Systematic review of phaeochromocytoma in pregnancy

Laparoscopic Surgery During Pregnancy: A Meta-Review and Quality Analysis Using the Assessment of Multiple Systematic Reviews (AMSTAR) 2 Instrument

Accumulation of experience with minimally invasive surgery over the last three decades has rendered laparoscopic surgery the mainstay of management for surgical pathology during pregnancy. In the present meta-review, we compiled the available evidence on the safety of laparoscopic and robotic-assisted surgeries during pregnancy, based on relevant systematic reviews (SR) and meta-analyses (MA). A systematic review was performed for articles published until February 2024 in English using PubMed/MEDLINE (Medical Literature Analysis and Retrieval System Online) and Google Scholar based on predefined selection and exclusion criteria. We implemented the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and included SRs and MAs examining women of childbearing age (population) who had undergone laparoscopic surgery or robotic-assisted laparoscopic surgery during pregnancy (intervention). The presence of comparison to open surgery was desirable but not mandatory (comparator). The included studies should necessarily report on fetal loss (outcome), and optionally on other metrics of fetal, maternal, or operative performance. We considered SRs/MAs analyzing randomized trials, observational studies, case reports, and case series (study design). The methodological quality of SRs/MAs not exclusively including case reports and case series was assessed with the Assessment of Multiple Systematic Reviews (AMSTAR) 2 instrument. A total of 1229 articles were screened, of which 78 were potentially eligible. Of these, 33 articles met our inclusion criteria, 18 containing SRs only and 15 SRs with MA. The examined disciplines were laparoscopic appendectomy (10 studies, 30.3%), laparoscopic cerclage for cervical insufficiency (eight studies, 24.2%), adnexal-ovarian laparoscopic surgery (five studies, 15.2%), laparoscopic cholecystectomy and biliary tree exploration (three studies, 9.1%), laparoscopic myomectomy (two studies, 6.1%), and one study each for laparoscopic surgery regarding pancreatic indications, adrenal indications, and bariatric complications (3.0%). The odds ratio/relative risk for fetal loss rate ranged from 0-1.9, with variable statistical significance depending on the discipline. Twenty-three out of the 33 studies were submitted to quality evaluation with the AMSTAR 2 instrument, with three being of "low quality" (13.0%) and the remaining 20 of "critically low quality" (87.0%). In conclusion, the widespread acceptance of laparoscopic surgery for treating surgical pathology during pregnancy is substantiated by heterogeneous and low-quality evidence. Literature mainly revolves around laparoscopic appendectomy, whereas other disciplines that may commonly arise during pregnancy, such as cholecystectomy and the acute abdomen following bariatric surgery, are underrepresented in the literature. Factors such as anatomical alterations that may affect surgical access, surgeon's expertise, and the biological course of the underlying pathology should be taken into consideration when selecting the appropriate mode of operating during pregnancy.

A rare case of pheochromocytoma in a pregnant woman presenting with chest pain: extraordinary management

BACKGROUND

Pheochromocytoma is rare in pregnant women. It presents as diverse symptoms, including hypertension and sweating. The symptoms of pregnant women with pheochromocytoma and comorbid hypertension often mimic the clinical manifestations of preeclampsia, and these women are often misdiagnosed with preeclampsia.

CASE PRESENTATION

In this case, a pregnant woman presented with chest pain as the primary symptom, and a diagnosis of pheochromocytoma was considered after ruling out myocardial ischemia and aortic dissection with the relevant diagnostic tools. This patient then underwent successful surgical resection using a nontraditional management approach, which resulted in a positive clinical outcome.

CONCLUSIONS

It is essential to consider pheochromocytoma as a potential cause of chest pain and myocardial infarction-like electrocardiographic changes in pregnant women, even if they do not have a history of hypertension.

Maternal pheochromocytoma and childbirth in Sweden 1973-2015: a population-based study on short and long-term outcome

PURPOSE

Data guiding management of pheochromocytoma and paraganglioma (PPGL) in pregnant women is limited, and long-term effects on the child are unknown. The aim of this retrospective registry-based case-cohort study was to assess how maternal PPGL and treatment impacts maternal and fetal outcome, including long-term outcome for the child. The main outcomes were maternal and fetal mortality and morbidity at delivery and relative healthcare consumption in children born by mothers with PPGL during pregnancy.

METHODS

The National Birth Register identified 4,390,869 pregnancies between 1973-2015. Data was crosslinked with three Swedish national registers to identify women diagnosed with pheochromocytoma or paraganglioma within one year before or after childbirth. Hospital records were reviewed and register data was collected for five age-matched controls for each child until age 18.

RESULTS

21 women and 23 children were identified (incidence 4.8/1.000.000 births/year), all women with adrenal pheochromocytomas (Pc). The majority (71%) were diagnosed post-partum. Nine women (43%) were hypertensive during pregnancy. Preterm delivery was more common in Pc patients compared to controls (30% vs 6%, p < 0.001). There was no maternal or fetal mortality. Timing of tumor removal did not affect gestational weight or APGAR scores. There was no observed difference in hospital admissions between children affected by maternal Pc and controls.

CONCLUSION

Pc was commonly diagnosed after delivery and raised the risk of pre-term delivery, suggesting a need for an increased awareness of this diagnosis. However, reassuringly, there was no fetal or maternal mortality or any observed long-term impact on the children.

Pheochromocytoma During Pregnancy: A Hidden Cause for Hypertension

Pheochromocytoma, a rare but potentially serious condition, poses challenges in timely identification, especially during pregnancy due to misconceptions about pregnancy-related hypertension causes. However, paroxysmal symptoms heighten diagnostic suspicion. The diagnosis relies on biochemical confirmation of catecholamine hypersecretion followed by imaging for tumor localization. When diagnosed at or after 24 weeks, alpha-adrenoceptor blockers are recommended during pregnancy to manage catecholamine excess, delaying tumor removal until viability or post-delivery. The rarity of this condition during pregnancy, coupled with diagnostic and management challenges, underscores its importance for obstetric professionals in addressing hypertensive control, delivery timing, and surgical intervention.

Pheochromocytoma/Paraganglioma (PPGL): A Misdiagnosed Cause of Hypertension during Pregnancy

Hypertension (HT) during pregnancy is not an infrequent obstetric problem, reaching a prevalence of 5-10%. This condition is highly associated with both maternal and fetal complications if not precisely diagnosed and managed. Even though primary HT, obesity, and preeclampsia are the main causes of HT in this period, other less familiar conditions must be considered during the investigation. Pheochromocytoma and paraganglioma (PPGL) are chromaffin cell tumors that produce, store, and secrete catecholamines, leading to HT and other adrenergic manifestations. Recognition of PPGL is crucial since misdiagnosis and improper management can lead to high morbidity and mortality, particularly during pregnancy. We report on two cases of PPGL diagnosed during pregnancy with different managements. Case 1 is a 25-year-old female at 31 weeks of first pregnancy, whose severe HT and life-threatening symptoms prompted an emergency delivery without previous confirmation or medical treatment of a suspected PPGL. After confirmation, a right adrenal PPGL was surgically resected 4 months later, following 15 days of medical therapy. Case 2 is a 22-year-old female at 18 weeks of pregnancy whose symptomatic PPGL was resected in the second trimester. A next-generation sequencing panel, including 23 PPGL-related genes, found no germline pathogenic variants (GPVs) in case 1 and an exon 1-4 germinative heterozygous deletion of the MAX gene in case 2. Despite the different medical approaches, both cases had satisfactory outcomes. Although uncommon, PPGL should be considered in the differential diagnosis of HT in pregnancy since missing the diagnosis and failing to introduce appropriate and timely treatment may lead to dramatic consequences for the mother and fetus. PPGL diagnosed during reproductive age is likely to result from GPV, prompting genetic investigation and counseling.

