1
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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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Thomopoulos C, Hitij JB, De Backer T, Gkaliagkousi E, Kreutz R, Lopez-Sublet M, Marketou M, Mihailidou AS, Olszanecka A, Pechère-Bertschi A, Pérez MP, Persu A, Piani F, Socrates T, Stolarz-Skrzypek K, Cífková R. Management of hypertensive disorders in pregnancy: a Position Statement of the European Society of Hypertension Working Group 'Hypertension in Women'. J Hypertens 2024; 42:1109-1132. [PMID: 38690949 DOI: 10.1097/hjh.0000000000003739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
Hypertensive disorders in pregnancy (HDP), remain the leading cause of adverse maternal, fetal, and neonatal outcomes. Epidemiological factors, comorbidities, assisted reproduction techniques, placental disorders, and genetic predisposition determine the burden of the disease. The pathophysiological substrate and the clinical presentation of HDP are multifarious. The latter and the lack of well designed clinical trials in the field explain the absence of consensus on disease management among relevant international societies. Thus, the usual clinical management of HDP is largely empirical. The current position statement of the Working Group 'Hypertension in Women' of the European Society of Hypertension (ESH) aims to employ the current evidence for the management of HDP, discuss the recommendations made in the 2023 ESH guidelines for the management of hypertension, and shed light on controversial issues in the field to stimulate future research.
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Affiliation(s)
- Costas Thomopoulos
- Department of Cardiology, General Hospital of Athens 'Laiko', Athens, Greece
| | - Jana Brguljan Hitij
- Department of Hypertension, University Medical Centre Ljubljana, Medical University Ljubljana, Slovenia
| | - Tine De Backer
- Cardiovascular Center & Clinical Pharmacology, University Hospital Gent, Belgium
| | - Eugenia Gkaliagkousi
- 3rd Department of Internal Medicine, Papageorgiou Hospital Faculty of Medicine, Aristotle University of Thessaloniki, Greece
| | - Reinhold Kreutz
- Charite-Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Marilucy Lopez-Sublet
- AP-HP, Hopital Avicenne, Centre d'Excellence Europeen en Hypertension Arterielle, Service de Medecine Interne, INSERM UMR 942 MASCOT, Paris 13-Universite Paris Nord, Bobigny, FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists)
| | - Maria Marketou
- School of Medicine, University of Crete, Heraklion, Greece
| | - Anastasia S Mihailidou
- Department of Cardiology and Kolling Institute, Royal North Shore Hospital, St Leonards
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Agnieszka Olszanecka
- 1st Department of Cardiology, Interventional Electrocardiology, and Hypertension, Jagiellonian University Medical College, Krakow, Poland
| | | | - Mariana Paula Pérez
- Department of Hypertension. Hospital de Agudos J. M. Ramos Mejía, Buenos Aires, Argentina
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Federica Piani
- Hypertension and Cardiovascular Risk Research Center, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Thenral Socrates
- Medical Outpatient and Hypertension Clinic, ESH Hypertension Centre of Excellence University Hospital Basel, Basel, Switzerland
| | - Katarzyna Stolarz-Skrzypek
- 1st Department of Cardiology, Interventional Electrocardiology, and Hypertension, Jagiellonian University Medical College, Krakow, Poland
| | - Renata Cífková
- Center for Cardiovascular Prevention, Charles University in Prague, First Faculty of Medicine and Thomayer University Hospital
- Department of Medicine II, Charles University in Prague, First Faculty of Medicine, Prague, Czech Republic
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3
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Ge T, Xie X, Liu J. A rare case of pheochromocytoma in a pregnant woman presenting with chest pain: extraordinary management. BMC Cardiovasc Disord 2024; 24:261. [PMID: 38769478 PMCID: PMC11103813 DOI: 10.1186/s12872-024-03943-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 05/15/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Pheochromocytoma is rare in pregnant women. It presents as diverse symptoms, including hypertension and sweating. The symptoms of pregnant women with pheochromocytoma and comorbid hypertension often mimic the clinical manifestations of preeclampsia, and these women are often misdiagnosed with preeclampsia. CASE PRESENTATION In this case, a pregnant woman presented with chest pain as the primary symptom, and a diagnosis of pheochromocytoma was considered after ruling out myocardial ischemia and aortic dissection with the relevant diagnostic tools. This patient then underwent successful surgical resection using a nontraditional management approach, which resulted in a positive clinical outcome. CONCLUSIONS It is essential to consider pheochromocytoma as a potential cause of chest pain and myocardial infarction-like electrocardiographic changes in pregnant women, even if they do not have a history of hypertension.
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Affiliation(s)
- Tao Ge
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College, No. 2, Zhe Shan West Road, Wuhu, 241001, Anhui, China
| | - Xiangrong Xie
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College, No. 2, Zhe Shan West Road, Wuhu, 241001, Anhui, China
| | - Jichun Liu
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College, No. 2, Zhe Shan West Road, Wuhu, 241001, Anhui, China.
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4
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Gunnesson L, Ragnarsson O, Nilsson M, Sengpiel V, Elfvin A, Elias E, Muth A. Maternal pheochromocytoma and childbirth in Sweden 1973-2015: a population-based study on short and long-term outcome. Endocrine 2024; 84:720-726. [PMID: 38421555 PMCID: PMC11076314 DOI: 10.1007/s12020-024-03749-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 02/15/2024] [Indexed: 03/02/2024]
Abstract
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.
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Affiliation(s)
- Lisa Gunnesson
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden.
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Oskar Ragnarsson
- Department of Endocrinology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Centre for Molecular and Translational Medicine, Gothenburg, Sweden
| | - Maria Nilsson
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Verena Sengpiel
- Department of Obstetrics and Gynecology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Elfvin
- The Queen Silvia Children's hospital, Department of Pediatrics, Gothenburg, Sweden
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erik Elias
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Andreas Muth
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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5
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Monteiro S, Rodrigues R, Almeida A, Monteiro MJ. Pheochromocytoma During Pregnancy: A Hidden Cause for Hypertension. Cureus 2024; 16:e61286. [PMID: 38947606 PMCID: PMC11211965 DOI: 10.7759/cureus.61286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2024] [Indexed: 07/02/2024] Open
Abstract
Pheochromocytoma, a rare but potentially serious condition, poses challenges in timely identification, especially during pregnancy due to misconceptions about pregnancy-related hypertension causes. However, paroxysmal symptoms heighten diagnostic suspicion. The diagnosis relies on biochemical confirmation of catecholamine hypersecretion followed by imaging for tumor localization. When diagnosed at or after 24 weeks, alpha-adrenoceptor blockers are recommended during pregnancy to manage catecholamine excess, delaying tumor removal until viability or post-delivery. The rarity of this condition during pregnancy, coupled with diagnostic and management challenges, underscores its importance for obstetric professionals in addressing hypertensive control, delivery timing, and surgical intervention.
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Affiliation(s)
- Sidonie Monteiro
- Obstetrics and Gynecology, Unidade Local de Saúde (ULS) do Médio Ave, Vila Nova de Famalicão, PRT
| | - Raquel Rodrigues
- Obstetrics and Gynecology, Unidade Local de Saúde (ULS) de Braga, Braga, PRT
| | - Amélia Almeida
- Obstetrics and Gynecology, Unidade Local de Saúde (ULS) do Médio Ave, Vila Nova de Famalicão, PRT
| | - Maria José Monteiro
- Obstetrics and Gynecology, Unidade Local de Saúde (ULS) de Braga, Braga, PRT
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6
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van de Bovenkamp AA, Kalkman DN, Beijk MAM, van de Veerdonk MC. Recurrent angina and cardiac ischaemia as a presentation of pheochromocytoma: a case report. Eur Heart J Case Rep 2024; 8:ytae153. [PMID: 38645675 PMCID: PMC11032188 DOI: 10.1093/ehjcr/ytae153] [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: 09/21/2023] [Revised: 03/09/2024] [Accepted: 03/19/2024] [Indexed: 04/23/2024]
Abstract
Background We present a case of a pregnant patient with recurrent angina, in which her symptoms were initially attributed to coronary artery spasm. However, during follow-up, she was diagnosed as having pheochromocytoma, a rare neuroendocrine tumour. Case summary The 35-year-old patient was admitted to the hospital because of chest pain and elevated cardiac troponins after the use of MDMA. Physical examination, electrocardiogram, echocardiography, coronary angiogram, and cardiac MRI were normal. Symptoms were attributed to coronary spasm, and a calcium antagonist was started. Ten months later, when 36 weeks pregnant, her symptoms returned. One week later, the patient was readmitted to the hospital with signs of acute left ventricular (LV) failure, highly elevated troponins, and severe global LV dysfunction. Urgent section caesarean was performed due to maternal morbidity and foetal tachycardia. During section, flushes and marked variability in blood pressure were noted. Laboratory metanephrines testing was performed. LV function recovered within 3 days without any therapeutic intervention. However, chest pain reoccurred, now accompanied with headaches, malignant hypertension, and accelerated idiopathic ventricular rhythms. (Nor)metanephrines tests were positive. A solid lesion in the right adrenal on CT scan confirmed the diagnosis of pheochromocytoma. Fluid repletion and alpha-blocker therapy were started. Due to persistent symptoms, urgent laparoscopic adrenalectomy was performed. Hereafter, the patient remained without symptoms. Discussion A pheochromocytoma may present with recurrent angina and can result in a catecholamine-induced cardiomyopathy. It is important to timely recognize this diagnosis in order to minimize morbidity and mortality.
