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Kishlyansky D, Ramesh R, Cook O, Luthra M. Inferior Laryngeal Nerve Paraganglioma With Norepinephrine Hypersecretion Diagnosed Shortly After Pregnancy. JCEM CASE REPORTS 2024; 2:luae107. [PMID: 38947415 PMCID: PMC11211820 DOI: 10.1210/jcemcr/luae107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Indexed: 07/02/2024]
Abstract
The diagnosis of pheochromocytoma or paraganglioma (PGL) during pregnancy is extremely rare, with 2 large case series suggesting that the prevalence is between 0.0002% and 0.007%. Here, we present a case of a 38-year-old woman who presented during pregnancy with clinical features suggestive of preeclampsia and was found to have a norepinephrine-secreting inferior laryngeal nerve PGL, which was diagnosed after pregnancy. She underwent uncomplicated surgical resection and genetic testing revealed a succinate dehydrogenase subunit B (SDHB) pathogenic variant. In conclusion, PGLs diagnosed during pregnancy and hypersecreting head and neck PGLs are both rare clinical entities. Hyperfunctioning PGLs may mimic pregnancy-induced hypertension or preeclampsia. Metanephrine testing should be considered in patients with atypical features and can be reliably assessed using nonpregnant reference ranges. Overall, maternal and fetal mortality has improved considerably with early diagnosis and treatment.
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Affiliation(s)
- David Kishlyansky
- McMaster University, Division of Endocrinology and Metabolism, Hamilton, ON L8S 4L8, Canada
| | - Rithvika Ramesh
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON L8P 1H6, Canada
| | - Olivia Cook
- McMaster University, Division of Endocrinology and Metabolism, Hamilton, ON L8S 4L8, Canada
| | - Meera Luthra
- McMaster University, Division of Endocrinology and Metabolism, Hamilton, ON L8S 4L8, Canada
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2
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Giorgi RB, Aroucha PT, Favreto TM, Montero MF, Velloni JMF, Korkes I, Ferreira EN, Olivati C, Lima JV, Kater CE, Costa-Barbosa FA. Pheochromocytoma/Paraganglioma (PPGL): A Misdiagnosed Cause of Hypertension during Pregnancy. Case Rep Obstet Gynecol 2024; 2024:6655229. [PMID: 38572182 PMCID: PMC10990643 DOI: 10.1155/2024/6655229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 01/12/2024] [Accepted: 03/04/2024] [Indexed: 04/05/2024] Open
Abstract
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.
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Affiliation(s)
- Rafael Buck Giorgi
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of Sao Paulo Medical School-EPM/Unifesp, São Paulo, Brazil
- Division of Endocrinology, Faculty of Medical Sciences and Health, Pontific Catholic University of São Paulo, Sorocaba, Brazil
| | - Priscila Teixeira Aroucha
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of Sao Paulo Medical School-EPM/Unifesp, São Paulo, Brazil
| | - Thalissa M. Favreto
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of Sao Paulo Medical School-EPM/Unifesp, São Paulo, Brazil
| | - Micaela F. Montero
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of Sao Paulo Medical School-EPM/Unifesp, São Paulo, Brazil
| | - Julia M. F. Velloni
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of Sao Paulo Medical School-EPM/Unifesp, São Paulo, Brazil
| | - Ilana Korkes
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of Sao Paulo Medical School-EPM/Unifesp, São Paulo, Brazil
| | | | - Caroline Olivati
- Research and Development Division, Fleury Group, São Paulo, Brazil
| | - Jose Viana Lima
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of Sao Paulo Medical School-EPM/Unifesp, São Paulo, Brazil
- Research and Development Division, Fleury Group, São Paulo, Brazil
- Division of Endocrinology and Metabolism, Department of Medicine, Santa Casa de São Paulo, São Paulo, Brazil
| | - Claudio E. Kater
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of Sao Paulo Medical School-EPM/Unifesp, São Paulo, Brazil
| | - Flavia A. Costa-Barbosa
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of Sao Paulo Medical School-EPM/Unifesp, São Paulo, Brazil
- Research and Development Division, Fleury Group, São Paulo, Brazil
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3
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Eccles-Smith J, Hopkins S, Conn J, Johnston S, Szabo R, Price S, Nankervis A. Paraganglioma in pregnancy: A case series and literature review. Obstet Med 2022; 15:19-24. [PMID: 35444717 PMCID: PMC9014550 DOI: 10.1177/1753495x211006012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 02/28/2021] [Accepted: 03/06/2021] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Jade Eccles-Smith
- Department of Obstetrics and Gynaecology, Royal Women’s
Hospital, Parkville Victoria, Australia,Jade Eccles-Smith, The Royal Women’s
Hospital, Grattan Street, Flemington Road, Parkville Victoria, Australia 3052.
