Adrenal diseases are rare diseases in pregnancy and include Cushing syndrome, primary aldosteronism, pheochromocytoma, and uncommon complication in adrenal cortex carcinoma (ACC) pregnancy [1]. In 1932, Harvey introduced Cushing syndrome for the first time and, in connection with this syndrome, chronic and long-term elevation of blood cortisol levels were described as major symptoms. People with chronic cortisol usually develop infertility since high levels of cortisol prevent ovulation [1, 2]. Cushing syndrome is very rare during pregnancy [3]. Due to the fact that the syndrome during pregnancy causes complications for the mother and the fetus, it is important to pay attention to it [2, 4, and 5].
In Cushing disease, there is a change in the level of gonadotropin secretion; as a result, changes in the adrenaline hormone result in abortion [5]. Symptoms and disorders that occur during the onset of the syndrome include weight gain, edema, glucose intolerance, increased blood glucose, increased protein excretion, increased blood pressure, fatigue, discomfort, and so on [4-7]. Cushing complications can even cause HELLP syndrome in the early days [8].
It is very difficult to diagnose Cushing syndrome during pregnancy because the symptoms and disorders caused by the syndrome are very similar to those of the pregnancy and these symptoms are overlapping [6]. Even Cushing symptoms can be confused with preeclampsia or diabetes [7]. Diagnosis of Cushing disease is based on the high levels of cortisol in the plasma, which is not suppressed by administration of dexamethasone. To diagnose, the presence of a complication is confirmed by increasing the release of cortisol in a 24-hour urine sample. None of the tests are completely correct and CT scan and MRI are used to detect and identify the causes of pituitary tumors, or hyperplasia of the adneral gland.
 The benign adenoma of the adrenal gland is the most common cause of Cushing appearance in pregnant women [7]. Less than 1.4% of cases of Cushing syndrome are independent of corticotropin and are often due to adrenal adenoma. In this disorder, tumors are usually bilateral and half are malignant. Occasionally, simultaneous increase of the androgens causes intense virilization; the accumulation of adipose tissue leads to the appearance of a typical Cushing, which consists of round face, fat lump between the shoulders and abdominal obesity. Other common symptoms in non-pregnant women include fatigue and weakness, hypertension, hirsutism, amenorrhea, personality changes, skin streriae easy skin bruise and impaired glucose tolerance testing [8, 9]. The most important cause of this complication is the changes in the production of adrenocorticosteroid hormone (ACTH). Corticosteroid levels increase with increase of ACTH. Since high levels of cortisol during pregnancy are a serious risk to mother and fetus, they should be monitored throughout pregnancy [10]. Increasing cortisol levels can lead to increased complications such as obesity, elevated blood glucose, muscle relaxation, high blood pressure and osteoporosis [11]. Each of these complications may include dangers such as decreased intrauterine growth, placental abruption, or even intrauterine death.
Patient and methods
A 36-year-old woman with a history of cesarean section in the first pregnancy who despite of IUD had her second pregnancy, referred to hospital. On the first visit, the IUD was removed and pregnancy continued. The results of the usual trials, at the beginning of pregnancy, indicated normal condition, including the thyroid test. In the embryo-screening screening tests conducted at 12 weeks, the results were completely normal. At this time, the first manifestation of blood pressure was observed in the patient. In the continuation of pregnancy, the patient was constantly monitored. At the end of the 34th week of pregnancy, due to previous cesarean section, proteinuria, elevated blood pressure with edema and increased blood glucose levels and delayed intrauterine growth of the fetus, the patient was under cesarean section.
During pregnancy, the patient had high blood pressure and blood pressure was not controlled after pregnancy. For women who develop elevated blood pressure after the first half of pregnancy and have protein in their urine, diagnosis of preeclampsia is given, and women who develop hypertension before they get pregnant or get it before the 20th week of pregnancy have disorder which is called chronic blood pressure. The patient's previous pregnancy was 3 years ago, and there was no high blood pressure between two pregnancies .However, due to the lack of precise control before her pregnancy and unwanted pregnancy, her hypertension became chronic, and gradually continued with her pregnancy. At week 16, the patient's blood pressure reached 150-160 SBP mm Hg and 90-100 DBP mm Hg. At this time, 24-hour urine protein was checked which was 450 mg. Patient treatment started with methyldopa. With progression in pregnancy, edema and proteinuria increased, and in 25 weeks gestational diabetes was diagnosed (GCT=185 mg / dL) and insulin therapy was given to the patient. Despite the daily consumption of three 200 mg methyldopa doses, blood pressure was not controlled and reached a level of 170 SBP mmHg and 110 DBP mmHg, and proteinuria was increasing. Regardless of repeated recommendations for termination of pregnancy, the patient refused to accept it and decided to continue the pregnancy. At 28th week, she was hospitalized in the hospital for controlling blood glucose and she received betamethasone 12 mg daily. At 29th week, the 24-hour protein excretion was 1062 mg, and she was still advised to end the pregnancy, but the patient still decided to continue pregnancy. At 32th week, ultrasound showed a decrease in fetal growth, but the doppler of the navel and central cerebellar arteries was normal and the amniotic fluid did not decrease. At the end of the 34th week, the uterine contractions began and was subjected to cesarean section due to the history of previous cesarean section and intrauterine growth retardation. The day before cesarean section, the patient's proteinuria reached 6 grams in 24-hour urine, but hemoglobin, platelet and hepatic enzymes were normal. During general anesthesia during cesarean section, the patient's blood pressure was 220 SBPmmHg and the edema was very severe. Her weight gain was 24 kg from 60 kg at the beginning of pregnancy to 84 kg at the time of cesarean section. 2 kg of this increase was over the past week. The summary of the results of the patient's tests prior to cesarean delivery is presented in Table 1 (Table).

