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Negro A, Verzicco I, Tedeschi S, Santi R, Palladini B, Calvi A, Giunta A, Cunzi D, Coghi P, Volpi R, Cabassi A. Unrecognised pheochromocytoma in pregnancy discovered through metoclopramide-triggered hypertensive emergency. Blood Press 2021; 30:322-326. [PMID: 34176388 DOI: 10.1080/08037051.2021.1945428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE Pheochromocytoma, a catecholamine-secreting tumour leading to neurological and cardiovascular life-threatening conditions through hypertension crisis, occurs in 0.1-0.5% of hypertensive patients, but it is extremely rare in pregnancy (0.0018-0.006%). Some classes of drugs, even commonly used in pregnancy, can trigger catecholamine secretion, precipitating the clinical situation. MATERIALS AND METHODS AND RESULTS We report a 33-year-old woman, gravida 2 para 1, with previous mild hypertension, was admitted to the emergency room, at 28 2/7 weeks of gestation due to headache, tachycardia and severe arterial hypertension (220/120 mm Hg) triggered by the antiemetic metoclopramide used for a week because of nausea. In the emergency room, a paradoxical rise in blood pressure followed intravenous labetalol infusion was observed. Both metoclopramide and labetalol-triggered hypertensive crisis raised the suspicion of an undiagnosed pheochromocytoma. Diagnostic work-up showed elevated normetanephrine urinary excretion and a right adrenal pheochromocytoma by abdominal magnetic resonance imaging. Oral alpha-1 and beta-1-adrenergic antagonist and calcium-channel blocker were started. At 33-weeks of gestation, she underwent a caesarean section giving birth to a female child. Seven weeks later she underwent a video-laparoscopic right adrenalectomy which normalised her blood pressure. CONCLUSIONS Both metoclopramide, a selective dopamine type-2 receptor antagonist and partial agonist of 5-hydroxytryptamine 4 receptor, and labetalol, a non-selective β-adrenoreceptor-blocker with weak α1-adrenergic antagonism, exacerbated an acute hypertensive crisis revealing an unrecognised pheochromocytoma in a pregnant patient. Careful attention to potential drug-triggered catecholamine crises and especially early recognition of pheochromocytomas, are mandatory in hypertensive pregnant women. A missed or delayed diagnosis could result in catastrophic results affecting foetal and maternal outcomes.
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Affiliation(s)
- Aurelio Negro
- Internal Medicine and Hypertension Center, Ospedale Sant'Anna di Castelnovo Ne' Monti, Castelnovo ne' Monti RE, Italy
| | - Ignazio Verzicco
- Unità di Fisiopatologia Medica, Clinica e Terapia Medica, Centro Ipertensione Arteriosa e Studio Malattie Cardiorenali, Dipartimento di Medicina e Chirurgia, University of Parma, Parma, Italy
| | - Stefano Tedeschi
- Unità di Fisiopatologia Medica, Clinica e Terapia Medica, Centro Ipertensione Arteriosa e Studio Malattie Cardiorenali, Dipartimento di Medicina e Chirurgia, University of Parma, Parma, Italy
| | - Rosaria Santi
- Internal Medicine and Hypertension Center, Ospedale Sant'Anna di Castelnovo Ne' Monti, Castelnovo ne' Monti RE, Italy
| | - Barbara Palladini
- Unità di Fisiopatologia Medica, Clinica e Terapia Medica, Centro Ipertensione Arteriosa e Studio Malattie Cardiorenali, Dipartimento di Medicina e Chirurgia, University of Parma, Parma, Italy
| | - Anna Calvi
- Unità di Fisiopatologia Medica, Clinica e Terapia Medica, Centro Ipertensione Arteriosa e Studio Malattie Cardiorenali, Dipartimento di Medicina e Chirurgia, University of Parma, Parma, Italy
| | - Alessandro Giunta
- Oncological Surgery, Azienda Unità sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia RE, Italy
| | - Davide Cunzi
- Internal Medicine and Hypertension Center, Ospedale Sant'Anna di Castelnovo Ne' Monti, Castelnovo ne' Monti RE, Italy.,Unità di Fisiopatologia Medica, Clinica e Terapia Medica, Centro Ipertensione Arteriosa e Studio Malattie Cardiorenali, Dipartimento di Medicina e Chirurgia, University of Parma, Parma, Italy
| | - Pietro Coghi