| | - Stephanie Hopkins
- Department of Medicine, University of Newcastle, Callaghan New
South Wales, Australia
| | - Jennifer Conn
- Department of Obstetrics and Gynaecology, Royal Women’s
Hospital, Parkville Victoria, Australia,Department of Diabetes and Endocrinology, Royal Melbourne
Hospital, Australia,Department of Medicine, University of Melbourne, Parkville
Victoria, Australia
| | - Stephanie Johnston
- University Hospital, Geelong Victoria, Australia,School of Medicine, Deakin University, Geelong Victoria,
Australia
| | - Rebecca Szabo
- Department of Obstetrics and Gynaecology, Royal Women’s
Hospital, Parkville Victoria, Australia,Department of Medical Education, University of Melbourne,
Parkville Victoria, Australia,Gandel Simulation Service, Royal Women’s Hospital, University of
Melbourne, Parkville Victoria, Australia
| | - Sarah Price
- Department of Obstetrics and Gynaecology, Royal Women’s
Hospital, Parkville Victoria, Australia,Department of Diabetes and Endocrinology, Royal Melbourne
Hospital, Australia,Department of Medicine, University of Melbourne, Parkville
Victoria, Australia
| | - Alison Nankervis
- Department of Obstetrics and Gynaecology, Royal Women’s
Hospital, Parkville Victoria, Australia,Department of Diabetes and Endocrinology, Royal Melbourne
Hospital, Australia,Department of Medicine, University of Melbourne, Parkville
Victoria, Australia
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4
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Langton K, Tufton N, Akker S, Deinum J, Eisenhofer G, Timmers H, Spaanderman M, Lenders J. Pregnancy and phaeochromocytoma/paraganglioma: clinical clues affecting diagnosis and outcome - a systematic review. BJOG 2021; 128:1264-1272. [PMID: 33342020 DOI: 10.1111/1471-0528.16635] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2020] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- K Langton
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Dresden, Germany.,Medical Faculty, Technical University Dresden, Dresden, Germany
| | - N Tufton
- Department of Endocrinology, St Bartholomew's Hospital, Bart's Health NHS Trust, London, UK
| | - S Akker
- Department of Endocrinology, St Bartholomew's Hospital, Bart's Health NHS Trust, London, UK
| | - J Deinum
- Medical Faculty, Technical University Dresden, Dresden, Germany.,Department of Medicine III, University Hospital Carl Gustav Carus, Dresden, Germany.,Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - G Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Dresden, Germany.,Medical Faculty, Technical University Dresden, Dresden, Germany.,Department of Medicine III, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Hjlm Timmers
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mea Spaanderman
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.,Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jwm Lenders
- Medical Faculty, Technical University Dresden, Dresden, Germany.,Department of Medicine III, University Hospital Carl Gustav Carus, Dresden, Germany.,Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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5
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Bancos I, Atkinson E, Eng C, Young WF, Neumann HPH. Maternal and fetal outcomes in phaeochromocytoma and pregnancy: a multicentre retrospective cohort study and systematic review of literature. Lancet Diabetes Endocrinol 2021; 9:13-21. [PMID: 33248478 PMCID: PMC7758862 DOI: 10.1016/s2213-8587(20)30363-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 09/17/2020] [Accepted: 09/26/2020] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA.
| | - Elizabeth Atkinson
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Charis Eng
- Genomic Medicine Institute, Lerner Research Institute, and Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Hartmut P H Neumann
- Section for Preventive Medicine, Faculty of Medicine, Albert-Ludwigs-University, Freiburg, Germany
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Gaujoux S, Hain É, Marcellin L, de Carbonnieres A, Goffinet F, Bertherat J, Dousset B. Adrenalectomy during pregnancy: A 15-year experience at a tertiary referral center. Surgery 2020; 168:335-339. [PMID: 32434659 DOI: 10.1016/j.surg.2020.03.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/18/2020] [Accepted: 03/28/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Adrenal lesions diagnosed during pregnancy remain rare, and their management is challenging because of maternal physiologic modifications, restricted imaging investigations, and contraindications to several treatments. Surgical issues of adrenalectomy during pregnancy and consequences on perinatal outcomes are poorly described. We therefore aimed to report maternal and fetal outcomes after adrenalectomy during pregnancy. METHODS All pregnant women who underwent adrenalectomy over a 15-year inclusion period were identified from a prospectively maintained database. Surgical management and maternal and fetal outcomes were reviewed. RESULTS From January 2003 to July 2018, a total of 12 women underwent adrenalectomy at a median gestation of 20 weeks. Of these women, 11 had hyper-secreting lesions, including 8 with cortisol oversecretion, and 11 had benign lesions, including cortisol-secreting adenoma (n = 5), pheochromocytoma (n = 2), primary pigmented, nodular adrenal disease (n = 1), severe Cushing's disease (n = 2), and hematoma (n = 1). A total of 3 patients with severe Cushing's disease (n = 2) and primary pigmented, nodular adrenal disease (n = 1) required bilateral adrenalectomy. One patient presented with a malignant adrenal Ewing sarcoma. Adrenalectomy during pregnancy was performed by the lateral laparoscopic transabdominal laparoscopic route in 9 patients. Postoperative morbidity occurred in 3 women. Maternal mortality was nil, but preterm birth occurred in 7 cases and intrauterine growth retardation was observed in 3 cases. Finally, among the 12 women, 10 had a child in good health. CONCLUSION During pregnancy, a lateral laparoscopic transabdominal approach is a feasible procedure. Maternal outcome is acceptable but fetal outcome is determined by the underlying disease, with a worse outcome when the adrenalectomy is indicated for malignant lesions or Cushing's syndrome.
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Affiliation(s)
- Sébastien Gaujoux
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France; Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; INSERM Unité 1016, Centre National de la Recherche Scientifique Unité Mixte de Recherche 8104, Institut Cochin, Paris, France.
| | - Élisabeth Hain
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France; Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France
| | - Louis Marcellin
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Gynecology Obstetrics and Reproductive Medicine, University Hospital Cochin, Assistance Publique - Hôpitaux de Paris (AP- HP), Paris, France
| | - Anne de Carbonnieres
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France
| | - François Goffinet
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Gynecology Obstetrics and Reproductive Medicine, University Hospital Cochin, Assistance Publique - Hôpitaux de Paris (AP- HP), Paris, France
| | - Jérôme Bertherat
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; INSERM Unité 1016, Centre National de la Recherche Scientifique Unité Mixte de Recherche 8104, Institut Cochin, Paris, France; Department of Endocrinology, Cochin Hospital, APHP, Paris, France
| | - Bertrand Dousset
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France; Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; INSERM Unité 1016, Centre National de la Recherche Scientifique Unité Mixte de Recherche 8104, Institut Cochin, Paris, France
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7
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Corsello SM, Paragliola RM. Evaluation and Management of Endocrine Hypertension During Pregnancy. Endocrinol Metab Clin North Am 2019; 48:829-842. [PMID: 31655779 DOI: 10.1016/j.ecl.2019.08.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Hypertension is a common clinical complication in pregnancy, representing possible short-term and long-term risks of complications for both mothers and babies. Even if in a majority of cases hypertension is essential, possible secondary causes, which can be related to endocrine disorders, must be detected and correctly managed. This review focuses on the evaluation and the management of primary hyperaldosteronism, Cushing syndrome, and pheochromocytoma in pregnancy.
