scholarly journals Curative resection of an aldosteronoma causing primary aldosteronism in the second trimester of pregnancy

2020 ◽  
Vol 2020 ◽  
Author(s):  
Skand Shekhar ◽  
Rasha Haykal ◽  
Crystal Kamilaris ◽  
Constantine A Stratakis ◽  
Fady Hannah-Shmouni
Keyword(s):  
Primary Aldosteronism ◽  
Secondary Hypertension ◽  
Uncontrolled Hypertension ◽  
List Type ◽  
Second Trimester ◽  
Unilateral Adrenalectomy ◽  
Fetal Complications ◽  
Common Etiology ◽  
History Of ◽  
In Pregnancy

Summary A 29-year-old primigravida woman with a known history of primary aldosteronism due to a right aldosteronoma presented with uncontrolled hypertension at 5 weeks of estimated gestation of a spontaneous pregnancy. Her hypertension was inadequately controlled with pharmacotherapy which lead to the consideration of surgical management for her primary aldosteronism. She underwent curative right unilateral adrenalectomy at 19 weeks of estimated gestational age. The procedure was uncomplicated, and her blood pressure normalized post-operatively. She did, however, have a preterm delivery by cesarean section due to intrauterine growth retardation with good neonatal outcome. She is normotensive to date. Learning points: Primary aldosteronism is the most common etiology of secondary hypertension with an estimated prevalence of 5–10% in the hypertensive population. It is important to recognize the subtypes of primary aldosteronism given that certain forms can be treated surgically. Hypertension in pregnancy is associated with significantly higher maternal and fetal complications. Data regarding the treatment of primary aldosteronism in pregnancy are limited. Adrenalectomy can be considered during the second trimester of pregnancy if medical therapy fails to adequately control hypertension from primary aldosteronism.

scholarly journals Management of primary hyperparathyroidism in pregnancy: a case series

2019 ◽  
Vol 2019 ◽  
Author(s):  
Aisling McCarthy ◽  
Sophie Howarth ◽  
Serena Khoo ◽  
Julia Hale ◽  
Sue Oddy ◽  
...  
Keyword(s):  
Primary Hyperparathyroidism ◽  
Serum Calcium ◽  
Case Series ◽  
Definitive Treatment ◽  
List Type ◽  
Second Trimester ◽  
Management Options ◽  
Neonatal Complications ◽  
Fetal Complications ◽  
In Pregnancy

Summary Primary hyperparathyroidism (PHPT) is characterised by the overproduction of parathyroid hormone (PTH) due to parathyroid hyperplasia, adenoma or carcinoma and results in hypercalcaemia and a raised or inappropriately normal PTH. Symptoms of hypercalcaemia occur in 20% of patients and include fatigue, nausea, constipation, depression, renal impairment and cardiac arrythmias. In the most severe cases, uraemia, coma or cardiac arrest can result. Primary hyperparathyroidism in pregnancy is rare, with a reported incidence of 1%. Maternal and fetal/neonatal complications are estimated to occur in 67 and 80% of untreated cases respectively. Maternal complications include nephrolithiasis, pancreatitis, hyperemesis gravidarum, pre-eclampsia and hypercalcemic crises. Fetal complications include intrauterine growth restriction; preterm delivery and a three to five-fold increased risk of miscarriage. There is a direct relationship between the degree of severity of hypercalcaemia and miscarriage risk, with miscarriage being more common in those patients with a serum calcium greater than 2.85 mmol/L. Neonatal complications include hypocalcemia. Herein, we present a case series of three women who were diagnosed with primary hyperparathyroidism in pregnancy. Case 1 was diagnosed with multiple endocrine neoplasia type 1 (MEN1) in pregnancy and required a bilateral neck exploration and subtotal parathyroidectomy in the second trimester of her pregnancy due to symptomatic severe hypercalcaemia. Both case 2 and case 3 were diagnosed with primary hyperparathyroidism due to a parathyroid adenoma and required a unilateral parathyroidectomy in the second trimester. This case series highlights the work-up and the tailored management approach to patients with primary hyperparathyroidism in pregnancy. Learning points: Primary hyperparathyroidism in pregnancy is associated with a high incidence of associated maternal fetal and neonatal complications directly proportionate to degree of maternal serum calcium levels. Parathyroidectomy is the definitive treatment for primary hyperparathyroidism in pregnancy and was used in the management of all three cases in this series. It is recommended when serum calcium is persistently greater than 2.75 mmol/L and or for the management of maternal or fetal complications of hypercalcaemia. Surgical management, when necessary is ideally performed in the second trimester. Primary hyperparathyroidism is genetically determined in ~10% of cases, where the likelihood is increased in those under 40 years, where there is relevant family history and those with other related endocrinopathies. Genetic testing is a useful diagnostic adjunct and can guide treatment and management options for patients diagnosed with primary hyperparathyroidism in pregnancy, as described in case 1 in this series, who was diagnosed with MEN1 syndrome. Women of reproductive age with primary hyperparathyroidism need to be informed of the risks and complications associated with primary hyperparathyroidism in pregnancy and pregnancy should be deferred and or avoided until curative surgery has been performed and calcium levels have normalised.

