Low or high doses of spironolactone for treatment of maternal Bartter's syndrome

"Exogenous" 5 Alpha Reductase Deficiency: A Case Report

Testosterone and dihydrotestosterone are significant drivers of male external genital development, and therefore teratogens that alter these hormone profiles have been hypothesized to cause aberrations in development. Here, we present the first case report of genitalia anomalies after prenatal exposure to spironolactone and dutasteride through 8-weeks of gestation. The patient was born with abnormal male external genitalia which was surgically managed. Long-term outcomes such as gender identity, sexual function, hormonal maturation through puberty, and fertility remain unknown. These numerous considerations necessitate multi-disciplinary management with close follow-up to address sexual, psychological, and anatomic concerns.

Adverse Effects of Mineralocorticoid Receptor Antagonist Administration

BACKGROUND

Mineralocorticoid receptor antagonists consist of a class of drugs with pleiotropic beneficial effects in several cardiovascular diseases. However, physicians frequently overlook their use due to the adverse effects of such agents.

OBJECTIVES

To determine the adverse effects of mineralocorticoid receptor antagonists and to suggest clinically meaningful options. We present data on the two most administered agents of this class: spironolactone and eplerenone.

METHOD

We conducted an in-depth review of the existing international literature to draft a mini review about the mineralocorticoid receptor antagonists-related side effects.

RESULT

Mineralocorticoid receptor antagonists are associated with increased risk of hyperkalemia and acute deterioration of renal function. Of note, these adverse effects are dose-dependent, more common during the initial period of treatment, and are usually reversed after the withdrawal of therapy. Sex-related adverse events are noted mainly in spironolactone while switching to eplerenone could attenuate those.

CONCLUSION

Mineralocorticoid receptor antagonists therapy is significantly limited due to their side effects. The development of novel non-steroidal mineralocorticoid receptor antagonists could substantially widen the use of such agents.

Evaluation and Management of Endocrine Hypertension During Pregnancy

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.

Adrenal disorders in pregnancy, labour and postpartum - an overview

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.

Primary aldosteronism and pregnancy

Hypertension (HT) is a complication of 8% of all pregnancies and 10% of HT cases are due to primary aldosteronism (PA). There is very little data on PA and pregnancy. Given the changes in the renin angiotensin system during pregnancy, the diagnosis of PA is difficult to establish during gestation. It may be suspected in hypertensive patients with hypokalemia. A comprehensive literature review identified reports covering 40 pregnancies in patients suffering from PA. Analysis of these cases shows them to be high-risk pregnancies leading to maternal and fetal complications. Pregnancy must be programmed, and if the patient has a unilateral form of PA, adrenalectomy should be performed prior to conception. It is customary to stop spironolactone prior to conception and introduce antihypertensive drugs that present no risk of teratogenicity. When conventional antihypertensive drugs used during pregnancy fail to control high blood pressure, diuretics, including potassium-sparing diuretics may be prescribed. Adrenalectomy can be considered during the second trimester of pregnancy exclusively in cases of refractory hypertension. A European retrospective study is currently underway to collect a larger number of cases.

Pregnancy and dermatologic therapy

Dermatologists should be familiar with medication safety in pregnancy to be able to prescribe safely and confidently to pregnant women or women who may become pregnant during the course of treatment for dermatologic conditions. Topical medications should be considered first-line therapy for pregnant women, but certain systemic medications are safe to use in pregnancy and may be prescribed if necessary. Dermatologic surgery may be performed during the second trimester of pregnancy with proper positioning, but elective procedures should be delayed until the postpartum period.

Effects of ACE inhibition during fetal development on cardiac microvasculature in adult spontaneously hypertensive rats

BACKGROUND

Early angiotensin-converting enzyme (ACE) inhibition is able to re-program spontaneously hypertensive rats (SHR) to express an attenuated form of disease in adulthood.

METHODS

Three groups of animals (n=5 each) were studied: Wistar male rats, SHR males, and SHR males obtained from dams treated with enalapril maleate (15 mg/kg/day) during gestation. Animals were sacrificed 180 days after birth, and hearts were removed for stereological quantification. Volume [Vv] (myocytes, cardiac interstitium and intramyocardial vessels), length [Lv] (intramyocardial vessels), surface [Sv] densities (myocyte and intramyocardial vessels), and the mean cross-sectional area [a] (myocyte) were estimated.

RESULTS

Blood pressure (BP) was lower in Wistar group, higher in SHR group, and intermediate in SHR-enalapril group (respectively: 122+/-8.4, 194+/-11.4, and 158+/-7.6 mm Hg, p<0.0001). Increased Vv (p=0.016), Lv (p<0.01), and Sv (p<0.01) of intramyocardial vessels were observed in SHR-enalapril group when compared to untreated SHR. A small but significant reduction was observed in a of myocytes (p=0.045).

CONCLUSION

Prenatal ACE inhibition resulted in partial hypertension attenuation as well as left ventricular hypertrophy (LVH). The positive impact on the vascular compartment came along with little or no difference in myocytes and interstitium, suggesting the involvement of a direct mechanism.

Maternal Bartter’s syndrome in pregnancy treated by amiloride

BACKGROUND

Bartter's syndrome is a rare condition during pregnancy. The prenatal management is difficult to maintain normal potassium serum levels.

CASE

We describe a 26-year-old woman with Bartter's syndrome. During pregnancy, she required increasing potassium and magnesium supplementations. Amiloride, a sparing potassium diuretic, was continued. She delivered an unaffected girl at term.

CONCLUSION

When Bartter's syndrome is associated with pregnancy, the management must be careful. Amiloride can be used to support potassium supplementation.

Bartter's syndrome and pregnancy

Bartter's syndrome is a rare renal tubular disorder and few cases are reported associated with pregnancy. We describe a case of long standing disease with a good obstetric outcome in which the main concern was to maintain normal potassium serum levels.