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Affiliation(s)
- Salvatore M Corsello
- Endocrinology, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS - Università Cattolica del Sacro Cuore, Largo Agostino Gemelli 8, I-00168, Rome, Italy
| | - Rosa Maria Paragliola
- Endocrinology, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS - Università Cattolica del Sacro Cuore, Largo Agostino Gemelli 8, I-00168, Rome, Italy.
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8
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Lenders JWM, Langton K, Langenhuijsen JF, Eisenhofer G. Pheochromocytoma and Pregnancy. Endocrinol Metab Clin North Am 2019; 48:605-617. [PMID: 31345526 DOI: 10.1016/j.ecl.2019.05.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Jacques W M Lenders
- Department of Internal Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 8, 6525 GA Nijmegen, The Netherlands; Department of Medicine III, Carl Gustav Carus University Medical Centre, Dresden, Germany.
| | - Katharina Langton
- Institute of Clinical Chemistry and Laboratory Medicine, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Fetcherstrasse 74, 01307 Dresden, Germany
| | - Johan F Langenhuijsen
- Department of Urology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Graeme Eisenhofer
- Department of Medicine III, Carl Gustav Carus University Medical Centre, Dresden, Germany; Institute of Clinical Chemistry and Laboratory Medicine, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Fetcherstrasse 74, 01307 Dresden, Germany
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9
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Normotensive, Oversized Pheochromocytoma in Twin-Pregnancy: Analysis of Therapeutic Challenges in a Rare Case. Case Rep Urol 2019; 2019:7141060. [PMID: 31249716 PMCID: PMC6556236 DOI: 10.1155/2019/7141060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/15/2019] [Indexed: 11/30/2022] Open
Abstract
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.
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10
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Abstract
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.
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Affiliation(s)
- Shigeo Iijima
- a Department of Regional Neonatal-Perinatal Medicine , Hamamatsu University School of Medicine , Shizuoka , Japan
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11
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Calina D, Docea AO, Golokhvast KS, Sifakis S, Tsatsakis A, Makrigiannakis A. Management of Endocrinopathies in Pregnancy: A Review of Current Evidence. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16050781. [PMID: 30836653 PMCID: PMC6427139 DOI: 10.3390/ijerph16050781] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 02/27/2019] [Accepted: 02/27/2019] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Daniela Calina
- Department of Clinical Pharmacy, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania.
| | - Anca Oana Docea
- Department of Toxicology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania.
| | | | - Stavros Sifakis
- Department of Obstetrics and Gynecology, Mitera Maternity Hospital, 71110 Heraklion, Crete, Greece.
| | - Aristides Tsatsakis
- Department of Forensic Sciences and Toxicology, Faculty of Medicine, University of Crete, 71110 Heraklion, Crete, Greece.
| | - Antonis Makrigiannakis
- Department of Obstetrics and Gynecology, Medical School, University of Crete, 71110 Heraklion, Crete, Greece.
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Canu L, Parenti G, De Filpo G, Mannelli M. Pheochromocytomas and Paragangliomas as Causes of Endocrine Hypertension. Front Endocrinol (Lausanne) 2019; 10:333. [PMID: 31214117 PMCID: PMC6558199 DOI: 10.3389/fendo.2019.00333] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 05/08/2019] [Indexed: 02/04/2023] Open
Abstract
Chromaffin tumors are included among the causes of secondary hypertension because of the release of catecholamines. Nevertheless, the clinical, cardiovascular, and hypertensive picture of patients affected by pheochromocytomas/paragangliomas (PPGL) is extremely variable, due to the different quantitative and qualitative releasing activity of these tumors. A consistent percentage of these patients, about 20%, is normotensive and not affected by the characteristic symptomatic crises due to sudden release of catecholamines. The factors causing such wide clinical variability are many and probably not all known. It is well known that many of these tumors are genetically determined and that the genetic profile influences the biochemical characteristics and the biology of the tumors as well as the clinical presentation of the affected patients. The number of asymptomatic or poorly symptomatic patients is increased after the introduction of genetic screening and the early diagnosis in mutation carriers. In this paper we can review the genotype-phenotype correlation of PPGLs with a focus on the cardiovascular picture.
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Affiliation(s)
- Letizia Canu
- Department Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | | | - Giuseppina De Filpo
- Department Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Massimo Mannelli
- Department Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
- *Correspondence: Massimo Mannelli
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Al-Sharefi A, Perros P, James RA. Phaeochromocytoma/paraganglioma and adverse clinical outcomes in patients with neurofibromatosis-1. Endocr Connect 2018; 7:EC-18-0208. [PMID: 30120202 PMCID: PMC6198184 DOI: 10.1530/ec-18-0208] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/08/2018] [Accepted: 08/15/2018] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Phaeochromocytomas/paragangliomas (PHAEO/PG) are linked to hereditary syndromes including neurofibromatosis type 1 (NF-1). Current guidelines do not recommend biochemical screening for PHAEO/PG in asymptomatic or normotensive patients with NF-1. This strategy may miss preventable morbidities in those patients who ultimately present with symptomatic PHAEO/PG. Our aim was to review the literature and extract data on mode of presentation and the incidence of reported adverse outcomes. METHODS PubMed and EMBASE literature search using the keywords "Phaeochromocytoma", "Paraganglioma" and "Neurofibromatosis" was performed looking for reported cases from 2000 to 2018. RESULTS 73 reports of NF-1 patients with PHAEO/PG were found. Patients were predominately women (n=40) with a median age of 46 years (range 16-82). PHAEO/PG was found incidentally in most patients, 36/73 did not present with typical symptoms while 27 patients were normotensive at diagnosis. 31 patients had adverse outcomes including metastases and death. CONCLUSION Given the protean presentation of PHAEO/PG, relying on symptomology and blood pressure status as triggers for screening is associated with adverse outcomes. Further studies are required to ascertain whether biochemical screening in asymptomatic and normotensive patients with NF-1 can reduce the rate of adverse outcomes.
