PREGNANCYANDADRENOCORTICALFUNCTION: ENDO--CRINE STUDIES OF PREGNANCYOCCURRINGIN TWO

ADRENAL-DEFICIENT WOhfEN.1By A. GORMANHILLS, ELEANORIL VEN[NIG, . CUTIS DOHAN,

GEORGED. WEBSTER, J.,2 A"" EDWIN M. RICHARDSON

(From the Edward B. Robinette Foundation and TV 2,adocrine Section, WKVihiW Pepper Labo-ratory of Clinical Medicine, Medical Clinic, Hospital of the University of Pennsylvania,

the Department of Obstetricsand Gynecology, m. the Department qi Surgery,School of Medicine, University of Pennsylaxia, Phdephiaa, Pennsyl-

vania; and the McGil University Clitic, Royal Victoria Hupital,Mostreal, Caned)

(Submitted for publicatidon February 23, 1954; accepted July 6, 1954)

It has been suggested by jailer and Knowlton(1) that when adrenal-deficient women becomepregnant, they exhibit "simulated adrenal corti-cal activity" attributable to an extra-adrenal sourceof "adrenal cortical-like" hormone. Observationswhich can be interpreted as lending support to thisview may be summarized as follows:

1. Pregnancy has been reported to prolong thesurvival of adrenalectomized animals (24).

2. Urinary 17-ketosteroid elimination (as esti-mated by the Zimmermann reaction) rises duringthe latter months of pregnancy in patients withAddison's disease (1, 5, 6) as well as in normalwomen (7).

3. Urinary excretion of neutral reducing lipidsrose to the normal range late in pregnancy in onepatient with Addison's disease (1).

4. A decrease of circulating eosinophils fourhours following the injection either of epinephrinor of corticotrophin was observed on three occa-sions in one Addisonian patient during pregancyand not thereafter (1).

The occurrence of pregnancy in two womenrendered adrenal-deficient by surgery because ofsevere hypertensive disease has provided an op-portunity to conduct certain studies, reported inthis communication, which bear upon the question.

I This investigation was supported in part by researchgrants H-1419 and H-922 from the National Heart In-stitute, U. S. Public Health Service; by a grant fromthe National Research Council of Canada; and by grantsfrom the Squibb Institute for Medical Research, Eli Lillyand Company, Ciba Pharmaceutical Products, Inc., Merckand Company, Inc. and the Publicker Industries Nutri-tional Fund.

2 Trainee of the National Heart Institute.

METHODS

Sodium and potassium were determined on a flamephotometer with internal lithium standard (8); creati-nine by the procedure of Bonsnes and Taussky (9); ureaby Karr's method (10). Urinary 17-ketosteroids wereestimated by the Holtorff-Koch modification (11) ofthe Zimmermann reaction. The measurements were oftotal neutral 17-ketosteroids, which would be expectedto be higher than values for the ketonic fraction com-monly reported. Neutral reducing lipids were estimatedusing the phosphomolybdate reaction according to Heard,Sobel, and Venning (12), and glycogenic corticoids bythe bioassay technique of Venning, Kazmin, and Bell (13).Values reported as "pH, hydrolyzed" represent deter-minations on extracts of urine acidified with hydrochloricacid and kept at pH, for one hour. "Glucuronidase hy-drolysis" signifies that the extracted material had initiallybeen subjected to hydrolysis for 48 hours at pH 4.5 inthe presence of p-glucuronidase (derived from spleen)in a concentration of 100 units per milliliter, and subse-quently to acid hydrolysis as described above.

In the tables, excretion of urinary steroids is generallygiven both uncorrected and corrected for urinary creati-nine excretion. The latter method of expression wasthought preferable where many of the urine collectionswere made outside the hospital, as in the case of thedata presented in Figure 1; in Figure 2, uncorrected dataare charted because creatinine analyses were not avail-able for all samples. Values for glycogenic corticoidexcretion are uncorrected for urinary creatinine excre-tion, and represent cortisone equivalents.

Eosinophils were enumerated by the method of Man-ners (14).

Case reports1. 5. C., H.U.P., Ob. 43769, was a 36-year-old colored

female who had bilateral thoracolumbar sympathectomyand subtotal adrenalectomy performed for hypertensionby Dr. Harold A. Zintel in three stages in June 1949 andMarch 1950. Her case has been reported in detail else-where (15). She became pregnant in August 1951.Gestation was uneventful, and she continued to take nosteroid save for an occasional 12.5 or 25 milligrams of

1466

PREGNANCYAND ADRENOCORTICALFUNCTION

EFECT OFPREGNANCYONURaRy SIEROD EXCRETION

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cortisone. The blood pressure was little affected bypregnancy, remaining throughout in the range of 115-140/80-100. On May 19, 1952, she was delivered by Cesareansection, performed by Dr. George Hoffman, of a normalmale infant weighing 1280 grams. Cortisone was ad-ministered at this time, and there were no post-partalcomplications. Mother and child remain in good health.

