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Veldhuizen GP, Alnazer RM, Kroon AA, Spaanderman MEA, de Leeuw PW. Variable effect of the post-partum menstrual cycle on aldosterone and renin in women with recent preeclampsia. J Hum Hypertens 2024:10.1038/s41371-024-00926-1. [PMID: 38898171 DOI: 10.1038/s41371-024-00926-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 06/13/2024] [Accepted: 06/14/2024] [Indexed: 06/21/2024]
Abstract
The purpose of the present study is to identify the impact of the postpartum menstrual cycle on aldosterone, renin, and their ratio of women with and without a preeclamptic pregnancy in the past. To this end, we analysed the data from 59 women with a history of preeclampsia and 39 healthy parous controls. Five to seven months post-partum, we measured aldosterone, renin, and the aldosterone-to-renin ratio during both the follicular and the luteal phase of the menstrual cycle. All measurements were taken in the supine position in the morning. Patients had maintained a standardized sodium diet in the week prior to the measurements. Our results show that in both post-partum women with recent preeclampsia and controls, average levels of renin and aldosterone are significantly elevated in the luteal phase as compared to the follicular phase. The aldosterone-to-renin ratio does not differ between the two phases in either group. Compared to controls, women with recent preeclampsia have significantly lower levels of renin, aldosterone, and aldosterone-to-renin ratio in the follicular phase. This remained consistent in the luteal phase, except for renin. A close correlation existed between the luteal and follicular aldosterone-to-renin ratio in the control group but not in the preeclampsia group. We conclude that both renin and aldosterone are significantly affected by the menstrual cycle whereas the resulting aldosterone-to-renin ratio is not. Post-partum women with recent preeclampsia tend to have lower values for aldosterone and the aldosterone-to-renin ratio than controls.
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Affiliation(s)
- Gregory P Veldhuizen
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
- Else Kroener Fresenius Center for Digital Health, Technical University Dresden, Dresden, Germany
| | - Rawan M Alnazer
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Abraham A Kroon
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Marc E A Spaanderman
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter W de Leeuw
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands.
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands.
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Abstract
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.
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Affiliation(s)
- Vittorio Forestiero
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Via Genova 3, 10126, Torino, Italy
| | - Elisa Sconfienza
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Via Genova 3, 10126, Torino, Italy
| | - Paolo Mulatero
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Via Genova 3, 10126, Torino, Italy.
| | - Silvia Monticone
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Via Genova 3, 10126, Torino, Italy
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Ohara N, Kobayashi M, Yoneoka Y, Hasegawa G, Aoki Y, Nakamura Y, Kazama Y, Nishiyama T. Primary Aldosteronism Presenting with Hypertension Five Days after Delivery: A Case Report and Literature Review. Intern Med 2022; 61:507-512. [PMID: 34393169 PMCID: PMC8907769 DOI: 10.2169/internalmedicine.7778-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
A 35-year-old Japanese woman with no history of hypertension developed hypertension 5 days after normal delivery. Endocrinological and radiological examinations indicated primary aldosteronism (PA) and a 1.4-cm left adrenal tumor. The patient underwent laparoscopic adrenalectomy, and a diagnosis of aldosterone-producing adenoma was confirmed immunohistochemically. Her plasma aldosterone concentration and blood pressure normalized. Cases of PA presenting with hypertension in the postpartum period have been reported. This case suggests that PA should be considered in women with postpartum hypertension, especially in those with blood pressure that suddenly increases shortly after delivery, even if they were normotensive before and throughout pregnancy.