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Affiliation(s)
- Ahmed Al-Sharefi
- A Al-Sharefi, Department of Endocrinology , Royal Victoria Infirmary , Newcastle upon Tyne, United Kingdom of Great Britain and Northern Ireland
| | - Petros Perros
- P Perros, Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom of Great Britain and Northern Ireland
| | - Robert Andrew James
- R James, Department of Endocrinology , Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom of Great Britain and Northern Ireland
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Extracorporeal Membrane Oxygenation for Treatment of Acute Inverted Takotsubo-Like Cardiomyopathy From Hemorrhagic Pheochromocytoma in Late Pregnancy. ACTA ACUST UNITED AC 2017; 7:196-199. [PMID: 27607406 DOI: 10.1213/xaa.0000000000000383] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We describe the first case of a pregnant woman presenting with an acute inverted takotsubo-like cardiomyopathy caused by a postpartum diagnosed hemorrhagic pheochromocytoma, successfully treated with percutaneous venoarterial extracorporeal membrane oxygenation (va-ECMO). During admission, an emergency cesarean delivery had to be performed. The fetus needed resuscitation for 5 minutes. The mother was successfully resuscitated and treated with percutaneous va-ECMO for 7 days. Despite advances in diagnostic techniques during the past decade, in many cases, pheochromocytoma in pregnancy is still missed. This results in a maternal and fetal mortality rate of up to 30% in both.
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Pheochromocytoma Presenting as Partial HELLP Syndrome. Case Rep Obstet Gynecol 2015; 2015:294326. [PMID: 26351602 PMCID: PMC4553187 DOI: 10.1155/2015/294326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 08/03/2015] [Accepted: 08/11/2015] [Indexed: 12/03/2022] Open
Abstract
Diagnosis of pheochromocytoma in partial HELLP syndrome is extremely rare. We report a case of a 25-year-old multigravida woman at 30 weeks of gestation who presented with clinical features consistent with partial HELLP syndrome. Her symptoms were not controlled by pharmacologic therapy, and the patient underwent urgent cesarean section. The patient gave birth to a viable baby, but she sustained an episode of ventricular fibrillation intraoperatively that did not result in any long-term sequelae. The patient's symptoms persisted postoperatively and work-up for secondary etiologies of hypertension demonstrated a right adrenal pheochromocytoma. Following resection, the patient's signs and symptoms resolved, and her lab tests normalized.
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Ramakrishna H. Pheochromocytoma resection: Current concepts in anesthetic management. J Anaesthesiol Clin Pharmacol 2015; 31:317-23. [PMID: 26330708 PMCID: PMC4541176 DOI: 10.4103/0970-9185.161665] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Pheochromocytoma represents very significant challenges to the anesthetist, especially when undiagnosed. These chromaffin tissue tumors are not uncommon in anesthetic practice and have varied manifestations. The perioperative management of these tumors has improved remarkably over the years, in conjunction with the evolution of surgical techniques (open laparotomy to laparoscopic techniques and now to robotic approaches in the present day). This review attempts to comprehensively address the intraoperative and postoperative issues in the management of these challenging tumors with an emphasis on hemodynamic monitoring and anesthetic technique.
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Affiliation(s)
- Harish Ramakrishna
- Department of Anesthesiology, Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
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Kitayama K, Kashiwagi S, Amano R, Noda S, Ohira G, Yamazoe S, Kimura K, Hamamoto K, Hamuro A, Ohsawa M, Onoda N, Hirakawa K. A case of bilateral pheochromocytoma during pregnancy. BMC Surg 2015; 15:55. [PMID: 25935403 PMCID: PMC4437682 DOI: 10.1186/s12893-015-0041-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 04/28/2015] [Indexed: 12/04/2022] Open
Abstract
Background Pheochromocytoma is a disease where catecholamines are secreted. If pheochromocytoma occurs during pregnancy, it can be difficult to diagnose because it is similar to pregnancy-induced hypertension. Furthermore, bilateral pheochromocytoma during pregnancy is even rarer than unilateral pheochromocytoma. Case presentation A 32-year-old primigravida, who was 12 weeks’ pregnant, was aware of right abdominal discomfort. Masses in both adrenal glands were observed by abdominal ultrasonography. She was diagnosed with pheochromocytoma. Bilateral adrenalectomy was undertaken at 15 weeks’ gestation and she continued pregnancy. At 39 weeks’ gestation, a healthy male neonate was delivered. She was discharged on the 4th postpartum day. Conclusions We present a case of bilateral pheochromocytoma during pregnancy that was diagnosed in the first trimester. Differentiating pheochromocytoma from pregnancy-induced hypertension is important. Early diagnosis and appropriate blood pressure management with medical treatment followed by surgical removal of the tumor results in good maternal and fetal outcomes.
