Administer Hydrocortisone Stress Dosing During Active Phase of Labor
STEP 1 — Gather Information
Confirm diagnosis of primary adrenal insufficiency (PAI) in pregnant patient; assess labor status: active phase defined as cervix dilation ≥4 cm and/or regular contractions every 5 minutes for the last hour; obtain intravenous access; review allergies and contraindications.
STEP 2 — Rule In / Rule Out
Rule in if pregnant PAI patient is in active phase of labor (cervix ≥4 cm and/or contractions q5min). Rule out if not in active labor, patient lacks confirmed PAI, or has known hypersensitivity to hydrocortisone.
STEP 3 — Classify or Stratify
Proceed to stress dosing regimen; no further stratification needed as all active labor PAI patients receive same stress dose.
STEP 4 — Decide
Administer hydrocortisone 100 mg IV bolus followed by continuous infusion of 200 mg/24 hours (or equivalent) until delivery; after delivery, taper rapidly to prepregnancy maintenance dose.
Clinical Guardrails / Mimics / Pitfalls
Do not use dexamethasone (not inactivated by placenta); avoid delaying stress dosing until after delivery; monitor for signs of fluid overload or infection; ensure patient has steroid emergency card; consider mineralocorticoid replacement if hypotension persists despite glucocorticoid stress dosing.
Concrete Clinical Example
A 32-year-old woman with known PAI at 39 weeks gestation presents with regular contractions every 4 minutes and cervix 5 cm dilated. She receives hydrocortisone 100 mg IV bolus, then infusion 200 mg/24 hrs. After vaginal delivery 2 hours later, infusion is stopped and she resumes her usual oral hydrocortisone 20 mg daily.
Source: Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, DOI:10.1210/jc.2015-1710