2. B. L., H.U.P., Ob. 44812, was an 18-year-old whitefemale followed by us since January 1951. Her com-

plaint, at that time, was severe and progressive headacheof six months' duration, accompanied by dizziness, blur-ring of vision, nausea, and vomiting. Blood pressure was

200-240/140-180, and retinopathy, Keith-Wagner GradeIV, was present. Phenolsulfonphthalein excretion was

15 per cent in 15 minutes, 70 per cent in two hours.Bilateral subdiaphragmatic sympathectomy and splanch-

nicectomy, left 95 per cent adrenalectomy, and right totaladrenalectomy were performed as a two-stage procedureby Dr. Zintel on January 27 and February 6, 1951. Af-ter operation, her symptoms were relieved and theretinopathy reverted to Grade I and II, but her bloodpressure remained high (165-200/120-140). She requiredno replacement therapy, and metabolic studies revealedthe presence of measurable adrenal cortical reserve.

The patient was married in 1952, and in early July1952 became pregnant. She was admitted to the hos-pital in September 1952, at which time the site of theleft adrenal was explored and an adrenal remnant weigh-ing 1.1 Gm. was removed. She was hospialized through-

out much of the remainder of her pregnancy and re-quired a minimum of 25 mgm. of oral cortisone daily atall times. She felt well but her blood pressure remainedelevated throughout her pregnancy. On January 20, 1953,in the 29th week of pregnancy, the patient went intospontaneous labor and was delivered by Dr. MichaelNewton of a living female infant weighing 800 grams,which, however, died of prematurity after three days.The post-partal course was uneventful and the patient,at the present time, remains asymptomatic, though herblood pressure is high (210-230/140-155). She con-tinues to require a minimum of 25 milligrams of oralcortisone daily.

COMMENT

It is clear that both our patients had gross

adrenal deficiency.8 B. L. may have had totaldeficiency, although we know of no practicalmethod of ascertaining the complete absence offunctioning adrenal cortical tissue. S. C. is cer-

tainly adrenal-deficient, as indicated by both mela-nosis and by her susceptibility to the precipitation

For convenience the term deficiency as used in thiscommunication, refers to lack of adrenal cortical tissue,of whatever degree; insfficiency indicates the physio-logic consequences, of whatever gravity, of lack of avail-able hormone in relation to need.

1467

INUTRA RM

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1468 A. HILLS, E. VENNING, F. DOHAN, G. WEBSTER, JR., AND E. RICHARDSON

of adrenal insufficiency; but she probably has sone mean values for normal women and for hyperten-functioning cortical tissue, since she requires sive women obtained in this, laboratory. Duringlittle or no substitution therapy. Repeated study pregnancy excretion of these substances by bothof 24-hour urinary sodium elimination during women was augmented, the values for neutral re-pregnancy in the two patients while they weretak-, .ducing lipids falling within the range of valuesing self-selected diets indicated that the difference which have been observed at corresponding timesbetween the patients with respect to their need for in a small number of observations of normal preg-substitution therapy is probably not. atlribitable nancy in this laboratory. The increases were un-to any important difference in their salt c`nstmp- related to hormone therapy, for in one patienttion: S. C. excreted 228 ± 42 milliequiivalents of (S. C. [Figure 1]) no hormone was given withinsodium per 24 hours, and B. L. 186 ±23 milli- 48 hours prior to the beginning of any of the col-equivalents. lections, while in the other (B. L. [Figure 2])

cortisone administration was kept substantiallyRESULTSconstant (25 to 37 milligrams daily) during and

Effect of pregnancy upon urinaryst~eroi4.exctvetion immediately prior to collections. The effect of

Neutral reducing lipids aud 17Zkitostz,<oids. pregnancy upon urinary steroid excretion in B. L.(Figures 1 and 2). The quantities of neutral 17- is somewhat more impressive when correction isketosteroids excreted following pregnancy by made for urinary creatinine excretion, though byB. L., and of neutral reducing lipids and neutral no means as striking as the influence of pregnancyketosteroids excreted by S. C in the non-preg- upon urinary streoid excretion in S. C. How-nant state, were both distinctly lower than the ever, the highest values in S. C. were observed

NEUTRAL REDUCINGupaS

ton*) IMJS4be.)

NEUTAL REDUCE"LIPIOS

(SLUC41OMNSASE(wm~/26 km I

GREATNNN £*Vs.*t4b.)

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OCRTISONE ACEATE111115411e.

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URINARY STEROID EXCRETIONDURING AND FOLLOWINGPREGNANCYI (L. 1S w I Total £iuc-

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PREGNA-1Y.MAN ADAENOCO*TICALFIMMON 1469

Urinary excreiion of glycogenic coricoids by adrixdefidient women d rhq,+nd folowilsg pregnancy

: ^-~~~~- ~~~ 7- 7 . ._~~~~~~ GlycogenicMedlcation* Motth of corticoids

Patient Date mgm./24 hr. ecy pgm./24 hr.