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Affiliation(s)
- Kishu Kitayama
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
| | - Shinichiro Kashiwagi
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan.
| | - Ryosuke Amano
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
| | - Satoru Noda
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
| | - Go Ohira
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
| | - Sadaaki Yamazoe
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
| | - Kenjiro Kimura
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
| | - Kae Hamamoto
- Department of Metabolism and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
| | - Akihiro Hamuro
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
| | - Masahiko Ohsawa
- Department of Diagnostic Pathology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
| | - Naoyoshi Onoda
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
| | - Kosei Hirakawa
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
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Pappachan JM, Raskauskiene D, Sriraman R, Edavalath M, Hanna FW. Diagnosis and management of pheochromocytoma: a practical guide to clinicians. Curr Hypertens Rep 2014; 16:442. [PMID: 24792093 DOI: 10.1007/s11906-014-0442-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Pheochromocytomas (PCCs) are rare catecholamine producing neuroendocrine tumors. The majority of these tumors (85 %) arise from the adrenal medulla. Those arising from the extra-adrenal neural ganglia are called paragangliomas (PGLs). Paroxysmal hypertension with sweating, headaches and palpitation are the usual presenting features of PCCs/ PGLs. Gene mutations are reported in 32-79 % of cases, making genetic screening mandatory in all the cases. The malignancy rates are 10-15 % for PCCs and 20-50 % for PGLs. Measurement of plasma or 24-hour urinary fractionated metanephrines is the best biochemical diagnostic test. Computed tomography or magnetic resonance imaging has high sensitivity (90-100 %) and reasonable specificity (70-90 %) for the anatomical localization. The functionality is assessed by different radionuclide imaging modalities such as metaiodobenzylguanidine (MIBG) scintigraphy, positron emission tomography or single photon emission computed tomography. The only modality of curative treatment is tumor excision. Proper peri-operative management improves the surgical outcomes. Annual follow up with clinical and biochemical assessment is recommended in all the cases after treatment. Children, pregnant women and older people have higher morbidity and mortality risk. De-bulking surgery, chemotherapy, radiotherapy, molecular agents like sunitinib and everolimus, radionuclide agents and different ablation procedures may be useful in the palliation of inoperable/metastatic disease. An update on the diagnostic evaluation and management of PCCs and PGLs is presented here.
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Affiliation(s)
- Joseph M Pappachan
- Department of Endocrinology, Walsall Manor Hospital, West Midlands, WS2 9PS, UK,
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Dong D, Li H. Diagnosis and treatment of pheochromocytoma during pregnancy. J Matern Fetal Neonatal Med 2014; 27:1930-4. [DOI: 10.3109/14767058.2014.880883] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Plu I, Sec I, Barrès D, Lecomte D. Pregnancy, Cesarean, and Pheochromocytoma: A Case Report and Literature Review. J Forensic Sci 2013; 58:1075-9. [DOI: 10.1111/1556-4029.12107] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2011] [Revised: 04/05/2012] [Accepted: 04/14/2012] [Indexed: 12/14/2022]
Affiliation(s)
- Isabelle Plu
- Institut medico-légal; 2 place Mazas; 75012; Paris; France
| | - Isabelle Sec
- Institut medico-légal; 2 place Mazas; 75012; Paris; France
| | - Denis Barrès
- Institut medico-légal; 2 place Mazas; 75012; Paris; France
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Abstract
Pregnancy is marked by alterations in a number of endocrine systems, including activation of the renin-angiotensin-aldosterone system and the hypothalamic-pituitary-adrenal axis. The placenta, the fetal adrenal glands and the liver constitute an interactive endocrine entity, known as the fetoplacental unit. In the fetoplacental unit, the fetal adrenal glands are the primary source of dehydroepiandrosterone sulphate, which is further metabolized by the fetal liver and placenta to produce a variety of oestrogens. Several disorders can affect both the fetal and maternal adrenal glands during pregnancy. The most common fetal adrenal disorder, steroid 21-hydroxylase deficiency, leads to abnormalities in sexual development and can be life threatening for the neonate. Although rare, maternal adrenal disorders are associated with considerable maternal mortality and morbidity if not promptly recognized and treated. However, diagnosis is often difficult to establish because of the endocrine changes occurring during normal pregnancies and the lack of reference values for the majority of the adrenal steroids. This Review provides an overview of adrenal steroid metabolism during pregnancy and focuses on diagnosis and treatment of the most common fetal and maternal adrenal disorders.
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Affiliation(s)
- Silvia Monticone
- Department of Physiology, Georgia Health Sciences University, 1120 15th Street, Augusta, GA 30912, USA
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23
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Abstract
A pheochromocytoma in a pregnant patient is one of the most threatening medical conditions for mother, fetus, and physician. Although extraordinarily rare with a frequency of 0.002% of all pregnancies, this tumor is notorious for its devastating consequences. As in non-pregnant patients, the signs and symptoms are quite variable but not specific, with hypertension being one of the most prominent signs. Confusion with the much more prevalent forms of pregnancy-related hypertension is the main cause of overlooking the diagnosis. If undiagnosed, maternal and fetal mortality is around 50%. Conversely, early detection and proper treatment during pregnancy decrease the maternal and fetal mortality to <5 and 15% respectively. For the biochemical diagnosis, plasma or urinary metanephrines are the tests of first choice since they have a nearly maximal negative predictive value. For reliable localization, only magnetic resonance imaging is suitable, with a sensitivity of more than 90%. When the tumor is diagnosed in the first 24 weeks of gestation, it should be removed by laparoscopic adrenalectomy after 10-14 days of medical preparation with the same drugs as in non-pregnant patients. If the tumor is diagnosed in the third trimester, the patient should be managed until the fetus is viable using the same drug regimen as for regular surgical preparation. Cesarean section with tumor removal in the same session or at a later stage is then preferred since vaginal delivery is possibly associated with higher mortality. Despite all technical diagnostic and therapeutic progress over the last decades, the key factor for further reduction of maternal and fetal mortality is early awareness and recognition of the potential presence of a pheochromocytoma in a pregnant patient with hypertension.
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Affiliation(s)
- Jacques W M Lenders
- Division of General Internal Medicine, Department of Medicine, Radboud Adrenal Centre, St Radboud University Nijmegen Medical Centre, PO Box 9101, 6500HB Nijmegen, The Netherlands.
