Massive bilateral phaeochromocytomas in association with Von Hippel Lindau syndrome in pregnancy

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.

MANAGEMENT OF CATECHOLAMINE-SECRETING TUMORS IN PREGNANCY: A REVIEW

OBJECTIVE

Catecholamine-secreting tumors (pheochromocytomas and paragangliomas) presenting during pregnancy are extremely rare, but they can be fatal to both mother and fetus. Recent discoveries in the genetic background of these tumors are expected to address an increasing number of at-risk women to prenatal diagnosis.

METHODS

The literature was reviewed in order to provide clinicians with a practical and updated guide on how to manage this life-threatening condition.

RESULTS

The clinical presentation of catecholamine-secreting tumors can be deceptive and mimic common disorders of pregnancy. Silent catecholamine-secreting tumors can become evident during pregnancy, and hypertension cannot be considered a hallmark for this condition: some women may be normotensive or develop orthostatic hypotension. Biochemical screening includes measurement of plasma free metanephrines or urinary fractioned metanephrines. Measurement of catecholamines, dopamine, and methoxytyramine can provide further information on tumor biology, location, and prognosis. Diagnostic imaging is limited, and medical treatment requires a cautious balance between hemodynamic control and effects on the fetoplacental unit. Several genes have been associated with syndromes including catecholamine-secreting tumors, and positive genetic testing can correlate with tumor behavior. Timing and modalities for tumor removal and delivery, including anesthetic management, depend on gestational age, maternal and fetal wellbeing, control of catecholamine excess, suspicion of multiple or malignant disease, and surgical accessibility to the tumor.

CONCLUSION

A timely diagnosis and a multidisciplinary approach are the keys to improve pregnancy outcomes in patients with a catecholamine-secreting tumor; each case should be managed in a tertiary referral center.

Systematic review of phaeochromocytoma in pregnancy

Background

Phaeochromocytoma in pregnancy is a rare and potentially dangerous situation for mother and fetus. This review aimed to assess current mortality rates and how medical and surgical management affect these.

Methods

Articles in English published between 2000 and 2011 were obtained from a MEDLINE search. Eligible publications presented women diagnosed with phaeochromocytoma in the antenatal or immediate postnatal period, and reported management and outcomes.

Results

A total of 135 reports were identified. After applying inclusion criteria, 77 pregnancies involving 78 fetuses were analysed. Fetal and maternal mortality rates were 17 per cent (13 of 78) and 8 per cent (6 of 77) respectively. Better outcomes were achieved when the diagnosis of phaeochromocytoma was made in the antenatal period than when it was made during labour or immediately postpartum (survival of both mother and fetus(es) in 48 of 56 versus 12 of 21 respectively; P = 0·012). When the diagnosis was made before 23 weeks' gestation, there was no difference in outcomes when phaeochromocytoma surgery was carried out in the second trimester, compared with when it was postponed to the third trimester or after delivery (fetal death 2 of 18 versus 2 of 8 respectively; P = 0·563).

Conclusion

This review, although limited by the rarity of the condition and level of available evidence, demonstrated that survival rates are improved if the diagnosis of phaeochromocytoma can be established antenatally. With diagnosis before 23 weeks' gestation, no definite advantage of proceeding with tumour removal during the second trimester could be demonstrated.

Pheochromocytoma and pregnancy: a rare but dangerous combination

OBJECTIVE

To review the literature on pheochromocytoma in pregnancy (PIP) published during the 11-year period 1998 through 2008.

METHODS

We searched MEDLINE data sources from 1998 through 2008 using the search terms "pheochromocytoma" and "pregnancy" and reviewed case reports of PIP published in English.

RESULTS

We identified 54 case reports in MEDLINE data sources, of which 51 reports including 60 cases were reviewed. In comparison with the previous decade, a decreased rate of antenatal diagnosis (from 83% to 70%) and increased maternal and fetal mortality (from 4% to 12% and from 10% to 17%, respectively) were observed. Prematurity was present in 53% of the infants of mothers with antenatally diagnosed pheochromocytoma who gave birth to a live infant. Hypertension was the most common manifestation (88%), with 33% of patients having antepartum hypertensive crises. Urinary catecholamines (64%) and metanephrines (40%) were the most commonly used tests, whereas urinary and plasma metanephrines were the most sensitive tests (100%). Ultrasonography had poor sensitivity (54%), especially during the third trimester. Magnetic resonance imaging was 100% sensitive for adrenal tumors but had only 50% sensitivity for extra-adrenal tumors. A syndromic or familial presentation was seen in 18% of patients, and 32% of patients had bilateral or extra-adrenal tumors.

CONCLUSION

In comparison with the previous decade, a decreased rate of antenatal diagnosis and increased maternal and fetal mortality were observed. Prematurity was a major morbidity associated with PIP. Hypertensive crises were more common during pregnancy. Urinary and plasma metanephrines had the highest sensitivity to detect PIP. Genetic screening should be offered to all pregnant women with pheochromocytoma.

Diagnosis and management of pheochromocytoma during pregnancy

Although the presence of pheochromocytoma in pregnancy is extremely rare, this association deserves much attention as the tumor constitutes a very high risk for both mother and fetus. Any pregnant woman with hypertension, especially if paroxysmal or labile, or with so far unexplained "spells", should induce the clinician to consider the possibility of a pheochromocytoma. Maternal and fetal survival depend a lot on an early diagnosis, a correct medical therapy and a correct timing of delivery and surgery. In this respect, a strict collaboration between obstetricians, endocrinologists, anesthesiologists and surgeons is pivotal.