scholarly journals Primary Hyperparathyroidism in Pregnancy: A Two-Case Report and Literature Review

2015 ◽  
Vol 2015 ◽  
pp. 1-3 ◽  
Author(s):  
A. D. Herrera-Martínez ◽  
R. Bahamondes-Opazo ◽  
R. Palomares-Ortega ◽  
C. Muñoz-Jiménez ◽  
M. A. Gálvez-Moreno ◽  
...  
Keyword(s):  
Case Report ◽  
Surgical Treatment ◽  
Early Diagnosis ◽  
Literature Review ◽  
Primary Hyperparathyroidism ◽  
Serum Levels ◽  
Second Trimester ◽  
Uncommon Disease ◽  
Fetal Complications ◽  
In Pregnancy

Primary hyperparathyroidism (PHPT) in pregnant women is an uncommon disease. It could be easily misdiagnosed because of physiologic changes during pregnancy; in some cases, patients could remain asymptomatic maintaining elevated calcium serum levels, and this situation represents a threat to the health of both mother and fetus. We present two cases of PHPT during pregnancy and their evolution after surgical treatment in the second trimester; there were no observed complications during pregnancy or delivery in our patients. Early diagnosis and medical/surgical treatment in PHPT are necessary for avoiding maternal and fetal complications which could not be predicted based on duration or severity of hypercalcemia. An appropriate management of PHPT during pregnancy is necessary for preserving the health of both the woman and the fetus.

scholarly journals Colon cancer presenting as pseudo-obstruction during pregnancy – A case report

2017 ◽  
Vol 10 (4) ◽  
pp. 198-200 ◽  
Author(s):  
Reeva Makhijani ◽  
Vicky H Bhagat ◽  
Mariam Fayek
Keyword(s):  
Colorectal Cancer ◽  
Colon Cancer ◽  
Colorectal Adenocarcinoma ◽  
Bowel Movement ◽  
Medical Oncology ◽  
Second Trimester ◽  
Total Abdominal Colectomy ◽  
Cancer In Pregnancy ◽  
History Of ◽  
In Pregnancy

The incidence of colorectal cancer in pregnancy is between 0.002 and 0.008%. Diagnosis is often delayed as symptoms of colorectal cancer can mimic as common complaints of pregnancy. We present the case of a 29-year-old with a history of chronic constipation who presented in the second trimester with abdominal pain, inability to tolerate anything orally and no bowel movement in more than three weeks. Non-contrast MRI at presentation failed to show an obstructing mass. Patient was treated conservatively for presumed pseudo-obstruction secondary to worsening constipation from chronic ondansetron use and pregnancy. After four days without clinical improvement, she had a colonoscopy that revealed a completely obstructing sigmoid mass, which biopsies confirmed was a primary colorectal adenocarcinoma. The patient underwent a total abdominal colectomy. She was referred to medical oncology and began adjuvant chemotherapy consisting of 5-fluorouracil, leucovorin and oxaloplatin four weeks post-operatively.

scholarly journals Advanced acromegaly: successful disease control for more than 16 years using octreotide LA

2020 ◽  
Vol 2020 ◽  
Author(s):  
Omayma Elshafie ◽  
Nicholas Woodhouse
Keyword(s):  
Clinical Symptoms ◽  
Tumour Size ◽  
Uncontrolled Hypertension ◽  
Therapeutic Trial ◽  
List Type ◽  
Residual Tumour ◽  
History Of ◽  
Successful Control ◽  
Long Acting

