Thursday, August 5, 2010

Cushing Syndrome: A Rare Occurrence in Pregnancy

Mundra, Vishal MD; Solorzano, Carmen C. MD, FACS; DeSantis, Pascual MD


This is a case of a 32-year-old woman who presented to the clinic at 11 weeks of gestation after she was found to have an adrenal mass during the work up of hypertension. An MRI prior to pregnancy revealed a right-sided 4.8-cm adrenal mass.

On examination, the patient was overweight, with no other features of Cushing syndrome like striae, buffalo hump, etc. At 15 weeks, her 24-hour urine cortisol was 1095 mcg/24 hours (4.0–50.0 mcg/24 h). Her repeat 24-hour urine cortisol at 21 and 25 weeks of gestation were 1655 and 3039 mcg, respectively. Her morning adrenocorticotropic hormone level was undetectable.

During the second trimester, she developed acne, striae, truncal obesity, and a “buffalo hump.” After consulting with her surgeon, she opted for adrenalectomy after pregnancy. At 22 weeks, she was started on metyrapone 250 mg daily but the urinary free cortisol remain elevated.

She had an emergent C-section at 34 weeks due to fetal heart decelerations. Metyrapone was discontinued after delivery. Surprisingly, the 24-hour urine Cortisol spontaneously dropped to 7.2 mcg prior to surgery.

A repeat CT prior to adrenalectomy revealed an increase in the size of the adrenal mass. The patient had an uneventful laparoscopic right adrenalectomy 2 months after delivery. The pathology was consistent with a cortical adenoma. The largest diameter of the tumor was 9 cm. The patient and the baby remained asymptomatic after the surgery.


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