S. C. 4/9-11/52 0 8th 1144/28-30/52 0 9X- 130

9/17-19/52 0 Post-partum 262/9-11/53 0 Not-partum, 41

6/20-22/53 0 Post-partum 346/22-24/53 ACTH60 Post-partum 466/24-26/53 ACTH60 Post-partum 386/26-28/53 ACTH60 Post-partum 506/28-30/53 ACTH60 I~ost-partum 42

B.L. 10/22-24/52 E25 4th 8812/2-4/52 E 25 6th 151

5/31 to6/2/53t E 37 Post-partum 766/2-10/53t E 37 Post-partum 42

ACTH60

6/25-27/53 E 37 Post-partum 457/27-29/53 E 37 Post-partum 23

* E: Cortisone acetate (oral) supplied-by Dr. Elmer Alpert of Merck and Company. ACTH: H. P. Acthar Gel(intramuscular), supplied by Dr. C. J. O'Donovan of the Armour Laboratories.

t Hydrolyzed at pH, only. All other samples subjected to initial hydrolysis with 0-glucuronidase followed byhydrolysis at pH,.

during the last six weeks of pregnancy, and com-parable specimens were not obtained in B. L. ow-ing to her premature delivery. Whether or notthe creatinine correction is applied, a progressiveincrease of urinary steroid excretion beginning asearly as the second trimester is observable in bothpatients during pregnancy.

Glycogenic coriicoids (Table I). Materialcapable of causing glycogen deposition in the liverof the fasted adrenalectomized mouse was ex-creted in the urine of both patients at all times.Following pregnancy, the values have been ofthe order of magnitude found in patients with Ad-dison's disease on minimal replacement therapy,and in B. L. the excretion of this material may beattributable, in part at least, to oral cortisone in-gestion. During the latter half of pregnancy bothwomen were excreting three to four times thisquantity, and at these periods the values were inthe range found in patients with Cushing's disease.These values fall close to the mean of those ob-served in normal pregnancy at corresponding timesas determined in the same laboratory (7).

Physiological studies during pregnancyResponse to intravenous corticotrophin (Table

II). Repeated attempts were made to obtain evi-

dence of an adrenal-like response to 24 or 48-hourcorticotrophin tests. Either 10 or 20 U.S.P.units in glucose or saline solution were adminis-tered by intravenous infusion over an eight-hourperiod, in order to supply a near maximum stimu-lating dose (16). Adrenal-like response wasevaluated in terms of 24 or 48-hour excretion ofneutral reducing lipids (using two methods ofhydrolysis), and of 17-ketosteroids, comparingthe experimental periods (reckoned from the be-ginning of the 8-hour infusions) with control val-ues, usually those for the period immediately pre-ceding the test infusion; and also by comparingthe eosinophil counts prior to and at the termina-tion of the infusion.

Responses to the infusions of corticotrophinuniformly were trivial or lacking in S. C. Thenormal eosinophil decrease at the end of suchan 8-hour infusion amounts to a minimum of 90per cent and the average increment in 24-hoururinary steroid excretion (i.e., the mean incre-ment of neutral reducing lipids determined follow-ing hydrolysis at pH, and by /3-glucuronidase andof 17-ketosteroids) amounts to a minimum of 6milligrams (17). A significant reduction (17) ofcirculating eosinophils was never seen in eitherpatient. In two of the tests in B. L., steroid out-

1469

A. HILLS, E. VENNING, F. DOHAN, G. WEBSTER, JR., AND E. RICHARDSON

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PREGNANCYAND ADRENOCORTICALFUNCTION 1471

put was somewhat increased on the days when sywptmatic and chemical evidence of early acutecorticotrophin was administered; but the in aditnad later appeared, in spite ofare small and of questionable significance, nd aQ t.eprovpa of additional exogenous hormone, ineffect of corticotrophin is observable on the oc- the wake of a dental infection followed by a toothcasions of the third test. extraction (FMIjre 4).

Precipitation of acute adrenal iBafficiency (Fig- S. C. was -wdas an outpatient during mostures 3, 4, and 5). Evidence of acute adrenal in- of her pregnancy.; Shy was admitted to the Meta-sufficiency was obtained in both patients during bolic Unit during the seventh month of pregnancy,pregnancy. B. L. was hospitalized for much of -in the course-of -which evidence was obtAined thatthe gestational period, and an effort was made, acute adrenal insufficiency could readily be pre-for therapeutic reasons, to supply no more than cipitated by dietary sodium restriction (Figurethe minimum required replacement therapy. 5). Urinary glycogenic corticoid was first de-Symptoms of incipient acute adrenal insufficiency termined six weeks later, but the excrttion ofappeared promptly whenever an attempt was made neutral reducing lipids and 17-ketosteroids wasto reduce the daily ration of cortisone acetate be- already elevated (Figure 1).low 25 milligrams per day. In Figure 3 areshown data indicating that adrenal insufficiency Response to corticotrophin following pregnancypromptly followed reduction of exogenous corti- (Tables I and III).sone to 12.5 milligrams daily; immediately prior A daily injection of potent, long-acting corti-to hormone reduction she was excreting glyco- cotrophin was given for eight days to both pa-genic corticoids in the urine in the amount -of 151 tients well after te post-partal period in an at-micrograms per 24 hours (Table I). Fran tempt to ascertain whether they harbor residual

BODYWEIGHT

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EVIDENCEOF ADRENALINSUFFICIENCY FOLLOWINGREDUCTIONOF EXOGENOUSHORMONEDURING 6th MONTHOF PREGNANCY

(CBL 18 we Total Adrenalectomy)

WEMNESSn~zsss

MWEXIAVTING

.-- -.~~~~~~~~~~~~~~

3?-6 ___W__I____ . ... -

12fl12/2/52 12/4 12/6 12/8 12/10 12AZ 12/14

FIGURE 3.Dotted lines represent the normal range for our laboratory.