Summary A 79-year-old male presented with a 10-year history of intermittent headache, sweating, persistent hand numbness and uncontrolled hypertension. He was receiving Nifedipine and Hydrochorothizide. On examination (O/E), his BP was 180/100 he was acromegalic. His growth hormone (GH) was 10 mIU/L (0.0–0.1) and his insulin-like growth factor (IGF-1): 952 µg/L (76–160). An MRI of the pituitary revealed a 3 × 2 cm pituitary macroadenoma. Surgery was refused and the family agreed for a therapeutic trial of octreotide. His GH levels fell immediately. Two weeks later he was switched to long-acting monthly octreotide in September 2003. During his 16-year follow-up, he has remained well and asymptomatic off medications for hypertension. His BP and IGF-1 levels were also normal until octreotide Long acting (LA) octrotide was stopped for 3 months at age 96. During this period the IGF-1 level returned to pretreatment levels 500 ng/L (50–141), GH 24 mIU/L (0.0–0.1), and a small residual tumour 0.5–0.8 cm was seen on the MRI. Octreotide LA was restarted and the IGF-1 and GH levels returned to normal. He continues the same treatment to date age 97 without side effects. We conclude that the successful control of IGF-1, GH levels, hypertension, tumour size and clinical symptoms for more than 16 years occurred using octreotide LA in an elderly advanced acromegalic patient. To the best of our knowledge, this is the first report of the successful use of octreotide LA for more than 16 years. Learning points: The value of a therapeutic trial of octreotide to identify responders. Control of GH and IGF-1 secretion using octreotide LA. The report of the successful use of octreotide for more than 16 years irrespective of age.

Abstract 16932: Primary Hyperaldosteronism And Resistant Hypertension In Pregnancy

Circulation ◽  
2021 ◽  
Vol 144 (Suppl_2) ◽  
Author(s):  
Agnes Koczo ◽  
Malamo E Countouris ◽  
Alisse Hauspurg ◽  
Kathryn Berlacher
Keyword(s):  
Kidney Disease ◽  
Resistant Hypertension ◽  
Chronic Kidney Disease Stage ◽  
Growth Restriction ◽  
Primary Hyperaldosteronism ◽  
Disease Stage ◽  
Uncontrolled Hypertension ◽  
Progression Of Kidney Disease ◽  
History Of ◽  
In Pregnancy

Case Presentation: A 42-year-old woman with history of primary hyperaldosteronism (PA), IDDM and chronic kidney disease stage 3b (baseline Cr 2.5 mg/dl) presented at 10 weeks gestation with uncontrolled hypertension during pregnancy. Given prior difficulties conceiving and lack of discussions surrounding pregnancy risks, preconception counseling had not been done. She was taking carvedilol, spironolactone, and furosemide at pregnancy diagnosis. Given unclear safety profile in pregnancy, her spironolactone was discontinued. Her regimen was uptitrated to nifedipine 90 mmHg, carvedilol 50mg BID, hydralazine 50mg TID and furosemide 80mg BID. At 18 weeks gestation, she was readmitted with severe range hypertension and fluid overload unresponsive to escalating diuretic dosing. Due to poor urine output and creatinine to 5.5 mg/dl, she was initiated on dialysis. Her fetus was diagnosed with severe intrauterine growth restriction (IUGR) and umbilical doppler noted reversal of umbilical artery end-diastolic flow indicating severely elevated arterial resistance (Figure). During admission, she developed resistant hypertension requiring nicardipine and esmolol drips and severe headache, concerning for superimposed preeclampsia (SIPE). At 25 weeks gestation, she was taken for urgent c-section. Given extreme prematurity and growth restriction, her newborn baby passed away shortly after delivery. Discussion: This case highlights complications which arise from PA and antepartum persistent hypertension including progression of kidney disease, heart failure, IUGR, SIPE, and preterm delivery. It further highlights unique challenges using targeted therapies of mineralocorticoid receptor antagonists in PA in pregnancy. This information is crucial as PA is an increasingly recognized cause of resistant hypertension in young adults. Both PA and preeclampsia involve pathophysiologic mechanisms in the RAAS pathway and deserve further attention and research.

scholarly journals Aldosterone- and cortisol-cosecreting adrenal adenoma, ovarian hyperthecosis and breast cancer

2020 ◽  
Vol 2020 ◽  
Author(s):  
John J Orrego ◽  
Joseph A Chorny
Keyword(s):  
Breast Cancer ◽  
Estrogen Receptor ◽  
Primary Aldosteronism ◽  
Adrenal Adenoma ◽  
Elevated Serum ◽  
Clinical Manifestations ◽  
List Type ◽  
Unilateral Adrenalectomy ◽  
Estrogen Receptor Positive ◽  
Positive Breast Cancer