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Affiliation(s)
- Arno A van de Bovenkamp
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Deborah N Kalkman
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Marcel A M Beijk
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Mariëlle C van de Veerdonk
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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7
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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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8
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Beard V, Ghawji M, Salman F, Oktaei H. Pheochromocytoma Diagnosed During First Trimester of Pregnancy. JCEM CASE REPORTS 2024; 2:luae027. [PMID: 38495398 PMCID: PMC10941258 DOI: 10.1210/jcemcr/luae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Indexed: 03/19/2024]
Abstract
Pheochromocytomas are rare catecholamine-secreting tumors that occur in 0.002% of pregnancies. These tumors result in high maternal and fetal morbidity and mortality unless diagnosed in early stages of development, because excess levels of catecholamines cause vasoconstriction of both maternal and uteroplacental vasculature. Paroxysmal hypertension is the most common manifestation, but its variability in presentation and similarity to other pregnancy-related conditions often make diagnosis of pheochromocytoma difficult. Thus, it is essential to consider underlying pathological causes of hypertension during gestation. Diagnosis and treatment of pheochromocytoma must be approached uniquely given the physiologic changes during pregnancy. The standard of care for diagnostic imaging during pregnancy is with magnetic resonance imaging. For these reasons, knowledge of therapy for pheochromocytomas in the pregnant patient is essential for clinical endocrinology practice.
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Affiliation(s)
- Victoria Beard
- Department of Medicine, The University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Maher Ghawji
- Department of Medicine, The University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Fariha Salman
- Department of Medicine, The University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Hooman Oktaei
- Department of Medicine, The University of Tennessee Health Science Center, Memphis, TN 38163, USA
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9
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Kumari S, Lamichhane R, Giri S, Chaudhary S, Neupane S, Dangol N. Pheochromocytoma disguised as gestational hypertensive disease during pregnancy: A case report. Clin Case Rep 2023; 11:e6932. [PMID: 36789317 PMCID: PMC9913178 DOI: 10.1002/ccr3.6932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 01/05/2023] [Accepted: 01/23/2023] [Indexed: 02/12/2023] Open
Abstract
Pheochromocytoma is often diagnosed prior to pregnancy. Sometimes, the disease may be diagnosed for the first-time during pregnancy masking itself as a hypertensive disease in pregnancy. Early diagnosis and timely, appropriate management reduce possible maternal and fetal complications. We identified a case of pheochromocytoma during pregnancy misdiagnosed as preeclampsia.
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Affiliation(s)
- Swati Kumari
- Department of Gynecology and ObstetricsTribhuvan University Institute of MedicineKathmanduNepal
| | | | - Subarna Giri
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineKathmanduNepal
| | | | | | - Neha Dangol
- Nepal Cardio Diabetes and Thyroid CenterKathmanduNepal
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10
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Ghades S, Abdeljabbare A, Fatnassi MR. Phéochromocytome au cours de la grossesse : un problème diagnostique, à propos d’un cas et revue de la littérature. IMAGERIE DE LA FEMME 2023. [DOI: 10.1016/j.femme.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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11
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Abstract
While most adrenal tumors are identified incidentally and are non-functional, hormone-secreting tumors can cause morbidity and mortality. Hemodynamic lability and hypertension in pregnancy are associated with worse maternal and fetal outcomes. Achieving a diagnosis of hormone excess due to adrenal tumors can be clinically more difficult in the gravid patient due to normal physiologic alterations in hormones and symptoms related to pregnancy. This review focuses on some nuances of the diagnostic work-up, perioperative care, and surgical management of adrenally-mediated cortisol excess, primary aldosteronism, and pheochromocytoma and paraganglioma in the pregnant patient.
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Affiliation(s)
| | - Sophie Dream
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
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12
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Akpalu J, Ampong C, Atiase Y, Yorke E, Takyi C, Coleman J, Darkwa EO, Adu-Aryee NA. Management of recurrent pheochromocytoma in pregnancy in a young Ghanaian. Ghana Med J 2022; 56:340-344. [PMID: 37575627 PMCID: PMC10416282 DOI: 10.4314/gmj.v56i4.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023] Open
Abstract
The co-existence of pheochromocytoma and pregnancy is rare, with poor maternal and foetal outcomes. This is a case report of a young Ghanaian woman with a pre-existing diagnosis of recurrent pheochromocytoma who became pregnant and experienced elevated blood pressure in the third trimester with proteinuria and abnormal liver function. She was managed as an in-patient and delivered a live baby via caesarean section at 34 weeks after detecting intra-uterine growth restriction. Management of such cases by a multidisciplinary team is recommended for optimal outcomes.
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Affiliation(s)
- Josephine Akpalu
- Endocrinology Unit, Department of Medicine and Therapeutics, University of Ghana Medical School
| | - Charlotte Ampong
- Endocrinology Unit, Department of Medicine and Therapeutics, Korle Bu Teaching Hospital
| | - Yacoba Atiase
- Endocrinology Unit, Department of Medicine and Therapeutics, University of Ghana Medical School
| | - Ernest Yorke
- Endocrinology Unit, Department of Medicine and Therapeutics, University of Ghana Medical School
| | - Charles Takyi
- Department of Obstetrics and Gynaecology, Korle Bu Teaching Hospital
| | - Jerry Coleman
- Department of Obstetrics and Gynaecology, Korle Bu Teaching Hospital
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13
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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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14
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Lopez AG, Duparc C, Renouf S, Machevin E, Le Guillou V, Sabourin JC, Defortescu G, Buffet A, Gimenez-Roqueplo AP, Dubessy C, Louiset E, Lefebvre H. Expression of LHCGR (Luteinizing Hormone/Chorionic Gonadotrophin Receptor) in Pheochromocytomas Unveils an Endocrine Mechanism Connecting Pregnancy and Epinephrine Overproduction. Hypertension 2022; 79:1006-1016. [PMID: 35189708 DOI: 10.1161/hypertensionaha.121.18864] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The mechanisms by which pregnancy may unmask pheochromocytomas and paragangliomas are not totally understood. We hypothesized that gestational hormones may participate in the pathophysiology of catecholamine excess during pregnancy. We report a case of silent pheochromocytoma revealed in a pregnant woman by life-threatening adrenergic myocarditis. METHODS In vitro studies were conducted to investigate the effect of estradiol and the pregnancy hormone hCG (human chorionic gonadotropin) on epinephrine secretion by cultured cells derived from the patient's tumor. Expression of LHCG (luteinizing hormone/chorionic gonadotropin) receptor was searched for in the patient's tumor, and a series of 12 additional pheochromocytoma by RT-Q-PCR and immunohistochemistry. LHCGR expression was also analyzed in silico in the pheochromocytomas and paragangliomas cohorts of the Cortico et Médullosurrénale: les Tumeurs Endocrines and The Cancer Genome Atlas databases. RESULTS hCG stimulated epinephrine secretion by cultured cells derived from the patient's pheochromocytoma. The patient's tumor expressed the LHCG receptor, which was colocalized with catecholamine-producing enzymes. A similar expression pattern of the LHCG receptor was also observed in 5 out of our series of pheochromocytoma. Moreover, in silico studies revealed that pheochromocytomas and paragangliomas display the highest expression levels of LHCG receptor mRNA among the 32 solid tumor types of The Cancer Genome Atlas cohort. CONCLUSIONS Pregnancy may thus favor surges in plasma catecholamine and hypertensive crises through hCG-induced stimulation of epinephrine production by pheochromocytomas.
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Affiliation(s)
- Antoine-Guy Lopez
- Normandie University, UNIROUEN, INSERM U1239, NorDIC, Rouen, France (A.-G.L., C. Duparc, S.R., C. Dubessy, E.L., H.L.).,Department of Endocrinology, Diabetes and Metabolic Diseases, Rouen University Hospital, France. (A.-G.L., H.L.)
| | - Céline Duparc
- Normandie University, UNIROUEN, INSERM U1239, NorDIC, Rouen, France (A.-G.L., C. Duparc, S.R., C. Dubessy, E.L., H.L.)
| | - Sylvie Renouf
- Normandie University, UNIROUEN, INSERM U1239, NorDIC, Rouen, France (A.-G.L., C. Duparc, S.R., C. Dubessy, E.L., H.L.)
| | - Elise Machevin
- Department of Gynaecology-Obstetrics, Evreux Hospital Centre, France (E.M.)
| | - Vincent Le Guillou
- Department of Thoracic and Cardiovascular Surgery, Rouen University Hospital, France. (V.L.G.)
| | - Jean-Christophe Sabourin
- Department of Pathology and INSERM 1245, Rouen University Hospital, France. (J.-C.S,).,Tumor BioBank-Centre for Biological Resources, Rouen University Hospital, France. (J.-C.S., H.L.)
| | - Guillaume Defortescu
- Normandie University, UNIROUEN, INSERM U1239, NorDIC, Rouen, France (A.-G.L., C. Duparc, S.R., C. Dubessy, E.L., H.L.).,Department of Urology, Rouen University Hospital, France. (G.D.)
| | - Alexandre Buffet
- Université de Paris, PARCC, INSERM, Paris, France (A.B., A.-P.G.-R.).,Service de Génétique, Assistance Publique-Hôpitaux de Paris, Hôpital européen Georges Pompidou, Paris, France (A.B., A.-P.G.-R.)
| | - Anne-Paule Gimenez-Roqueplo
- Université de Paris, PARCC, INSERM, Paris, France (A.B., A.-P.G.-R.).,Service de Génétique, Assistance Publique-Hôpitaux de Paris, Hôpital européen Georges Pompidou, Paris, France (A.B., A.-P.G.-R.)
| | - Christophe Dubessy
- Normandie University, UNIROUEN, INSERM, PRIMACEN, Rouen, France (C. Dubessy)
| | - Estelle Louiset
- Normandie University, UNIROUEN, INSERM U1239, NorDIC, Rouen, France (A.-G.L., C. Duparc, S.R., C. Dubessy, E.L., H.L.)
| | - Hervé Lefebvre
- Normandie University, UNIROUEN, INSERM U1239, NorDIC, Rouen, France (A.-G.L., C. Duparc, S.R., C. Dubessy, E.L., H.L.).,Department of Endocrinology, Diabetes and Metabolic Diseases, Rouen University Hospital, France. (A.-G.L., H.L.).,Tumor BioBank-Centre for Biological Resources, Rouen University Hospital, France. (J.-C.S., H.L.)
