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Vecchiola A, Uslar T, Friedrich I, Aguirre J, Sandoval A, Carvajal CA, Tapia-Castillo A, Martínez-García A, Fardella CE. The role of sex hormones in aldosterone biosynthesis and their potential impact on its mineralocorticoid receptor. Cardiovasc Endocrinol Metab 2024; 13:e0305. [PMID: 38846628 PMCID: PMC11155591 DOI: 10.1097/xce.0000000000000305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 04/22/2024] [Indexed: 06/09/2024]
Abstract
Blood pressure (BP) regulation is a complex process involving various hormones, including aldosterone and its mineralocorticoid receptor. Mineralocorticoid receptor is expressed in several tissues, including the kidney, and plays a crucial role in regulating BP by controlling the sodium and water balance. During different stages of life, hormonal changes can affect mineralocorticoid receptor activity and aldosterone levels, leading to changes in BP. Increasing evidence suggests that sex steroids modulate aldosterone levels. Estrogens, particularly estradiol, mediate aldosterone biosynthesis by activating classical estrogen receptors and the G protein-coupled receptor. Progesterone acts as an anti-mineralocorticoid by inhibiting the binding of aldosterone to the mineralocorticoid receptor. Moreover, progesterone inhibits aldosterone synthase enzymes. The effect of testosterone on aldosterone synthesis is still a subject of debate. However, certain studies show that testosterone downregulates the mRNA levels of aldosterone synthase, leading to decreased plasma aldosterone levels.
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Affiliation(s)
- Andrea Vecchiola
- Departamento de Endocrinología, Facultad de Medicina, Centro Traslacional de Endocrinología UC (CETREN), Pontificia Universidad Católica de Chile
| | - Thomas Uslar
- Departamento de Endocrinología, Facultad de Medicina, Centro Traslacional de Endocrinología UC (CETREN), Pontificia Universidad Católica de Chile
| | - Isidora Friedrich
- Departamento de Endocrinologìa, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago
| | - Joaquin Aguirre
- Departamento de Endocrinologìa, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago
| | - Alejandra Sandoval
- Escuela de Tecnología Médica, Facultad de Ciencias, Pontificia Universidad Católica de Valparaíso, Valparaíso, Chile
| | - Cristian A. Carvajal
- Departamento de Endocrinología, Facultad de Medicina, Centro Traslacional de Endocrinología UC (CETREN), Pontificia Universidad Católica de Chile
| | - Alejandra Tapia-Castillo
- Departamento de Endocrinología, Facultad de Medicina, Centro Traslacional de Endocrinología UC (CETREN), Pontificia Universidad Católica de Chile
| | - Alejandra Martínez-García
- Departamento de Endocrinología, Facultad de Medicina, Centro Traslacional de Endocrinología UC (CETREN), Pontificia Universidad Católica de Chile
| | - Carlos E. Fardella
- Departamento de Endocrinología, Facultad de Medicina, Centro Traslacional de Endocrinología UC (CETREN), Pontificia Universidad Católica de Chile
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Balachandran DM, Subbaiah M, Dorairajan G. Primary aldosteronism during pregnancy and eplerenone use – a case report. Obstet Med 2023. [DOI: 10.1177/1753495x231160322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Abstract
Primary aldosteronism is one of the important causes of secondary hypertension. However, pregnancy with primary aldosteronism is rare. Eplerenone is an aldosterone antagonist which is used in the treatment of primary aldosteronism. This is a case of successful pregnancy outcome in a young woman who was known to have primary aldosteronism and was on oral eplerenone from preconception. There are only five case reports on eplerenone use during pregnancy in the literature.
