Hydrocortisone Loading Dose for Elective Cesarean Section with Adrenal Insufficiency

Intraoperative Protocol

For elective cesarean section in patients with adrenal insufficiency, the American College of Obstetricians and Gynecologists recommends administering hydrocortisone 100 mg IV at induction, followed immediately by a continuous infusion of 200 mg over 24 hours 1, 2
Cesarean section is classified as major surgery and requires the same stress-dose steroid coverage as other major surgical procedures, according to the American Society of Anesthesiologists 1, 2
The loading dose consists of hydrocortisone 100 mg IV bolus at surgical induction, which should be given before the procedure begins, as recommended by the American College of Surgeons 1, 2, 3
Immediately after the bolus, initiate a continuous IV infusion of hydrocortisone 200 mg/24 hours, approximately 8.3 mg/hour, as suggested by the Society of Critical Care Medicine 1, 2, 3
This protocol applies to both patients with primary or secondary adrenal insufficiency and patients on chronic adrenosuppressive doses of steroids, according to the Endocrine Society 1, 2

Continue the hydrocortisone 200 mg/24h IV infusion while the patient is NPO or experiencing postoperative vomiting, as recommended by the American Society of Anesthesiologists 1, 2, 3
An alternative to continuous infusion is hydrocortisone 50 mg IV or IM every 6 hours, though continuous infusion is preferred for maintaining stable cortisol levels, according to the Society of Critical Care Medicine 1, 2
Once tolerating oral intake, resume oral glucocorticoid at double the pre-surgical dose for 48 hours if recovery is uncomplicated, as suggested by the American College of Obstetricians and Gynecologists 1, 2, 3
If complications arise or recovery is prolonged, continue double oral dose for up to one week, according to the Endocrine Society 1, 2, 3

Never delay steroid administration for diagnostic testing in patients with known or suspected adrenal insufficiency—treat immediately, as recommended by the American College of Emergency Physicians 4
Do not use dexamethasone as the primary agent for patients with adrenal insufficiency, as it lacks mineralocorticoid activity and has a prolonged half-life that makes dose adjustment difficult, according to the Society of Critical Care Medicine 4
Ensure patients with primary adrenal insufficiency receive fludrocortisone once oral intake resumes, as they require mineralocorticoid replacement in addition to glucocorticoid coverage, as suggested by the Endocrine Society 4
Do not abruptly discontinue stress-dose steroids—always taper gradually to maintenance doses over 48 hours to one week depending on recovery, according to the American Society of Anesthesiologists 1, 2, 3