Pheochromocytoma Diagnosed During First Trimester of Pregnancy

Pheochromocytomas are rare catecholamine-secreting tumors that occur in 0.002% of pregnancies. These tumors result in high maternal and fetal morbidity and mortality unless diagnosed in early stages of development, because excess levels of catecholamines cause vasoconstriction of both maternal and uteroplacental vasculature. Paroxysmal hypertension is the most common manifestation, but its variability in presentation and similarity to other pregnancy-related conditions often make diagnosis of pheochromocytoma difficult. Thus, it is essential to consider underlying pathological causes of hypertension during gestation. Diagnosis and treatment of pheochromocytoma must be approached uniquely given the physiologic changes during pregnancy. The standard of care for diagnostic imaging during pregnancy is with magnetic resonance imaging. For these reasons, knowledge of therapy for pheochromocytomas in the pregnant patient is essential for clinical endocrinology practice.

The Silent Killer Seeks Young Blood: A Case Report on the Perioperative Anesthetic Management of a Paraganglionoma in Pregnancy

Pheochromocytomas and paraganglionomas are rare neuroendocrine tumors. The multisystem effects of these tumors on the pregnant woman and fetus, the timing of surgery in relation to the pregnancy, and the pharmacological treatment have several anesthetic implications. Case reports on elective cesarean section followed by postpartum resection of the tumor are scarce. A case is presented of a 31-year-old nulliparous female where an antenatal diagnosis of a paraganglionoma was made at 19 weeks gestation for whom an elective cesarean section was performed at 31 weeks gestation under graded lumbar epidural anesthesia, followed by an elective open surgical removal of the tumor six weeks postpartum.

Paraganglioma in pregnancy, a mimic of preeclampsia: a case report

BACKGROUND

The new presentation of pheochromocytoma or paraganglioma in pregnancy is very rare and can be life-threatening for mother and child.

CASE PRESENTATION

We present the case of a 26-year-old gravida 3 para 2 otherwise healthy Caucasian woman at 34 weeks gestation who presented with new onset hypertension associated with headaches, dry heaves, diaphoresis, and palpitations. She was initially diagnosed with preeclampsia and treated with labetalol and an urgent cesarean section, delivering a healthy baby girl. The diagnosis of preeclampsia came into question when, 6 weeks postpartum, she continued to have hypertension with atypical features. Testing revealed metastatic paraganglioma associated with a succinate dehydrogenase B gene mutation. The patient was then started on alpha-adrenergic blockade and has had close blood pressure monitoring while discussion of advances therapies is ongoing.

CONCLUSION

This case demonstrates how paraganglioma/pheochromocytoma can be misdiagnosed as preeclampsia due to the overlapping features of new-onset hypertension late in pregnancy accompanied by headache and proteinuria. It is impractical to routinely screen for paraganglioma/pheochromocytoma in all pregnant patients diagnosed with preeclampsia due to the rarity of these tumors and the harm from high false-positive rates. Therefore, it is incumbent on the provider to have a high degree of suspicion for paraganglioma/pheochromocytoma when clinical features are unusual for preeclampsia, such as intermittent palpitations, diaphoresis, orthostatic hypotension, or hyperglycemia. Early detection of paraganglioma/pheochromocytoma with interventions to mitigate the risk of hypertensive crisis greatly reduce maternal and fetal mortality. Fortunately, our patient delivered a healthy baby and did not have any additional pregnancy complications despite the delay in her diagnosis.

The diagnosis and management of pheochromocytoma and paraganglioma during pregnancy

Diagnosis of pheochromocytoma or paraganglioma (PPGL) in pregnancy has been associated historically with high rates of materno-fetal morbidity and mortality. Recent evidence suggests outcomes are improved by recognition of PPGL before or during pregnancy and appropriate medical management with alpha-blockade. Whether antepartum surgery (before the third trimester) is required remains controversial and open to case-based merits. Women with PPGL in pregnancy are more commonly delivered by Caesarean section, although vaginal delivery appears to be safe in selected cases. At least some PPGLs express the luteinizing hormone/chorionic gonadotropin receptor (LHCGR) which may explain their dramatic manifestation in pregnancy. PPGLs in pregnancy are often associated with heritable syndromes, and genetic counselling and testing should be offered routinely in this setting. Since optimal outcomes are only achieved by early recognition of PPGL in (or ideally before) pregnancy, it is incumbent for clinicians to be aware of this diagnosis in a pregnant woman with hypertension occurring before 20 weeks' gestation, and acute and/or refractory hypertension particularly if paroxysmal and accompanied by sweating, palpitations and/or headaches. All women with a past history of PPGL and/or heritable PPGL syndrome should be carefully assessed for the presence of residual or recurrent disease before considering pregnancy.

Primary aldosteronism in pregnancy

Primary aldosteronism (PA) is the most common form of secondary hypertension. Although hypertensive disorders seem to affect around 5-10% of pregnancies worldwide, literature counts less than 80 cases of PA diagnosed during the peri-partum period. In this review we discuss about current knowledge on pathophysiology, natural history, diagnosis and treatment of PA in pregnancy. Because of the physiologic changes in the renin-angiotensin-aldosterone system (RAAS) and the contraindication to both confirmatory test and subtype differentiation, diagnosis of PA during pregnancy is challenging and relies mostly on detection of low/suppressed renin and high aldosterone levels. The course of pregnancy in patients with PA is highly variable, ranging from progesterone-induced amelioration of blood pressure (BP) control to severe and resistant hypertension with potential maternal and fetal complications. Mineralcorticoid receptor antagonists (MRA) are the recommended and most effective drugs for treatment of PA. As the anti-androgenic effect of spironolactone can potentially interfere with sexual development, their prescription is not recommended during pregnancy. On the other side, eplerenone, has proven to be safe and effective in 6 pregnant women and may be added to conventional first line drug regimen in presence of resistant hypertension or persistent hypokalemia. Ideally, patients with unilateral forms of PA should undergo adrenalectomy prior to conception, however, when PA is diagnosed during pregnancy and medical therapy fails to adequately control hypertension or its complications, adrenalectomy can be considered during the second trimester in case of unilateral adrenal mass at MRI-scan.