1472~A.HILLS, E. yENNING, F., DOHAN, G. WEBSTER,; JR., AND) E. RICHARDSON

EVIDENCE OF ADRENAL INSUFFICIENCYOCCURRINGDURING 7th MONTH OF PREGNANCY

(B.L. 18W. () Totol Adrenolectomy)

WEAK(DI77Y

rOOmH TOOTH ANOREXICASCESS EXTRACTION NAUSEATED

I 1~ 4 41

~~~~~uu~~~~~~~~~~~~x u u w s-~~~~~~~~~~~~~~~~~~~~~DATE US/53 I/I MI V21 4*3

FIGuRz 4.

Dotted lines represent the norsial range for our laboratory.

adrenal cortical tissue which is capable. of in-

creasing its output of hormone under intense,

continuous, and rather prolonged stimulation.

One control and four experimental 48-hour urine

collections were obtained and analyzed for 17-

ketosteroids, neutral reducing lipids (following

hydrolysis at pH, and also with 8-glucuronidase),and glycogenic corticoids.

A small increase in the urinary excretion of

neutral reducing lipids as determined following

glucuronidase hydrolysis was noted in B. L. fol-

lowing corticotrophin administration; and a simi-

lar increase was observed in S. C., the increase be-

ing more convincing if the uncorrected steroid

values are used. Conversely, an increment of uri-

nary 17-ketosteroid observable in B. L. on the

basis of the values corrected for Wine creatinin

excretion becomes rather unconv incing when the

uncorrected values are used& S. C. showed -no in-

crease of 17-ketosteroid excretion, and neither

patient increased her output either of neutral re--

ducing lipids as determined following acid hy-

drolysis or of glycogenic corticoids in response to

corticotrophin stimulation.

DISCUSSION

Do adrenal-deficient women exhibit adrenal-like

activity during pregnancy?

It would seem desirable tq define precisely what

is meant by "adrenal cortical-like" activity. In-

creased excretion of -neutral reducing lipids and

17-ketosteroids (Zimmermann reaction) certainly

indicates adrenal cortical- activation under certain

conditions, notably adrenal.,s'timulation by corti-

cotrophin; yet the simple finding of increased ex-

cretion of these materials under special circum-

stances, such as pregnancy, -cannot be assumed to

'reflect adrenal. activity unless it is reasonably cer-

tain at least that the secretions of other glands

cannot -provide precursors of the 'urinary sub-

stances giving the~phosphomolybdate and Zimmer-

mann reactions. For example, an increase in the

urinary excretion of 17-ketosterioids, derived from

BODYWEIGHT

(Pou~nds) 95

LABORDELIVE R

4

145

1401

1251

SERUMI

NA

linES/I

SEIAMIC

(mEW'L)

IBUN

(ingn%)

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0

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1472

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I

PREGNANCYAND ADRENOCORTICALFUNCTION

TABLE III

Effect of depot (intramuscular) corticotrophin upon urinary steroid excretion and circulating eosinophils inadrenal-deficient womenfollowing pregnancy

Steroid (mg./24 hr.)Steroid (mg./24 hr.) Creatinine (Gm./24 hr.)

Neutral reducing Neutral reducingACTH* Urine lipids lipids osiophileUSP creatinine

Pt. Date units Gm./24 hr. pH, G'dase 17-KS pH, G'dase 17-KS per mm.' Date

1953 1953S. C.t 6/20-22 0 .73 2.2 3.1 1.6 3.0 4.2 2.2 45 6/22

6/22-24 60 1.08 2.0 4.5 3.8 1.9 4.2 3.56/24-26 60 .98 2.5 7.9 3.4 2.6 8.1 3.56/26-28 60 1.30 3.5 7.5 2.6 2.7 5.8 2.0 64 6/296/28-30 60 1.25 3.0 6.0 2.2 2.4 4.8 1.8 55 6/30

B. L.$ 5/31-6/2 0 .98 3.7 8.4 5.6 3.8 8.6 5.7 155 6/26/2-4 60 .85 3.4 11.6 5.1 4.0 13.7 6.0 255 6/46/4-6 60 .74 2.9 10.8 4.7 3.9 14.6 6.4 171 6/56/6-8 60 .92 3.2 13.2 7.0 3.5 14.3 7.6 137 6/66/8-10 60 .80 2.7 12.6 6.4 3.4 15.8 8.0 160 6/10

H. P. Acthar Gel, supplied by Dr. C. J. O'Donovan of the Armour Laboratories.t Thirteen months post-partum.t Four and one-half months post-partum. Patient received, throughout the period shown, 37 milligrams of oral

cortisone acetate daily, supplied by Dr. Elmer Alpert of Merck and Company.

an interstitial cell tumor would neither reflectadrenal -activity nor imply the secretion of com-pounds possessing the characteristic structural orbiologic properties of the alpha-ketolic hormonesof the adrenal cortex.

It is proposed, therefore, to understand by"adrenal-like" activity the secretion of compoundswith physiological properties supposed to be pos-sessed exclusively or at least predominantly by theC-21 alpha-ketolic steroid hormones of the adrenal

EVIDENCE OFADRENALINSUFFICIENCYDEVELOPING DURING 7th MONTHOFPREGNANCY

(S.C. 36 C. 0 SUBTOTAL ADRENALECTOMY)

BODYWEIGHT(KILOS)

SERUMSODIIUM

(mrEqIL)

CUMULATIVESODIUM

BALANCEin EqJ24 )

DIETARYSODIUM

(m Eq./24hrs.)

sOC

140

135

130

125

20C

-30C

DizzD'ZZI. I

DizzyL

--~~~44 4, . . - .

¶1.Dote 2-24-52 25 26 27 ;

FIGURE 5.

Dotted lines represent the normal range for our laboratory.

28 29 3-I

1473

A. HILLS, E. VENNING, F. DOHAN, G. WEBSTERl, JL, AND E. RICHARDSON

