Table 1.

Suggested management of GC treatment in pregnancy.

Disease	Pre-conception	First trimester	Second and third trimesters	Delivery	Post-partum
Adrenal insufficiency	1. Hydrocortisone 10–12 mg/m2/day (usually 15–20 mg) in two or three divided oral doses;2. Cortisone acetate (once daily 25–37.5 mg/day), prednisone or prednisolone (3–5 mg/day) can also be used.3. Avoid dexamethasone as it is not inactivated by 11β-HSD2.Note: (a) Prednisone and cortisone both require activation by maternal 11β-HSD1 (to form active prednisolone and cortisol respectively);(b) Women on other GCs should be switched to hydrocortisone.	Maintain preconception doses. No need to adjust GC replacement dose unless there is evidence of intercurrent illness. Parenteral GCs if intractable vomiting.	Adjust according to clinical course, often a 20–40% increase in the third trimester is needed.	100 mg of hydrocortisone intramuscularly (or intravenously) at the onset of active labour (cervix dilation >4 cm or contractions every 5 min for 1 h, or both), followed by hydrocortisone 200 mg every 24 h either via continuous intravenous infusion or 50 mg every 6 h is recommended.	Adjust according to clinical condition or intercurrent illness. For the first two to four days a double oral dose should be maintained, provided there are no complications and pre-conception dose can be restored thereafter.
Congenital adrenal hyperplasia	1. Use prednisone, prednisolone or hydrocortisone, all of which are inactivated by placental 11β-HSD2;2. Consider steroid treatment in women with NCCAH who are infertile or have history of miscarriage;3. Pre-conception counselling and genetic testing in both the women and partners;4. Dexamethasone treatment should still be regarded as experimental and not routine.	Maintain preconception doses. No need to adjust GC replacement dose unless there is evidence of intercurrent illness.Parenteral GCs if intractable vomiting	Adjust according to clinical course, often a 20–40% increase in the third trimester is needed.	100 mg hydrocortisone intramuscularly (or intravenously) at the onset of active labour (cervix dilation >4 cm or contractions every 5 min for 1 h, or both), followed by hydrocortisone 200 mg every 24 h either via continuous intravenous infusion or 50 mg every 6 h is recommended.	Adjust according to clinical condition or intercurrent illness. For the first two to four days a double oral dose should be maintained, provided there are no complications and pre-conception dose can be restored thereafter.
Antenatal treatment for lung maturation			4 × 6 mg IM doses of dexamethasone given 12 h apartor2 × 12 mg IM doses of betamethasone 24 h apart. Note: IV administration can be considered in anti coagulated women, Consider the possibility of tertiary adrenal insufficiency.	If adrenal insufficiency has been diagnosed, follow treatment above.	If adrenal insufficiency has been diagnosed, follow treatment above.
All above	Women should be advised of possible adrenal crises; GC dose adjustment in case of stressful situations (a double dose for the period of illness and parenteral glucocorticoid in case of vomiting or emergency situations); Education for the woman and the partner regarding self-administration of parenteral hydrocortisone, and the wearing of an alert bracelet or equivalent is essential.

GC: glucocorticoid; 11β-HSD: 11: β-hydroxysteroid dehydrogenase; NCCAH: non-classic congenital adrenal hyperplasia.