Pheochromocytoma disguised as gestational hypertensive disease during pregnancy: A case report

Pheochromocytoma is often diagnosed prior to pregnancy. Sometimes, the disease may be diagnosed for the first-time during pregnancy masking itself as a hypertensive disease in pregnancy. Early diagnosis and timely, appropriate management reduce possible maternal and fetal complications. We identified a case of pheochromocytoma during pregnancy misdiagnosed as preeclampsia.

Surgical treatment of adrenal tumors during pregnancy

While most adrenal tumors are identified incidentally and are non-functional, hormone-secreting tumors can cause morbidity and mortality. Hemodynamic lability and hypertension in pregnancy are associated with worse maternal and fetal outcomes. Achieving a diagnosis of hormone excess due to adrenal tumors can be clinically more difficult in the gravid patient due to normal physiologic alterations in hormones and symptoms related to pregnancy. This review focuses on some nuances of the diagnostic work-up, perioperative care, and surgical management of adrenally-mediated cortisol excess, primary aldosteronism, and pheochromocytoma and paraganglioma in the pregnant patient.

Intrapartum adrenalectomy for pheochromocytoma presenting in pregnancy: A case report

Pheochromocytoma is one of the rare causes of hypertension in pregnancy, occurring in one in every 50,000 pregnancies. The aim of this case report is to describe an atypical presentation of pheochromocytoma at 35 weeks gestation, where it presented with right flank pain and seizures, its preoperative medical optimization, and intrapartum concurrent surgical management. It also discusses various clinical presentations of pheochromocytoma in pregnancy, appropriate laboratory and radiological investigations, and different modalities of treatment. It is important to consider the possibility of the diagnosis of pheochromocytoma when considering the different causes of high blood pressure in a term pregnancy. Prompt antenatal diagnosis and timely management are critical to reducing maternal and perinatal morbidity and mortality rates.

Intraoperative Serum Catecholamine Levels in a Pregnant Woman With Pheochromocytoma Undergoing Cesarean Delivery With Combined Spinal-Epidural Anesthesia: A Case Report

Pheochromocytoma has a significant effect on perioperative hemodynamics; however, little is known about the changes caused by pheochromocytoma in pregnant women during cesarean delivery. Moreover, cesarean delivery in pregnant women with pheochromocytoma is often performed, along with pheochromocytoma removal, under general anesthesia depending on the time of delivery. Therefore, changes in the hemodynamics of these patients during cesarean delivery under spinal anesthesia combined with epidural anesthesia, along with their serum catecholamine concentration, have not been reported.

In this report, we describe the changes in the maternal intraoperative hemodynamics and serum catecholamine level of a pregnant woman with pheochromocytoma who underwent cesarean delivery under combined spinal-epidural anesthesia at 35 weeks of gestation. No significant change in the hemodynamics and serum catecholamine level was observed, and the procedure was carried out safely.

Cesarean delivery in an optimized pheochromocytoma patient under combined spinal-epidural anesthesia might be feasible without concurrent surgical removal of pheochromocytoma.

Paraganglioma in pregnancy: A case series and literature review

Paragangliomas are rare neuroendocrine neoplasms which are often catecholamine-secreting and associated with familial syndromes. Described here are three women with a variety of pathology: isolated secretory paraganglioma diagnosed in pregnancy, secretory metastatic paraganglioma in pregnancy and non-secretory metastatic paraganglioma in pregnancy. Whilst paragangliomas are associated with morbidity and mortality during pregnancy, good maternal and fetal outcomes can be achieved through individualised care within the context of a multidisciplinary team. Although paragangliomas are associated with morbidity and mortality in pregnancy, good maternal and fetal outcomes can be achieved through individualised care within the context of a multidisciplinary team.

Pheochromocytoma as a rare hypertensive complication rarely associated with pregnancy: Diagnostic difficulties (Review)

This review provides a brief clinically relevant review of pheochromocytoma in pregnancy, to raise awareness among doctors in obstetrics and the aim is to serve as the first point of reference when confronted by their presence. Pheochromocytomas are neuroendocrine, catecholamine-secreting tumours. Despite having the highest incidence rate among other hormone-secreting adrenal tumours, they remain rare especially when associated with pregnancy. The non-specific presentation of pheochromocytomas, the difficulties in their diagnosis during pregnancy as well as the high maternal and fetal mortality rates associated with them, present a challenge. Clinical suspicion and meticulous patient history-taking remain the primary lines of defense, while biochemical proof of catecholamine excess (or their metabolites) and imaging-based localisation of the tumour are required for diagnosis. Antenatal diagnosis and complete localisation of the tumour increase the likelihood of successful outcomes for both mother and newborn. Magnetic resonance imaging (MRI) remains the method of choice during pregnancy without excluding the use of ultrasound. Treatment goals should include the avoidance of hypertensive crises while maintaining adequate uteroplacental circulation. The target blood pressure is not strictly defined but is in line with the general guideline addressing chronic hypertension during pregnancy. Antihypertensive medications remain the cornerstone in managing pheochromocytoma. As a first-line, the α-adrenergic, nonselective antagonist phenoxybenzamine is the most frequently used agent, while α1-selective adrenergic antagonists with or without the addition of β- or β1-blockers are also prescribed in certain cases, rendering calcium channel blockers as 'second-choice'. Blood-pressure control of the mother and the well-being of the fetus are determining factors in deciding the time of delivery, which is preferably conducted by Caesarean section. Excision of the tumour(s) remains the final treatment goal. Lifelong biochemical testing is required with or without medical treatment, to address mineralocorticoid or glucocorticoid deficits. Despite ever-improving positive outcome rates, pheochromocytoma associated with pregnancy remains a pathology with high mortality and morbidity rates.

Special situations in pheochromocytomas and paragangliomas: pregnancy, metastatic disease, and cyanotic congenital heart diseases

The aim of our study was to describe the epidemiology, diagnosis, and treatment of the most complex pheochromocytoma and paraganglioma (PGL) cases, including pheochromocytoma/PGL during pregnancy, in cyanotic congenital heart diseases (CCHDs), and metastatic pheochromocytoma. The English and Spanish literature was thoroughly evaluated searching for articles reporting clinical studies, case reports, or reviews of pheochromocytoma/PGL in pregnancy and in CCHD and metastatic pheochromocytoma/PGL. Particular settings in the diagnosis and management of pheochromocytoma and PGLs remain challenging. Those special situations include the diagnosis during pregnancy or in the context of CCHD since the typical clinical features of pheochromocytoma may be confounded with preeclampsia during pregnancy and with the complications commonly observed in CCHD. In addition, although some clinical and genetic features have been associated with higher risk of metastatic pheochromocytoma, the detection and prediction of the development of metastatic disease involve another complex situation that may require special hormonal determinations as plasmatic 3-methoxytyramine and nuclear medicine studies including ¹⁸FDG PET-CT or ¹⁸F-FDOPA PET-CT, among others. Furthermore, the selection of the most appropriate treatment in these situations, as well as the moment to carry it out, requires special care as limited evidence is available. This article reviews the epidemiology, diagnosis, and treatment of the pheochromocytoma/PGL during pregnancy, metastatic pheochromocytoma/PGL, and pheochromocytoma/PGL in CCHD. The diagnosis, and especially the treatment, of metastatic pheochromocytomas and pheochromocytoma/PGL during pregnancy and in CCHD is challenging. Thus, these cases should be management in reference centres by multidisciplinary teams specialized in the pheochromocytoma/PGL treatment.

