Pregnancy in a Woman Suffering from Type 1 Diabetes Associated with Addison's Disease and Hashimoto's Thyroiditis (Fully Developed Autoimmune Polyglandular Syndrome Type 2)

Abstract

In this article the pregnancy of a woman suffering from the complete triad typical of Autoimmune Polyglandular Syndrome Type 2 (Addison's disease + type 1 diabetes + Hashimoto's thyroiditis) is reported. By using insulin pump therapy with insulin lispro, it was possible to balance diabetes control with changes of steroid replacement therapy. Pregnancy was uneventful until week 27, when signs of preeclampsia occurred. The boy was born without difficulty at gestational age 37 weeks by planned cesarean section but signs of diabetic fetopathy (macrosomia, hypoglycaemia and hypocalcaemia) were expressed. He required a short course of hydrocortisone therapy. He made a good and rapid recovery. The mother made a good post-operative recovery too, but 4 months after the delivery microalbuminuria as well as mild hyperuricemia are still present. Interdisciplinary approach and very careful observation of the mother as well as of the child enabled successful outcome of this highly risky pregnancy.

What is the best diagnostic and therapeutic management strategy for an Addison patient during pregnancy?

“…These have some similarity to pregnancy‐induced conditions such as hyperemesis gravidarum . However, a personal or familial history of autoimmune disease should raise clinical suspicion of PAI in the context of typical symptoms . Hyperpigmentation is a more specific sign of PAI, resulting from increased ACTH stimulation of skin melanocortin 1 receptors .…”

“…20 However, a personal or familial history of autoimmune disease should raise clinical suspicion of PAI in the context of typical symptoms. 21 Hyperpigmentation is a more specific sign of PAI, resulting from increased ACTH stimulation of skin melanocortin 1 receptors. 22 It sometimes is mistaken for chloasma of pregnancy, however, the latter is a melanosis that is restricted to sun-exposed areas only, whereas ACTH-driven hyperpigmentation typically affects areas of increased mechanical friction, such as scars, nipples, knuckles, toes and in severe cases also the oral mucosa in contact with teeth.…”

MANAGEMENT OF ENDOCRINE DISEASE: Fertility, pregnancy and lactation in women with adrenal insufficiency

“…To ensure evaluation of cases in the context of modern treatment, only cases dating 1976 onward were considered for inclusion (8,20,26,27,28,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52). This search identified 28 cases of primary AI, a case series with 17 cases of treated adrenocortical carcinoma patients, out of which 7 were included as they were on hydrocortisone treatment following surgical treatment (51) PAI (5) Y (2/5)…”

Adrenal Disease and Pregnancy

“…Primary adrenal insufficiency from infections, bilateral metastatic disease, hemorraghe or infarction is uncommon. Secondary adrenal insufficiency, from pituitary neoplasm or glucocorticoid suppression of the hypothalamic-pituitary-adrenal axis is more common (Stechova, 2004). Gestation in patients with AI should be considered high-risk pregnancy .…”