cortex. It would appear that any attempt to es- creased secretion of C-21 alpha-ketolic steroids,tablish the development of adrenal cortical-like one might expect that-the urinary values for neu-activity during pregnancy in adrenal-deficient Wal reducing lipids would parallel those for gly-women, in this sense, must start with one or cogenic corticoids throughout pregnancy; but themore of the three following findings: 1) aug- parallelism is not impressive in normal pregnantmented recovery from biological fluids, during women (7). Furthermore, the phosphomolyb-pregnancy in such women, of compounds which date reaction, which was used for the determina-can be shown to have the chemical structure or tion of neutral reducing lipids in our studies ascharacteristic physiologic activity of C(21 alpha- well as in those of Jailer and Knowlton, is notketolic steroids, or elk of compouds which Ac4n specific for C-21 alpha-ketolic steroids; it is given,be derived from such steroids and from no others; for example, by any substance possessing an alpha-2) demonstration of a temporary capacity to re- beta unsaturated 3-ketone group (18), which isspord ding pregrancy to cortilatrophin ad- p irsent n progesterone. It is true that proges-ministratkon in terms accetable idices of aug- iterqne bWs never bvei found in urine, and that themented excretion of ~C-21 aipha-ketolic steroid;; lketne -function has been reduced in its known3) demonstration of conspicuous protection, dur- urinary derivatives. These, however, representing the pregnant state, against the development less than 29 per cent of ,tsU egradation productsof acute adrenal insufficiency. (19), and it is entirely possible that hitherto uni-

1) The data (Figures l and 2) confirm the oh- dentified metabolites of p'ogesterone could be re-servation of others that adrenal-deficient women sponsible, in some part, for the increase in the ex-excrete an increased quantity of 17-ketosteroids cretion of neutral reducing lipids observed in theseand of neutral reducing lipids in the urine during patients.pregnancy. However, in view of the non-speci- The glycogenic corticoids, however, can scarcelyficity of the Zimmermann and phosphomolybdate be supposed to derive from any source other thanreactions, and of the augmentation and diversifi- the 11-oxygenated C-21 alpha-ketolic steroidscation of the function of at least several of the ep- characteristically present in the secretion of thedocrine organs during pregnancy, it is exceed- adrenal cortex. The increased elimination of theseingly difficult to exclude the possibility that hor- substances in the urine of our patients duringmones other than C-21 alpha-ketolic steroids elabo- pregnancy (Table I) therefore constitutes con-rated by the ovary or placenta might serve as the vincing evidence for increased endogenous pro-precursors for urinary compounds giving these duction of such compounds, unless it can be sup-reactions. One of us (7) has specifically pointed posed that a higher proportion of secreted corti-out that the Zimmermann reaction, by which 17- cal hormone reaches the urine in active form dur-ketosteroids are usually estimated, is given by the ing pregnancy, owing to some alteration duringpregnanolones, which derive from progesterone that state of the usual pathways of steroid metab-and appear in greatly augmented quantity in preg- olism.nancy urine, as well as by other 3- and 2Oketos- 2) Jailer and Knowlton (1) observed a 40 perteroids. It is therefore open to question whether cent decrease in circulating eosinophils on threethe increased urinary elimination of substances occasions four hours following a test injection ofgiving the Zimmermann reaction necessarily indi- epinephrin (twice, subcutaneously) and cortico-cates the development of elike-aetlit w troi (once, intramuscularly) during the latterpregnancy. Indeed, no iui i.7kt s t of pregnancy in an arl deficient woman;excretion is commonly fo u r - on repetition of the tests following pregnancy, nowhen the more specific antfinon'torda- similar decrease was observed. These findingstion is used to estimate 17-ketosteroids (7), were interpreted as indicating a temporary ca-though in one Addisdnia who- beame pregnatpat *t pregnant advenaldeflcient woman toboth methods indicated increase 17-ketosterdid d lor adrenal4ike response to agentselimination (6). capable of stimulating the adrenal cortex.

If the increased urinary excretion of neutral A 50 per cent reduction of circulating eosino-reducing lipids during pregnancy reflects an in- phils (20) has generally been taken to represent

1474

PREGNANCYAND ADRENOCORTICALFUNCTION

the minimum decrease constituting a positive re-sponse to the four-hour ACTHtest; and a recentstatistical study (21) locates the minimum normaldecrease at 60 per cent. An eosinophil decreaseof 40 per cent in the four-hour ACTH test maywell fall within the range of changes which canbe ascribed to the combined effects of randomfluctuations of the eosinophil count and of enu-meration error. A similar objection may also beurged against the significance attached to theeosinophil responses to epinephrin; moreover, sub-sequent work has indicated that epinephrin maydepress the eosinophil count by a mechanismother than adrenal cortical activation (22). Inboth of our patients, near maximal stimulationwith intravenous corticotrophin failed to elicitevidence of any consequential adrenal-like responseduring pregnancy (Table II).

3) Available reports of the effect of pregnancyupon the survival of adrenalectomized animals(2-4, 23-25) throw little light upon the possibledevelopment of adrenal-like activity in humanpregnancy. Any prolongation of survival whichmight be observed as a result of pregnancy in theadrenalectomized animal might perhaps be at-tributed to the beneficial effects of certain sex hor-mones rather than to adrenal-like activity; forestrus in dogs and cats (26, 27) and progesteronein rats and ferrets (28-31) have been reported toprolong the survival of adrenal-deficient animals.Actually, however, while the survival of adrenal-ectomized bitches is reported (3) to be prolongedby pregnancy, a similar report for cats (2) couldnot be confirmed by other investigators (23, 24);and experiments in the white rat (4, 25) are alsoconflicting. The lack of agreement on this sub-ject among physiologists, and the possibility ofdifferences between species, appear to compel re-liance upon clinical studies for the elucidation ofthe effect of pregnancy upon the physiology ofhuman adrenal deficiency.

