Hypercortisolism during pregnancy

　　One, Etiology

　　5. Excessive secretion of adrenocorticotropic hormone (ACTH) by the pituitary gland is the most common type of this disease, accounting for about 70%. The most common (80%) lesion is pituitary ACTH microadenoma, 10% is pituitary anterior lobe macroadenoma, and about 10% is hypothalamic dysfunction, with excessive secretion of corticotropin-releasing hormone (CRH), which increases ACTH secretion through regulation. Excessive ACTH stimulates the diffuse hyperplasia of the bilateral adrenal cortex, the hyperplastic and hypertrophic fasciculate cells can secrete a large amount of glucocorticoids, and the androgens in the reticular zone can also be secreted in large quantities. In patients with long-standing disease or older age, nodules may appear in the hyperplastic adrenal cortex, and they have a certain degree of autonomous function.

　　4. Adrenal cortical tumors account for 25% (20% are adenomas, 5% are adenocarcinomas) of the incidence of hypercortisolism. These tumors have autonomous growth and secretion functions,不受垂体ACTH的控制，and secrete large amounts of cortisol, which can feedback inhibit the release of pituitary ACTH. The level of ACTH in the patient's blood decreases, and the adrenal cortical atrophy occurs on the ipsilateral and contralateral sides of the tumor. Children with adrenal cortical adenocarcinoma are more common.

　　3. ectopic ACTH syndrome Lung cancer, thymoma, and pancreatic cancer, medullary thyroid cancer can produce ACTH, stimulating the adrenal cortex to secrete excessive amounts of glucocorticoids.

　　Two, Pathogenesis

　　The acidophilic cells of the anterior pituitary gland in patients with Cushing's syndrome often undergo hyaline变性 and vacuolation, which is usually the result of increased secretion of adrenal cortical hormones. In this case, the secretion of gonadotropins is undoubtedly affected, leading to corresponding changes in the ovaries, impaired follicle development, and the formation of a large number of atretic follicles, resulting in amenorrhea. Although amenorrhea is one of the prominent symptoms of the syndrome, 20% of patients have normal menstruation and can become pregnant. The clinical symptoms often appear for the first time during pregnancy or after delivery, so it is speculated that the patient was mild before pregnancy, and the condition worsened after pregnancy and delivery.

　　1. Hypertension and pre-eclampsia during pregnancy are almost unavoidable, and pulmonary edema is also relatively common. The hypertensive disorder of pregnancy often occurs early, usually before 24 weeks of pregnancy, and may be related to adrenal cortical hyperfunction and increased aldosterone secretion, leading to sodium and water retention.

　　2. Abortion, preterm delivery, and stillbirth can account for 65% of the total number of pregnancies, which may be related to severe preeclampsia and the strong anti-insulin action of corticosteroids, which can increase blood sugar levels.

　　Cushing's syndrome, also known as Cushing's disease, follows the general nursing routine of internal medicine and this system disease.

　　One, condition observation

　　1. Obesity, hypertension.

　　2. Dry skin, subcutaneous hemorrhage, acne, traumatic suppuration, cyanosis of the extremities, edema, hirsutism, low muscle strength, fatigue, a sense of fatigue, osteoporosis, and pathological fractures, etc.

　　3. Urine volume, urine characteristics such as hematuria, proteinuria, and glycosuria.

　　4. Mental symptoms such as insomnia, restlessness, depression, and excitement.

　　5. Fever due to infection.

　　6. Abnormal menstruation in female patients.

　　Two, symptomatic care

　　1. Prevent infection, keep the skin clean, bathe frequently, change clothes, and keep the bed unit flat and clean. Do good oral and perineal care.

　　2. Observe for mental symptoms and prevent accidents. When patients are restless, abnormally excited, or depressed, they should be closely monitored to prevent falls. Use bedrails or restraints to protect patients, do not place dangerous items near patients, avoid刺激性 words and actions, be patient and meticulous, and show more concern and care.

　　3. Observe patients with adrenal cancer chemotherapy for nausea, vomiting, drowsiness, ataxia, and memory loss.

　　4. Measure height and weight weekly to prevent sudden spinal compression fractures.

　　5. Perform all tests correctly and send them for testing in a timely manner.

　　Three, general care

　　1. Bed rest, light activity may be appropriate for mild cases.

　　2. Diet should be high in protein, vitamins, low in fat, low in sodium, and high in potassium. Each meal should not be too much or too little, and meals should be taken evenly.

　　Four, health guidance

　　1. In daily life, patients should pay attention to preventing infection, keeping the skin clean, preventing trauma, and fractures.

　　2. Guide the patient to correctly take a balanced diet with nutrition, and provide low-sodium, high-potassium, and high-protein foods.

　　3. Follow the doctor's advice to take medication, do not reduce or stop medication arbitrarily.

　　4. Regular outpatient follow-up.

　　1. General examination shows an increase in red blood cell count and hemoglobin content, an increase in the total white blood cell count and neutrophils, and a decrease in the absolute values of lymphocytes and eosinophils.