Unrecognised pheochromocytoma in pregnancy discovered through metoclopramide-triggered hypertensive emergency

PURPOSE

Pheochromocytoma, a catecholamine-secreting tumour leading to neurological and cardiovascular life-threatening conditions through hypertension crisis, occurs in 0.1-0.5% of hypertensive patients, but it is extremely rare in pregnancy (0.0018-0.006%). Some classes of drugs, even commonly used in pregnancy, can trigger catecholamine secretion, precipitating the clinical situation.

MATERIALS AND METHODS AND RESULTS

We report a 33-year-old woman, gravida 2 para 1, with previous mild hypertension, was admitted to the emergency room, at 28 2/7 weeks of gestation due to headache, tachycardia and severe arterial hypertension (220/120 mm Hg) triggered by the antiemetic metoclopramide used for a week because of nausea. In the emergency room, a paradoxical rise in blood pressure followed intravenous labetalol infusion was observed. Both metoclopramide and labetalol-triggered hypertensive crisis raised the suspicion of an undiagnosed pheochromocytoma. Diagnostic work-up showed elevated normetanephrine urinary excretion ​​and a right adrenal pheochromocytoma by abdominal magnetic resonance imaging. Oral alpha-1 and beta-1-adrenergic antagonist and calcium-channel blocker were started. At 33-weeks of gestation, she underwent a caesarean section giving birth to a female child. Seven weeks later she underwent a video-laparoscopic right adrenalectomy which normalised her blood pressure.

CONCLUSIONS

Both metoclopramide, a selective dopamine type-2 receptor antagonist and partial agonist of 5-hydroxytryptamine 4 receptor, and labetalol, a non-selective β-adrenoreceptor-blocker with weak α1-adrenergic antagonism, exacerbated an acute hypertensive crisis revealing an unrecognised pheochromocytoma in a pregnant patient. Careful attention to potential drug-triggered catecholamine crises and especially early recognition of pheochromocytomas, are mandatory in hypertensive pregnant women. A missed or delayed diagnosis could result in catastrophic results affecting foetal and maternal outcomes.

Pheochromocytoma and Paraganglioma in Pregnancy: a New Era

PURPOSE OF REVIEW

Pheochromocytoma and paraganglioma (PPGL) in pregnancy is a rare entity and management of these patients is fraught with uncertainty. Our objective is to review current literature and discuss diagnosis and management of these patients.

RECENT FINDINGS

Outcomes of PPGL in pregnancy have improved in recent years. The greatest risk for adverse maternal and fetal outcomes is the diagnosis of PPGL after delivery. Alpha- and beta-adrenergic blockade is well tolerated and is associated with less adverse outcomes. Antepartum surgery is not associated with improved maternal or fetal outcomes. Biochemical testing and cross-sectional imaging should be performed prior to conception for patients with a known germline variant associated with PPGL.

CONCLUSIONS

Medical therapy should be initiated when PPGL is diagnosed in pregnancy. Antepartum surgery should be reserved for special circumstances. Case detection testing in high-risk patients can identify PPGL before pregnancy.

A Misleading Presentation of Pheochromocytoma in Pregnancy: A Case Report

Pheochromocytoma is a catecholamine-secreting adrenal tumor and also a rare cause of secondary hypertension in pregnancy. Its low prevalence, nonspecific clinical presentation, and symptoms similar to preeclampsia generate a diagnostic challenge during pregnancy. A 23-year-old hypertensive pregnant woman at 36th gestational week of her first pregnancy was admitted with severe hypertension (210/150 mmHg), headache and proteinuria that made us presume the case as severe preeclampsia. In spite of starting with maximum doses of antihypertensive medications like IV labetolol,and oral nifedipine, loading dose of an anticonvulsant drug, and IV magnesium sulphate, her symptoms persisted. Keeping in view the risks involved to mother and fetus, we delivered the baby by emergency cesarean section. In the postoperative period, along with severe uncontrolled hypertension, she developed tremors, palpitation, and sweating that all led us to further diagnostic workup for secondary causes of hypertension. Eventually, a diagnosis of pheochromocytoma was confirmed by abdominopelvic contrast- enhanced computed tomography and by increased 24-hour urine metanephrine, normetanephrine, and vanillylmandelic acid levels. Subsequently, adrenal suppression was achieved by a multidisciplinary approach, and then she underwent laparoscopic adrenalectomy. This case highlights the importance of maintaining a high index of suspicion and multidisciplinary approach while investigating secondary causes of hypertension in young women, thereby differentiating it from preeclampsia.

Postpartum pheochromocytoma-induced takotsubo syndrome

A postpartum patient with acute-onset dyspnoea and hypotention, associated with reduced left ventricular function requiring intensive blood pressure control, was initially misdiagnosed as having peripartum cardiomyopathy. Her clinical symptoms rapidly resolved. Echocardiography revealed reversible left ventricular dysfunction with apical ballooning and coronary angiography was normal. Based on these findings, we diagnosed takotsubo syndrome. Over the next two months, the patient experienced repeated bouts of elevated sympathetic activity. On workup, we found an adrenal mass and elevated urine metanephrines. After adrenalectomy, histology confirmed pheochromocytoma. Our patient had the rare diagnosis of postpartum pheochromocytoma-induced takotsubo syndrome.

Pregnancy and phaeochromocytoma/paraganglioma: clinical clues affecting diagnosis and outcome - a systematic review

BACKGROUND

Phaeochromocytoma and paraganglioma (PPGL) in pregnancy, if not diagnosed antepartum, pose a high risk for mother and child.

OBJECTIVE

To examine the clinical clues of antepartum and postpartum/postmortem diagnosis of PPGL.

SEARCH STRATEGY

Case reports on PPGL in pregnancy published between 1 January 1988 and 30 June 2019 in English, German, Dutch or French.

SELECTION CRITERIA

Case reports containing a predefined minimum of clinical data on PPGL and pregnancy.

DATA COLLECTION AND ANALYSIS

Two authors independently performed data extraction and assessed data quality. We calculated odds ratios (OR) (with 95% confidence intervals) and used uni- and multivariable logistic regression analysis.