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Därr R, Lenders JWM, Hofbauer LC, Naumann B, Bornstein SR, Eisenhofer G. Pheochromocytoma - update on disease management. Ther Adv Endocrinol Metab 2012; 3:11-26. [PMID: 23148191 PMCID: PMC3474647 DOI: 10.1177/2042018812437356] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Pheochromocytomas are rare endocrine tumors that can present insidiously and remain undiagnosed until death or onset of clear manifestations of catecholamine excess. They are often referred to as one of the 'great mimics' in medicine. These tumors can no longer be regarded as a uniform disease entity, but rather as a highly heterogeneous group of chromaffin cell neoplasms with different ages of onset, secretory profiles, locations, and potential for malignancy according to underlying genetic mutations. These aspects all have to be considered when the tumor is encountered, thereby enabling optimal management for the patient. Referral to a center of specialized expertise for the disease should be considered wherever possible. This is not only important for surgical management of patients, but also for post-surgical follow up and screening of disease in patients with a hereditary predisposition to the tumor. While preoperative management has changed little over the last 20 years, surgical procedures have evolved so that laparoscopic resection is the standard of care and partial adrenalectomy should be considered in all patients with a hereditary condition. Follow-up testing is essential and should be recommended and ensured on a yearly basis. Managing such patients must now also take into account possible underlying mutations and the appropriate selection of genes for testing according to disease presentation. Patients and family members with identified mutations then require an individualized approach to management. This includes consideration of distinct patterns of biochemical test results during screening and the appropriate choice of imaging studies for tumor localization according to the mutation and associated differences in predisposition to adrenal, extra-adrenal and metastatic disease.
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Abstract
Endocrine tumours occur rarely in pregnant women but present clinicians with unique challenges. A high index of suspicion is often required to make a diagnosis since the symptoms and signs associated with many of these tumours, including insulinoma, adrenocortical carcinoma and phaeochromocytoma, mimic those of normal pregnancy or its complications, such as pre-eclampsia. The evidence base which informs management is very limited hence decisions on investigation and therapy must be individualised and undertaken jointly by the multidisciplinary medical team and the patient. The optimal strategy will depend on the nature and stage of the endocrine tumour, gestational stage, treatments available and patient wishes. Thus, surgical intervention, appropriately timed, may be considered in pregnancy for resectable adrenocortical carcinoma or phaeochromocytoma, but delayed until the postpartum period for well-differentiated thyroid cancer. Medical therapy may be required to reduce the drive to tumour growth, control symptoms of hormone excess and to minimise the risks of surgery, anaesthesia or labour.
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Affiliation(s)
- A Lansdown
- Centre for Endocrine and Diabetes Sciences, School of Medicine, Cardiff University, UK.
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Nakajima Y, Masaoka N, Sodeyama M, Tsuduki Y, Sakai M. Pheochromocytoma-related cardiomyopathy during the antepartum period in a preterm pregnant woman. J Obstet Gynaecol Res 2011; 37:908-11. [DOI: 10.1111/j.1447-0756.2010.01423.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Snabboon T, Plengpanich W, Houngngam N, Buranasupkajorn P, Plengvidhya N, Sereepapong W, Sunthornyothin S, Shotelersuk V. Concurrent bilateral pheochromocytoma and thoracic paraganglioma during pregnancy. Endocrine 2010; 37:261-4. [PMID: 20960261 DOI: 10.1007/s12020-009-9292-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Accepted: 12/16/2009] [Indexed: 10/20/2022]
Abstract
Although hypertension occurring during pregnancies is not uncommon and its prognosis is generally excellent, some of its unusual causes can lead to catastrophic consequences, especially in undiagnosed cases. Here, we report a pregnant woman who presented with hypertension in her early pregnancy. It was subsequently found to be caused by bilateral pheochromocytoma. After removal of both tumors, catecholamine levels unexpectedly and unexplainably remained elevated. At 23 weeks of gestation, the fetus was found dead in utero. After the fetal death, additional studies were performed and revealed a thoracic paraganglioma. To our knowledge, this is the first report of a case of three catecholamine-producing tumors occurring concurrently during a pregnancy. Genetic analysis helped identify this unprecedented condition; the patient harbored a heterozygous missense mutation c.482G>A in exon 3 of the VHL gene, indicating von Hippel-Lindau syndrome. Physicians who care for hypertensive pregnant patients should be aware of this condition as its diagnosis would probably lead to a better outcome.
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Affiliation(s)
- Thiti Snabboon
- Division of Endocrine and Metabolism, Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University, Patumwan, Bangkok, 10330, Thailand.
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Affiliation(s)
- Greg A H Pearson
- Department of Obstetrics and Gynaecology, North Devon District Hospital, Barnstaple, Devon, UK.
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Wattanachanya L, Bunworasate U, Plengpanich W, Houngngam N, Buranasupkajorn P, Sunthornyothin S, Shotelersuk V, Snabboon T. Bilateral pheochromocytoma during the postpartum period. Arch Gynecol Obstet 2009; 280:1055-8. [DOI: 10.1007/s00404-009-1057-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Accepted: 03/16/2009] [Indexed: 11/24/2022]
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Abstract
Ronald Ma and colleagues describe the differential diagnosis, investigation, and management of a 21-year-old pregnant woman presenting with hypertension and proteinuria at 20 weeks of gestation.
