AbstractSince SARS-COV-2 appeared in Wuhan City, China and rapidly spread throughout Europe, a real revolution occurred in the daily routine and in the organization of the entire health system. While non-urgent clinical services have been reduced as far as possible, all kind of specialists turned into COVID-19 specialists. Obstetric assistance cannot be suspended and, at the same time, safety must be guaranteed. In addition, as COVID-19 positive pregnant patients require additional care, some of the clinical habits need to be changed to face emerging needs for a vulnerable but unstoppable kind of patients. We report the management set up in an Obstetrics and Gynecology Unit during the COVID-19 era in a University Hospital in Milan, Italy.

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Introduction Cushing's syndrome (CS) is a clinical condition characterized by excessive cortisol production, associated with metabolic complications, such as diabetes mellitus, dyslipidemia, metabolic syndrome, hypertension, and cardiovascular diseases. Nowadays, the occurrence of autoimmune diseases in CS have not been completely evaluated in the previous studies. Objective The aim of this study was to evaluate the occurrence of autoimmune diseases in CS patients after successfully treated. Materials and Methods From January 2001 to December 2017, in our Secondary Hypertension Unit, we evaluated 147 CS patients (91 with ACTH-independent disease, 54 with ACTH-dependent disease, and 2 patients with ectopic ACTH production. Results 109 CS patients (74.1%) were surgically treated (67 ACTH-independent CS patients (61.5%) undergone adrenalectomy and 42 ACTH-dependent CS (38.5%) undergone transsphenoidal surgery) and evaluated after 6, 12, and 24 months after clinical and biochemical remission of disease. In 9 (8.3%) of overall treated CS patients (8.3%), during follow-up, we observed the onset of some manifestations of autoimmune diseases. In particular, one patient had a systemic lupus erythematosus, one patient had rheumatoid arthritis, 4 patients reported autoimmune thyroiditis (Basedow-Graves' disease and Hashimoto's thyroiditis), one patient had clinical features of psoriasis, one patient showed myasthenia gravis, and one patient had giant cell arteritis. Conclusions Our results demonstrate that patients successfully treated for CS could develop autoimmune diseases. Therefore, after treatment, CS patients need to be strictly monitored in order to evaluate the possible onset of autoimmune diseases.

The patient was under treatment with irbesartan (150 mg once a day) plus hydrochlorothiazide (12.5 mg once a day) for arterial hypertension. He did not report any complaints of episodic headaches, palpitations, sweating, chest pain, or hematuria. On physical examination, the patient's heart rate was 68 beats per minute and his blood pressure (BP) was 140/ 80 mmHg without postural drop. His height and weight were 180 cm and 92 kg, respectively, with a body mass index of 28 kg/m 2 , and a waist circumference 110 cm. No cardiac murmurs or abdominal bruits were revealed. We performed ambulatory blood pressure monitoring (ABPM), which revealed a global mean BP of 129/75 mmHg with a lack of nocturnal fall in the BP (nondipping profile). The electrocardiogram was unremarkable, but an echocardiogram showed mild left ventricular concentric remodeling. Blood tests were normal except for the serum creatinine level (1.2 mg/dL; n.v. 0.50-0.90) and high serum acid uric (9.7 mg/dL; n.v. 2.40-5.70). A hormone investigation for the adrenal gland, including a low-dose dexamethasone suppression test and plasma cortisol values, was normal. Repeated 24h urinary metanephrines measurements were in the normal range, 150 and 234 μg/24h, respectively (normal value 0-350 μg/24h); and vanillylmandelic acid 1.8 and 2.7 μg/24h, respectively, (normal value 0-10, mg/24h) (Tab. I). Because of suspected renal and adrenal neoplasms, a surgical consult was requested and the patient simultaneously underwent an ipsilateral adrenalectomy and a radical nephrectomy. In particular, the surgical treatment was performed with a midline incision with a transperitoneal approach. The operative time was around 130 minutes and the approximate blood loss was 30 cc. The postoperative course was uneventful, and the patient was discharged from hospital and attended a regular follow-up.