MAIN RESULTS

Maternal and fetal/neonatal mortalities were 9.0% (18/200) and 14.2% (29/204), respectively. Maternal mortality was 42-fold higher with PPGL diagnosed postpartum/postmortem (17/58; 29.3%) than antepartum (1/142; 0.7%) (adjusted OR 45.9, 95% CI 5.67-370, P = 0.0003). Offspring mortality was 2.6-fold higher with PPGL diagnosed postpartum/postmortem than antepartum (OR 3.1, 95% CI 1.38-6.91, P = 0.0044). Hypertension at admission (OR 2.29, 95% CI 1.12-4.68, P = 0.022), sweating (OR 3.14, 95% CI 1.29-7.63, P = 0.014) and a history of PPGL, a known PPGL-associated gene mutation or adrenal mass (OR 8.87, 95% CI 1.89-41.64, P = 0.0056) were independent factors of antepartum diagnosis. Acute onset of symptoms (OR 8.49, 95% CI 3.52-20.5, P < 0.0001), initial diagnosis of pre-eclampsia (OR 6.34, 95% CI 2.60-15.5, P < 0.0001), admission for obstetric care (OR 10.71, 95% CI 2.70-42.45, P = 0.0007) and maternal tachycardia (OR 2.72, 95% CI 1.26-5.85, P = 0.011) were independent factors of postpartum diagnosis.

CONCLUSION

Several clinical clues can assist clinicians in considering an antenatal diagnosis of PPGL in pregnancy, thus potentially improving outcome.

TWEETABLE ABSTRACT

Systematic review of 204 pregnant patients with phaeochromocytoma identified clinical clues for a timely antepartum diagnosis.

Maternal and fetal outcomes in phaeochromocytoma and pregnancy: a multicentre retrospective cohort study and systematic review of literature

BACKGROUND

Phaeochromocytoma or paraganglioma (collectively known as PPGL) in pregnant women can lead to severe complications and death due to associated catecholamine excess. We aimed to identify factors associated with maternal and fetal outcomes in women with PPGL during pregnancy.

METHODS

We did a multicentre, retrospective study of patients with PPGL and pregnancy between Jan 1, 1980, and Dec 31, 2019, in the International Pheochromocytoma and Pregnancy Registry and a systematic review of studies published between Jan 1, 2005, and Dec 27, 2019 reporting on at least five cases. The inclusion criteria were pregnancy after 1980 and PPGL before or during pregnancy or within 12 months post partum. Eligible patients from the retrospective study and systematic review were included in the analysis. Outcomes of interest were maternal or fetal death and maternal severe cardiovascular complications of catecholamine excess. Potential variables associated with these outcomes were evaluated by logistic regression.

FINDINGS

The systematic review identified seven studies (reporting on 63 pregnancies in 55 patients) that met the eligibility criteria and were of adequate quality. A further 197 pregnancies in 186 patients were identified in the International Pheochromocytoma and Pregnancy Registry. After excluding 11 pregnancies due to potential overlap, the final cohort included 249 pregnancies in 232 patients with PPGL. The diagnosis of PPGL was made before pregnancy in 37 (15%) pregnancies, during pregnancy in 134 (54%), and after delivery in 78 (31%). Of 144 patients evaluated for genetic predisposition for phaeochromocytoma, 95 (66%) were positive. Unrecognised PPGL during pregnancy (odds ratio 27·0; 95% CI 3·5-3473·1), abdominal or pelvic tumour location (11·3; 1·5-1440·5), and catecholamine excess at least ten-times the upper limit of the normal range (4·7; 1·8-13·8) were associated with adverse outcomes. For patients diagnosed during pregnancy, α-adrenergic blockade therapy was associated with fewer adverse outcomes (3·6; 1·1-13·2 for no α-adrenergic blockade vs α-adrenergic blockade), whereas surgery during pregnancy was not associated with better outcomes (0·9; 0·3-3·9 for no surgery vs surgery).

INTERPRETATION

Unrecognised and untreated PPGL was associated with a substantially higher risk of either maternal or fetal complications. Appropriate case detection and counselling for premenopausal women at risk for PPGL could prevent adverse pregnancy-related outcomes.

FUNDING

US National Institutes of Health.

Pheochromocytoma and Paraganglioma: From Clinical Findings to Diagnosis

The majority of pheochromocytoma (PCC) and paraganglioma (PGL) are endocrine active tumors, and they cause clinical symptoms by secreting excess one or more catecholamines (epinephrine, norepinephrine, and dopamine) and their inactive metabolites (metanephrine, normetanephrine, 3-metoxythromine). Although signs and symptoms regarding excess catecholamine often develop in PCC and PGL (PPGL), non-functional PPGLs may present with local compression symptoms. Persistent, sometimes worsening hypertension is the most common finding and occurs in 80-90% of the patients. Classically defined symptom triad; headache, sweating and palpitations are seen in only 25% of the patients with PCC. The difference of clinical symptoms may be related to the tumor secretion, epinephrine or norepinephrine. All patients with signs and symptoms suggestive of catecholamine excess should be screened by biochemical tests regardless of whether they have hypertension or not. Not all patients with newly diagnosed hypertension need to be screened, but only patients with additional tips for catecholamine excess should be screened. Approximately 20% of the PPGLs are diagnosed in childhood, and the male/female ratio is 2/1. 60-90% of pediatric patients present with hypertension. PPGL in pregnancy is rare, and the estimated incidence ranges between 1/15000-1/54000. Although early diagnosis is the most important factor in preventing mortality, diagnosis is not as easy as it is a rare condition. Hypertension is a common complication in pregnancy, occurring in 5-10%. Computed tomography should not be used as the imaging method during pregnancy; the first choice is magnetic resonance imaging with gadolinium or without contrast. Plasma free metanephrine or 24-hour urinary fractionated metanephrine level is recommended as a screening test for the diagnosis of PPGL in the Endocrine Society Clinical Practice Guideline. In suspicious situations, tests should be repeated. Since 40% of these patients have germline mutations, genetic tests are recommended for all patients with PPGL regardless of family history and age. Preoperative knowledge of germline mutations affects the surgical approach and the extent of adrenalectomy. After the biochemical diagnosis is made in PPGL, the tumor is localized with imaging methods to make the operation plan. In this review, we aimed to evaluate the clinical findings, diagnostic tests, and imaging studies for tumor localization in PPGL.

Pheochromocytoma diagnosed during pregnancy: a case report

Pheochromocytoma is a rare catecholamine producing tumor. During pregnancy, this tumor can mimic gestational hypertension, preeclampsia or eclampsia. We present a case of a 38-year-old, multiparous woman admitted at 36 weeks of gestation due to hypertension. After cesarean section, she developed an unexplainable worsening of her hypertension that was resistant to the traditional therapy. Additional investigation lead to the diagnosis of pheochromocytoma. This case highlights the importance of an early diagnosis and the need of a multidisciplinary approach for the improvement of pregnancy outcomes in patients with pheochromocytoma.

ROBOTIC PARAGANGLIOMA RESECTION IN A PREGNANT PATIENT

Objective

Functional paragangliomas in pregnancy are rare; however, if not recognized and treated early, they can be life-threatening. New treatment approaches with robotic resection are promising.

