Lee Jessica H, Torpy David J
Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia.
Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
Rev Endocr Metab Disord. 2023 Feb;24(1):57-69. doi: 10.1007/s11154-022-09745-6. Epub 2022 Jul 11.
Adrenal insufficiency requires prompt diagnosis in pregnancy, as untreated, it can lead to serious consequences such as adrenal crisis, intrauterine growth restriction and even foetal demise. Similarities between symptoms of adrenal insufficiency and those of normal pregnancy can complicate diagnosis. Previously diagnosed adrenal insufficiency needs monitoring and, often, adjustment of adrenal hormone replacement. Many physiological changes occur to the hypothalamic-pituitary-adrenal (HPA) axis during pregnancy, often making diagnosis and management of adrenal insufficiency challenging. Pregnancy is a state of sustained physiologic hypercortisolaemia; there are multiple contributing factors including high plasma concentrations of placental derived corticotropin-releasing hormone (CRH), adrenocorticotropin (ACTH) and increased adrenal responsiveness to ACTH. Despite increased circulating concentrations of CRH-binding protein (CRH-BP) and the major cortisol binding protein, corticosteroid binding globulin (CBG), free concentrations of both hormones are increased progressively in pregnancy. In addition, pregnancy leads to activation of the renin-angiotensin-aldosterone system. Most adrenocortical hormone diagnostic thresholds are not applicable or validated in pregnancy. The management of adrenal insufficiency also needs to reflect the physiologic changes of pregnancy, often requiring increased doses of glucocorticoid and at times mineralocorticoid replacement, especially in the last trimester. In this review, we describe pregnancy induced changes in adrenal function, the diagnosis and management of adrenal insufficiency in pregnancy and areas requiring further research.
肾上腺功能不全在孕期需要及时诊断，因为若不治疗，可能会导致严重后果，如肾上腺危象、胎儿宫内生长受限甚至胎死宫内。肾上腺功能不全的症状与正常妊娠的症状相似，这会使诊断变得复杂。先前诊断出的肾上腺功能不全需要进行监测，并且通常需要调整肾上腺激素替代治疗。孕期下丘脑 - 垂体 - 肾上腺（HPA）轴会发生许多生理变化，这常常使肾上腺功能不全的诊断和管理具有挑战性。妊娠是一种持续的生理性高皮质醇血症状态；有多种促成因素，包括胎盘来源的促肾上腺皮质激素释放激素（CRH）、促肾上腺皮质激素（ACTH）的血浆浓度升高以及肾上腺对ACTH的反应性增加。尽管循环中的CRH结合蛋白（CRH - BP）和主要的皮质醇结合蛋白——皮质类固醇结合球蛋白（CBG）浓度增加，但两种激素的游离浓度在孕期会逐渐升高。此外，妊娠会导致肾素 - 血管紧张素 - 醛固酮系统激活。大多数肾上腺皮质激素诊断阈值在孕期并不适用或未经验证。肾上腺功能不全的管理也需要反映妊娠的生理变化，通常需要增加糖皮质激素剂量，有时还需要补充盐皮质激素，尤其是在妊娠晚期。在本综述中，我们描述了妊娠引起的肾上腺功能变化、孕期肾上腺功能不全的诊断和管理以及需要进一步研究的领域。