Summary We describe a 56-year-old postmenopausal woman with hypertension, hypokalemia and severe alopecia who was found to have a 4.5-cm lipid-poor left adrenal mass on CT scan performed to evaluate her chronic right-sided abdominal pain. Hormonal studies revealed unequivocal evidence of primary aldosteronism and subclinical hypercortisolemia of adrenal origin. Although a laparoscopic left adrenalectomy rendered her normotensive, normokalemic and adrenal insufficient for 2.5 years, her alopecia did not improve and she later presented with facial hyperpigmentation acne, worsening hirsutism, clitoromegaly, and an estrogen receptor-positive breast cancer. Further testing demonstrated markedly elevated serum androstenedione and total and free testosterone and persistently undetectable DHEAS levels. As biochemical and radiologic studies ruled out primary adrenal malignancy and obvious ovarian neoplasms, a bilateral salpingo-oophorectomy was undertaken, which revealed bilateral ovarian hyperthecosis. This case highlights how the clinical manifestations associated with hyperaldosteronism and hypercortisolemia masqueraded the hyperandrogenic findings. It was only when her severe alopecia failed to improve after the resolution of hypercortisolism, hyperandrogenic manifestations worsened despite adrenal insufficiency and an estrogen receptor-positive breast cancer was found, did it becomes apparent that her symptoms were due to ovarian hyperthecosis. Learning points: As cortisol cosecretion appears to be highly prevalent in patients with primary aldosteronism, the term ‘Connshing’ syndrome has been suggested. The associated subclinical hypercortisolemia could be the driver for the increased metabolic alterations seen in patients with Conn syndrome. The identification of these dual secretors before adrenal venous sampling could alert the clinician about possible equivocal test results. The identification of these dual secretors before unilateral adrenalectomy could avoid unexpected postoperative adrenal crises. Hyperfunctioning adrenal and ovarian lesions can coexist, and the clinical manifestations associated with hypercortisolemia can masquerade the hyperandrogenic findings.

scholarly journals A Misleading Presentation of Pheochromocytoma in Pregnancy: A Case Report

2021 ◽  
Author(s):  
Jasmina Begüm ◽  
Supriya Kumari ◽  
Manwar Ali ◽  
Saubhagya Kumar Jena ◽  
Kishore Behera ◽  
...  
Keyword(s):  
Multidisciplinary Approach ◽  
Anticonvulsant Drug ◽  
Secondary Hypertension ◽  
Uncontrolled Hypertension ◽  
Vanillylmandelic Acid ◽  
Diagnostic Challenge ◽  
Antihypertensive Medications ◽  
Emergency Cesarean ◽  
Secondary Causes ◽  
In Pregnancy

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.

scholarly journals The Biochemical Profile of Familial Hypocalciuric Hypercalcemia and Primary Hyperparathyroidism during Pregnancy and Lactation: Two Case Reports and Review of the Literature

2016 ◽  
Vol 2016 ◽  
pp. 1-6 ◽  
Author(s):  
S. A. Ghaznavi ◽  
N. M. A. Saad ◽  
L. E. Donovan
Keyword(s):  
Primary Hyperparathyroidism ◽  
Case Reports ◽  
Diagnostic Error ◽  
Calcium Handling ◽  
Familial Hypocalciuric Hypercalcemia ◽  
Second Trimester ◽  
Clearance Ratio ◽  
Fetal Complications ◽  
Pregnancy And Lactation ◽  
History Of

Background. Primary hyperparathyroidism (PHPT) and Familial Hypocalciuric Hypercalcemia (FHH) result in different maternal and fetal complications in pregnancy. Calcium to creatinine clearance ratio (CCCR) is commonly used to help distinguish these two conditions. Physiological changes in calcium handling during pregnancy and lactation can alter CCCR, making it a less useful tool to distinguish PHPT from FHH. Cases. A 25-year-old female presented with hypercalcemia and an inappropriately normal PTH. Her CCCR was 0.79% before pregnancy and rose to 1.99% in her second trimester. The proband’s mother and neonate had asymptomatic hypercalcemia. Genetic analysis revealed a CaSR mutation consistent with FHH. A 19-year-old female presented with a history of nephrolithiasis who underwent emergent caesarean section at 29 weeks of gestation for severe preeclampsia. At delivery, she was diagnosed with hypercalcemia with an inappropriately normal PTH and a CCCR of 2.67%, which fell to 0.88% during lactation. Parathyroidectomy cured her hypercalcemia. Pathology confirmed a parathyroid adenoma. Conclusion. These cases illustrate the influence of pregnancy and lactation on renal calcium indices, such as the CCCR. To avoid diagnostic error of women with hypercalcemia during pregnancy and lactation, calcium biochemistry of first-degree relatives and genetic testing of select patients are recommended.

scholarly journals “Relieving the Pressure” With Unilateral Adrenalectomy in a Case of Chronic Resistant Hypertension From Primary Aldosteronism