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Frayssinet C, Vezzosi D, Huyghe E, Lorenzini F, Bennet A, Caron P. Surrénalectomie par cœlioscopie rétropéritonéale au cours de la grossesse chez une patiente présentant un phéochromocytome dans le cadre d’une NEM2a : un nouveau cas et revue de la littérature. ANNALES D'ENDOCRINOLOGIE 2008; 69:53-7. [DOI: 10.1016/j.ando.2007.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Eisenhofer G, Rivers G, Rosas AL, Quezado Z, Manger WM, Pacak K. Adverse drug reactions in patients with phaeochromocytoma: incidence, prevention and management. Drug Saf 2008; 30:1031-62. [PMID: 17973541 DOI: 10.2165/00002018-200730110-00004] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The dangers of phaeochromocytomas are mainly due to the capability of these neuroendocrine tumours to secrete large quantities of vasoactive catecholamines, thereby increasing blood pressure and causing other related adverse events or complications. Phaeochromocytomas are often missed, sometimes only becoming apparent during therapeutic interventions that provoke release or interfere with the disposition of catecholamines produced by the tumours. Because phaeochromocytomas are rare, evidence contraindicating use of specific drugs is largely anecdotal or based on case reports. The heterogeneous nature of the tumours also makes adverse reactions highly variable among patients. Some drugs, such as dopamine D(2) receptor antagonists (e.g. metoclopramide, veralipride) and beta-adrenergic receptor antagonists (beta-blockers) clearly carry high potential for adverse reactions, while others such as tricyclic antidepressants seem more inconsistent in producing complications. Other drugs capable of causing adverse reactions include monoamine oxidase inhibitors, sympathomimetics (e.g. ephedrine) and certain peptide and corticosteroid hormones (e.g. corticotropin, glucagon and glucocorticoids). Risks associated with contraindicated medications are easily minimised by adoption of appropriate safeguards (e.g. adrenoceptor blockade). Without such precautions, the state of cardiovascular vulnerability makes some drugs and manipulations employed during surgical anaesthesia particularly dangerous. Problems arise most often when drugs or therapeutic procedures are employed in patients in whom the tumour is not suspected. In such cases, it is extremely important for the clinician to recognise the possibility of an underlying catecholamine-producing tumour and to take the most appropriate steps to manage and treat adverse events and clinical complications.
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Affiliation(s)
- Graeme Eisenhofer
- Department of Clinical Chemistry and Laboratory Medicine, University of Dresden, Dresden, Germany.
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Junglee N, Harries S, Davies N, Scott-Coombes D, Scanlon M, Rees D. Pheochromocytoma in Pregnancy: When is Operative Intervention Indicated? J Womens Health (Larchmt) 2007; 16:1362-5. [DOI: 10.1089/jwh.2007.0382] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- N. Junglee
- Centre for Endocrine and Diabetes Sciences, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales
| | - S.E. Harries
- Department of Anaesthetics, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales
| | - N. Davies
- Department of Obstetrics and Gynaecology, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales
| | - D. Scott-Coombes
- Department of Surgery, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales
| | - M.F. Scanlon
- Centre for Endocrine and Diabetes Sciences, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XN, Wales
| | - D.A. Rees
- Centre for Endocrine and Diabetes Sciences, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XN, Wales
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Abstract
Urologic tumors during pregnancy are rare. Presenting symptoms of malignancies may be mistaken as typical symptoms in pregnancy. Evaluation and treatment of tumors of the adrenal gland, kidney, ureter, bladder, and urethra are reviewed based upon stage and type of tumor and stage of pregnancy.
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Affiliation(s)
- Frances M Martin
- Division of Urology, Department of Surgery, University of Kentucky College of Medicine, University of Kentucky Chandler Medical Center, 800 Rose Street, Room MS-283, Lexington, KY 40536, USA
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Abstract
Pheochromocytomas and paragangliomas are rare neural crest-derived tumors of sympathetic (generally catecholamine producing) or parasympathetic (rarely catecholamine producing) origin. Patients affected by these tumors present with a variable clinical picture, often making diagnosis troublesome. Surgery is the treatment of choice, but requires appropriate medical management before, during, and after tumor resection. Appropriate follow-up of patients is particularly important to identify recurrences, remaining disease, or developing malignancy. Currently, however, no firm guidelines exist about what form follow-up should take. There is also a general lack of prospective studies establishing the best approaches for management and treatment of the tumor. Choice of the many available different therapeutic options instead usually depends on institutional experience and clinical setting, which may vary for different groups of patients. At the First International Symposium on Pheochromocytoma (ISP2005), held in Bethesda in October 2005, a panel of experts addressed and discussed the many therapeutic options and problems associated with management and treatment of patients with pheochromocytoma, reporting their personal experience and sharing their opinions with those of patient representatives. The aim of this special Discussion Session was to reconcile differences of opinion and reach agreement about appropriate management and therapeutic options. This article summarizes the discussion and the recommendations derived from that session.
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Affiliation(s)
- Massimo Mannelli
- Endocrinology Unit, Department of Clinical Physiopathology, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy.
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Cunningham SC, Suh HS, Winter JM, Montgomery E, Schulick RD, Cameron JL, Yeo CJ. Retroperitoneal paraganglioma: single-institution experience and review of the literature. J Gastrointest Surg 2006; 10:1156-63. [PMID: 16966036 DOI: 10.1016/j.gassur.2006.05.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2006] [Accepted: 05/08/2006] [Indexed: 02/08/2023]
Abstract
Paragangliomas are rare tumors arising from extra-adrenal chromaffin cells. We examined the clinical characteristics of all patients at our institution having paragangliomas resected from 1984 through 2005. Of 253 resections, 22 (9%) were retroperitoneal and were selected for further study. The ratio of males to females was 1.3:1, and the median age was 39 years. The average size, rate of metastasis (i.e., malignancy), and rate of function was 7.4 cm, 9.5%, and 57.1%, respectively. Tumors larger than 7 cm were more likely to require adjacent organ resection (P = 0.01). The overall 5-year survival was 73%. Survival was significantly worse after metastasis (P = 0.0023) but did not depend on the tumor diameter, the secreting function of the tumor, the status of surgical margins of resection, or status of the resected lymph nodes.
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Affiliation(s)
- Steven C Cunningham
- Department of Oncology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Moretti A, Minuto M, Berti P, Bernini GP, Mannelli M, Miccoli P. Unusual association of adrenal pheochromocytoma and para-aortic neurofibroma in pregnancy. J Endocrinol Invest 2006; 29:738-41. [PMID: 17033264 DOI: 10.1007/bf03344185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The association of pheochromocytoma (PHEO) and pregnancy is uncommon and life threatening for both the fetus and the mother. Early diagnosis and treatment is essential to decrease maternal and fetal mortality and to differentiate the disease from the more common pre-eclampsia. While medical treatment should be started immediately after diagnosis, the timing of surgical treatment is still debated. We describe the case of a 27-yr-old woman in the 18th week of pregnancy who showed a biochemical pattern typical of PHEO and, by imaging studies, 2 tumors with the same characteristics: the first localized on the right adrenal gland, the second at the right renal hilum. The patient underwent surgery because of suspicion of malignant PHEO with local metastasis, while histology revealed a rare association of a solitary PHEO and para-aortic neurofibroma, both tumors embryologically deriving from a common cell precursor.