Methods

We present a case of a pregnant female with a paraganglioma which was successfully resected during the second trimester using Da Vinci Xi robotic system. Paraganglioma was diagnosed with plasma and urinary catecholamines and metanephrines, a contrast computed tomography (CT) scan, and confirmed with surgical pathology.

Results

The patient was initially seen in the emergency room prior to the index pregnancy for nausea, vomiting, and intermittent, left lower quadrant abdominal pain, episodic sweating, palpitations, and anxiety. CT scan of the abdomen and pelvis showed a 4.8 × 4.3 cm heterogeneously enhancing mass in the left retroperitoneum adjacent to the aorta just below the left adrenal gland. She had normal plasma metanephrines but elevated plasma normetanephrines of 7.12 nmol/L (normal, <0.89 nmol/L). Twenty-four-hour urine norepinephrine and catecholamines were elevated to 604 μg (normal, <90 μg/24 hours) and 610 μg (normal, <115 μg/24 hours), respectively. Chromogranin A was elevated to 940 ng/mL (normal, 0 to 95 ng/mL). Paraganglioma was suspected. Doxazosin was started for blood pressure control. The patient became pregnant unexpectedly shortly after. She was managed by a multidisciplinary team. At 18 weeks of pregnancy, she underwent a transabdominal robotic resection of the left retroperitoneal paraganglioma with an excellent outcome.

Conclusion

Functional paragangliomas in pregnancy are rare but must be recognized and treated early to reduce maternal and fetal complications. An innovative robotic approach should be considered and explored.

Pheochromocytoma

Pheochromocytomas are rare tumors originating in the adrenal medulla. They may be sporadic or in the context of a hereditary syndrome. A considerable number of pheochromocytomas carry germline or somatic gene mutations, which are inherited in the autosomal dominant way. All patients should undergo genetic testing. Symptoms are due to catecholamines over production or to a mass effect. Diagnosis is confirmed by raised plasma or urine metanephrines or normetanephrines. Radiology assists in the tumor location and any local invasion or metastasis. All the patients should have preoperative preparation with α-blockers and/or other medications to control hypertension, arrhythmia, and volume expansion. Surgery is the definitive treatment. Follow up should be life-long.

Endocrine causes of hypertension in pregnancy

Hypertension is a common and morbid complication of pregnancy. While endocrine causes of secondary hypertension are not rare, women with these conditions do not often conceive, and even less commonly are these disorders diagnosed during pregnancy. This review will consider conditions of adrenal hormone excess that cause secondary hypertension: primary aldosteronism (PA), Cushing syndrome (CS), and pheochromocytoma/paraganglioma. We emphasize that pregnancy itself elicits changes in the regulation of aldosterone and cortisol production and standard endocrine testing algorithms. Furthermore, conventional imaging modalities and pharmacotherapies are often contraindicated in pregnancy, which complicates diagnosis and management. Nevertheless, surgical management in the second trimester is the preferred treatment strategy for most of these rare cases when feasible. This article will discuss the approach to patients with endocrine causes of hypertension during pregnancy with emphasis on those aspects that deviate from the assessment and treatment of non-pregnant patients.

Pheochromocytoma and Pregnancy

Pheochromocytoma during pregnancy, although rare, is a perilous condition. The wellbeing of mother and fetus are at stake if not diagnosed and treated antenatally and timely. The diagnosis is frequently overlooked because of the aspecific nature of signs and symptoms and confusion with pregnancy-related hypertension. Measurements of plasma or urinary free metanephrines have the highest diagnostic accuracy. MRI is preferred over ultrasonography. The optimal time for surgical removal is before 24 weeks of gestation or at/after delivery. Laparoscopic adrenalectomy should be preceded by medical pretreatment. Cesarean delivery is preferred in these patients; vaginal delivery might be considered in selected pretreated patients.

Adrenal disorders in pregnancy, labour and postpartum - an overview

Adrenal disorders may manifest during pregnancy for the first time, or present from before pregnancy as either undiagnosed or diagnosed and treated. They may present as hormonal hypofunction or hyperfunction, or with mass effects or other non-endocrine effects. Adrenal disorders such as Cushing's syndrome, Addison's disease, pheochromocytoma, primary hyper-aldosteronism and adreno-cortical carcinoma are rare in pregnancy. Pregnancy presents special problems in the evaluation of the hypothalamic-pituitary-adrenal and renin-angiotensin-aldosterone axis as these undergoe major changes during pregnancy. Diagnosis is challenging as symptoms associated with pregnancy are also seen in adrenal diseases. A timely diagnosis and treatment is critical as these disorders can cause maternal and foetal morbidity and mortality. A high index of suspicion must be maintained as they can go unrecognised and untreated. An early diagnosis and treatment often improves outcomes. The aim of this article is to review the patho-physiology, clinical manifestation, diagnosis and management of various adrenal disorders during pregnancy.

The adrenal cortex: Physiology and diseases in human pregnancy

Pregnancy is characterized by marked alterations in the hypothalamic-pituitary-adrenal axis and in the function of the adrenal gland. Some of those alterations have clinical characteristics that are similar to those of adrenal gland disorders. While adrenal disorders are rare among pregnant women, they harbor the potential for significant morbidity if they remain unrecognized and untreated. As the majority of patients with adrenal disorders present with clinical features that are typical of normal pregnancy - diagnosis during pregnancy is not uncommonly delayed. A high index of suspicion must be practiced for these disorders as they might carry severe obstetrical negative outcomes. In this review we will survey the normal function of adrenal glands in pregnancy and the role of adrenal hormones in pregnancy. We will outline the adrenal disorders that commonly present during pregnancy and review the literature on treatment modalities.

Paraganglioma in pregnancy: interdisciplinary management during pregnancy

Paragangliomas are tumors that originate from the extra-adrenal neural crest, the incidence of which during pregnancy is not more than two to eight cases per million people per year and are known to be highly morbid. The purpose of this report is to describe the experience and results obtained during management of a primigravida diagnosed with paraganglioma on week 21.2 and received both medical and surgical management with good maternal and perinatal outcomes. This case report evidences the importance of practicing interdisciplinary management of patients with clinical suspicion of paragangliomas or pheochromocytomas during pregnancy at high-complexity centers even in a medium-income country.

Normotensive, Oversized Pheochromocytoma in Twin-Pregnancy: Analysis of Therapeutic Challenges in a Rare Case

An asymptomatic, normotensive 36-year-old woman in the second trimester of a twin-gestation was diagnosed with a 11 cm adrenal pheochromocytoma. Considering the hemodynamic stability of the patient, tumor size, and gestational age, the therapeutic decision of a multidisciplinary team ensued open surgical excision without any preoperative antihypertensive preparation. Following successful removal of pheochromocytoma, the patient had a normal subsequent course of pregnancy and cesarean section delivery of healthy twins at term. This unique case of a normotensive, incidental, large-sized pheochromocytoma in a twin-pregnancy illustrates that the decisions of management in such a rare occurrence should be based on individual features of the patient. Our experience supports that α-adrenergic blockade may not be essential in normotensive pheochromocytoma in pregnancy and open-surgery remains as a safe approach in the management of large adrenal tumors in twin-pregnant patients following a multidisciplinary consultation.

