Case series highlights importance of managing Cushing’s with pregnancy

There are fewer than 250 cases of the syndrome at pregnancy reported

Lindsey Shapiro, PhD avatar

by Lindsey Shapiro, PhD |

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A pregnant woman, holding a teddy bear, holds her stomach, with stars around her.

Reaching a prompt diagnosis of Cushing’s syndrome and managing it appropriately during pregnancy are critical for minimizing the condition’s harmful effects on the mother and her child, according to case series that followed five women who gave birth at a clinic in Australia.

The series also highlighted the challenges of diagnosing Cushing’s in women who are already pregnant. “CS represents a rare and difficult to diagnose condition in pregnancy,” the researchers wrote in “Diverse presentations of Cushing’s syndrome during pregnancy — A case series,” which was published in the Australian and New Zealand Journal of Obstetrics and Gynecology. “Close monitoring of the associated complications with involvement of a multidisciplinary team are recommended.”

Cushing’s syndrome encompasses various conditions that feature excessive levels of the hormone cortisol. A common type is Cushing’s disease, where its excess is caused by a tumor in the pituitary gland. Too much cortisol, or hypercortisolism, significantly disrupts the function of the gonad glands that produce the hormones involved in reproduction, leading to low libido and diminished fertility in both men and women.

When Cushing’s occurs during pregnancy, it’s considered a high-risk condition. Left untreated, it’s associated with an increased risk of complications for the mother and fetus.

But, cortisol-lowering medications may be associated with side effects or can be dangerous, and must be used with care during pregnancy.

“Given the significantly increased risk of morbidity [adverse events] associated with CS [Cushing’s syndrome] in pregnancy, early diagnosis and effective treatment are important and patients should be managed with multidisciplinary care,” wrote the researchers, who described seven pregnancies among five women (mean age, 32.8) with Cushing’s who were seen at a maternity clinic in Australia between 2006 and 2022 to explore the best way to manage the disease during pregnancy, which has fewer than 250 reported cases in the literature.

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Four women were diagnosed with Cushing’s disease, while the other had a tumor in the adrenal glands, which are responsible for producing cortisol. Two women began showing symptoms of Cushing’s after they were pregnant.

Cushing’s diagnoses were reached with different type of cortisol tests, with MRI scans confirming the tumors in the pituitary or adrenal glands.

It can be difficult to diagnose Cushing’s in pregnant women, the researchers said, since some of its clinical features, such as weight gain, stretch marks, or acne overlap. Hormonal changes during pregnancy can also interfere with interpreting standard lab tests to measure cortisol levels.

“Due to the paucity of pregnancy-specific guidelines on the interpretation of these diagnostic tests or established reference ranges in pregnancy, it is recommended that clinicians use a range of modalities and clinical judgement,” the researchers wrote.

All the pregnancies that occurred before Cushing’s treatment started were complicated by high blood pressure and diabetes that required medical treatment. None of the women required cortisol-lowering medications during pregnancy.

Four infants were delivered via C-section and three via vaginal delivery. Among those with untreated Cushing’s, the babies’ median birth weight was 2,450 grams, or about 5.4 pounds. None of the women had preeclampsia, a complication marked by high blood pressure and organ damage, and none of the newborns died.

The case of a woman who had two pregnancies at the clinic underscores the importance of proper Cushing’s management, researchers said.

During the woman’s first pregnancy, which occurred before Cushing’s treatment, the woman had high blood pressure and diabetes, and the baby was smaller than normal inside the womb. These complications weren’t seen with her second pregnancy, which occurred after surgery to remove the pituitary tumor that caused her Cushing’s disease.

“Pregnancy in patients with CS poses a diagnostic and therapeutic challenge,” the researchers wrote. “Timely diagnosis and treatment significantly improve maternal morbidity and mortality.”