Cushing’s syndrome (CS) is rare in pregnancy and easy to overlook because many signs (weight gain, hypertension, glucose intolerance, edema) mimic normal gestation. This case of a 26-year-old primigravida illustrates how CS can present as gestational diabetes and preeclampsia, only to be recognized postpartum. Six months after delivery, persistent hypertension, facial swelling, easy bruising, violaceous striae, and proximal muscle weakness prompted testing that confirmed ACTH-independent CS from an adrenal source. Laparoscopic adrenalectomy normalized blood pressure and improved symptoms.
Why it’s missed
- Symptom overlap with pregnancy: edema, weight gain, hypertension, glucose intolerance.
- Testing pitfalls: physiologic HPA-axis activation in pregnancy complicates interpretation of screening tests (UFC, late-night cortisol, dex suppression).
- Low prevalence: <250 published pregnancy cases → low clinical suspicion.
Red flags in this case
- Both gestational diabetes and gestational hypertension/preeclampsia.
- Postpartum persistence of hypertension and new classic CS features (bruising, purple striae, proximal myopathy, moon-facies).
- Markedly elevated 24-h urinary free cortisol (>3× ULN on 3 days) and non-suppressible cortisol on dexamethasone testing with low-normal ACTH → ACTH-independent CS.
Management considerations
- Multidisciplinary team (obstetrics, endocrinology, radiology, surgery, anesthesia, neonatology).
- During pregnancy, definitive treatment depends on gestational age and severity (medical control vs. surgery in 2nd trimester when necessary).
- Postpartum adrenalectomy is often curative for unilateral adrenal adenoma; careful peri-op steroid management is required.
Takeaway
In pregnant patients with both gestational diabetes and hypertension—especially when blood pressure remains high postpartum—consider CS. Early recognition and targeted treatment reduce maternal–fetal complications and can be life-changing.