Death from adrenal insufficiency occurring inassociation with pregnancy was frequent in Ad-disonians before salt and hormone therapy weredeveloped; and while the fatalities commonly fol-lowed the stress of delivery or abortion, it ap-pears that the condition of the untreated Addi-sonian may deteriorate progressively throughoutgestation (32). The literature dealing with preg-nancy complicated by Addison's disease, which

has been reviewed to 1950 (6, 33), furnishes noevidence that hormone requirement regularly de-creases at any time during pregnancy, substitutiontherapy having been considered necessary or de-sirable throughout gestation in most cases. Thefirst trimester with its associated vomiting is es-pecially hazardous even to the steroid-treatedAddisonian (34, 35), but also in the third tri-mester extra therapy may be required (6), andadrenal crisis has been reported to follow dietarysalt reduction and feeding of potassium in theseventh month (36). The vulnerability of ourpatients to adrenal insufficiency during the latterpart of pregnancy (Figures 3, 4, and 5) is thus inaccord with the experience of others.

Evidence to suggest the development of adrenal-like activity during pregnancy in adrenal-deficientwomen, then, is confined essentially to the findingthat the urinary excretion of steroids commonlyused as indices of adrenal cortical secretion, andespecially of steroids exhibiting the biological ac-tivity of 11-oxygenated alpha-ketolic steroids, isenhanced during pregnancy in such women. Thecentral problem in interpreting the data is thereconciliation of the vulnerability to adrenal in-sufficiency of the adrenal-deficient pregnantwomen with the concurrent high values for uri-nary excretion of glycogenic corticoids associatedwith pregnancy in such women. Since adrenal in-sufficiency in the physiologic sense results frominadequacy of hormone in relation to need, itsappearance in our patients means only that thequantity of hormone available to them at the time(endogenous plus exogenous) was inadequate totheir needs. If pregnancy itself very greatlyincreases the requirement for adrenal hormone,the augmented urinary steroid excretion of gly-cogenic corticoids might faithfully reflect an in-creased secretion of C-21 alpha-ketolic steroids,the adrenal insufficiency representing an increaseof need in excess of increase of supply of hormone.On the other hand, if pregnancy does not strik-ingly increase basal hormone requirement, onewould have to infer that the urinary steroid excre-tion of glycogenic corticoids by these patients doesnot reliably reflect the availability of alpha-ketolicsteroids, but rather an increase in the proportionof available (secreted plus exogenous) hormonerecovered in the urine; for it is difficult to sup-pose that a secretion rate corresponding to that

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A. HILLS, E. VENNING, F. DOHAN, G. WEBSTER, JR., AND E. RICHARDSON

found in Cushing's disease would not be morethan adequate to protect against the mild stressof salt withdrawal in S. C.,4 or the more consider-able stress of dental infection and tooth extractionin B. L.; nor could one otherwise account at allfor the need for exogenous hormone exhibited byB. L. during her pregnancy.

A definitive choice between these alternatives isprobably not warranted at present; but some evi-dence can be urged in support of the view that in-creased excretion of urinary steroids during preg-nancy in these women may be attributable to al-terations of the metabolism of secreted or ad-ministered steroids rather than an increased rateof secretion. Dobriner, Lieberman, Rhoads, andTaylor (37) found that the two 11-oxygenated17-ketosteroids normally present in the urine ofnongravid women are excreted in much smallerquantity as pregnancy progresses. As these com-pounds are indubitably derived from 1 1-oxy-genated alpha-ketols ("glucocorticoids") secretedby the adrenal cortex (38) their near disappear-ance from the urine in normal pregnancy wouldappear to suggest that pregnancy is associatedwith hindrance to the oxidative removal of thealpha-ketol side chain of adrenal steroids. A de-crease in the proportion of available alpha-ketolicsteroid disposed of in this fashion would be con-sistent with an enhancement of the proportion ofavailable alpha-ketol appearing as such (i.e., asneutral reducing lipids and glycogenic corticoids)in the urine.

Moreover clinical experience with B. L. issomewhat difficult to reconcile with the view that

'We have forborne to interject into the discussion thefurther complication of a distinction between the "gluco-corticoids" (11-oxygenated alpha-ketolic steroids), whosesecretion alone is reflected in the glycogenic corticoids,and the "mineralocorticoids." Yet in the instance ofadrenal insufficiency precipitated by curtailment of so-dium 'intake (Figure 5) one might raise the objectionthat a very large secretion of glucocorticoids might failto protect against salt deprivation. A need for "mineralo-corticoids" cannot, however, be invoked to account forB. L.'s requirement for small quantities of cortisone dur-ing her pregnancy. Nor can a need for mineralocorticoidsvery plausibly explain the precipitation of adrenal in-sufficiency by infection and surgery in a patient receiv-ing both desoxycorticosterone and cortisone (Figure 4);for the 11-17-oxygenated steroids are presumably theprincipal agents conferring protection against stresses ofthis kind.