Impact of maternal pheochromocytoma on the fetus and neonate

Pheochromocytoma during pregnancy is rare but potentially harmful to the mother and fetus. Fetal risks are mainly determined by the vasoconstrictive effects of maternal catecholamine on uteroplacental circulation, because the fetus is protected from the direct effects of high catecholamine levels at the placental interface. Uteroplacental insufficiency may lead to spontaneous abortion, fetal growth restriction, premature delivery, and fetal hypoxia, followed by fetal distress and/or birth asphyxia. Adrenalectomy is recommended during the second trimester. When a diagnosis is made during the late second or third trimester, appropriate medical treatment until term and planned delivery with concurrent or delayed adrenalectomy can result in good fetal outcomes. Moreover, when adrenalectomy is planned after delivery, there is concern regarding the potential of antihypertensive drugs to be transferred to breast milk. It is generally known that early detection and proper treatment of pheochromocytoma during pregnancy decrease maternal and fetal mortality. However, in recent case series, antenatal maternal pheochromocytoma diagnosis did not significantly decrease the risk of fetal and neonatal mortality and morbidity, contrary to the maternal death and complication rates. Although intrauterine ischemia and hypoxia due to uteroplacental insufficiency can affect the long-term outcomes of neonates, no systematic studies have been performed.

Management of Endocrinopathies in Pregnancy: A Review of Current Evidence

Pregnancy in women with associated endocrine conditions is a therapeutic challenge for clinicians. These disorders may be common, such us thyroid disorders and diabetes, or rare, including adrenal and parathyroid disease and pituitary dysfunction. With the development of assisted reproductive techniques, the number of pregnancies with these conditions has increased. It is necessary to recognize symptoms and correct diagnosis for a proper pharmacotherapeutic management in order to avoid adverse side effects both in mother and fetus. This review summarizes the pharmacotherapy of these clinical situations in order to reduce maternal and fetal morbidity.

Laparoscopic management of paraganglioma in a pregnant woman: a case report

Introduction:

Paraganglioma is an extremely rare catecholamine-producing tumor during pregnancy. Paraganglioma carries high risks of fetal and maternal mortality during pregnancy. We report a pregnant woman with paraganglioma in the second trimester.

Case Description:

A 24-year-old pregnant woman presented with severe hypertension in the 17th week of gestation. Hormonal examination and Magnetic Resonance Imaging (MRI) confirmed the diagnosis of extra adrenal pheochromocytoma (paraganglioma). She underwent laparoscopic tumor excision successfully.

Conclusions:

A high index of suspicion is needed to diagnose paraganglioma in a pregnant patient with hypertension. Laparoscopic tumor removal for paraganglioma seems to be a feasible and safe procedure during pregnancy.

Successful management of a third-trimester pregnancy complicated by pheochromocytoma: case report

Pheochromocytoma (PH) is a tumor that arises from chromaffin cells of the adrenal medulla. Though being this benign neoplasm very rare in pregnancies, lack of treatment nevertheless causes high mortality rates for both the mother and the fetus. Classic symptoms related to PH are hypertension, abdominal pain, diaphoresis, and headache; but it can be easily misdiagnosed as gestational hypertension or preeclampsia. Its appearance is sporadic, but there are some genetic disorders that favor its onset (e.g. MEN 2A and 2B). Individual management is needed, because no single protocol is suitable in such a complex and rare condition. In this paper we describe our experience in the clinical and surgical management of a young pregnant patient affected by PH, and in particular the specific and unique pharmacological treatment with doxazosin, the use of corticosteroids and a close monitoring of fetal well-being, which proved being an effective approach.

Postpartum Diagnosis of Cardiac Paraganglioma: A Case Report

BACKGROUND

Extra-adrenal pheochromocytomas, or paragangliomas, originate from neural crest chromaffin cells and can be found anywhere along the sympathetic chain from head to toe.

CASE REPORT

A 34-year-old female presented 4 days postpartum with episodes of palpitations, hypertension, and shortness of breath. Two episodes in the emergency department confirmed hypertension and supraventricular tachycardia (SVT). A mediastinal mass was noted during workup for pulmonary embolus and was subsequently diagnosed as a cardiac paraganglioma. Our patient underwent surgical resection and was doing well 3 months postoperatively. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case represents a rare presentation of mediastinal paraganglioma with episodic SVT and hypertension postpartum, diagnosed during workup for pulmonary embolus. Although exceedingly rare, emergency physicians should consider paragangliomas in the differential of pregnant or postpartum women who present with episodic hypertension, palpitations, headache, and sweating.

Extra-adrenal paraganglioma masquerading as severe preeclampsia

Paraganglioma in pregnancy is an extremely rare condition and its diagnosis is often delayed because the clinical symptoms can mimic those of preeclampsia or gestational hypertension. Here, we report the case of a 32-year-old, gravida 2, para 1 woman who presented with severe headache, palpitation, and sweating at 37 weeks' gestation. Although emergent cesarean section was performed on the assumption of severe preeclampsia, blood pressure fluctuated and heart rate remained tachycardiac. We suspected that she might have thromboembolic lesion in the chest or pheochromocytoma. Chest and abdominal computed tomography revealed a 4 cm mass in the left para-aortic space. Serum and urinary catecholamine levels were found to be significantly increased. She underwent laparoscopic mass removal and the pathology confirmed paraganglioma. When typical paroxysmal hypertension is accompanied by headache, palpitation, and sweating during pregnancy, adrenal tumors should be considered.

Pheochromocytoma diagnosed during pregnancy: lessons learned from a series of ten patients

BACKGROUND

Pheochromocytoma (PHEO) in pregnancy is a life-threatening condition. Its management is challenging with regards to the timing and type of surgery.

METHODS

A retrospective review of the management of ten patients diagnosed with pheochromocytoma during pregnancy was performed. Data were collected on the initial diagnostic workup, symptoms, treatment, and follow-up.

RESULTS

PHEO was diagnosed in ten patients who were between the 10th and the 29th weeks of pregnancy. Six patients had none to mild symptoms, while four had complications of paroxysmal hypertension. Imaging investigations consisted of MRI, CT scan and ultrasounds. All had urinary metanephrines, measured as part of their workup. Three patients had MEN 2A, one VHL syndrome, one suspected SDH mutation. All patients were treated either with α/β blockers or calcium channel blockers to stabilize their clinical conditions. Seven patients underwent a laparoscopic adrenalectomy before delivery. Three out of these seven patients had a bilateral PHEO and underwent a unilateral adrenalectomy of the larger tumor during pregnancy, followed by a planned cesarean section and a subsequent contralateral adrenalectomy within a few months after delivery. Three patients had emergency surgery for maternal or fetal complications, with C-section followed by concomitant or delayed adrenalectomy. All newborns from the group of planned surgery were healthy, while two out three newborns within the emergency surgery group died shortly after delivery secondary to cardiac and pulmonary complications.

