Acute endocrinopathies during pregnancy

A case of bilateral pheochromocytoma during pregnancy

Background

Pheochromocytoma is a disease where catecholamines are secreted. If pheochromocytoma occurs during pregnancy, it can be difficult to diagnose because it is similar to pregnancy-induced hypertension. Furthermore, bilateral pheochromocytoma during pregnancy is even rarer than unilateral pheochromocytoma.

Case presentation

A 32-year-old primigravida, who was 12 weeks’ pregnant, was aware of right abdominal discomfort. Masses in both adrenal glands were observed by abdominal ultrasonography. She was diagnosed with pheochromocytoma. Bilateral adrenalectomy was undertaken at 15 weeks’ gestation and she continued pregnancy. At 39 weeks’ gestation, a healthy male neonate was delivered. She was discharged on the 4th postpartum day.

Conclusions

We present a case of bilateral pheochromocytoma during pregnancy that was diagnosed in the first trimester. Differentiating pheochromocytoma from pregnancy-induced hypertension is important. Early diagnosis and appropriate blood pressure management with medical treatment followed by surgical removal of the tumor results in good maternal and fetal outcomes.

Management of paroxysmal hypertension due to incidental pheochromocytoma in pregnancy

A 25-year-old, full-term pregnant woman diagnosed with pre-eclampsia was referred to our tertiary care hospital with severe resistant hypertension. Her blood pressure remained labile despite the usual medications, which led to the suspicion of an underlying endocrinological problem. Further biochemical and radiological investigations confirmed the diagnosis of pheochromocytoma. The patient was invasively monitored and treated with alpha blockade, beta blocker, and vasodilators. The primary goals for the management of pheochromocytoma in pregnancy are early diagnosis, avoidance of a hypertensive crisis during delivery, and definitive surgical treatment. This case illustrates that one needs to be cautious when such a presentation of paroxysmal hypertension is present. With a multidisciplinary team approach, proper planning, and adequate preoperative medical management, pheochromocytoma in pregnancy can be managed successfully.

Hydrocortisone improves somnolence without hypotension in the postpartum period

Hypothalamic-pituitary-adrenal (HPA) axis abnormality and adrenal insufficiency secondary to chronic steroid treatment can be present in the perioperative period. When this occurs in pregnant patients during the peripartum period, the usually expected physiological changes may not be present. The hypotension associated with adrenal insufficiency may be masked by the normal physiological changes of pregnancy and delivery. We report on a patient whose only presenting symptom was mental status changes; this occurred without any significant hemodynamic changes. These mental status changes responded within minutes to a single dose of hydrocortisone. We recommend administering a pharmacological dose of steroid as a maneuver to rule out adrenal insufficiency when faced with a patient with an unexplained altered mental status while other differential diagnoses are considered.

Magnetic resonance imaging in sheehan's syndrome: case report and literature review of imaging studies

OBJECTIVE

To present the first documentation of pituitary atrophy on magnetic resonance imaging (MRI) in a patient with Sheehan's syndrome and review the published radiologic findings in this syndrome.

METHODS

We describe the clinical and laboratory findings in a young woman with Sheehan's syndrome, provide the MRI results, and discuss the previously published radiologic studies of this syndrome.

RESULTS

A 31-year-old woman, who was examined 11 months after severe postpartum hemorrhage, had clinical and biochemical findings consistent with Sheehan's syndrome (loss of axillary hair, amenorrhea, and impaired pituitary reserve for luteinizing hormone, follicle-stimulating hormone, thyrotropin, growth hormone, and corticotropin). MRI showed a partially empty sella in conjunction with invagination of the optic chiasm anteriorly into the pituitary fossa.

CONCLUSION

Because of its greater spatial resolution, higher signal-to-noise ratio, and potential for multiplanar images, MRI can provide more precise and detailed findings than other radiologic studies and can facilitate diagnosis of Sheehan's syndrome.

Bilateral pheochromocytoma during pregnancy

BACKGROUND

Pheochromocytoma is a rare disease of the chromaffin cells that secrete catecholamines. It may occur during pregnancy. Bilateral pheochromocytoma in pregnancy is even rarer.