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A102-A103
Author(s):  
Danielle Brooks ◽  
Gustavo Fernandez-Ranvier ◽  
Carlos Rios ◽  
Nirali A Shah
Keyword(s):  
Blood Pressure ◽  
Resistant Hypertension ◽  
Primary Aldosteronism ◽  
Complete Resolution ◽  
Surgical Intervention ◽  
Uncontrolled Hypertension ◽  
Laboratory Evaluation ◽  
Plasma Aldosterone Concentration ◽  
Unilateral Adrenalectomy ◽  
Increased Risk

Abstract Introduction: Primary aldosteronism is an under-recognized cause of resistant hypertension that is associated with an increased risk of cardiovascular disease and mortality. While surgical intervention may not lead to complete resolution of hypertension, partial success (defined by reduction in blood pressure and/or medications) can be achieved and future cardiovascular risks can be minimized. We present a case of a patient with primary aldosteronism whose chronic resistant hypertension improved significantly after unilateral adrenalectomy. Clinical Case: A 54-year-old female with resistant hypertension for 17 years and hypokalemia was diagnosed with primary aldosteronism. The patient had uncontrolled hypertension despite atenolol 50 mg, nifedipine XL 60 mg, triamterene-hydrochlorothiazide 37.5-25 mg, lisinopril 40 mg daily. Laboratory evaluation was significant for plasma aldosterone concentration (PAC) 26.8 ng/dL (reference: 0.0–30.0 ng/dL), plasma renin activity (PRA) 0.168 ng/mL/hr (reference: 0.167–5.380 ng/mL/hr), PAC/PRA ratio 159.5, and potassium of 3.2 mmol/L (reference: 3.5–4.5mmol/L). Other workup showed plasma normetanephrines 128 pg/mL (reference: 0–145 pg/mL), metanephrines 25 pg/mL (reference: 0–62 pg/mL), and two normal midnight salivary cortisol tests. Saline infusion testing confirmed primary aldosteronism with a non-suppressed aldosterone level of 15.6 ng/dL (normal <5 ng/dL). Abdominal imaging revealed two low-density right adrenal nodules consistent with adenomas and thickening of the left adrenal gland. The patient underwent adrenal vein sampling (AVS) with cosyntropin stimulation, which showed lateralization to the right adrenal. Despite adding clonidine 0.1 mg three times daily, hydralazine 25 mg three times daily and spironolactone 100 mg daily (which substituted triamterene-hydrochlorothiazide) after AVS, her blood pressure remained uncontrolled with blood pressure ranging from 150–180/90–110 mmHg. A laparoscopic right adrenalectomy was performed. Pathology revealed two adrenal cortical adenomas. At the one-month post-operative visit, her potassium was normal, PAC was 4.3 ng/dL, and blood pressure improved on a reduced regimen of atenolol, lisinopril, and nifedipine. Conclusion: In patients with chronic uncontrolled hypertension due to primary aldosteronism, surgical intervention may not lead to complete resolution of hypertension but may lead to partial clinical success. Residual hypertension may be due to underlying vascular changes associated with long-term exposure to elevated aldosterone. The post-operative PAC in our case was less than 5 ng/dL suggesting biochemical cure and potentially reduced cardiovascular risk. This case emphasizes that adrenalectomy should be considered in resistant hypertension, even if complete clinical cure may not be attainable to reduce future cardiovascular events.

scholarly journals Surgical Treatment of “Large Uterine Masses” in Pregnancy: A Single-Center Experience

2021 ◽  
Vol 18 (22) ◽  
pp. 12139
Author(s):  
Anna Franca Cavaliere ◽  
Annalisa Vidiri ◽  
Salvatore Gueli Alletti ◽  
Anna Fagotti ◽  
Maria Concetta La Milia ◽  
...  
Keyword(s):  
Surgical Treatment ◽  
Uterine Fibroids ◽  
First Trimester ◽  
Second Trimester ◽  
Histologic Diagnosis ◽  
Single Center Experience ◽  
Fetal Complications ◽  
Benign Nature ◽  
The Masses ◽  
In Pregnancy

Uterine myomas or uterine fibroids are the most common benign uterine masses affecting women. The management of large myoma during pregnancy is challenging, and surgical treatment is a possible option. We report nine cases of pregnant women affected by uterine masses larger than 10 cm, who underwent surgical treatment during the second trimester of pregnancy. In all cases, the masses were preconceptionally unknown and diagnosed during the first trimester. In eight cases, no maternal and fetal complications arose during or after surgical treatment and delivery occurred at full term of pregnancy. In one case, spontaneous abortion was recorded. In all cases, histologic diagnosis demonstrated the benign nature. Women affected by large uterine masses diagnosed for the first time in pregnancy could be taken into consideration for surgical treatment in a referral center during the second trimester.

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