CONCLUSIONS

PHEO in pregnancy is a rare condition. Maternal and fetal prognosis improved over the last decades, but still lethal consequences may be present if misdiagnosed or mistreated. A thorough multidisciplinary team approach should be tailored on an individual basis to better manage the pathology. Unilateral adrenalectomy in a pregnant patient with bilateral PHEO may be an option to avoid the risk of adrenal insufficiency after bilateral adrenalectomy.

Pheochromocytomas and Hypertension

PURPOSE OF REVIEW

Pheochromocytomas and paragangliomas (PPGLs) are uncommon catecholamine-producing neuroendocrine neoplasms that usually present with secondary hypertension. This review is to update the current knowledge about these neoplasms, the pathophysiology, genetic aspects and diagnostic and therapeutic algorithms based on scientific literature mostly within the past 3 years.

RECENT FINDINGS

Eighty to eighty-five percent of PPGLs arise from the adrenal medulla (pheochromocytomas; PCCs) and the remainder from the autonomic neural ganglia (paragangliomas; PGLs). Catecholamine excess causes chronic or paroxysmal hypertension associated with sweating, headaches and palpitations, the presenting features of PPGLs, and increases the cardiovascular morbidity and mortality. Genetic testing should be considered in all cases as mutations are reported in 35-40% of cases; 10-15% of PCCs and 20-50% of PGLs can be malignant. Measurements of plasma-free metanephrines or 24-h urine-fractionated metanephrines help biochemical diagnosis with high sensitivity and specificity. Initial anatomical localization after biochemical confirmation is usually with computed tomography (CT) or magnetic resonance imaging (MRI). ¹²³Iodine metaiodobenzylguanidine (¹²³I-MIBG) scintigraphy, positron emission tomography (PET) or single-photon emission computed tomography (SPECT) is often performed for functional imaging and prognostication prior to curative or palliative surgery. Clinical and biochemical follow-up is recommended at least annually after complete tumour excision. Children, pregnant women and older people have higher morbidity and mortality risk. De-bulking surgery, chemotherapy, radiotherapy, radionuclide agents and ablation procedures are useful in the palliation of incurable disease. PPGLs are unique neuroendocrine tumours that form an important cause for endocrine hypertension. The diagnostic and therapeutic algorithms are updated in this comprehensive article.

Hypertensive crisis in pregnancy due to a metamorphosing pheochromocytoma with postdelivery Cushing's syndrome

Pheochromocytomas in pregnancy are rare but potentially lethal. Even rarer is the combination of pheochromocytoma in pregnancy with subsequent development of ectopic Cushing's syndrome. We report a 36-year-old woman, previously diagnosed with essential hypertension, who developed severe hypertension in pregnancy complicated by insulin-dependent gestational diabetes. A cesarean section was performed at 32 weeks following a hypertensive crisis after routine administration of betamethasone. Postnatal persistence of signs and symptoms of catecholamine excess led to the diagnosis of a left adrenal pheochromocytoma. Between diagnosis and planned tumor removal, the patient developed signs and symptoms of Cushing's syndrome (facial edema and hirsutism, myopathy and fatigue). Biochemical testing confirmed hypercortisolism with extremely elevated levels of plasma adrenocorticotropin, urinary cortisol and multiple steroids of a plasma panel that were all normal at previous testing. The previously noradrenergic tumor also started producing epinephrine. Histopathological examination confirmed the pheochromocytoma, which was also immunohistochemically positive for adrenocorticotropin. Full post-surgical recovery was sustained with normal blood pressure and biochemical findings after one year. This report not only underlines the chameleon behavior of pheochromocytoma but also illustrates its potential for a metamorphosing presentation. Corticosteroid administration in pregnancy requires a cautious approach in patients with hypertension.

Malignant pheochromocytoma with multiple vertebral metastases causing acute incomplete paralysis during pregnancy: Literature review with one case report

RATIONALE

We present a rare case of malignant pheochromocytoma with thoracic metastases during pregnancy that presented with symptoms of myelopathy and was treated with circumferential decompression, stabilization, and radiation. The management of this unique case is not well documented. The clinical manifestations, imaging results, pathological characteristics, treatment and prognosis of the case were analyzed.

PATIENT CONCERNS

A 26-year-old pregnant woman with a history of paroxysmal hypertension during the second trimester presented with lower extremity weakness, numbness, urinary incontinence, and back pain. Imaging studies revealed a right adrenal pheochromocytoma, multiple metastases at T8, T11, T12, and the pelvis girdle causing significant multilevel cord compression and significant osteolytic lesions at T11 and T12.

DIAGNOSES

We believe this is the first reported case of metastatic pheochromocytoma of the thoracic spine presenting with symptoms of myelopathy during pregnancy.

INTERVENTIONS

A healthy neonate was delivered by emergency caesarean section at 34 weeks. Subsequently, the patient underwent a circumferential spinal cord decompression and a stabilization procedure.

OUTCOMES

The patient's neurological deficits improved significantly after the surgery, and the postoperative period was uneventful at the 6-month follow-up visit.

LESSONS

This article emphasizes that metastatic pheochromocytoma of the spine, although rare, should be part of the differential when a patient presents with elevated blood pressure, weakness, and urinary incontinence.

ENDOCRINOLOGY IN PREGNANCY: Pheochromocytoma in pregnancy: case series and review of literature

Pheochromocytoma in pregnancy is extremely rare. Early recognition is crucial as antepartum diagnosis can largely decrease maternal and fetal mortality rates. As symptoms of pheochromocytoma are rather similar to those of other far more common causes of hypertension during pregnancy, timely diagnosis is a challenge. In pregnant patients, similar to non-pregnant patients, increased plasma and/or 24-h urine (nor)metanephrine concentrations most reliably confirm the diagnosis of pheochromocytoma. MRI and ultrasound are the only imaging modalities that can be used safely during pregnancy to localize the tumor. During pregnancy, pretreatment consists of alpha blockade as usual. However, dosing of α-adrenergic receptor blockers during pregnancy is a challenge as hypertension must be treated while preserving adequate uteroplacental circulation. When the diagnosis is made within the first 24 weeks of pregnancy, it is generally recommended to remove the tumor in the second trimester, while resection is generally postponed till after delivery when the diagnosis is made in the third trimester and medical pretreatment is sufficient. Both during and after pregnancy, laparoscopic surgery is the preferred approach for resection of the tumor. There is no consensus in literature about the preferred route and timing of delivery. Therefore, in our opinion, decisions should be made on an individual basis by an experienced and dedicated multidisciplinary team. Over the last decades, maternal and fetal prognosis has improved considerably. Further increasing awareness of this rare diagnosis and treatment of these patients by a dedicated team in a tertiary referral hospital are critical factors for optimal maternal and fetal outcome.