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Affiliation(s)
- Nobumasa Ohara
- Department of Endocrinology and Metabolism, Uonuma Kikan Hospital, Japan
| | - Michi Kobayashi
- Department of Endocrinology and Metabolism, Uonuma Kikan Hospital, Japan
- Department of Diabetes, Endocrinology and Metabolism, Center Hospital of the National Center for Global Health and Medicine, Japan
| | | | - Go Hasegawa
- Department of Pathology, Uonuma Kikan Hospital, Japan
| | - Yayoi Aoki
- Department of Pathology, Tohoku University Hospital, Japan
| | - Yasuhiro Nakamura
- Division of Pathology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Japan
| | - Yoshiki Kazama
- Department of Obstetrics and Gynecology, Uonuma Kikan Hospital, Japan
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Okaki H, Matsumoto Y, Makino Y, Morishita Y, Takagi K. Primary aldosteronism during pregnancy: Case report and literature review. HYPERTENSION RESEARCH IN PREGNANCY 2022. [DOI: 10.14390/jsshp.hrp2022-013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Hiromu Okaki
- Perinatal and Maternal Center of Saitama Medical Center, Jichi Medical University
| | - Yuko Matsumoto
- Perinatal and Maternal Center of Saitama Medical Center, Jichi Medical University
| | - Yuko Makino
- Perinatal and Maternal Center of Saitama Medical Center, Jichi Medical University
| | | | - Kenjiro Takagi
- Perinatal and Maternal Center of Saitama Medical Center, Jichi Medical University
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Kulkarni S, Dominiczak AF, Touyz RM, Spence JD, Batlle D, Barigou M, Brown M, Carey RM, Elijovich F, Taler S, Wilkinson IB. CONNed in Pregnancy. Hypertension 2021; 78:241-249. [PMID: 34058849 DOI: 10.1161/hypertensionaha.121.17021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Spoorthy Kulkarni
- From the Cambridge University hospitals NHS foundation trust, Cambridge United Kingdom (S.K.)
| | - Anna F Dominiczak
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (A.F.D.), University of Glasgow, United Kingdom
| | - Rhian M Touyz
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (R.M.T.), University of Glasgow, United Kingdom
| | - J David Spence
- Stroke Prevention & Atherosclerosis Research Centre, Western University, London, Ontario, Canada (J.D.S.)
| | - Daniel Batlle
- Division of Nephrology and Hypertension, Northwestern University Feinberg Medical School, Chicago, IL (D.B.)
| | - Mohammed Barigou
- Endocrinology diabetes and metabolism division, Lausanne University hospital (CHUV), Switzerland (M. Barigou)
| | - Morris Brown
- The Centre for Clinical Pharmacology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, United Kingdom Clinical Pharmacology Unit (M. Brown)
| | - Robert M Carey
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia Health System, Charlottesville (R.M.C.)
| | - Fernando Elijovich
- Department of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN (F.E.)
| | - Sandra Taler
- Division of Nephrology & Hypertension, Mayo Clinic, Rochester, MN (S.T.)
| | - Ian B Wilkinson
- Division of Experimental Medicine and Immuno-therapeutics, University of Cambridge, United Kingdom (I.B.W.)
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Pintavorn P, Munie S. A Case Report of Recurrent Hypokalemia During Pregnancies Associated With Nonaldosterone-Mediated Renal Potassium Loss. Can J Kidney Health Dis 2021; 8:20543581211017424. [PMID: 34104455 PMCID: PMC8165817 DOI: 10.1177/20543581211017424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 04/11/2021] [Indexed: 11/15/2022] Open
Abstract
Rationale Geller et al reported a rare mutation in the mineralocorticoid receptor (MR) resulting in constitutive MR activity. Progesterone, normally an MR antagonist, acts as a potent agonist with this mutation. Progesterone levels can increase 100-fold during pregnancy and thus lead to increased MR activity in this setting, resulting in hypertension (HTN) and hypokalemia during pregnancy and resolution of hypokalemia after delivery. Presenting concerns Our patient was a 33-year-old African American female with a history of pregnancy-induced HTN associated with hypokalemia during her last pregnancy. She presented with muscle weakness from profound hypokalemia complicated by nephrogenic diabetes insipidus (DI) and rhabdomyolysis. Diagnosis Her admission potassium was 1.9 mmol/L (3.5-5.1 mmol/L) with a 24-hour urine potassium of 35 mmol per day and an unmeasurable serum aldosterone level. Her potassium normalized 1 day after delivery off potassium supplementation and amiloride, which were last given 1 day prior to her delivery. Recurrent hypokalemia from nonaldosterone-mediated renal potassium wasting during pregnancy (with normal potassium in a nongestational state) is consistent with the cases of gain-of-function mutation in MR that Geller et al report. A definite diagnosis requires genetic analysis. Interventions Her hypokalemia was refractory to potassium replacement but quickly responded to an inhibitor of the epithelial sodium channel (ENaC), amiloride. Outcomes Her potassium normalized on amiloride 10 mg per day and KCL 40 mEq daily during the remainder of her pregnancy, and her nephrogenic DI resolved after this correction of hypokalemia. After her delivery, her potassium remained normal off the potassium supplements and amiloride. Novel findings Pregnancy-induced hypokalemia from an activating MR mutation has rarely been reported. Pregnancy-induced HTN is often the first differential diagnosis in a patient who develops worsening in her HTN during pregnancy. We should also consider the possibility of a gain-of-function mutation in MR in these patients who also have associated hypokalemia.