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15
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Kurosawa S, Yamasaki H, Hasegawa W, Mori T. Major intraoperative bleeding and drastic change in circulatory dynamics in a pregnant patient with metastatic pheochromocytoma: a case report. JA Clin Rep 2022; 8:13. [PMID: 35192091 PMCID: PMC8863998 DOI: 10.1186/s40981-022-00504-9] [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: 10/02/2021] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Metastatic pheochromocytoma in the spine is a very rare complication during pregnancy. We report anesthesia in a pregnant woman for resection of an undiagnosed spinal tumor, accompanied by remarkable hemodynamic changes and massive bleeding. CASE PRESENTATION A 33-year-old woman at 17 weeks of gestation presented with the rapid progress of bilateral lower leg paralysis. A diagnosis of spinal tumor was made, and surgical resection was planned. Although the surgery was suspended because of remarkable hemodynamic changes and massive bleeding, fetal heart rate was stable. Postoperative examination revealed pheochromocytoma in the urinary bladder as a primary lesion with spinal metastasis. CONCLUSION Although spinal pheochromocytoma is extremely rare in pregnant women, it should be suspected when abnormal hypertension is observed with accompanying neurological deficits. Preservation of maternal circulation and uteroplacental blood flow should be the first priority during anesthesia.
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Affiliation(s)
- Sumire Kurosawa
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, 1-5-7 Asahimachi, Abeno-ku, Osaka City, Osaka, 545-8586, Japan
| | - Hiroyuki Yamasaki
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, 1-5-7 Asahimachi, Abeno-ku, Osaka City, Osaka, 545-8586, Japan.
| | - Wakuya Hasegawa
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, 1-5-7 Asahimachi, Abeno-ku, Osaka City, Osaka, 545-8586, Japan
| | - Takashi Mori
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, 1-5-7 Asahimachi, Abeno-ku, Osaka City, Osaka, 545-8586, Japan
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16
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Aftiss F, El Mezzeoui S, El Aidouni G, Merbouh M, Nasri S, Jabi R, Bkiyar H, Skikar I, Bouziane M, Housni B. Surgical and anesthetic management of paraganglioma diagnosed in a 2nd trimester parturient: Case report. Ann Med Surg (Lond) 2021; 72:103094. [PMID: 34934482 PMCID: PMC8654780 DOI: 10.1016/j.amsu.2021.103094] [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: 09/11/2021] [Revised: 11/18/2021] [Accepted: 11/20/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction Neuroendocrine tumors represent a rare entity whose diagnosis is based on clinical, biological and radiological arguments. When they are secreting, they expose the patient to serious complications that can be much more severe during pregnancy and engage the vital prognosis of both the mother and the fetus, which requires multidisciplinary management: anesthesiologist resuscitator - obstetrician – endocrinologist. Case presentation In our article, we report the case of a patient with an estimated pregnancy at 25 weeks of amenorrhea (WA) with a history of 3 miscarriages related to atypical gravid hypertension. The treatment consisted of preoperative medical preparation followed by removal of the paraganglioma and postoperative monitoring. The maternal-fetal evolution was favorable. Conclusion The non-negligible morbi-mortality of this type of tumors require a multidisciplinary management. Neuroendocrine tumors represent a rare entity whose diagnosis is based on clinical, biological and radiological arguments. The treatment consisted of preoperative medical preparation, removal of the paraganglioma and postoperative monitoring. The anesthetic and surgical management of pheochromocytomas and paragangliomas in pregnant women presents a real challenge.
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Affiliation(s)
- F Aftiss
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco
| | - S El Mezzeoui
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco
| | - G El Aidouni
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco
| | - M Merbouh
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco
| | - S Nasri
- Department of Radiology, Mohamed VI University Hospital Center, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - R Jabi
- Department of General Surgery, Mohamed VI University Hospital Center, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - H Bkiyar
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Oujda, Morocco.,Oujda Medical Simulation Training Center, Morocco
| | - I Skikar
- Department of Radiology, Mohamed VI University Hospital Center, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - M Bouziane
- Department of General Surgery, Mohamed VI University Hospital Center, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - B Housni
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Oujda, Morocco.,Oujda Medical Simulation Training Center, Morocco
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17
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Mabrouk MY, Jabi R, Bouzayan L, Yassin K, Bouziane M. Management of a Left Lateral Aortic Paraganglioma During Pregnancy: A Rare Case Report. Cureus 2021; 13:e19221. [PMID: 34873546 PMCID: PMC8640192 DOI: 10.7759/cureus.19221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2021] [Indexed: 12/25/2022] Open
Abstract
Paragangliomas are rare neuroendocrine tumors mostly diagnosed in young adults. Their association with pregnancy is even rarer, and their impact is even more serious in the absence of adequate management, which may vitally involve maternal and fetal prognosis. In this report, we present a rare case of a left lateral aortic paraganglioma in a pregnant woman in her third trimester during her 31 weeks of gestation, who consulted for a hypertensive peak; the methoxylated derivatives were positive. An abdominal MRI showed a left lateral aortic mass, suggesting a paraganglioma. After a multidisciplinary discussion, the patient underwent laparoscopic surgical resection of the mass after preoperative medical preparation. Pathological examination confirmed the diagnosis of paraganglioma. The overall stay was six days without any short-term complications, including anything related to fetal viability, with a vaginal delivery at 37 weeks of amenorrhea. The patient was followed up for six months with no complications. We highlight the importance of preoperative medical preparation followed by surgical resection in the framework of a multidisciplinary consultation for an improved maternal-fetal prognosis.
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Affiliation(s)
- Mohamed Yassine Mabrouk
- Faculty of Medicine and Pharmacy, Laboratory of Anatomy, Microsurgery and Surgery Experimental and Medical Simulation (LAMCESM) Mohammed 1st University, Department of General Surgery, Mohamed VI University Hospital, Oujda, MAR
| | - Rachid Jabi
- Faculty of Medicine and Pharmacy, Laboratory of Anatomy, Microsurgery and Surgery Experimental and Medical Simulation (LAMCESM) Mohammed 1st University, Department of General Surgery, Mohamed VI University Hospital, Oujda, MAR
| | - Laila Bouzayan
- Faculty of Medicine and Pharmacy, Laboratory of Anatomy, Microsurgery and Surgery Experimental and Medical Simulation (LAMCESM) Mohammed 1st University, Department of General Surgery, Mohamed VI University Hospital, Oujda, MAR
| | - Kradi Yassin
- Faculty of Medicine and Pharmacy, Laboratory of Anatomy, Microsurgery and Surgery Experimental and Medical Simulation (LAMCESM) Mohammed 1st University, Department of General Surgery, Mohamed VI University Hospital, oujda, MAR
| | - Mohammed Bouziane
- Faculty of Medicine and Pharmacy, Laboratory of Anatomy, Microsurgery and Surgery Experimental and Medical Simulation (LAMCESM) Mohammed 1st University, Department of General Surgery, Mohamed VI University Hospital, Oujda, MAR
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18
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Special situations in pheochromocytomas and paragangliomas: pregnancy, metastatic disease, and cyanotic congenital heart diseases. Clin Exp Med 2021; 22:359-370. [PMID: 34591219 DOI: 10.1007/s10238-021-00763-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 09/18/2021] [Indexed: 01/08/2023]
Abstract
The aim of our study was to describe the epidemiology, diagnosis, and treatment of the most complex pheochromocytoma and paraganglioma (PGL) cases, including pheochromocytoma/PGL during pregnancy, in cyanotic congenital heart diseases (CCHDs), and metastatic pheochromocytoma. The English and Spanish literature was thoroughly evaluated searching for articles reporting clinical studies, case reports, or reviews of pheochromocytoma/PGL in pregnancy and in CCHD and metastatic pheochromocytoma/PGL. Particular settings in the diagnosis and management of pheochromocytoma and PGLs remain challenging. Those special situations include the diagnosis during pregnancy or in the context of CCHD since the typical clinical features of pheochromocytoma may be confounded with preeclampsia during pregnancy and with the complications commonly observed in CCHD. In addition, although some clinical and genetic features have been associated with higher risk of metastatic pheochromocytoma, the detection and prediction of the development of metastatic disease involve another complex situation that may require special hormonal determinations as plasmatic 3-methoxytyramine and nuclear medicine studies including 18FDG PET-CT or 18F-FDOPA PET-CT, among others. Furthermore, the selection of the most appropriate treatment in these situations, as well as the moment to carry it out, requires special care as limited evidence is available. This article reviews the epidemiology, diagnosis, and treatment of the pheochromocytoma/PGL during pregnancy, metastatic pheochromocytoma/PGL, and pheochromocytoma/PGL in CCHD. The diagnosis, and especially the treatment, of metastatic pheochromocytomas and pheochromocytoma/PGL during pregnancy and in CCHD is challenging. Thus, these cases should be management in reference centres by multidisciplinary teams specialized in the pheochromocytoma/PGL treatment.