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Affiliation(s)
- A Moretti
- Department of Internal Medicine, University of Pisa, 56100 Pisa, Italy
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Fallo F, Pezzi V, Sonino N, Altavilla G, Barzon L. Adrenal incidentaloma in pregnancy: clinical, molecular and immunohistochemical findings. J Endocrinol Invest 2005; 28:459-63. [PMID: 16075931 DOI: 10.1007/bf03347228] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Adrenal incidentalomas detected during pregnancy are very rare, and the natural history of these tumors during gestation is unknown. We report a case of a pregnant woman with an adrenal mass discovered serendipitously, who was followed-up during gestation and underwent adrenalectomy shortly after delivery. This allowed the evaluation of both the clinical outcome and the molecular/immunohistochemical correlates. Estrogens may indeed influence the function and proliferation of human adrenal cells, and a state of circulating estrogen excess can represent an in vivo model to test their effect on the adrenals. No evidence of adrenal change in morphology and function was found in our patient throughout pregnancy, as shown by adrenal ultrasound imaging and adrenal hormone measurements. Four months after delivery, the patient underwent laparoscopic right adrenalectomy, and pathologic analysis revealed a 2.7 cm benign adrenocortical adenoma. The diameter of the adrenal mass at ultrasonography correlated highly with post-partum mass diameter measured by abdominal computed tomography (CT). Quantitative expression of both ERalpha and ERbeta by real-time RT-PCR analysis and Western blotting findings did not differ among adenoma, normal adjacent adrenal and normal adrenal control tissues. This case of an adrenal incidentaloma discovered during pregnancy shows that a close observation with endocrine investigations and ultrasonography could be an appropriate approach, delaying the decision of surgical intervention after delivery. Estrogen receptor mRNA levels in the adrenal mass similar to those observed in normal adrenals suggest that estrogen oversecretion during pregnancy was not a risk factor for tumor progression.
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Affiliation(s)
- F Fallo
- Department of Medical and Surgical Sciences, University of Padova, Padova, Italy.
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Abstract
Human pregnancy is marked by alterations in several endocrine systems--perhaps most notably, the striking increase in steroid hormone production by the adrenals of the fetus and mother. Morphologically and physiologically, the human fetal adrenal glands are remarkable organs. In proportion to the adult organs, the adrenal cortex is the largest organ of the fetus. At term, they produce more steroid and weigh the same as adrenal glands of the adult. Much of the steroid that is released by the fetal and maternal adrenals during pregnancy is the sulfated form of dehydroepiandrosterone (DHEA-S), which is used by the placenta to produce estrogens. Herein, we discuss the physiologic and pathophysiologic hormonal changes of the fetal and maternal adrenals during the course of pregnancy.
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Affiliation(s)
- William E Rainey
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75235-9032, USA.
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Magee LA, Abdullah S. The safety of antihypertensives for treatment of pregnancy hypertension. Expert Opin Drug Saf 2004; 3:25-38. [PMID: 14680459 DOI: 10.1517/14740338.3.1.25] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This review addresses the maternal and perinatal benefits and risks of antihypertensive therapy in pregnancy. It covers the diagnosis of hypertension in pregnancy (with a brief discussion of ambulatory blood pressure measurement) followed by both the general principles of management of pregnancy hypertension and the specifics of individual antihypertensive drugs and drug classes. Discussion is focused on quantitative overviews of randomised, controlled trials, although observational literature is also discussed, particularly in reference to the potential teratogenicity of agents and the safety of their administration to nursing mothers. The treatment of severe hypertension is addressed separately from the treatment of mild-to-moderate hypertension, for which the maternal and fetal risks are substantially different.
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Affiliation(s)
- L A Magee
- Department of Specialized Women's Health, BC Women's Hospital and Health Centre, 4500 Oak Street, Room IU59, Vancouver, BCV6H 3N1, Canada.
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Martinelli P, Maruotti GM, Pasquali D, Paladini D, Agangi A, Rippa E, Colantuoni V, Bellastella A, Sinisi AA. Genetic prenatal RET testing and pregnancy management of multiple endocrine neoplasia Type II A (MEN2A): a case report. J Endocrinol Invest 2004; 27:357-60. [PMID: 15233556 DOI: 10.1007/bf03351062] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Multiple endocrine neoplasia 2A (MEN 2A) is an inherited dominant syndrome characterised by medullary thyroid carcinoma, adrenal pheochromocytoma and hyperparathyroidism due to specific RET proto-oncogene mutations. Fertile MEN 2A women are at risk of complicated pregnancy because of unrecognised pheochromocytoma and transmission of RET mutation to the progeny. This condition may cause psychological distress in affected pregnant patients and their families. Here we describe the genetic prenatal testing, the pregnancy management and obstetric outcome in a MEN 2A patient with a right side adrenal hyperplasia and elevated calcitonin levels, a condition suspicious for possible recurrence of pheochromocytoma. We confirm that maternal or fetal complications are rare when MEN 2A diagnosis is made before pregnancy and an accurate monitoring is instituted. Furthermore, our results indicate that prenatal testing for RET mutations is highly recommended in making decisions and assuring parents on the lifelong risk of tumors. This will avoid the psychological distress that can further complicate the pregnancy of affected women.
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Affiliation(s)
- P Martinelli
- Department of Obstetrics and Gynecology, Federico II University, Naples, Italy
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