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Affiliation(s)
| | - Stephanie Munie
- Medical University of South Carolina, College of Medicine, Charleston, SC, USA
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Marques-Sá J, Barbosa M, Fernandes V, Santos MJ. Nearly fatal hypokalaemia due to non-hypertensive primary hyperaldosteronism in the post partum. BMJ Case Rep 2021; 14:14/3/e240018. [PMID: 33753383 PMCID: PMC7986951 DOI: 10.1136/bcr-2020-240018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A previously healthy postpartum 33-year-old woman was admitted at the emergency department after two episodes of syncope. In the waiting room, she collapsed, ventricular fibrillation was detected, and she was reanimated by electric cardioversion. At admission, she was conscient, with blood pressure of 102/74 mm Hg and heart rate of 78 bpm. In the laboratory workup, severe hypokalaemia was found (K+ 1.77 mEq/L). Abdominopelvic CT revealed a 27 mm nodule in the right adrenal gland. High aldosterone and low plasma renin levels were detected, and the diagnosis of primary hyperaldosteronism was made, although she never had hypertension. Posteriorly, a cosecretion of aldosterone and cortisol was found. Two months after admission, the patient remained stable with normal K+ levels under spironolactone and a right adrenalectomy was performed. The cure of primary hyperaldosteronism and a partial adrenal insufficiency were confirmed. K+ levels and blood pressure remained normal without treatment and 10 months after surgery hydrocortisone was suspended.
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Affiliation(s)
| | | | - Vera Fernandes
- Endocrinology Department, Braga Hospital, Braga, Portugal
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Shekhar S, Haykal R, Kamilaris C, Stratakis CA, Hannah-Shmouni F. Curative resection of an aldosteronoma causing primary aldosteronism in the second trimester of pregnancy. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200043. [PMID: 32755966 PMCID: PMC7424322 DOI: 10.1530/edm-20-0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 07/13/2020] [Indexed: 11/21/2022] Open
Abstract
SUMMARY A 29-year-old primigravida woman with a known history of primary aldosteronism due to a right aldosteronoma presented with uncontrolled hypertension at 5 weeks of estimated gestation of a spontaneous pregnancy. Her hypertension was inadequately controlled with pharmacotherapy which lead to the consideration of surgical management for her primary aldosteronism. She underwent curative right unilateral adrenalectomy at 19 weeks of estimated gestational age. The procedure was uncomplicated, and her blood pressure normalized post-operatively. She did, however, have a preterm delivery by cesarean section due to intrauterine growth retardation with good neonatal outcome. She is normotensive to date. LEARNING POINTS Primary aldosteronism is the most common etiology of secondary hypertension with an estimated prevalence of 5-10% in the hypertensive population. It is important to recognize the subtypes of primary aldosteronism given that certain forms can be treated surgically. Hypertension in pregnancy is associated with significantly higher maternal and fetal complications. Data regarding the treatment of primary aldosteronism in pregnancy are limited. Adrenalectomy can be considered during the second trimester of pregnancy if medical therapy fails to adequately control hypertension from primary aldosteronism.
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Affiliation(s)
- Skand Shekhar
- Section on Endocrinology and Genetics, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Rasha Haykal
- Section on Endocrinology and Genetics, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Crystal Kamilaris
- Section on Endocrinology and Genetics, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Fady Hannah-Shmouni
- Section on Endocrinology and Genetics, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
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Piccoli GB, Mannucci C. Preeclampsia: A Diagnosis-Nondiagnosis That Is Too Easily Made: The Case of Primary Hyperaldosteronism. Kidney Blood Press Res 2020; 45:363-367. [PMID: 32325453 DOI: 10.1159/000507116] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 03/10/2020] [Indexed: 11/19/2022] Open
Affiliation(s)
- Giorgina Barbara Piccoli
- Néphrologie, Centre Hospitalier Le Mans, Le Mans, France, .,Department of Clinical and Biological Sciences, Università di Torino, Torino, Italy,
| | - Claudia Mannucci
- Néphrologie, Centre Hospitalier Le Mans, Le Mans, France.,Nephrology Service, Università di Pisa, Pisa, Italy
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