very large quantities of adrenal steroids were be-ing secreted endogenously by this patient. Asshown in Figure 3, reduction of exogenous corti-sone from 25 to 12.5 milligrams daily resulted inthe prompt appearance of manifestations of adre-nal insufficiency. If her total basal hormone re-quirement amounted to about 25 milligrams perday, a reduction of 12.5 milligrams per day wouldbe expected to result promptly in the appearanceof adrenal insufficiency; but if her requirement(and supply) of cortisone equivalent were manytimes greater, it seems surprising that withdrawalof so relatively small a quantity would be followedso promptly by symptomatic and chemical signsof adrenal insufficiency.

It is true that normal pregnant women are re-ported (39) to exhibit an increased concentra-tion of "17-hydroxycorticoids" in the blood.Whether a similar increase is observable in preg-nant adrenal-deficient women is not known; but itmay be pointed out that the finding does not in anycase afford conclusive proof of hyperadrenocorti-cism during pregnancy. If, as seems possible,pregnancy results in inhibition of the oxida-tive removal of the alpha-ketolic side chain, se-creted 17-hydroxy alpha-ketolic steroids might beexpected to survive for a longer period (and,hence, to be present in higher concentration in theblood) in a form detectable by the Porter-Silberreaction, though loss of biologic activity mightwell result from reduction of ring A or changeselsewhere in the steroid molecule.

There is thus nothing to disprove, and a gooddeal of circumstantial evidence to justify the sug-gestion, that the urinary steroid excretion inadrenal-deficient pregnant women may not re-liably establish that any consequential increase inthe supply of adrenal-like hormone occurs in suchwomen during pregnancy.

With regard to the urinary steroid data in ourpatients there appear, therefore, to be two pos-sible alternative interpretations neither of whichcan be definitely ruled out3 at present: 1) The

5Some guidance in selecting the correct explanationmight possibly be anticipated from a quantitative com-parison of the steroid excretion data from normal preg-nant women with those from adrenal-deficient pregnantwomen. Any such hope is disappointed, for the indi-vidual variation in the excretion of glycogenic corticoids(7) and of neutral reducing lipids at any time during

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urinary steroid values reflect a greatly increasedrate of secretion of adrenal or adrenal-like steroidsduring pregnancy, the increased availability ofsuch steroids being ineffective in protecting againstadrenal insufficiency because of a concomitantmarked increase of the requirement for adrenalhormone; or 2) the urinary steroid values are

misleading when accepted at face value as indi-cators of the rate of adrenal secretion during preg-

nancy; the high values for the chemically deter-mined steroids may be partly ascribable to non-

specific chromogens, and the excretion of neutralreducing lipids and glycogenic corticoids may re-

flect an increase in the proportion of availablehormone eliminated in the urine as alpha-ketols.

Are any adrenal-like steroids which may be se-

creted during pregnancy by adrenal-deficientwomen necessarily of extra-adrenal origin!

Even if one were to adopt the view that the aug-

mented excretion of urinary steroid during preg-

nancy indicates increased secretion of alpha-ketolicsteroids, the inference that such compounds mustbe secreted by some organ other than the maternaladrenal cortex will still not be firmly establisheduntil it is wholly clear that the latter organ can-

not be their source. Even in the "totally adrenal-ectomized" patient the possibility of residualadrenal cortical tissue cannot be wholly dismissed;and in the individual rendered adrenal-deficientby subtotal adrenalectomy (17) as well as in thepatient with Addison's disease (40) there is evi-dence that measurable though subnormal corticalfunction can be present.

Weknow of no evidence which can exclude thepossibility that an adrenal remnant or rest mightnot be affected by pregnancy in such a fashion as

to increase its output of adrenal hormone. It istrue that a barely adequate adrenal remnant shouldbe at all times under near-maximal stimulation byendogenous corticotrophin, according to current

pregnancy is very large, and the data are few; in con-

sequence no significant comparison can be made. Onecan state only that available data do not permit a dem-onstration that the excretion of neutral reducing lipidsand of glycogenic corticoids differ significantly in preg-nant adrenal-deficient patients as compared with normalpregnant women. No data are available in our labora-tory concerning the excretion of 17-ketosteroids duringnormal pregnancy.