　　2. The 24-hour urinary 17-hydroxycorticosteroid content is significantly elevated, exceeding 38.4μmol/24h (13.9mg/24h) (male) and 30.9μmol/24h (11.2mg/24h) (female), and the total content of 17-ketosteroids is often also above 40.3μmol/24h (11.6mg/24h) (male) and 37.3μmol/24h (8.5mg/24h) (female).

　　3. The blood cortisol concentration is elevated, with the concentration at midnight exceeding 0.28μmol/l (10.1mg/dl) and at 8 am in a quiet state exceeding 0.69μmol/l (24.9mg/dl).

　　4. The diurnal rhythm of blood cortisol is lost, that is, the cortisol concentration at midnight exceeds the level at 8 am, and the diurnal rhythm may disappear in the early stage of the disease.

　　5. In the low-dose dexamethasone suppression test, hypercortisolism is not suppressed, while other reactive or functional hypercortisolism can cause the blood cortisol concentration or 24-hour urinary 17-hydroxycorticosteroid content to decrease by more than 50% from the baseline. It is mainly used to differentiate from simple obesity. Method: Simplified method, blood cortisol concentration is measured at 8 am on the first day as the baseline, dexamethasone 1.5mg is taken at midnight, and blood cortisol concentration is re-measured at 8 am the next day. Standard method, the blood cortisol concentration or 24-hour urinary 17-hydroxycorticosteroid content is measured at 8 am on the first day, and dexamethasone 0.75mg is taken three times a day for 4 days, and then the blood cortisol concentration or urinary 17-hydroxycorticosteroid content is re-examined and compared with the pre-treatment level.

　　6. In the high-dose dexamethasone suppression test, the suppression of adrenal cortical hyperplasia is often more than 50%, while adrenal adenoma or adenocarcinoma is not significantly suppressed. Method: On the day before the test, the blood cortisol or urinary 17-hydroxycorticosteroid content is measured, and then dexamethasone 2mg is taken every 6 hours for 5 days. After that, the blood cortisol concentration or urinary 17-hydroxycorticosteroid content is re-examined and compared with the pre-treatment level.

　　7. In the ACTH stimulation test, normal individuals, simple obesity, and adrenal cortical hyperplasia can show an increase in blood cortisol concentration or urinary 17-hydroxycorticosteroid content by more than twice after the injection of ACTH. Adrenal adenoma or adenocarcinoma does not show significant elevation. Method: Simplified method, blood cortisol concentration is measured at 8 am, and ACTH 25mg is administered intramuscularly or intravenously immediately, blood cortisol concentration is measured at 8:30 am and 9 am. Standard method, on the first and second days, 24-hour urine is collected to measure the content of 17-hydroxycorticosteroids, from the third to fourth day, ACTH 24mg (added to 500ml of 5% glucose solution) is administered intravenously from 8 am for 8 hours, and the content of 17-hydroxycorticosteroids in 24-hour urine is measured daily.

　　8. Imaging examinations are localization examinations, including B-ultrasound, CT scan, adrenal angiography, magnetic resonance imaging, venous catheter segmental blood collection for cortisol determination, etc. If conditions permit, isotope scanning or γ-ray photography with 131 iodine-labeled cholesterol can also be performed to assist in diagnosis.

　　Appropriate Food Therapy Recipes:

　　1. Foods with low sodium content, such as beans and bean products, vegetables, fruits, etc.

　　2. Foods high in potassium include: fresh mushrooms, cucumbers, oranges, sweet corn, glutinous rice, potatoes, longans, grapes, coconuts, persimmons, watermelons, mangos, etc. 3. High-protein foods include: soybeans, broad beans, green peas, peanuts, beef, pork, chicken, duck, internal organs, eggs, milk powder, etc.

　　3. Alkaline foods include: beans, vegetables, fruits, chestnuts, lilies, dairy products, lotus root, egg whites, kelp, tea leaves, etc.

　　4. High-vitamin diet: grapes, pineapples, mangos, cantaloupe, cherries, mung bean sprouts, green beans

　　1. The combination of gestational hypercortisolism is prone to abortion, stillbirth, perinatal death, and preterm delivery. Therefore, during pregnancy, it is necessary to strengthen surveillance and hospitalize in advance.

　　2. Pregnant women often develop gestational hypertension in the second trimester of pregnancy. At the same time, due to the anti-insulin effect of corticosteroids, blood glucose levels rise, so it is necessary to actively control gestational hypertension and treat diabetes. After active treatment, the duration of pregnancy can be extended, and the chance of delivering a live baby increases.

　　3. Metyrapone is a corticosteroid synthesis inhibitor, taken 1-2g per day in divided doses, which can be increased to 4-6g per day. Metyrapone has few side effects and can reduce blood cortisol levels and alleviate symptoms. ④ Surgical treatment. For those with hypercortisolism caused by adrenal cortical tumors during pregnancy, surgery can be considered after confirmation. Bevan believes that surgery during pregnancy is safe and can significantly reduce the incidence of stillbirth and preterm delivery.