CASE

A 26-year-old woman, gravida 2, para 0-0-1-0, 18 weeks' pregnancy, was initially seen with elevated blood pressure (170/100 mmHg) and mild headache. The cause of hypertension was conventionally investigated and bilateral pheochromocytoma was finally searched for and found. Bilateral adrenalectomy was undertaken at 23 weeks' gestation and Cesarean section was performed at 31 weeks' gestation due to intrauterine growth retardation (IUGR) and compromised fetal well-being. The maternal outcome was uneventful and the baby was physiologically complicated only by neonatal jaundice.

CONCLUSION

Pheochromocytoma should be searched for in the conventionally differential diagnosis in hypertension during pregnancy, especially in the young. Early diagnosis and proper management with medical treatment followed by surgical removal of the tumor usually result in good maternal and fetal outcomes.

Pheochromocytoma and pregnancy: a case report and review of anesthetic management

PURPOSE

To describe a patient diagnosed with pheochromocytoma in the third trimester of pregnancy and discuss the perioperative and anesthetic management.

CLINICAL FEATURES

A 32-yr-old previously healthy woman (gravida 4, para 2) presented to our tertiary care obstetrical hospital at 34 weeks five days gestation with a history of labile blood pressure and severe hypertension. A week prior to admission she began having episodes of severe headache, dizziness, sweating and nausea. On a routine obstetric visit she was noted to be severely hypertensive with a blood pressure of 200/120 mmHg. Biochemical investigations confirmed the diagnosis of pheochromocytoma and magnetic resonance imaging demonstrated a 3 cm x 3 cm right adrenal mass. The patient was invasively monitored in the intensive care unit and treated with alpha- followed by beta-blockade with phenoxybenzamine and metoprolol. A multidisciplinary conference was organized involving endocrinology, anesthesiology, general surgery and obstetrics to determine the most appropriate management of the patient. An uncomplicated laparoscopic adrenalectomy was performed following a period of recovery after an uneventful elective Cesarean delivery.

CONCLUSIONS

The primary goals in the management of pheochromocytoma in pregnancy are early diagnosis, avoidance of a hypertensive crisis during delivery and definitive surgical treatment. Timing of surgical resection will depend on the gestational age at which diagnosis is made. Cesarean section is the preferred mode of delivery when the tumour is still present. This case illustrates that with antenatal diagnosis, advanced methods of tumour localization, adequate preoperative adrenergic blockade and team planning, pheochromocytoma in pregnancy can be treated successfully.

Pheochromocytoma in a pregnant woman with multiple endocrine neoplasia type 2a

Pheochromocytoma is a rare cause of hypertension. Its coexistence with pregnancy is exceptional and laparoscopic removal has rarely been reported. We describe the case of a 34-year-old woman with multiple endocrine neoplasia type 2a (MEN 2a) with adrenal pheochromocytoma diagnosed in the 6th week of pregnancy. After pretreatment with phenoxybenzamine, a successful transperitoneal laparoscopic adrenalectomy was performed in the twentieth week of gestation. The management of pheochromocytoma in pregnancy and the indications for laparoscopic surgery in pregnant patients are discussed.

Recurrent post-partum pulmonary eosinophilia

In 1980 a 23 year old woman developed idiopathic eosinophilic pneumonia which was successfully treated with corticosteroids. She subsequently developed two identical relapses in the post-partum period.

Hyponatraemia and spontaneous hypoglycaemia

Images

Resolution of hyperthyroidism in a pregnant woman with toxic thyroid nodule by percutaneous ethanol injection

Overt hyperthyroidism was found in a 35-year-old pregnant woman at the 13th week of gestation who was referred to us for tachycardia, tremors, and weight loss. Clinical signs, symptoms, and laboratory findings led to the diagnosis of toxic thyroid nodule. She was treated with ultrasound guided percutaneous ethanol injection (PEI) and, after 2 weeks of treatment, the woman was completely euthyroid. These findings suggest that during pregnancy PEI appears to be a rapid and safe therapy for toxic nodular goiter and an effective alternative to the administration of antithyroid drugs.

Thyrotoxicosis in pregnancy presenting as pancytopenia

Delay in diagnosis of thyroid disease can result in morbidity and mortality. Thyroid disorders are not uncommon in the reproductive age group and therefore in pregnancy; recognition of both the common and the more unusual manifestations will optimize outcome.