concepts of the homeostatic mechanism regulatingadrenal cortical secretion (41), and our two pa-tients exhibited little evidence of adrenal responseto 24 and- 48-hour corticotrophin tests duringpregnancy (Table II). It is, however, conceivablethat stimulation over months by corticotrophinhypothetically elaborated in large excess duringpregnancy might result in actual hypertrophy oran adrenal remnant with consequent increase inthe secretion of adrenal hormone. An attempt(Tables I and III) to simulate such a putative ef-fect of pregnancy, conducted in our patients inthe post-partal state by continuous stimulation overan 8-day period with depot corticotrophin, is atbest suggestive of a modest response of the adrenalcortex to corticotrophin; a large increase of steroidexcretion, such as had accompanied pregnancy,could not be reproduced. Certainly, however,the possibility of such activation during preg-nancy under the influence of more prolonged stim-ulation by corticotrophin, or perhaps by someseparate adrenal-growth-promoting factor (42),has not been excluded.

It seems most unlikely that the fetal adrenalmakes any appreciable contribution of adrenalcortical hormone to the maternal organism duringpregnancy. The newborn infant, whether bornof a normal (43) or an adrenal-deficient mother(1), excretes only very small quantities of uri-nary steroids, including biocorticoids, and is re-sistant to corticotrophin stimulation (44). Jailerand Knowlton (1) suggested that the placentamight constitute an extra-adrenal source of"adrenal-like" hormone; and placentas of animaland of human origin have subsequently been re-ported to contain biologically active corticoid ma-terial (45, 46). However, there is no evidence toexclude the possibility that the material is simplystored there.

Since it is not possible to state with assurancethat pregnancy causes increased secretion of C-21alpha-ketolic steroids in adrenal-deficient women,nor that such secreted steroids cannot originate inmaternal adrenal tissue, satisfactory proof of anyextra-adrenal source of adrenal hormone is lack-ing at present.

From the point of view of practical manage-ment of the adrenal-deficient woman who becomespregnant, it is imperative to emphasize the factthat gestation does not decrease the hazard of

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acute adrenal insufficiency. The physiologicalstudies conducted in our patients, as well as nu-merous reports in the literature, necessitate theconclusion that any extra C-21 alpha-ketolic ster-oids, of whatever source, which may become avail-able to the severely adrenal-deficient woman inpregnancy are unable to prevent the prompt ap-pearance of acute adrenal insufficiency at any timeduring pregnancy when specific therapy is with-held. While pregnancy of itself appears to havelittle effect upon hormone requirement, its com-plications and the stress of delivery will ordinarilyrequire additional replacement therapy exactlyas will any stress in a non-pregnant adrenal-defi-cient person.

SUMMARY

1. Increased urinary elimination of 17-keto-steroids (Zimmermann reaction) and of neutralreducing lipids is regularly found during preg-nancy in adrenal-deficient women. The increaseis observable as early as the beginning of the sec-ond trimester, and is progressive to term.

2. Urinary excretion of glycogenic corticoidswas increased three- to four-fold during the latterhalf of pregnancy in two adrenal-deficient women.

3. Neither patient was protected by the preg-nant state against the development of acute adrenalcortical insufficiency, and no decrease in hormonerequirement was noted during pregnancy in theone patient requiring substitution therapy.

4. Neither patient developed during pregnancyany striking capacity to respond to near-maximalstimulation by intravenous corticotrophin over a24- or 48-hour test period.

5. More prolonged (8-day) stimulation withdepot corticotrophin following pregnancy failedin both subjects to reproduce the large increasesof urinary steroids which accompanied pregnancy.

6. The values for the urinary excretion of 17-ketosteroids, neutral reducing lipids and particu-larly glycogenic corticoids observed in adrenal-deficient pregnant women suggest that suchwomen acquire during pregnancy an endogenoussource of large quantities of C-21 alpha-ketolicsteroid hormones; but it is possible, for reasonswhich have been discussed, that these commonlyused indices of adrenal secretory activity becomemisleading during pregnancy, and that little or

no increase of the secretion of alpha-ketolic ster-oids accompanies pregnancy in adrenal-deficientwomen.

7. If adrenal-deficient womendo develop an en-hanced endogenous supply of adrenal-like alpha-ketolic steroids when they become pregnant, preg-nancy must increase their requirement for hor-mone together with the supply since such womenremain vulnerable to adrenal insufficiency duringgestation. The source of supply of any such ster-oids is apparently not the fetal adrenal; that anyorgan other than residual material adrenal tissuecan be implicated awaits demonstration.

ACKNOWLEDGMENTS

The authors wish to acknowledge the aid and sup-port of Drs. William A. Jeffers and Carl Bachman inthe conduct of these studies, and their kindness in re-viewing the manuscript.

Technical assistance was rendered by Mrs. IrmgaardLandolt, Mr. Walter Applin, Mrs. Helen Bulaschenko,Mrs. Hana Conover, and Miss Katherine Macatsoris.

Through the kindness of Dr. Elmer Alpert, the MerckCompany sustained hospitalization costs for B. L. through-out much of her pregnancy.

Weare indebted to Dr. James Walker for the sodiumanalyses used for the construction of Figure 5.

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