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19
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Pheochromocytoma in Pregnancy: A Syndromic Association. J Obstet Gynaecol India 2021; 72:48-54. [PMID: 35928058 PMCID: PMC9343562 DOI: 10.1007/s13224-021-01532-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/21/2021] [Indexed: 10/20/2022] Open
Abstract
Introduction Pheochromocytoma during pregnancy is a rare cause of secondary hypertension with lethal consequences to both mother and fetus. As patients are young, the possibility of syndromic associations like MEN-2, VHL, NF-1, etc., needs to be considered. Methodology Three primigravida were diagnosed before the 20th week of gestation when they presented with classical triad of pheochromocytoma. Results Diagnosis of pheochromocytoma was confirmed by 24 h urinary metanephrine/normetanephrine or epinephrine/norepinephrine levels. Non-contrast MRI abdomen could localize the tumor. One patient had medullary thyroid carcinoma with hyperparathyroidism, indicative of MEN-2A. Another patient had brain stem hemangioblastoma, pancreatic cysts and family history of spinal hemangioblastoma, so diagnosed to have Von Hippel-Lindau (VHL) syndrome. Whereas, the third patient had sporadic pheochromocytoma. Preoperatively, they required antihypertensive medications including prazosin and metoprolol. They underwent laparoscopic/open adrenalectomy between 19th and 21st week of gestation without complication. Histopathology in all the three patients revealed low-grade pheochromocytoma by pheochromocytoma of the adrenal gland scaled score. None required antihypertensive medications after surgery. All the three newborns were small for gestational age, while one neonate expired due to intra-cardiac rhabdomyoma. So, the timely evaluation and surgical intervention for pheochromocytoma avoid lethal consequences. Conclusions Pregnancy leads to unmasking of pheochromocytoma as it is physiological stress. The syndromic association is more frequent as the population is younger. A poor fetal outcome like IUGR can be explained by endovascular changes in uterine vessel or due to the associated manifestations of MEN-2A, VHL syndromes. Family members should be screened for associated syndromic feature.
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20
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Abstract
PURPOSE OF REVIEW Pheochromocytoma and paraganglioma (PPGL) in pregnancy is a rare entity and management of these patients is fraught with uncertainty. Our objective is to review current literature and discuss diagnosis and management of these patients. RECENT FINDINGS Outcomes of PPGL in pregnancy have improved in recent years. The greatest risk for adverse maternal and fetal outcomes is the diagnosis of PPGL after delivery. Alpha- and beta-adrenergic blockade is well tolerated and is associated with less adverse outcomes. Antepartum surgery is not associated with improved maternal or fetal outcomes. Biochemical testing and cross-sectional imaging should be performed prior to conception for patients with a known germline variant associated with PPGL. CONCLUSIONS Medical therapy should be initiated when PPGL is diagnosed in pregnancy. Antepartum surgery should be reserved for special circumstances. Case detection testing in high-risk patients can identify PPGL before pregnancy.
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21
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Duquesnay C, Espiard S, Cardot-Bauters C, Carnaille B, Gonzalez M, Jourdain M, Richardson M, Garabedian C. [Pheochromocytomas and paragangliomas in pregnancy: About four cases and key messages on management]. ACTA ACUST UNITED AC 2021; 49:881-888. [PMID: 33962044 DOI: 10.1016/j.gofs.2021.04.012] [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: 07/28/2020] [Indexed: 10/21/2022]
Abstract
OBJECTIFS The diagnosis of a pheochromocytoma or paraganglioma secreting during pregnancy is a rare and serious situation, involving maternal-fetal prognosis. The purpose of this case series is to discuss the management of these patients. METHODS This is a retrospective study of cases of pheochromocytoma (n=2) or paraganglioma (n=2) managed during pregnancy between 2013 and 2020 in one center (Lille, France). RESULTS We report four cases of patients with a diagnosis of pheochromocytoma or paraganglioma during pregnancy, at respectively 4, 28, 31 and 34 weeks of amenorrhea (AS). Their pregnancies were affected by a sudden onset of hypertension sometimes associated with headaches, sweating, and palpitations. All patients delivered by Caesarean section after calcium channel blocker impregnation, with a good outcome. Tumor removal took place at a distance from delivery for each patient. CONCLUSIONS The therapeutic strategy includes antihypertensive treatment with calcium channel blockers or alphablockers and surgical curative treatment linked to gestational age. Multidisciplinary management as well as early diagnosis can improve the maternal-fetal prognosis. The preferred way of delivery is Caesarean section, but vaginal delivery can also be considered. Removal should ideally take place at a distance from the birth. The analysis of these cases has led to the development of a protocol for monitoring and management of parturients with diagnosis of pheochromocytoma or paraganglioma during pregnancy.
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Affiliation(s)
- C Duquesnay
- Clinique d'obstétrique, hôpital Jeanne-de-Flandre, CHU de Lille, avenue Eugène-Avinée, 59000 Lille, France.
| | - S Espiard
- Service d'endocrinologie, hôpital Claude-Huriez, CHU de Lille, rue Michel-Polonowski, 59000 Lille, France
| | - C Cardot-Bauters
- Service d'endocrinologie, hôpital Claude-Huriez, CHU de Lille, rue Michel-Polonowski, 59000 Lille, France
| | - B Carnaille
- Service de chirurgie générale, hôpital Claude-Huriez, CHU de Lille, rue Michel-Polonowski, 59000 Lille, France
| | - M Gonzalez
- Clinique d'anesthésie, hôpital Jeanne-de-Flandre, CHU de Lille, avenue Eugène-Avinée, 59000 Lille, France
| | - M Jourdain
- Service de réanimation, hôpital Salengro, CHU de Lille, avenue du Pr Emile-Laine, 59000 Lille, France
| | - M Richardson
- Clinique de cardiologie, institut cœur poumon, CHU de Lille, 2, boulevard du Pr Jules-Leclercq, 59000 Lille, France
| | - C Garabedian
- EA 2694 Metrics, environnement périnatal et santé, clinique d'obstétrique,Université de Lille, hôpital Jeanne-de-Flandre, CHU de Lille, avenue Eugène-Avinée, 59000 Lille, France
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22
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Begum J, Kumari S, Ali M, Kumar Jena S, Behera K, Mishra P. A Misleading Presentation of Pheochromocytoma in Pregnancy: A Case Report. Medeni Med J 2021; 36:69-74. [PMID: 33828893 PMCID: PMC8020182 DOI: 10.5222/mmj.2021.29660] [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: 12/01/2020] [Accepted: 01/20/2021] [Indexed: 11/25/2022] Open
Abstract
Pheochromocytoma is a catecholamine-secreting adrenal tumor and also a rare cause of secondary hypertension in pregnancy. Its low prevalence, nonspecific clinical presentation, and symptoms similar to preeclampsia generate a diagnostic challenge during pregnancy. A 23-year-old hypertensive pregnant woman at 36th gestational week of her first pregnancy was admitted with severe hypertension (210/150 mmHg), headache and proteinuria that made us presume the case as severe preeclampsia. In spite of starting with maximum doses of antihypertensive medications like IV labetolol,and oral nifedipine, loading dose of an anticonvulsant drug, and IV magnesium sulphate, her symptoms persisted. Keeping in view the risks involved to mother and fetus, we delivered the baby by emergency cesarean section. In the postoperative period, along with severe uncontrolled hypertension, she developed tremors, palpitation, and sweating that all led us to further diagnostic workup for secondary causes of hypertension. Eventually, a diagnosis of pheochromocytoma was confirmed by abdominopelvic contrast- enhanced computed tomography and by increased 24-hour urine metanephrine, normetanephrine, and vanillylmandelic acid levels. Subsequently, adrenal suppression was achieved by a multidisciplinary approach, and then she underwent laparoscopic adrenalectomy. This case highlights the importance of maintaining a high index of suspicion and multidisciplinary approach while investigating secondary causes of hypertension in young women, thereby differentiating it from preeclampsia.
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Affiliation(s)
- Jasmina Begum
- All India Institute of Medical Sciences, Department of Obstetrics and Gynecology, Bhubaneswar, India
| | - Supriya Kumari
- All India Institute of Medical Sciences, Department of Obstetrics and Gynecology, Bhubaneswar, India
| | - Manwar Ali
- All India Institute of Medical Sciences, Department of General Surgery, Bhubaneswar, India
| | - Saubhagya Kumar Jena
- All India Institute of Medical Sciences, Department of Obstetrics and Gynecology, Bhubaneswar, India
| | - Kishore Behera
- All India Institute of Medical Sciences, Department of Endocrinology, Bhubaneswar, India
| | - Pritinanda Mishra
- All India Institute of Medical Sciences, Department of Pathology, Bhubaneswar, India
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23
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Elsamadicy EA, Yazdani S, Karuppiah A, Marcano I, Turan O, Kodali BS, Jessel R. Paraganglioma Presenting as Hypoxia and Syncope in Pregnancy: A Case Report. A A Pract 2021; 15:e01411. [PMID: 33684077 DOI: 10.1213/xaa.0000000000001411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Paragangliomas (PGLs) are rare tumors with an incidence of 0.007% in pregnant women. Patients with PGLs commonly present with hypertension and tachycardia. This case report describes the evaluation and management of a multiparous woman at 32 weeks of gestation with syncope, hypoxia, and tachycardia as unusual presenting symptoms of PGL. Her symptoms were attributable to paradoxical effects of circulating catecholamines on downregulated alpha-adrenergic receptors resulting in decreased systemic vascular resistance.