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Affiliation(s)
| | - Murali Subbaiah
- Department of Obstetrics and Gynaecology, JIPMER, Puducherry, India
| | - Gowri Dorairajan
- Department of Obstetrics and Gynaecology, JIPMER, Puducherry, India
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3
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Sanga V, Rossitto G, Seccia TM, Rossi GP. Management and Outcomes of Primary Aldosteronism in Pregnancy: A Systematic Review. Hypertension 2022; 79:1912-1921. [PMID: 35686552 DOI: 10.1161/hypertensionaha.121.18858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Primary aldosteronism (PA) in pregnancy (PAP) can be a serious condition and is challenging to diagnose. This study was conceived to help in the diagnosis of PAP and provide suggestions on management of PAP based on evidence retrieved using a Population, Intervention, Comparison, and Outcome search strategy. Based on the changes of aldosterone and renin occurring in normal pregnancies, we developed a nomogram that will allow to identify PAP cases. Moreover, we found that published PAP cases fell into 4 main groups differing for management and outcomes: (1) unilateral medically treated, (2) unilateral surgically treated, (3) bilateral medically treated and (4) familial forms. Results showed that complications involved 62.2% of pregnant women with nonfamilial PA and 18.5% of those with familial hyperaldosteronism type I. Adrenalectomy during pregnancy in women with PAP did not improve maternal and fetal outcomes, over medical treatment alone. Moreover, cure of maternal hypertension and mother and baby outcome were better when unilateral PA was discovered and surgically treated before or after pregnancy. Therefore, fertile women with arterial hypertension should be screened for PA before pregnancy and, if necessary, subtyped to identify unilateral forms of PA. This will allow to furnish adequate counseling, a chance for surgical cure and, therefore, for a pregnancy not complicated by aldosterone excess.
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Affiliation(s)
- Viola Sanga
- Internal and Emergency Medicine Unit (V.S., G.R., T.M.S., G.P.R.), Department of Medicine - DIMED, University of Padua, Italy.,PhD Arterial Hypertension and Vascular Biology (V.S.), Department of Medicine - DIMED, University of Padua, Italy
| | - Giacomo Rossitto
- Internal and Emergency Medicine Unit (V.S., G.R., T.M.S., G.P.R.), Department of Medicine - DIMED, University of Padua, Italy.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (G.R.)
| | - Teresa Maria Seccia
- Internal and Emergency Medicine Unit (V.S., G.R., T.M.S., G.P.R.), Department of Medicine - DIMED, University of Padua, Italy
| | - Gian Paolo Rossi
- Internal and Emergency Medicine Unit (V.S., G.R., T.M.S., G.P.R.), Department of Medicine - DIMED, University of Padua, Italy
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Sanga V, Seccia TM, Rossi GP. A systematic review of pathophysiology and management of familial hyperaldosteronism type 1 in pregnancy. Endocrine 2021; 74:5-10. [PMID: 34043182 PMCID: PMC8440273 DOI: 10.1007/s12020-021-02763-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 05/10/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE Familial hyperaldosteronism type 1 (FH-1) is a rare autosomal dominant form of primary aldosteronism, which features a marked phenotypic heterogeneity, ranging from mild to severe forms of arterial hypertension that can be complicated by stroke and cardiovascular events at a young age. As affected patients usually reach the fertile age, transmission of the disease to offspring is common. Notwithstanding this, reports of FH-1 in pregnancy are limited and there is a lack of treatment guidelines. METHODS AND RESULTS We searched the PubMed and EuropePMC databases with a PICO strategy to retrieve available information on management of FH-1 patients during pregnancy. We could identify seven relevant articles, which are herein reviewed. CONCLUSION Based on available information on pathophysiology and treatment of FH-1 in pregnancy, recommendations for the rational management of FH-1 in pregnancy are provided.
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Affiliation(s)
- Viola Sanga
- Hypertension and Emergency Unit, Department of Medicine - DIMED, University of Padua, Padova, Italy
- PhD Arterial Hypertension and Vascular Biology, Department of Medicine - DIMED, University of Padua, Padova, Italy
| | - Teresa Maria Seccia
- Hypertension and Emergency Unit, Department of Medicine - DIMED, University of Padua, Padova, Italy
| | - Gian Paolo Rossi
- Hypertension and Emergency Unit, Department of Medicine - DIMED, University of Padua, Padova, Italy.
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5
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Sanga V, Lenzini L, Seccia TM, Rossi GP. Familial hyperaldosteronism type 1 and pregnancy: successful treatment with low dose dexamethasone. Blood Press 2021; 30:133-137. [PMID: 33390031 DOI: 10.1080/08037051.2020.1863771] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE Familial hyperaldosteronism type 1 (FH-1) is an autosomal dominant form of primary aldosteronism (PA), featuring a marked phenotypic heterogeneity, ranging from mild forms of PA and arterial hypertension (HT) to severe forms complicated by stroke at a young age. Affected patients usually reach the fertile age; hence, transmission of the disease to offspring is common. Notwithstanding this, only anecdotal reports of FH-1 in pregnancy exist and recommendations for treatment remain vague. MATERIALS AND METHODS AND RESULTS We herein report on a novel FH-1 pedigree featuring very severe HT, fatal aortic dissection, and high rate of early stroke, where a young FH-1 woman was successfully managed throughout pregnancy with low-dose dexamethasone. CONCLUSIONS Based on this experience and on available information on pathophysiology of FH-1 in pregnancy, the pros and cons of dexamethasone administration in the treatment of FH-1 in pregnancy are also discussed.