- Unità di Fisiopatologia Medica, Clinica e Terapia Medica, Centro Ipertensione Arteriosa e Studio Malattie Cardiorenali, Dipartimento di Medicina e Chirurgia, University of Parma, Parma, Italy
| | - Riccardo Volpi
- Unità di Fisiopatologia Medica, Clinica e Terapia Medica, Centro Ipertensione Arteriosa e Studio Malattie Cardiorenali, Dipartimento di Medicina e Chirurgia, University of Parma, Parma, Italy
| | - Aderville Cabassi
- Unità di Fisiopatologia Medica, Clinica e Terapia Medica, Centro Ipertensione Arteriosa e Studio Malattie Cardiorenali, Dipartimento di Medicina e Chirurgia, University of Parma, Parma, Italy
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E Paula FDA, Dos Santos RI, Ferruzzi OA, Melo RO, Takaku M. Laparoscopic approach to pheochromocytoma in pregnancy: case report. Int Braz J Urol 2018; 44:629-633. [PMID: 29412551 PMCID: PMC5996791 DOI: 10.1590/s1677-5538.ibju.2017.0540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 11/22/2017] [Indexed: 11/30/2022] Open
Abstract
A 32-year-old 22-week pregnant hypertensive woman with sporadic episodes of headaches, sweating, and facial flushing was diagnosed with pheochromocytoma through biochemical and imaging tests. Perioperative management included a multidisciplinary approach, symptom stabilization with α blockade followed by β blockade, and tumor resection by laparoscopic adrenalectomy at 24 weeks gestation. The diagnosis was confirmed by histopathological examination and immuno-histochemistry tests. The decision for surgical removal of the tumor was based on maternal symptoms, tumor size, gestational age, the possibility of doing a laparos-copy, and the expertise of the surgical team.
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Affiliation(s)
- Felipe de Almeida E Paula
- Hospital Regional do Câncer de Presidente Prudente, Presidente Prudente, SP, Brasil.,Santa Casa de Misericórdia de Presidente Prudente, Presidente Prudente, SP, Brasil.,Faculdade de Medicina de Presidente Prudente, Universidade do Oeste Paulista, Presidente Prudente, SP, Brasil
| | - Ravisio Israel Dos Santos
- Hospital Regional do Câncer de Presidente Prudente, Presidente Prudente, SP, Brasil.,Santa Casa de Misericórdia de Presidente Prudente, Presidente Prudente, SP, Brasil.,Faculdade de Medicina de Presidente Prudente, Universidade do Oeste Paulista, Presidente Prudente, SP, Brasil
| | | | - Rafael Osti Melo
- Faculdade de Medicina de Presidente Prudente, Universidade do Oeste Paulista, Presidente Prudente, SP, Brasil
| | - Mariana Takaku
- Hospital Regional do Câncer de Presidente Prudente, Presidente Prudente, SP, Brasil.,Santa Casa de Misericórdia de Presidente Prudente, Presidente Prudente, SP, Brasil
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Zuber SM, Kantorovich V, Pacak K. Hypertension in pheochromocytoma: characteristics and treatment. Endocrinol Metab Clin North Am 2011; 40:295-311, vii. [PMID: 21565668 PMCID: PMC3094542 DOI: 10.1016/j.ecl.2011.02.002] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Pheochromocytoma is a tumor of the chromaffin cells in the adrenal medulla and sympathetic paraganglia, which synthesizes and secretes catecholamines. Norepinephrine, epinephrine, and dopamine all act on their target receptors, which causes a physiologic change in the body. High circulating levels of catecholamines can lead to severe hypertension and can have devastating effects on multiple body systems (eg, cardiovascular, cerebrovascular), and can lead to death if untreated. Although surgical treatment represents the only modality of ultimate cure, pharmacologic preoperative treatment remains the mainstay of successful outcome.
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Affiliation(s)
- Samuel M. Zuber
- Section of Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Vitaly Kantorovich
- Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Karel Pacak
- Section of Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
- Corresponding author: Karel Pacak, MD, PhD, Dsc, Professor of Medicine, Bldg 10/CRC 1East Rm 3140, 10 Center Dr, Bethesda, MD 20892-1109, (301) 496-8935, (301) 402-0884 (fax),
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