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Affiliation(s)
- Emad A Elsamadicy
- From the Departments of Obstetrics, Gynecology and Reproductive Sciences
| | | | | | | | - Ozhan Turan
- From the Departments of Obstetrics, Gynecology and Reproductive Sciences
| | | | - Rebecca Jessel
- From the Departments of Obstetrics, Gynecology and Reproductive Sciences
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24
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Pambinezhthu F, Hamza N, Al Kharusi M, Ramadhan F, Al Busaidi N, Kamona A. Hereditary Paraganglioma in an Omani Family. Oman Med J 2021; 36:e229. [PMID: 33628464 PMCID: PMC7897353 DOI: 10.5001/omj.2021.10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 02/01/2020] [Indexed: 11/22/2022] Open
Abstract
Pheochromocytomas are tumors derived from chromaffin cells within the medulla of adrenal glands, whereas paragangliomas are tumors derived from extra-adrenal chromaffin cells of the sympathetic prevertebral and paravertebral ganglia. The growing deployment of genetic testing has shown that approximately 30% of pheochromocytoma and paraganglioma (PPGL) patients carry familial pathogenic germline mutations in known PPGL-susceptibility genes. This prompts genetic screening of their family members and leads to an increase in the detection of asymptomatic PPGLs or non-secreting tumors reported in familial cases discovered after the index patient work-up. Here, we present three case reports of affected members of a single Omani family with a history of paraganglioma and highly variable clinical presentations among the affected members. Eight out of the 16 siblings (50.0%) in the second generation of the reported family pedigree were carriers of the succinate dehydrogenase B:c.574T>C mutation, reflecting the autosomal dominant inheritance risk of paraganglioma and other associated tumors. This report highlights the complexity of managing such families and encourages further discussion regarding the management of asymptomatic PPGL-associated mutation carriers. Genetic screening has enabled the early detection of PPGLs, for which early surgical intervention can significantly impact prognosis and treatment strategies to reduce morbidity and mortality. Although PPGLs are similar tumors, they warrant distinction from each other with respect to their differences in locations, manifestations, secretory functions, genetic syndromes, and propensity to metastasize. While current guidelines are clear concerning symptomatic PPGL cases, the management of asymptomatic mutation carriers requires further elucidation.
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Affiliation(s)
| | - Nishath Hamza
- National Genetic Centre, Royal Hospital, Muscat, Oman
| | | | - Fatma Ramadhan
- Department of Histopathology and Cytology, Royal Hospital, Muscat, Oman
| | - Noor Al Busaidi
- National Diabetes and Endocrinology Centre, Royal Hospital, Muscat, Oman
| | - Atheel Kamona
- Department of Radiology, Royal Hospital, Muscat, Oman
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25
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Cífková R, Johnson MR, Kahan T, Brguljan J, Williams B, Coca A, Manolis A, Thomopoulos C, Borghi C, Tsioufis C, Parati G, Sudano I, McManus RJ, van den Born BJH, Regitz-Zagrosek V, de Simone G. Peripartum management of hypertension: a position paper of the ESC Council on Hypertension and the European Society of Hypertension. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 6:384-393. [PMID: 31841131 DOI: 10.1093/ehjcvp/pvz082] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 12/10/2019] [Indexed: 12/26/2022]
Abstract
Hypertensive disorders are the most common medical complications in the peripartum period associated with a substantial increase in morbidity and mortality. Hypertension in the peripartum period may be due to the continuation of pre-existing or gestational hypertension, de novo development of pre-eclampsia or it may be also induced by some drugs used for analgesia or suppression of postpartum haemorrhage. Women with severe hypertension and hypertensive emergencies are at high risk of life-threatening complications, therefore, despite the lack of evidence-based data, based on expert opinion, antihypertensive treatment is recommended. Labetalol intravenously and methyldopa orally are then the two most frequently used drugs. Short-acting oral nifedipine is suggested to be used only if other drugs or iv access are not available. Induction of labour is associated with improved maternal outcome and should be advised for women with gestational hypertension or mild pre-eclampsia at 37 weeks' gestation. This position paper provides the first interdisciplinary approach to the management of hypertension in the peripartum period based on the best available evidence and expert consensus.
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Affiliation(s)
- Renata Cífková
- Center for Cardiovascular Prevention, Charles University in Prague, First Faculty of Medicine and Thomayer Hospital, Vídeňská 800, 140 59 Prague 4, Czech Republic.,Department of Medicine II, Charles University in Prague, First Faculty of Medicine, Prague, Czech Republic
| | - Mark R Johnson
- Institute of Reproductive and Developmental Biology, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK
| | - Thomas Kahan
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Jana Brguljan
- Division of Internal Medicine, Department of Hypertension, Medical Faculty, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Bryan Williams
- UCL Institute of Cardiovascular Sciences, University College London, London, UK
| | - Antonio Coca
- Hypertension and Vascular Risk Unit, Department of Internal Medicine, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | - Costas Thomopoulos
- Department of Cardiology, Helena Venizelou General & Maternal Hospital, Athens, Greece
| | - Claudio Borghi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Costas Tsioufis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Gianfranco Parati
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Cardiology Unit, Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, S.Luca Hospital, Milan, Italy
| | - Isabella Sudano
- Department of Cardiology, University Heart Center Zurich, University Hospital and University of Zurich, Zurich, Switzerland
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Bert-Jan H van den Born
- Departments of Internal and Vascular Medicine, Department of Public Health, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Vera Regitz-Zagrosek
- Berlin Institute for Gender in Medicine and CCR, Charité University Medicine Berlin, and DZHK, Partner Site Berlin, Germany
| | - Giovanni de Simone
- Department of Advanced Biomedical Sciences, Hypertension Research Center, Federico II University, Naples, Italy
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Murakami H, Sonoo T, Hashimoto H, Nakamura K. Pheochromocytoma crisis in a patient with newly diagnosed neurofibromatosis type 1. BMJ Case Rep 2021; 14:14/1/e237231. [PMID: 33495177 PMCID: PMC7839903 DOI: 10.1136/bcr-2020-237231] [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: 01/27/2023] Open
Abstract
Pheochromocytoma occasionally engenders catecholamine-induced hypertension crisis. Pheochromocytoma is clinically identified in 0.1%-5.7% of patients with neurofibromatosis type 1 (NF1), which is 10 times more frequently than in healthy individuals. This report describes a case of newly diagnosed NF1 presenting with pheochromocytoma crisis, with severe electrolyte depletion and deteriorating recurrent ventricular tachycardia storm. Characteristic skin lesions such as café-au-lait macules and neurofibromas contributed to the diagnosis of NF1 and pheochromocytoma. No recurrence of electrolyte depletion was found after the adrenalectomy. Primary care physicians must distinguish the characteristic skin lesions of NF1, such as café-au-lait macules and neurofibromas and recognise the risk for pheochromocytoma.
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Affiliation(s)
- Hisashi Murakami
- Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan
| | - Tomohiro Sonoo
- Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan
| | - Hideki Hashimoto
- Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan
| | - Kensuke Nakamura
- Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan
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Prakash P, Kulshrestha V, Ramachandran R, Kumar R. Successful Pregnancy Outcomes After Laparoscopic Management of Pheochromocytoma. J Endourol Case Rep 2020; 6:170-173. [PMID: 33102719 DOI: 10.1089/cren.2019.0139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background: Pheochromocytoma is a rare cause of hypertension in pregnancy, which is often overlooked; especially in late pregnancy because of more prevalent pre-eclampsia. It has been associated with significant morbidity and mortality rates in both mother and fetus, if not diagnosed and treated in time. Minimally invasive surgery has been infrequently used for surgical management of pheochromocytoma in pregnancy, with <20 reported cases in English literature. Case Presentation: A 26-year-old pregnant woman presented at 9 weeks of gestation with complaints of palpitations, sweating, and headache; with past history of first trimester spontaneous abortion caused by accelerated hypertension. She was found to have hypertension and diabetes, but no pedal edema, weight gain, or proteinuria. Ultrasonogram and MRI of abdomen revealed a left adrenal mass and 24 hours urinary catecholamines levels were increased, suggesting a pheochromocytoma. After preoperative optimization in consultations with obstetricians, endocrinologists, and anesthetists, she underwent laparoscopic left adrenalectomy during 15th week of gestation. Perioperative hospital course was uneventful for both mother and the fetus. After adrenalectomy, her diabetes was cured and hypertension was controlled with single antihypertensive. She was readmitted at 31 weeks of gestation with accelerated hypertension and underwent emergency caesarean for impending eclampsia at 32 weeks, and delivered a healthy female baby. 131I-meta-iodobenzylguanidine (MIBG) scan and 68Ga-[1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid]-1-NaI(3)-octreotide positron emission tomography-CT (68Ga-DOTANOC PET-CT) scan was obtained in postpartum period to rule out any extra-adrenal pheochromocytoma, both of which did not reveal any abnormality. At 1 year follow-up, she is normoglycemic and hypertension controlled on single antihypertensive. Conclusion: Pheochromocytoma in pregnancy is a rare but potentially lethal condition, and high index of suspicion is required for early diagnosis. Multidisciplinary coordination is required for effective management of this rare condition. Laparoscopic adrenalectomy is safe in second trimester of pregnancy for both mother and fetus.
