Pheochromocytoma in Pregnancy: When is Operative Intervention Indicated?

Thoracic epidural analgesia in a patient with von Hippel-Lindau disease

von Hippel-Lindau disease (VHLD) is an autosomal dominant disorder characterized by central nervous system hemangioblastomas and renal tumors. Here, we report a case of thoracic epidural placement in a 35-year-old woman with VHLD presenting for left open heminephrectomy for renal masses. We also reviewed the literature on this topic.

Paraganglioma in pregnancy: A case series and literature review

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.

Pheochromocytoma diagnosed during pregnancy: lessons learned from a series of ten patients

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.

Sudden onset of pheochromocytoma multisystem crisis at 38 weeks of gestation resulted in intrauterine fetal death: A case report

A 24-year-old woman at 38 weeks of gestation with no past medical history was transferred to our hospital because of acute onset of severe dyspnea. Her conscious level was E4V2M5 on the Glasgow Coma Scale and she displayed stress cardiomyopathy (Takotsubo cardiomyopathy) with multiple organ failure. Intrauterine fetal death was confirmed. After immediate application of intubated ventilation, percutaneous cardiopulmonary support and hemodialysis, she was diagnosed with pheochromocytoma multisystem crisis. After multidisciplinary team discussion, surgical resection of the left pheochromocytoma was performed on the same day. However, the bleeding from retroperitoneal drainage did not decrease, therefore, on the fourth day of hospitalization, embolization of the left renal artery under angiography was performed. A 2774 g female infant was stillborn spontaneously on the seventh day of hospitalization. Percutaneous cardiopulmonary support was discontinued on the fifth day of hospitalization and the tracheal tube was extubated on the 11th day. The patient was discharged after 30 days.

Pheochromocytoma after Cesarean Section

Pheochromocytoma is a catecholamine-producing tumor. There are a very few reported cases of clinical pheochromocytoma. Here, we report a 27-year-old woman para 1 live 1 with chief complaint of headache, confusion, nausea, and vomiting 2 days after cesarean section. She was anxious and had palpitation. On physical examination, fever, tachycardia, tachypnea, high blood pressure, and right thyroid nodule were found. She was managed as pregnancy-induced hypertension at first. In laboratory data, epinephrine, norepinephrine, metanephrine, normetanephrine, and vanillylmandelic acid were increased in 24 h urine collection. An adrenal mass was detected in abdominal computed tomography. Regarding clinical and paraclinical findings, pheochromocytoma was diagnosed. The patient received medical treatment, but it was not effective; hence, she underwent adrenalectomy.

[PHEOCHROMOCYTOMA DURING PREGNANCY-2 CASE REPORTS]

(Introduction) A pheochromocytoma diagnosed during pregnancy is rare, and also its fetal and maternal mortality is high if undiagnosed. We report two cases with successful pregnancy outcome with pheochromocytoma. (Case 1) A 31-years-old previously healthy woman presented at 19 week period of gestation with high blood pressure. High urine catecholamine level and a left adrenal mass recognized by magnetic resonance imaging (MRI) confirmed adrenal pheochromocytoma. The patient had good blood pressure control after we started doxazosin 4 mg daily, and Caesarean section was performed at 35 week period of gestation. Two months after delivery, laparoscopic adrenalectomy was performed and she was discharged in the absence of hypertension. (Case 2) A 31-years-old previously healthy woman presented at 29 week period of gestation with exacerbation of headache and palpitation. High urine catecholamine level and a mass recognized close to the inferior vena cava by MRI confirmed extraadrenal pheochromocytoma. The patient had good blood pressure after we started doxazosin 4 mg daily and labetalol hydrochloride 200 mg daily. Caesarean section was performed at 35 week period of gestation. One month after delivery, laparotomic resection of the tumor was performed. Seven years later, hypertension reoccurred and there was an extraadrenal pheochromocytoma recurrence. We had a laparotomic resection for the recurrent tumor, and now she is in the absence of hypertension. (Conclusion) Pheochromocytoma should be considered as a differential diagnosis in a case of high blood pressure occurred during pregnancy. Early detection and appropriate treatment is crucial to reduce fetal and maternal mortality.

Vaginal delivery in a patient with pheochromocytoma, medullary thyroid cancer, and primary hyperparathyroidism (multiple endocrine neoplasia type 2A, Sipple's syndrome)

Multiple endocrine neoplasia 2A (MEN 2A), or Sipple's syndrome is a rare inherited dominant syndrome, characterised by medullary thyroid carcinoma, adrenal pheochromocytoma and hyperparathyroidism, due to specific RET proto-oncogene mutations. The women with MEN 2A syndrome are at risk of complicated pregnancy because of unrecognised pheochromocytoma and transmission of RET mutation to the progeny. We report a case of a woman with MEN 2A diagnosed in early pregnancy. Alpha-blockade medical therapy was used effectively and time was given for fetal maturation. Uncomplicated vaginal delivery performed under epidural analgesia. Six weeks postpartum adrenalectomy, thyroidectomy and parathyroidectomy were performed uneventfully.

Systematic review of phaeochromocytoma in pregnancy

Background

Phaeochromocytoma in pregnancy is a rare and potentially dangerous situation for mother and fetus. This review aimed to assess current mortality rates and how medical and surgical management affect these.

Methods

Articles in English published between 2000 and 2011 were obtained from a MEDLINE search. Eligible publications presented women diagnosed with phaeochromocytoma in the antenatal or immediate postnatal period, and reported management and outcomes.

