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Also, although, again I highly recommend you talk to your doctor... in some ways it seems odd that you would be so high when you weren't before. But, there's a couple of things to think about ....1) during pregnancy your adrenal response (normally) would increase 60 to 80 percent 2) the ACTH test (and I'm assuming you had the high dose 250 ug test because that's what appears to be most often given) gives you what is called a superphysiological dose - more than your body could ever produce on its own to see how your adrenals work 3) what you are given for the test is a shot of the hormone that the pituitary produces - if you have a primary deficiency, your adrenal glands won't respond adequately or at all to that hormone because the adrenal glands aren't working right. if you have a secondary deficiency, the theory is that your response won't be good because your adrenals will have started to not respond as well because they have not been getting ACTH from the pituitary ( i think effectively the adrenal gland falls a asleep - I've seen it referred to as atrophy). I've read for secondary deficiency, that if the ACTH test were repeated the next day, the response would be higher (I think because your adrenals woke up a bit). 4) From what I could see from doing my own research for myself, the information out there about what test results are right for pregnancy in this area seems to be on the sparse side ( probably because there's not a lot of testing in pregnant women for this issue).

I've seen all sorts of estimated ranges as to where your AM cortisol should be in your 3rd trimester. I've seen 25 to 35 as the right range. In a medical journal article (cite to follow), Ihe authors note that in 4 different studies, the following ranges were considered normal 13.7 to 37.7, 20.9 to 50, 21.6 to 31.2, and 24-36.2 (American Journal of Obst & Gynecology 183:669-73(2000). In this article, among other things, 6 women with normal adrenal function were given the low dose ACTH test (1 ug as opposed to 250). The highest result achieved was a bit over 50. That's only 6 women though and I wonder if those 6 women would have gone higher with the high dose test, or if with more normal women, the range would have been different.

So, anyway, from what you said before, it sounds like your AM cortisol is way, way too low even if you weren't pregnant. Low blood pressure is a classic sign of low cortisol. I don't know why you would score so high on the ACTH stim test, although perhaps it is a lab error. Or maybe you are secondary and normally your pituitary wouldn't be putting out the right amount of ACTH, but your adrenals have woken up from being stimulated during pregnancy ( I think the placenta produces a hormone like ACTH) . Perhaps you could have a secondary deficiency and because you're pregnant your adrenals have really woken up and when given ACTH they react well (but again, if you have a secondary deficiency, your body would not be supplying the right amount of ACTH and so it won't react to stress appropriately to trigger your body to make enough cortisol when it's needed).

I searched high and low for myself for a study dealing with ACTH stimulation tests in women that had a secondary deficiency because of a true pituitary problem. I didn't find anything other than articles looking at women who's response was suppressed because of taking steriod injections for lung maturity. In fact that study I cited about, looks at that issue. That study involved only 8 pregnant women who were taking the steriod injections and none of them had ACTH response rates that went above 30. In a later article (which I still can't find) another researcher uses that study to conclude that 30 should be considered the cuttoff for the 250 ug ACTH stim test in pregnant women in late pregnancy (although he's not sure himself if that cutoff is correct).

Again, please keep in mind that I'm not a doctor. I'm only sharing with you things I read when I was pregnant and worried; and I'm strongly suggesting that you speak with your doctor. Please don't not talk to your doctor and also not take the medicine you've been prescribed. Please get answers to all your questions and if you don't trust your doctor, try to get a second opinion quickly before you just decide not to take the medication. Also, you need to know from your doctor whether you should be treated during delivery since this is a highly stressful time for your body and if your body isn't going to produce ACTH and cortisol correctly, you would need to be medicated during delivery (and I believe for days later). If you need such treatment, your endo needs to communicate this to your OB.