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Affiliation(s)
- Viola Sanga
- Hypertension and Emergency Unit, Department of Medicine - DIMED, University of Padua, Padova, Italy.,PhD Arterial Hypertension and Vascular Biology, Department of Medicine - DIMED, University of Padua, Padova, Italy
| | - Livia Lenzini
- Hypertension and Emergency Unit, Department of Medicine - DIMED, University of Padua, Padova, Italy
| | - Teresa Maria Seccia
- Hypertension and Emergency Unit, Department of Medicine - DIMED, University of Padua, Padova, Italy
| | - Gian Paolo Rossi
- Hypertension and Emergency Unit, Department of Medicine - DIMED, University of Padua, Padova, Italy
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Berberich AJ, Penava D, Sun D, MacDougall A, Lum A, Van Uum S. High aldosterone, hypertension and adrenal adenoma in a 36-year-old pregnant patient: Is this primary aldosteronism? Obstet Med 2020; 13:88-91. [PMID: 32714441 DOI: 10.1177/1753495x18786422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 06/08/2018] [Indexed: 11/16/2022] Open
Abstract
A 36-year-old woman presented at 16 weeks' gestation with severe hypertension. In comparison to the non-pregnant reference normal ranges, potassium was 3.1-3.9 mmol/L, aldosterone 2570-3000 pmol/L (N 250-2885) renin was unsuppressed (24-76.4 ng/L (N1.7-23.9)), with aldosterone to renin ratios in the reference range. An adrenal MRI scan demonstrated a 1.8 × 1.4 cm left adrenal adenoma. Primary aldosteronism was strongly suspected and surgery considered. However, she was managed conservatively with labetalol and modified-release nifedipine with no obstetric complications. Post-partum blood pressures remained elevated with normal aldosterone (539 pmol/L), unsuppressed renin (5.2 ng/L) and normal aldosterone-to-renin ratio (104 (N < 144)). Suspected primary hyperaldosteronism is challenging to investigate and manage in pregnancy. The accepted screening and confirmatory tests are either contraindicated or not validated in pregnancy. Pregnancy has significant effects on the renin-angiotensin-aldosterone pathway leading to physiologic elevations in both aldosterone and renin. While primary hyperaldosteronism has been associated with poor pregnancy outcomes, optimal management in pregnancy is not clearly established.
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Affiliation(s)
- Amanda J Berberich
- Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Deborah Penava
- Department of Obstetrics and Gynecology, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Dongmei Sun
- Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Arlene MacDougall
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Andrea Lum
- Department of Radiology, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Stan Van Uum
- Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
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Manoharan M, Sinha P, Sibtain S. Adrenal disorders in pregnancy, labour and postpartum - an overview. J OBSTET GYNAECOL 2019; 40:749-758. [PMID: 31469031 DOI: 10.1080/01443615.2019.1648395] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Adrenal disorders may manifest during pregnancy for the first time, or present from before pregnancy as either undiagnosed or diagnosed and treated. They may present as hormonal hypofunction or hyperfunction, or with mass effects or other non-endocrine effects. Adrenal disorders such as Cushing's syndrome, Addison's disease, pheochromocytoma, primary hyper-aldosteronism and adreno-cortical carcinoma are rare in pregnancy. Pregnancy presents special problems in the evaluation of the hypothalamic-pituitary-adrenal and renin-angiotensin-aldosterone axis as these undergoe major changes during pregnancy. Diagnosis is challenging as symptoms associated with pregnancy are also seen in adrenal diseases. A timely diagnosis and treatment is critical as these disorders can cause maternal and foetal morbidity and mortality. A high index of suspicion must be maintained as they can go unrecognised and untreated. An early diagnosis and treatment often improves outcomes. The aim of this article is to review the patho-physiology, clinical manifestation, diagnosis and management of various adrenal disorders during pregnancy.
