conservatively by controlling comorbidities. Pituitary or adrenal surgery should ideally be performed during the second trimester and patients should then be treated for adrenal insufficiency. Experience with anticortisolic drugs is limited. Metyrapone was found to allow control of hypercortisolism, with a risk of worsening hypertension. Cabergoline may be an alternative option. The use of other drugs is not advised because of potential teratogenicity and/or lack of information. Non-hormonal (mechanical) contraception is recommended until sustained biological remission is obtained.

Cushing's syndrome and pregnancy outcomes: a systematic review of published cases

Pregnancy in Cushing's syndrome (CS) is extremely rare due to the influence of hypercortisolism on the reproductive axis. Purpose of this study is to investigate whether the etiology of CS in pregnancy determines a different impact on the fetal/newborn and maternal outcomes. We performed a systematic review of cases published in the literature from January 1952 to April 2015 including the words "Cushing AND pregnancy". We included 168 manuscripts containing 220 patients and 263 pregnancies with active CS during pregnancy and with a history of CS but treated and cured hypercortisolism at the time of gestation. Adrenal adenoma was the main cause of active CS during pregnancy (44.1 %). Women with active CS had more gestational diabetes mellitus (36.9 vs. 2.3 %, p = 0.003), gestational hypertension (40.5 vs. 2.3 %, p < 0.001) and preeclampsia (26.3 vs. 2.3 %, p = 0.001) than those with cured disease. The proportion of fetal loss in active CS was higher than in cured CS (23.6 vs. 8.5 %, p = 0.021), as well as global fetal morbidity (33.3 vs. 4.9 %, p < 0.001). The predictors of fetal loss in active CS were etiology of hypercortisolism [Odds Ratio -OR-for pregnancy-induced CS 4.7 (95 % Confidence Interval-CI 1.16-18.96), p = 0.03], publication period [OR for "1975-1994" 0.10 (95 % CI 0.03-0.40), p = 0.001] and treatment during gestation (p = 0.037, [OR medical treatment 0.25 (95 % CI 0.06-1.02), p = 0.052], [OR surgical treatment 0.34 (95 % CI 0.11-1.06), p = 0.063]). The period of diagnosis of CS (before, during or after pregnancy) was the only predictor of overall fetal morbimortality [OR for diagnosis during pregnancy 4.66 (95 % CI 1.37-15.83), p = 0.014]. Patients with active CS, especially in pregnancy-induced CS, experienced more problems in pregnancy and had the worst fetal prognosis in comparison to other causes. Diagnosis of CS during pregnancy was also associated with worse overall fetal morbimortality. Both medical treatment and surgery during pregnancy appeared to be protective in avoiding fetal loss.

[Arterial hypertension during pregnancy: Always preeclampsia?]

Cushing's syndrome is a rare condition during pregnancy, but it is associated with serious maternal and fetal complications. The most common etiology during pregnancy is the presence of an adrenocortical adenoma. Urinary free cortisol over 3 times the upper limit of normal usually indicates Cushing's syndrome during pregnancy. The treatment of choice is surgical, and the ideal time for surgery is before the third trimester.

Surgical management of recurrent Cushing's disease in pregnancy: A case report

Background:

Cushing's disease is a condition rarely encountered during pregnancy. It is known that hypercortisolism is associated with increased maternal and fetal morbidity and mortality. When hypercortisolism from Cushing's disease does occur in pregnancy, the impact of achieving biochemical remission on fetal outcomes is unknown. We sought to clarify the impact of successful surgical treatment by presenting such a case report.

Case Description:

A 38-year-old pregnant woman with recurrent Cushing's disease after 8 years of remission. The patient had endoscopic transsphenoidal of her pituitary adenoma in her 18^th week of pregnancy. The patient had postoperative biochemical remission and normal fetal outcome with no maternal complications.

Conclusion:

Transsphenoidal surgery for Cushing's disease can be performed safely during the second trimester of pregnancy.

Cushing's syndrome during pregnancy caused by adrenal cortical adenoma: a case report and literature review

Cushing's syndrome (CS) during pregnancy is a rare condition with significant maternal and fetal complications. A case of CS during the third trimester of pregnancy secondary to adrenocortical adenoma was reported. Literature review revealed the disadvantages of different treatments in this period. Besides the conservative treatment, surgery is recommended for CS during the third trimester of pregnancy secondary to adrenal adenoma, if an experienced surgeon is available.

Cushing's syndrome in pregnancy

Cushing's syndrome is a rare condition in the general population and is even less common during pregnancy with only a few cases reported in literature. The diagnosis of Cushing's syndrome may be difficult during pregnancy because the typical features of the disorder and pregnancy may overlap. However, Cushing's syndrome results in increased fetal and maternal complications, and diagnosis and treatment are critical. This report describes a case of 26-year-old female at the 19th week of pregnancy with symptoms and signs of hypercortisolism, where ACTH-independent Cushing's syndrome was diagnosed and treated by robotic laparoscopic adrenalectomy at the 21th week of gestation.

A Pregnant Woman Who Underwent Laparoscopic Adrenalectomy due to Cushing's Syndrome

Cushing's syndrome (CS) may lead to severe maternal and fetal morbidities and even mortalities in pregnancy. However, pregnancy complicates the diagnosis and treatment of CS. This study describes a 26-year-old pregnant woman admitted with hypertension-induced headache. Hormonal analyses performed due to her cushingoid phenotype revealed a diagnosis of adrenocorticotropic hormone- (ACTH-) independent CS. MRI showed a 3.5 cm adenoma in her right adrenal gland. After preoperative metyrapone therapy, she underwent a successful unilateral laparoscopic adrenalectomy at 14-week gestation. Although she had a temporary postoperative adrenal insufficiency, hormonal analyses showed that she has been in remission since delivery. Findings in this patient, as well as those in previous patients, indicate that pregnancy is not an absolute contraindication for laparoscopic adrenalectomy. Rather, such surgery should be considered a safe and efficient treatment method for pregnant women with cortisol-secreting adrenal adenomas.