Take care of yourself. (hugs)
Vent all you want! (smiles)

I didn't find anything in print saying that the ITT shouldn't be done while pregnant. I also didn't see anything at all saying it was safe. I would not have taken it myself during pregnancy. I'm with you there and I'm pretty sure my doctor would not have done it. You might want to ask your OB about this. I have a feeling your OB wouldn't like it. I would be very nervous (probably an understatement) about having my blood sugar go below 40, even for the short time that the test has you go below 40, while pregnant.

The following is long, so read on only if you want (smiles).,,,

The reason I've read so much about this is because I had a severe postpartum hemorrhage with my first pregnancy, with no blood transfusion. And, I've had symptoms that match up with Sheehan's syndrome, a hypopituitarism that can be caused by a postpartum hemorrhage. As my endo puts it, I have classic symptoms, but the blood work in his opinion doesn't show it - plus he told me that because I got pregnant that I couldn't be hypopit - and that's not true. Prior to pregnancy, I had a lot of "low normal" pit hormone results.

Before I was pregnant, my AM cortisol was 8.9 (range starts at 4 something). I was still trying to figure out why I was having these problems (although I suspected SHeehan's) when I became pregnant. I got brushed off by one endo while pregnant. I then saw an expert out of town (3 hour drive) who believed that I could be hypopit but she couldn't be sure because of the pregnancy. By that point, my Free T4 had dipped just below normal and my OB called it "borderline" and wasn't going to treat it. This endo prescribed thryoid medication and told me that it was safer to give it to me while pregnant to be sure I had enough thyroid medication that it was to let me go without. She also wanted me monitored by a local endo to make sure cortisol stayed ok (my numbers at that point were slightly higher, but she thought they should be much higher), particularly with the thyroid medicine replacement. Btw, this out of town endo doesn't run the ITT at all because she says it's too dangerous. Not pregnant, though, frankly I'd prefer the ITT.

Anyway, so the out of town endo wanted me to work with a local endo. So, I went shopping for a new endo and ended up with the current guy. Unfortunately, he doesn't specialize in pit issues and he has spent most of our appointments telling me it isn't possible for me to have a pit problem. But, at least he ran some things for me - like the ACTH stimulation test. But, I had to research for myself what it meant during pregnancy. I certainly wasn't going to trust this non-expert who disputed an expert to tell me things were absolutely ok unless I could confirm it. It might sound egotistical or silly, but I had myself and this little baby to protect and I had to know I was getting good treatment. It was only after I found the article showing that my stim test results weren't as great as he thought for him to agree to write a letter to my OB telling them what to look for and how to treat an adrenal crash during delivery.

For my stim test which I took in the begining of the 2nd half of my second trimester ( i dont' recall how many weeks I was), I started at 15.9 for cortisol and I went up to 29.1. As I said this endo thought that was great, but this article I found (which I still cant' find and it's driving me crazy) opined that 30 should be the cutoff.

Fortunately, I made it through the delivery ok with no adrenal crash. That's also making me feel pretty good that I might not have an adrenal problem. But, I'd feel much better with an ITT or at least a repeat ACTH.

So anyway, because I made it through delivery with no crash, this endo pronounced me basically ok and he had me go off the thyroid medicine with the plan to test again in 4 weeks to see if I really needed it. Well, anyway, I did that and the following week I had it tested again (by another doctor) and I had a normal TSH and a below normal Free T4 - consistent with a pit problem. I had that test done, ironically, because my prolactin results and inability to breastfeed got me accepted into a study on prolactin deficiency and breastfeeding. As a part of that study, I had to have a normal Free T4.

So, needless to say I got the endo to allow me back on the thyroid medicine. But it wasn't easy. This endo basically told me that because it was so uncommon to have one pit deficiency without others that I couldn't have a pit problem. So anyway, he then had me have an MRI which came out normal.

Well, from that prolactin study, I learned that I have a partial prolactin deficiency too. So that's two pit hormone problems.

I don't have a followup with this local endo for almost another year (that's the earliest he'll see me - because he's convinced I don't have a pit problem).

I'll be going for another opinion somewhere down the road, perhaps out of town again (Dr. Friedman in CA?).

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