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Affiliation(s)
| | - Prabha Sinha
- Department of Obstetrics and Gynaecology, Oman Medical College, Muscat, Oman
| | - Shabnum Sibtain
- Department of Obstetrics and Gynaecology, Azra Naheed Medical College, Lahore, Pakistan
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Abstract
: Adrenal diseases--including disorders such as Cushing's syndrome, Addison's disease, pheochromocytoma, primary hyperaldosteronism and congenital adrenal hyperplasia--are relatively rare in pregnancy, but a timely diagnosis and proper treatment are critical because these disorders can cause maternal and fetal morbidity and mortality. Making the diagnosis of adrenal disorders in pregnancy is challenging as symptoms associated with pregnancy are also seen in adrenal diseases. In addition, pregnancy is marked by several endocrine changes, including activation of the renin-angiotensin-aldosterone system and the hypothalamic-pituitary-adrenal axis. The aim of this article was to review the pathophysiology, clinical manifestation, diagnosis and management of various adrenal disorders during pregnancy.
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9
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Yuen KCJ, Chong LE, Koch CA. Adrenal insufficiency in pregnancy: challenging issues in diagnosis and management. Endocrine 2013; 44:283-92. [PMID: 23377701 DOI: 10.1007/s12020-013-9893-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 01/21/2013] [Indexed: 10/27/2022]
Abstract
Adrenal insufficiency (AI) in pregnancy is relatively rare, but it is associated with significant maternal and fetal morbidity and mortality if untreated during gestation or in the puerperium. Hence, timely diagnosis and decisive treatment by the clinician are critical. However, due to pregnancy-induced metabolic and endocrine changes and the resemblance of symptomatology of AI to those of pregnancy, the diagnosis is often difficult to recognize and challenging to confirm. Normal pregnancy is a state of glucocorticoid excess particularly in the latter stages, and normative values for serum cortisol levels are not well-established. Furthermore, testing the hypothalamic-pituitary-adrenal axis using validated stimulation tests during pregnancy are lacking. Therefore, it is the aim of the present review to discuss and to summarize the current knowledge, focussing on the challenges in recognizing AI in pregnancy and interpreting the diagnostic tests, and to propose a clinical approach for optimizing the management of AI in women diagnosed before or during pregnancy.
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Affiliation(s)
- Kevin C J Yuen
- Division of Endocrinology, Diabetes and Clinical Nutrition, Department of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mailcode L607, Portland, OR, 97239-3098, USA,
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10
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Bretherton I, Pattison D, Pattison S, Varadarajan S. An Endocrine Cause of Acute Post-partum Hypertension. Obstet Med 2013; 6:30-32. [PMID: 27757150 PMCID: PMC5052777 DOI: 10.1258/om.2012.120012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2012] [Indexed: 11/18/2022] Open
Abstract
This is a case of acute peri-partum hypertension secondary to Conn's syndrome. The timing of presentation offers a rare insight into the hormonal physiology of pregnancy and its impact on blood pressure regulation. This case highlights the challenges of diagnosing primary hyperaldosteronism in the peripartum period and the high index of suspicion required by the obstetric physician.
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Affiliation(s)
- Ingrid Bretherton
- Department of Endocrinology, Austin Health, Heidelberg, Australia
- Department of Endocrinology, Northern Health, Epping, Australia
| | - David Pattison
- Department of Endocrinology, Austin Health, Heidelberg, Australia
- Department of Endocrinology, Northern Health, Epping, Australia
| | - Sarah Pattison
- Department of Endocrinology, Austin Health, Heidelberg, Australia
- Department of Endocrinology, Northern Health, Epping, Australia
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Abstract
Adrenal disorders may manifest during pregnancy de novo, or before pregnancy undiagnosed or diagnosed and treated. Adrenal disorders may present as hormonal hypofunction or hyperfunction, or with mass effects or other nonendocrine effects. Pregnancy presents special problems in the evaluation of the hypothalamic-pituitary-adrenal axis in addition to the usual considerations. The renin-angiotensin-aldosterone axis undergoes major changes during pregnancy. Nevertheless, the common adrenal disorders are associated with morbidity during pregnancy and their management is more complicated. A high index of suspicion must be maintained for these disorders lest they go unrecognized and untreated.
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Affiliation(s)
- Dima Abdelmannan
- Division of Clinical and Molecular Endocrinology, Department of Medicine, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
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