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Affiliation(s)
- Pradeep Prakash
- Department of Urology, All India Institute of Medical Sciences, New Delhi, India
| | - Vidushi Kulshrestha
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Rashmi Ramachandran
- Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajeev Kumar
- Department of Urology, All India Institute of Medical Sciences, New Delhi, India
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28
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Pheochromocytoma and Paraganglioma: From Clinical Findings to Diagnosis. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2020; 54:271-280. [PMID: 33312023 PMCID: PMC7729715 DOI: 10.14744/semb.2020.14826] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 06/26/2020] [Indexed: 12/13/2022]
Abstract
The majority of pheochromocytoma (PCC) and paraganglioma (PGL) are endocrine active tumors, and they cause clinical symptoms by secreting excess one or more catecholamines (epinephrine, norepinephrine, and dopamine) and their inactive metabolites (metanephrine, normetanephrine, 3-metoxythromine). Although signs and symptoms regarding excess catecholamine often develop in PCC and PGL (PPGL), non-functional PPGLs may present with local compression symptoms. Persistent, sometimes worsening hypertension is the most common finding and occurs in 80-90% of the patients. Classically defined symptom triad; headache, sweating and palpitations are seen in only 25% of the patients with PCC. The difference of clinical symptoms may be related to the tumor secretion, epinephrine or norepinephrine. All patients with signs and symptoms suggestive of catecholamine excess should be screened by biochemical tests regardless of whether they have hypertension or not. Not all patients with newly diagnosed hypertension need to be screened, but only patients with additional tips for catecholamine excess should be screened. Approximately 20% of the PPGLs are diagnosed in childhood, and the male/female ratio is 2/1. 60-90% of pediatric patients present with hypertension. PPGL in pregnancy is rare, and the estimated incidence ranges between 1/15000-1/54000. Although early diagnosis is the most important factor in preventing mortality, diagnosis is not as easy as it is a rare condition. Hypertension is a common complication in pregnancy, occurring in 5-10%. Computed tomography should not be used as the imaging method during pregnancy; the first choice is magnetic resonance imaging with gadolinium or without contrast. Plasma free metanephrine or 24-hour urinary fractionated metanephrine level is recommended as a screening test for the diagnosis of PPGL in the Endocrine Society Clinical Practice Guideline. In suspicious situations, tests should be repeated. Since 40% of these patients have germline mutations, genetic tests are recommended for all patients with PPGL regardless of family history and age. Preoperative knowledge of germline mutations affects the surgical approach and the extent of adrenalectomy. After the biochemical diagnosis is made in PPGL, the tumor is localized with imaging methods to make the operation plan. In this review, we aimed to evaluate the clinical findings, diagnostic tests, and imaging studies for tumor localization in PPGL.
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29
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Misasi G, Pancetti F, Giannini A, Simoncini T, Mannella P. Pheochromocytoma diagnosed during pregnancy: a case report. Gynecol Endocrinol 2020; 36:650-653. [PMID: 32314609 DOI: 10.1080/09513590.2020.1754392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Pheochromocytoma is a rare catecholamine producing tumor. During pregnancy, this tumor can mimic gestational hypertension, preeclampsia or eclampsia. We present a case of a 38-year-old, multiparous woman admitted at 36 weeks of gestation due to hypertension. After cesarean section, she developed an unexplainable worsening of her hypertension that was resistant to the traditional therapy. Additional investigation lead to the diagnosis of pheochromocytoma. This case highlights the importance of an early diagnosis and the need of a multidisciplinary approach for the improvement of pregnancy outcomes in patients with pheochromocytoma.
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Affiliation(s)
- Giulia Misasi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa Italy
| | - Federica Pancetti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa Italy
| | - Andrea Giannini
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa Italy
| | - Tommaso Simoncini
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa Italy
| | - Paolo Mannella
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa Italy
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30
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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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31
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Patel D, Phay JE, Yen TWF, Dickson PV, Wang TS, Garcia R, Yang AD, Kim LT, Solórzano CC. Update on Pheochromocytoma and Paraganglioma from the SSO Endocrine and Head and Neck Disease Site Working Group, Part 2 of 2: Perioperative Management and Outcomes of Pheochromocytoma and Paraganglioma. Ann Surg Oncol 2020; 27:1338-1347. [PMID: 32112213 DOI: 10.1245/s10434-020-08221-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Indexed: 01/10/2023]
Abstract
This is the second part of a two-part review on pheochromocytoma and paragangliomas (PPGLs). In this part, perioperative management, including preoperative preparation, intraoperative, and postoperative interventions are reviewed. Current data on outcomes following resection are presented, including outcomes after cortical-sparing adrenalectomy for bilateral adrenal disease. In addition, pathological features of malignancy, surveillance considerations, and the management of advanced disease are also discussed.
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Affiliation(s)
- Dhaval Patel
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Tina W F Yen
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paxton V Dickson
- Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Roberto Garcia
- Division of Surgical Oncology, National Cancer Institute of Panama/Paitilla Medical Center, Panama City, Panama
| | - Anthony D Yang
- Division of Surgical Oncology, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lawrence T Kim
- Division of Surgical Oncology and Endocrine Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Carmen C Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University, Nashville, TN, USA
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32
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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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33
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Chua MWJ, Sek KSY, Tai ES. The Great Masquerador: A Young Female with Multiple Endocrine Neoplasia Type 2A and Bilateral Pheochromocytomas. Am J Med 2019; 132:e767-e770. [PMID: 31103648 DOI: 10.1016/j.amjmed.2019.04.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 04/18/2019] [Accepted: 04/18/2019] [Indexed: 11/16/2022]
Affiliation(s)
| | - Kathleen Su-Yen Sek
- Division of Endocrinology, Department of Medicine, National University Health System, Singapore
| | - E Shyong Tai
- Division of Endocrinology, Department of Medicine, National University Health System, Singapore
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34
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Yadav S, Singh N, Jain S, Pradhan M. Identification and management of rare causes of chronic hypertension in pregnancy in a tertiary referral centre of North India. Pregnancy Hypertens 2019; 17:249-252. [PMID: 31487648 DOI: 10.1016/j.preghy.2019.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 07/08/2019] [Accepted: 07/14/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Sangeeta Yadav
- Department of Maternal and Reproductive Health, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh 226014, India
| | - Neeta Singh
- Department of Maternal and Reproductive Health, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh 226014, India
| | - Shruti Jain
- Department of Maternal and Reproductive Health, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh 226014, India
| | - Mandakini Pradhan
- Department of Maternal and Reproductive Health, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh 226014, India.
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35
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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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36
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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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37
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Levin G, Elchalal U, Rottenstreich A. The adrenal cortex: Physiology and diseases in human pregnancy. Eur J Obstet Gynecol Reprod Biol 2019; 240:139-143. [PMID: 31284087 DOI: 10.1016/j.ejogrb.2019.06.036] [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: 03/02/2019] [Revised: 06/18/2019] [Accepted: 06/28/2019] [Indexed: 11/28/2022]
Abstract
Pregnancy is characterized by marked alterations in the hypothalamic-pituitary-adrenal axis and in the function of the adrenal gland. Some of those alterations have clinical characteristics that are similar to those of adrenal gland disorders. While adrenal disorders are rare among pregnant women, they harbor the potential for significant morbidity if they remain unrecognized and untreated. As the majority of patients with adrenal disorders present with clinical features that are typical of normal pregnancy - diagnosis during pregnancy is not uncommonly delayed. A high index of suspicion must be practiced for these disorders as they might carry severe obstetrical negative outcomes. In this review we will survey the normal function of adrenal glands in pregnancy and the role of adrenal hormones in pregnancy. We will outline the adrenal disorders that commonly present during pregnancy and review the literature on treatment modalities.
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Affiliation(s)
- Gabriel Levin
- Department of Obstetrics and Gynecology, Hadassah University Hospital, Jerusalem, Israel.
| | - Uriel Elchalal
- Department of Obstetrics and Gynecology, Hadassah University Hospital, Jerusalem, Israel
| | - Amihai Rottenstreich
- Department of Obstetrics and Gynecology, Hadassah University Hospital, Jerusalem, Israel
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38
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Nieto AJ, Trochez L, Ramírez D, Arguello P, Guzman G, Pachajoa H, Escobar Vidarte MF. Paraganglioma in pregnancy: interdisciplinary management during pregnancy. Gynecol Endocrinol 2019; 35:567-570. [PMID: 30786782 DOI: 10.1080/09513590.2019.1576619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Paragangliomas are tumors that originate from the extra-adrenal neural crest, the incidence of which during pregnancy is not more than two to eight cases per million people per year and are known to be highly morbid. The purpose of this report is to describe the experience and results obtained during management of a primigravida diagnosed with paraganglioma on week 21.2 and received both medical and surgical management with good maternal and perinatal outcomes. This case report evidences the importance of practicing interdisciplinary management of patients with clinical suspicion of paragangliomas or pheochromocytomas during pregnancy at high-complexity centers even in a medium-income country.
