Increase Hydrocortisone Dose in Pregnancy, Particularly During Third Trimester
STEP 1 — Gather Information
Collect gestational age, current hydrocortisone dose and schedule, maternal symptoms (fatigue, nausea, vomiting, postural hypotension or hypertension, weight changes, hyperglycemia), weight, blood pressure, and any signs of over- or under-replacement; end with assessment of symptom pattern.
STEP 2 — Rule In / Rule Out
Is the patient pregnant with confirmed PAI and at ≥28 weeks gestation? If yes, proceed to symptom classification; if no, continue routine trimester‑based monitoring and do not apply this specific increase algorithm.
STEP 3 — Classify or Stratify
Classify symptom pattern: under‑replacement (fatigue, nausea, hypotension, weight loss, hyponatremia); over‑replacement (weight gain, hyperglycemia, insomnia, edema, hypertension); or stable (no concerning signs); end with a classification decision.
STEP 4 — Decide
If under‑replacement signs are present, increase hydrocortisone dose by 20‑40% (e.g., from 20 mg to 25 mg daily) divided into two or three doses; if over‑replacement, maintain current dose or consider reduction after obstetric review; if stable, maintain current dose; end with dosing adjustment order.
Clinical Guardrails / Mimics / Pitfalls
Avoid glucocorticoid over‑replacement that can cause Cushingoid features, maternal hyperglycemia, hypertension, or fetal growth restriction; do not use dexamethasone in pregnancy due to lack of placental inactivation; avoid abrupt dose changes without maternal‑fetal monitoring; ensure mineralocorticoid adequacy when increasing hydrocortisone.
Concrete Clinical Example
A 32‑year‑on‑known PAI at 30 weeks gestation reports fatigue, postural hypotension, and 2 kg weight loss despite hydrocortisone 20 mg daily. Assessment indicates glucocorticoid under‑replacement. Increase hydrocortisone to 25 mg daily in divided doses, reassess symptoms and weight in 1‑2 weeks.
Source: Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, DOI:10.1210/jc.2015-1710