Results

A total of 135 reports were identified. After applying inclusion criteria, 77 pregnancies involving 78 fetuses were analysed. Fetal and maternal mortality rates were 17 per cent (13 of 78) and 8 per cent (6 of 77) respectively. Better outcomes were achieved when the diagnosis of phaeochromocytoma was made in the antenatal period than when it was made during labour or immediately postpartum (survival of both mother and fetus(es) in 48 of 56 versus 12 of 21 respectively; P = 0·012). When the diagnosis was made before 23 weeks' gestation, there was no difference in outcomes when phaeochromocytoma surgery was carried out in the second trimester, compared with when it was postponed to the third trimester or after delivery (fetal death 2 of 18 versus 2 of 8 respectively; P = 0·563).

Conclusion

This review, although limited by the rarity of the condition and level of available evidence, demonstrated that survival rates are improved if the diagnosis of phaeochromocytoma can be established antenatally. With diagnosis before 23 weeks' gestation, no definite advantage of proceeding with tumour removal during the second trimester could be demonstrated.

Adrenal disorders in pregnancy

Adrenal disorders may manifest during pregnancy de novo, or before pregnancy undiagnosed or diagnosed and treated. Adrenal disorders may present as hormonal hypofunction or hyperfunction, or with mass effects or other nonendocrine effects. Pregnancy presents special problems in the evaluation of the hypothalamic-pituitary-adrenal axis in addition to the usual considerations. The renin-angiotensin-aldosterone axis undergoes major changes during pregnancy. Nevertheless, the common adrenal disorders are associated with morbidity during pregnancy and their management is more complicated. A high index of suspicion must be maintained for these disorders lest they go unrecognized and untreated.

Endocrine oncology in pregnancy

Endocrine tumours occur rarely in pregnant women but present clinicians with unique challenges. A high index of suspicion is often required to make a diagnosis since the symptoms and signs associated with many of these tumours, including insulinoma, adrenocortical carcinoma and phaeochromocytoma, mimic those of normal pregnancy or its complications, such as pre-eclampsia. The evidence base which informs management is very limited hence decisions on investigation and therapy must be individualised and undertaken jointly by the multidisciplinary medical team and the patient. The optimal strategy will depend on the nature and stage of the endocrine tumour, gestational stage, treatments available and patient wishes. Thus, surgical intervention, appropriately timed, may be considered in pregnancy for resectable adrenocortical carcinoma or phaeochromocytoma, but delayed until the postpartum period for well-differentiated thyroid cancer. Medical therapy may be required to reduce the drive to tumour growth, control symptoms of hormone excess and to minimise the risks of surgery, anaesthesia or labour.

Medical management of pheochromocytoma: Role of the endocrinologist

Pheochromocytoma is a rare tumor arising from chromaffin cells in adrenal medulla or other paraganglia in the body, which may be associated with many genetic syndromes and mutation. The role of endocrinologist is in biochemical diagnosis of suspected cases; its anatomic and functional localization with the help of imaging like CT, MRI, and nuclear scanning; preoperative control of hypertension; and postoperative follow-up of cases that have undergone surgical resection. Familial and genetic screening of cases and their family is important to detect occult cases. Endocrinologist will also play a role in cases with malignant pheochromocytoma in assessment of metastasis, control, chemoradiotherapy, and follow-up.

Phaeochromocytoma in pregnancy: timing of surgery, mode of delivery and magnesium

Phaeochromocytoma in pregnancy is rare. It is associated with high rates of fetal and maternal mortality especially in undiagnosed cases. There are no reliable data comparing outcomes regarding the timing of removal of tumour, or comparing outcomes between vaginal and caesarean delivery. Management should be individualized based upon consultation between the mother, obstetrician, anaesthetist, surgeon and physician. Magnesium infusion should be considered peripartum and/or at the timing of tumour resection.

Pheochromocytoma and pregnancy: a rare but dangerous combination

OBJECTIVE

To review the literature on pheochromocytoma in pregnancy (PIP) published during the 11-year period 1998 through 2008.

METHODS

We searched MEDLINE data sources from 1998 through 2008 using the search terms "pheochromocytoma" and "pregnancy" and reviewed case reports of PIP published in English.

RESULTS

We identified 54 case reports in MEDLINE data sources, of which 51 reports including 60 cases were reviewed. In comparison with the previous decade, a decreased rate of antenatal diagnosis (from 83% to 70%) and increased maternal and fetal mortality (from 4% to 12% and from 10% to 17%, respectively) were observed. Prematurity was present in 53% of the infants of mothers with antenatally diagnosed pheochromocytoma who gave birth to a live infant. Hypertension was the most common manifestation (88%), with 33% of patients having antepartum hypertensive crises. Urinary catecholamines (64%) and metanephrines (40%) were the most commonly used tests, whereas urinary and plasma metanephrines were the most sensitive tests (100%). Ultrasonography had poor sensitivity (54%), especially during the third trimester. Magnetic resonance imaging was 100% sensitive for adrenal tumors but had only 50% sensitivity for extra-adrenal tumors. A syndromic or familial presentation was seen in 18% of patients, and 32% of patients had bilateral or extra-adrenal tumors.

CONCLUSION

In comparison with the previous decade, a decreased rate of antenatal diagnosis and increased maternal and fetal mortality were observed. Prematurity was a major morbidity associated with PIP. Hypertensive crises were more common during pregnancy. Urinary and plasma metanephrines had the highest sensitivity to detect PIP. Genetic screening should be offered to all pregnant women with pheochromocytoma.