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Affiliation(s)
- Albaro J Nieto
- a High Complexity Obstetric Unit, Department of Gynecology and Obstetrics , Fundación Valle del Lili , Santiago de Cali , Colombia
- b Department of Health Sciences, Faculty of Medicine , ICESI University , Santiago de Cali , Colombia
| | - Lizette Trochez
- b Department of Health Sciences, Faculty of Medicine , ICESI University , Santiago de Cali , Colombia
| | - Daniela Ramírez
- b Department of Health Sciences, Faculty of Medicine , ICESI University , Santiago de Cali , Colombia
| | - Pedro Arguello
- c Department of Surgery , Fundación Valle del Lili , Santiago de Cali , Colombia
| | - Guillermo Guzman
- d Department of Endocrinology , Fundación Valle del Lili , Santiago de Cali , Colombia
| | - Harry Pachajoa
- e Department of Genetics , Fundación Valle del Lili , Santiago de Cali , Colombia
| | - María Fernanda Escobar Vidarte
- a High Complexity Obstetric Unit, Department of Gynecology and Obstetrics , Fundación Valle del Lili , Santiago de Cali , Colombia
- b Department of Health Sciences, Faculty of Medicine , ICESI University , Santiago de Cali , Colombia
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Dodd SE, Singh RJ, Martin YN. Catecholamine and Metanephrine Levels in Breast Milk Before and After Paraganglioma Resection. Breastfeed Med 2019; 14:276-277. [PMID: 30874459 DOI: 10.1089/bfm.2019.0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Catecholamine and metanephrine transfer into breast milk in the setting of secreting paraganglioma or pheochromocytoma has not been previously described. Materials and Methods: We present an investigation in which we measured catecholamine and metanephrine levels in the breast milk in a single patient undergoing resection of a paraganglioma at 5 weeks postpartum. Results:As expected, levels were elevated preoperatively and decreased rapidly after resection. Conclusion:This information may be clinically relevant for patient management when pheochromocytoma or paraganglioma resection is delayed with respect to the delivery of the infant or in the postoperative monitoring of the patient's status.
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Affiliation(s)
- Sarah E Dodd
- 1 Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ravinder J Singh
- 2 Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Yvette N Martin
- 1 Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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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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41
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Radfar MH, Shakiba B, Afyouni A, Hoshyar H. Laparoscopic management of paraganglioma in a pregnant woman: a case report. Int Braz J Urol 2018; 44:1032-1035. [PMID: 29570256 PMCID: PMC6237544 DOI: 10.1590/s1677-5538.ibju.2017.0698] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Accepted: 01/18/2018] [Indexed: 12/27/2022] Open
Abstract
Introduction: Paraganglioma is an extremely rare catecholamine-producing tumor during pregnancy. Paraganglioma carries high risks of fetal and maternal mortality during pregnancy. We report a pregnant woman with paraganglioma in the second trimester. Case Description: A 24-year-old pregnant woman presented with severe hypertension in the 17th week of gestation. Hormonal examination and Magnetic Resonance Imaging (MRI) confirmed the diagnosis of extra adrenal pheochromocytoma (paraganglioma). She underwent laparoscopic tumor excision successfully. Conclusions: A high index of suspicion is needed to diagnose paraganglioma in a pregnant patient with hypertension. Laparoscopic tumor removal for paraganglioma seems to be a feasible and safe procedure during pregnancy.
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Affiliation(s)
- Mohammad Hadi Radfar
- Urology and Nephrology Research Center, Shahid Labbafinejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Behnam Shakiba
- Urology and Nephrology Research Center, Shahid Labbafinejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Afyouni
- Urology and Nephrology Research Center, Shahid Labbafinejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hassan Hoshyar
- Urology and Nephrology Research Center, Shahid Labbafinejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Teasdale S, Morton A. Changes in biochemical tests in pregnancy and their clinical significance. Obstet Med 2018; 11:160-170. [PMID: 30574177 PMCID: PMC6295771 DOI: 10.1177/1753495x18766170] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 02/22/2018] [Indexed: 12/11/2022] Open
Abstract
Interpretation of laboratory investigations relies on reference intervals. Physiological changes in pregnancy may result in significant changes in normal values for many biochemical assays, and as such results may be misinterpreted as abnormal or mask a pathological state. The aims of this review are as follows: 1. To review the major physiological changes in biochemical tests in normal pregnancy. 2. To outline where these physiological changes are important in interpreting laboratory investigations in pregnancy. 3. To document the most common causes of abnormalities in biochemical tests in pregnancy, as well as important pregnancy-specific causes.
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Affiliation(s)
- Stephanie Teasdale
- Queensland Diabetes and Endocrine Centre, Mater Misericordiae Hospital, Brisbane, Australia
| | - Adam Morton
- Queensland Diabetes and Endocrine Centre, Mater Misericordiae Hospital, Brisbane, Australia
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43
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Valdeyron C, Chartier C, Accoceberry M, Chadeyras JB, Gallot D. [Pheochromocytoma and pregnancy: About one case]. ACTA ACUST UNITED AC 2018; 46:667-668. [PMID: 30120067 DOI: 10.1016/j.gofs.2018.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Indexed: 11/29/2022]
Affiliation(s)
- C Valdeyron
- Pôle femme et enfant, service de gynécologie obstétrique, CHU Clermont-Ferrand, 1, place Lucie et Raymond Aubrac, 63003 Clermont-Ferrand cedex 1, France
| | - C Chartier
- Pôle médecine péri-opératoire, CHU Clermont-Ferrand, 1, place Lucie et Raymond Aubrac, 63003 Clermont-Ferrand cedex 1, France
| | - M Accoceberry
- Pôle femme et enfant, service de gynécologie obstétrique, CHU Clermont-Ferrand, 1, place Lucie et Raymond Aubrac, 63003 Clermont-Ferrand cedex 1, France
| | - J-B Chadeyras
- Centre Jean Perrin, service de chirurgie thoracique, 58, rue Montalembert, 63000 Clermont-Ferrand, France
| | - D Gallot
- Pôle femme et enfant, service de gynécologie obstétrique, CHU Clermont-Ferrand, 1, place Lucie et Raymond Aubrac, 63003 Clermont-Ferrand cedex 1, France; Équipe « Translational approach to epithelial injury and repair », université Clermont Auvergne, CNRS, Inserm, GReD, 63000 Clermont-Ferrand, France.
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44
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Successful Management of Pheochromocytoma Detected in Pregnancy by Interval Adrenalectomy in a VHL Patient. Case Rep Endocrinol 2018; 2018:9014585. [PMID: 30105106 PMCID: PMC6076903 DOI: 10.1155/2018/9014585] [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: 01/29/2018] [Revised: 05/01/2018] [Accepted: 05/22/2018] [Indexed: 11/26/2022] Open
Abstract
A 34-year-old mother with diabetes mellitus for 6 years presented in the late second trimester of her third pregnancy with new onset hypertension and characteristic hyperadrenergic spells. Clinical examination was unremarkable except a blood pressure of 170/110 mmhg. She had an elevated 24 hour urinary normetanephrine level with ultrasonic evidence of a hyperechoic hypervascular well-defined right supra renal mass of 6 x 5 cm in size which was very suggestive of a pheochromocytoma. Her management decisions were made by a multidisciplinary team which decided to deliver the baby by lower segment cesarean section (LSCS) as the pregnancy was advanced and to proceed with interval adrenalectomy after contrast enhanced computer tomography (CECT) of the abdomen with adrenal protocol. As a result a healthy baby was delivered by an uncomplicated elective LSCS at 36 weeks of POA. CECT abdomen with adrenal protocol confirmed a right-sided pheochromocytoma without any evidence of metastasis. Uncomplicated laparoscopic right adrenalectomy led to a clinical and biochemical recovery of the patient while histology confirmed the pheochromocytoma without any evidence of invasion. Subsequent follow up revealed cerebellar hemangioblastomas and retinal angioma in the right eye which led to a clinical diagnosis of Von Hippel Lindau disease (VHL). Even though clinical criteria for Von Hippel Lindau disease were fulfilled, her VHL genetic test was negative. At present she and her family are under surveillance of the endocrine team.
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Extra-adrenal paraganglioma masquerading as severe preeclampsia. Obstet Gynecol Sci 2018; 61:520-523. [PMID: 30018907 PMCID: PMC6046359 DOI: 10.5468/ogs.2018.61.4.520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 07/15/2017] [Accepted: 08/16/2017] [Indexed: 12/29/2022] Open
Abstract
Paraganglioma in pregnancy is an extremely rare condition and its diagnosis is often delayed because the clinical symptoms can mimic those of preeclampsia or gestational hypertension. Here, we report the case of a 32-year-old, gravida 2, para 1 woman who presented with severe headache, palpitation, and sweating at 37 weeks' gestation. Although emergent cesarean section was performed on the assumption of severe preeclampsia, blood pressure fluctuated and heart rate remained tachycardiac. We suspected that she might have thromboembolic lesion in the chest or pheochromocytoma. Chest and abdominal computed tomography revealed a 4 cm mass in the left para-aortic space. Serum and urinary catecholamine levels were found to be significantly increased. She underwent laparoscopic mass removal and the pathology confirmed paraganglioma. When typical paroxysmal hypertension is accompanied by headache, palpitation, and sweating during pregnancy, adrenal tumors should be considered.