Table 1) Prepartum Tests

The result of cesarean section was a 34-week-old baby weighing 1700 grams admitted to NSAID. After the operation, a severe pre-eclampsia was diagnosed for the patient and received Magnesium sulfate in the ICSI. Despite of receiving Labetalol, the blood pressure did not decrease from 160 SBP mmHg and 100 DBP mmHg, and nitroglycerin was prescribed to control the patient's blood pressure in the ICSI. Finally, injectable Furosemide and Albumin and Diovan tablets were prescribed to control the patient's blood pressure. During the first 48 hours after cesarean section, edema decreased and the patient lost weight by 14 kg. Echocardiography was performed during the hospitalization, which was normal. Despite receiving treatment with Furosemide, Methyldopa, and Diovan, blood pressure was 160 mm SBP mildew and 100 mm Hg DBP and 24 hours protein was 1638 mg. One week after delivery. At 12 weeks postpartum, blood pressure was between 140-150 SBP mmHg and 100-110 DBP Hgmm. Fasting blood glucose returned to normal (88 mg / dL), edema continued and the patient was in a state of weakness and fatigue. Due to high blood pressure, the causes of secondary hypertension began to be investigated. In the usual trials and renal and immunological tests, it was remarkable that hyperlipidemia was observed and proteinuria was continued. According to the history of the patient, the possibility of nephritic syndrome or renal artery disorder was initially considered. The most important patient tests after cesarean delivery are listed in Table 2 (Table 2).

Table 2) Postpartum tests

The abdominal MRI was requested for examination of the renal artery. In randomized MRI, a right adrenal mass of 3 cm was observed (Figure. 1).
As a result, the possibility of Cushing disease was diagnosed for the patient. This diagnosis was confirmed by performing dexamethasone suppression test and adrenocorticotropin measurement. After laparoscopic adrenalectomy to the right, gradually Corticosteroids was discontinued for the patient and all signs of high blood pressure, edema, proteinuria, high blood glucose and hyperlipidemia were removed. Weakness and pain of proximal muscles was continued up to one year after adrenalectomy, which gradually improved with physiotherapy. A 24-hour proteinuria test after adrenalectomy surgery was about 99 mg after 7.5 postpartum months.

Discussion
Although Cushing syndrome often occurs at the age of fertility, Cushing syndrome has also been observed during pregnancy in rare cases [8, 12]. Cortisol is considered as a natural barrier to follicular growth and ovulation, and it is usually difficult to detect [12, 13]. During pregnancy, increased estrogen release from the placenta leads to stimulation of the adrenal glands and liver, and increased activity of the adrenal cortex is associated with increased cortisol levels [12]. In this condition, the level of cortisol in the blood rises and, therefore, the diagnosis of the disease is based on the high levels of cortisol in the blood [7]. Response to stress is one of the most important tasks of cortisol. When the amount of cortisol in the blood is appropriate, the hypothalamus and pituitary release less corticotropin and adrenocorticotropin. This means that the cortisol released by the adrenal gland, as usual, is always as much as the body needs, but the level of cortisol in the bloodstream increases as a result of the Cushing complication [4, 12, and 14]. Cushing syndrome is associated with significant complications and, if left untreated, it can even be up to 70% with death [12].
The most important symptoms of this complication in the mother is hypertension and diabetes during pregnancy [12, 14, and 15]. In our study, a pregnant person had high blood pressure, which then became chronic blood pressure due to lack of control. Other symptoms of the patient were the incidence of gestational diabetes at the 25^th week, which led to insulin therapy for the patient. In the sample, clinical symptoms of the syndrome were clearly observed. Although, it was possible that the Cushing complication be mistaken with preeclampsia due to the similarity of the symptoms, with cortisol serum and urine tests and observing their high levels, severe edema, nephritic syndrome and radiographic confirmation, the disease was diagnosed. Eventually, this diagnosis was confirmed by testing for dexamethasone suppression and adrenocorticotropin measurement. After laparoscopic adrenalectomy to the right, gradually corticosteroid was discontinued and all symptoms of high blood pressure, edema, proteinuria, high blood glucose and hyperlipidemia were resolved. Regarding the risks of this complication for mother and fetus, as well as high probability of fetal death, management of the patient was effective in identifying and acting appropriately and timely in maternal and fetal rescue.
 
Conclusion
In a sample that was examined in this study, symptoms of Cushing syndrome was appeared in form of high blood pressure in the first weeks of pregnancy. This is not the typical occurrence of pre-eclampsia, but the patient's blood pressure in repeated studies led to chronic hypertension and then excessive pressure. Other symptoms including increased blood sugar, skin striae, abdominal obesity, and fatigue are associated with Cushing symptoms during pregnancy. The same has led to a lack of recognition of the underlying condition during pregnancy. It is recommended that in all patients with non-typical and more severe symptoms than those of normal symptoms during pregnancy, other differential diagnosis always be considered in order to prevent the complications, if possible, before the end of pregnancy.
 
Acknowledgements: The case was not found by the authors.
Ethical permissions: The case was not found by the authors.
Conflict of interests: The case was not found by the authors.
Financial support: This study was supported by Sarem Fertility and Infertility Research Center.
Contribution of authors: Maryam Almasi Nasr Abadi (First author), author of the article/main author/author of discussion (%40); Seyedeh Bahareh Mir Armandehi (Second author), author of the article/main author/author of discussion (%40); Zahra Roostaee (Third author), author of the article/helper author/author of discussion (%20).