Pregnancy during the course of Cushing's syndrome: a case report and literature review

Summary: Cushing's syndrome is an endocrine disorder that causes anovulatory infertility secondary to hypercortisolism; therefore, pregnancy rarely occurs during its course. We present the case of a 24-year-old, 16-week pregnant female with a 10-month history of unintentional weight gain, dorsal gibbus, nonpruritic comedones, hirsutism and hair loss. Initial biochemical, hormonal and ultrasound investigations revealed hypokalemia, increased nocturnal cortisolemia and a right adrenal mass. The patient had persistent high blood pressure, hyperglycemia and hypercortisolemia. She was initially treated with antihypertensive medications and insulin therapy. Endogenous Cushing's syndrome was confirmed by an abdominal MRI that demonstrated a right adrenal adenoma. The patient underwent right laparoscopic adrenalectomy and anatomopathological examination revealed an adrenal adenoma with areas of oncocytic changes. Finally, antihypertensive medication was progressively reduced and glycemic control and hypokalemia reversal were achieved. Long-term therapy consisted of low-dose daily prednisone. During follow-up, despite favorable outcomes regarding the patient's Cushing's syndrome, stillbirth was confirmed at 28 weeks of pregnancy. We discuss the importance of early diagnosis and treatment of Cushing's syndrome to prevent severe maternal and fetal complications.

Learning points: Pregnancy can occur, though rarely, during the course of Cushing's syndrome. Pregnancy is a transient physiological state of hypercortisolism and it must be differentiated from Cushing's syndrome based on clinical manifestations and laboratory tests. The diagnosis of Cushing's syndrome during pregnancy may be challenging, particularly in the second and third trimesters because of the changes in the maternal hypothalamic-pituitary-adrenal axis. Pregnancy during the course of Cushing's syndrome is associated with severe maternal and fetal complications; therefore, its early diagnosis and treatment is critical.

Keywords: 2020; ACTH; Adrenal; Adrenocortical adenoma; Alopecia; April; Blood pressure; Cortisol; Cortisol (9am); Cortisol (midnight); Cortisol (serum); Cushing's syndrome; Dorsal gibbus*; Ecchymoses; Facies - moon; Female; General practice; Headache; Hirsutism; Hispanic or Latino - other; Histopathology; Hypercortisolaemia; Hyperglycaemia; Hypertension; Hypokalaemia; Insulin; Laparoscopic adrenalectomy; MRI; Methyldopa*; Myasthaenia; Obstetrics; Peru; Potassium; Potassium chloride; Prednisone; Pregnant adult; Rash; Striae; Transaminase; Ultrasound scan; Unique/unexpected symptoms or presentations of a disease; Urinary free cortisol; Weight gain.