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46
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Morton A, Teasdale S. Review article: Investigations and the pregnant woman in the emergency department - part 1: Laboratory investigations. Emerg Med Australas 2018; 30:600-609. [PMID: 29656593 DOI: 10.1111/1742-6723.12957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 02/07/2018] [Indexed: 12/17/2022]
Abstract
Accurate assessment of the pregnant patient in the ED depends on knowledge of physiological changes in pregnancy, and how these changes may impact on pathology tests, appearance on point-of-care ultrasound and electrocardiography. In addition the emergency physician needs to be cognisant of disorders that are unique to or more common in pregnancy. Part 1 of this review addresses potential deviations in laboratory investigation reference intervals resulting from physiological alterations in pregnancy, and the important causes of abnormal laboratory results in pregnancy. Part 2 will address the role of point-of-care ultrasound in pregnancy, physiological changes that may affect interpretation of point-of-care ultrasound, physiological changes in electrocardiography, and the safety of radiological procedures in the pregnant patient.
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Affiliation(s)
- Adam Morton
- Mater Health and The University of Queensland, Brisbane, Queensland, Australia
| | - Stephanie Teasdale
- Mater Health and The University of Queensland, Brisbane, Queensland, Australia
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47
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Donatini G, Kraimps JL, Caillard C, Mirallie E, Pierre F, De Calan L, Hamy A, Larin O, Tovkay O, Cherenko S. Pheochromocytoma diagnosed during pregnancy: lessons learned from a series of ten patients. Surg Endosc 2018; 32:3890-3900. [PMID: 29488089 DOI: 10.1007/s00464-018-6128-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 02/23/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Pheochromocytoma (PHEO) in pregnancy is a life-threatening condition. Its management is challenging with regards to the timing and type of surgery. METHODS A retrospective review of the management of ten patients diagnosed with pheochromocytoma during pregnancy was performed. Data were collected on the initial diagnostic workup, symptoms, treatment, and follow-up. RESULTS PHEO was diagnosed in ten patients who were between the 10th and the 29th weeks of pregnancy. Six patients had none to mild symptoms, while four had complications of paroxysmal hypertension. Imaging investigations consisted of MRI, CT scan and ultrasounds. All had urinary metanephrines, measured as part of their workup. Three patients had MEN 2A, one VHL syndrome, one suspected SDH mutation. All patients were treated either with α/β blockers or calcium channel blockers to stabilize their clinical conditions. Seven patients underwent a laparoscopic adrenalectomy before delivery. Three out of these seven patients had a bilateral PHEO and underwent a unilateral adrenalectomy of the larger tumor during pregnancy, followed by a planned cesarean section and a subsequent contralateral adrenalectomy within a few months after delivery. Three patients had emergency surgery for maternal or fetal complications, with C-section followed by concomitant or delayed adrenalectomy. All newborns from the group of planned surgery were healthy, while two out three newborns within the emergency surgery group died shortly after delivery secondary to cardiac and pulmonary complications. CONCLUSIONS PHEO in pregnancy is a rare condition. Maternal and fetal prognosis improved over the last decades, but still lethal consequences may be present if misdiagnosed or mistreated. A thorough multidisciplinary team approach should be tailored on an individual basis to better manage the pathology. Unilateral adrenalectomy in a pregnant patient with bilateral PHEO may be an option to avoid the risk of adrenal insufficiency after bilateral adrenalectomy.
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Affiliation(s)
- G Donatini
- Department of General and Endocrine Surgery, CHU Poitiers, 2 Rue de la Miletrie, 86021, Poitiers, France.
| | - J L Kraimps
- Department of General and Endocrine Surgery, CHU Poitiers, 2 Rue de la Miletrie, 86021, Poitiers, France
| | - C Caillard
- Department of General and Endocrine Surgery, CHU Nantes, Nantes, France
| | - E Mirallie
- Department of General and Endocrine Surgery, CHU Nantes, Nantes, France
| | - F Pierre
- Department of Obstetrics and Gynaecology, CHU Poitiers, Poitiers, France
| | - Loïc De Calan
- Department of General and Endocrine Surgery, CHU Tours, Tours, France
| | - A Hamy
- Department of General and Endocrine Surgery, CHU Angers, Angers, France
| | - O Larin
- Department of Endocrine Surgery, Ukrainian Scientific and Practical Center for Endocrine Surgery of Public Health Ministry of Ukraine, Kiev, Ukraine
| | - O Tovkay
- Department of Endocrine Surgery, Ukrainian Scientific and Practical Center for Endocrine Surgery of Public Health Ministry of Ukraine, Kiev, Ukraine
| | - S Cherenko
- Department of Endocrine Surgery, Ukrainian Scientific and Practical Center for Endocrine Surgery of Public Health Ministry of Ukraine, Kiev, Ukraine
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48
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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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Langton K, Gruber M, Masjkur J, Steenblock C, Peitzsch M, Meinel J, Lenders J, Bornstein S, Eisenhofer G. Hypertensive crisis in pregnancy due to a metamorphosing pheochromocytoma with postdelivery Cushing's syndrome. Gynecol Endocrinol 2018; 34:20-24. [PMID: 28937294 DOI: 10.1080/09513590.2017.1379497] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Pheochromocytomas in pregnancy are rare but potentially lethal. Even rarer is the combination of pheochromocytoma in pregnancy with subsequent development of ectopic Cushing's syndrome. We report a 36-year-old woman, previously diagnosed with essential hypertension, who developed severe hypertension in pregnancy complicated by insulin-dependent gestational diabetes. A cesarean section was performed at 32 weeks following a hypertensive crisis after routine administration of betamethasone. Postnatal persistence of signs and symptoms of catecholamine excess led to the diagnosis of a left adrenal pheochromocytoma. Between diagnosis and planned tumor removal, the patient developed signs and symptoms of Cushing's syndrome (facial edema and hirsutism, myopathy and fatigue). Biochemical testing confirmed hypercortisolism with extremely elevated levels of plasma adrenocorticotropin, urinary cortisol and multiple steroids of a plasma panel that were all normal at previous testing. The previously noradrenergic tumor also started producing epinephrine. Histopathological examination confirmed the pheochromocytoma, which was also immunohistochemically positive for adrenocorticotropin. Full post-surgical recovery was sustained with normal blood pressure and biochemical findings after one year. This report not only underlines the chameleon behavior of pheochromocytoma but also illustrates its potential for a metamorphosing presentation. Corticosteroid administration in pregnancy requires a cautious approach in patients with hypertension.
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Affiliation(s)
- Katharina Langton
- a Institute of Clinical Chemistry and Laboratory Medicine , University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden , Dresden , Germany
| | - Matthias Gruber
- b Department of Medicine III , University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden , Dresden , Germany
| | - Jimmy Masjkur
- b Department of Medicine III , University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden , Dresden , Germany
| | - Charlotte Steenblock
- b Department of Medicine III , University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden , Dresden , Germany
| | - Mirko Peitzsch
- a Institute of Clinical Chemistry and Laboratory Medicine , University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden , Dresden , Germany
| | - Jörn Meinel
- c Institute of Pathology , University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden , Dresden , Germany
| | - Jacques Lenders
- b Department of Medicine III , University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden , Dresden , Germany
- d Department of Internal Medicine , Radboud University Medical Center , Nijmegen , the Netherlands
| | - Stefan Bornstein
- b Department of Medicine III , University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden , Dresden , Germany
| | - Graeme Eisenhofer
- a Institute of Clinical Chemistry and Laboratory Medicine , University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden , Dresden , Germany
- b Department of Medicine III , University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden , Dresden , Germany
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Liu S, Song A, Zhou X, Kong X, Li WA, Wang Y, Liu Y. Malignant pheochromocytoma with multiple vertebral metastases causing acute incomplete paralysis during pregnancy: Literature review with one case report. Medicine (Baltimore) 2017; 96:e8535. [PMID: 29095319 PMCID: PMC5682838 DOI: 10.1097/md.0000000000008535] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE We present a rare case of malignant pheochromocytoma with thoracic metastases during pregnancy that presented with symptoms of myelopathy and was treated with circumferential decompression, stabilization, and radiation. The management of this unique case is not well documented. The clinical manifestations, imaging results, pathological characteristics, treatment and prognosis of the case were analyzed. PATIENT CONCERNS A 26-year-old pregnant woman with a history of paroxysmal hypertension during the second trimester presented with lower extremity weakness, numbness, urinary incontinence, and back pain. Imaging studies revealed a right adrenal pheochromocytoma, multiple metastases at T8, T11, T12, and the pelvis girdle causing significant multilevel cord compression and significant osteolytic lesions at T11 and T12. DIAGNOSES We believe this is the first reported case of metastatic pheochromocytoma of the thoracic spine presenting with symptoms of myelopathy during pregnancy. INTERVENTIONS A healthy neonate was delivered by emergency caesarean section at 34 weeks. Subsequently, the patient underwent a circumferential spinal cord decompression and a stabilization procedure. OUTCOMES The patient's neurological deficits improved significantly after the surgery, and the postoperative period was uneventful at the 6-month follow-up visit. LESSONS This article emphasizes that metastatic pheochromocytoma of the spine, although rare, should be part of the differential when a patient presents with elevated blood pressure, weakness, and urinary incontinence.
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Affiliation(s)
- Shuzhong Liu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
| | - An Song
- Department of Endocrinology, Key Laboratory of Endocrinology, National Health and Family Planning Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College
| | - Xi Zhou
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
| | - Xiangyi Kong
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - William A. Li
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI
| | - Yipeng Wang
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
| | - Yong Liu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
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