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Miyazaki H, Miura D, Koguchi Y, Takamatsu C, Sakaguchi Y. Intraoperative Serum Catecholamine Levels in a Pregnant Woman With Pheochromocytoma Undergoing Cesarean Delivery With Combined Spinal-Epidural Anesthesia: A Case Report. Cureus 2022; 14:e24727. [PMID: 35673320 PMCID: PMC9165681 DOI: 10.7759/cureus.24727] [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] [Accepted: 05/03/2022] [Indexed: 11/30/2022] Open
Abstract
Pheochromocytoma has a significant effect on perioperative hemodynamics; however, little is known about the changes caused by pheochromocytoma in pregnant women during cesarean delivery. Moreover, cesarean delivery in pregnant women with pheochromocytoma is often performed, along with pheochromocytoma removal, under general anesthesia depending on the time of delivery. Therefore, changes in the hemodynamics of these patients during cesarean delivery under spinal anesthesia combined with epidural anesthesia, along with their serum catecholamine concentration, have not been reported. In this report, we describe the changes in the maternal intraoperative hemodynamics and serum catecholamine level of a pregnant woman with pheochromocytoma who underwent cesarean delivery under combined spinal-epidural anesthesia at 35 weeks of gestation. No significant change in the hemodynamics and serum catecholamine level was observed, and the procedure was carried out safely. Cesarean delivery in an optimized pheochromocytoma patient under combined spinal-epidural anesthesia might be feasible without concurrent surgical removal of pheochromocytoma.
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2
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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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3
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Mohamed RS, Antonypillai CN, Mahendran H. Paraganglioma presenting as hypertension during pregnancy, proteinuria, thrombocytosis, and diabetes mellitus: a case report. J Med Case Rep 2021; 15:352. [PMID: 34238353 PMCID: PMC8268307 DOI: 10.1186/s13256-021-02923-1] [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: 05/22/2019] [Accepted: 05/23/2021] [Indexed: 11/10/2022] Open
Abstract
Background Paraganglioma is a very rare cause of pregnancy-induced hypertension. The objective of this case report is to present a case of paraganglioma presented during pregnancy and missed. Later, the diagnosis was made during the postpartum period because of persistence of hypertension. Case presentation Here, we describe the case of a patient with paraganglioma who initially presented with pregnancy-induced hypertension and gestational diabetes mellitus. She had persistence of hypertension and diabetes mellitus following delivery with proteinuria, thrombocytosis, and spells. Once her pelvic paraganglioma was removed, her blood pressure and blood sugar were normal without antihypertensives or hypoglycemic agents, respectively. Her proteinuria settled with near-normal platelet counts. Conclusion Although neuroendocrine tumors are a rare cause of pregnancy-induced hypertension, it should be suspected in the appropriate clinical setting. Diabetes mellitus, proteinuria, and thrombocytosis can be a clinical feature in paraganglioma.
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Affiliation(s)
- Ramjan Sanas Mohamed
- Department of Diabetes and Endocrinology, Teaching Hospital Kandy, 379/3, Waragashinna, Akurana, Kandy, Sri Lanka.
| | | | - Harishanthi Mahendran
- Department of Diabetes and Endocrinology, Teaching Hospital Kandy, 379/3, Waragashinna, Akurana, Kandy, Sri Lanka
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Abstract
Pheochromocytomas are rare tumors originating in the adrenal medulla. They may be sporadic or in the context of a hereditary syndrome. A considerable number of pheochromocytomas carry germline or somatic gene mutations, which are inherited in the autosomal dominant way. All patients should undergo genetic testing. Symptoms are due to catecholamines over production or to a mass effect. Diagnosis is confirmed by raised plasma or urine metanephrines or normetanephrines. Radiology assists in the tumor location and any local invasion or metastasis. All the patients should have preoperative preparation with α-blockers and/or other medications to control hypertension, arrhythmia, and volume expansion. Surgery is the definitive treatment. Follow up should be life-long.
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Abstract
Hypertension is a common and morbid complication of pregnancy. While endocrine causes of secondary hypertension are not rare, women with these conditions do not often conceive, and even less commonly are these disorders diagnosed during pregnancy. This review will consider conditions of adrenal hormone excess that cause secondary hypertension: primary aldosteronism (PA), Cushing syndrome (CS), and pheochromocytoma/paraganglioma. We emphasize that pregnancy itself elicits changes in the regulation of aldosterone and cortisol production and standard endocrine testing algorithms. Furthermore, conventional imaging modalities and pharmacotherapies are often contraindicated in pregnancy, which complicates diagnosis and management. Nevertheless, surgical management in the second trimester is the preferred treatment strategy for most of these rare cases when feasible. This article will discuss the approach to patients with endocrine causes of hypertension during pregnancy with emphasis on those aspects that deviate from the assessment and treatment of non-pregnant patients.
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Affiliation(s)
- Alison H Affinati
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Department of Pharmacology, University of Michigan, Ann Arbor, MI, USA
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6
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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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7
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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: 28] [Impact Index Per Article: 5.6] [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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8
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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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9
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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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10
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Golshevsky JR, Karel K, Teale G. Phaeochromocytoma Causing Acute Pulmonary Oedema during Emergency Caesarean Section. Anaesth Intensive Care 2019; 35:423-7. [PMID: 17591141 DOI: 10.1177/0310057x0703500319] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We report a case of severe acute pulmonary oedema following induction of general anaesthesia for emergency caesarean section. After several hours of aggressive resuscitation, both mother and child had a favourable outcome. Postoperative investigation of acute renal failure demonstrated a supra-adrenal mass. Further investigation confirmed bilateral phaeochromocytoma as the cause of her condition. A literature review confirmed this to be a rare but important clinical entity, owing to its high mortality. Antenatal diagnosis greatly improves survival. Magnesium sulphate appears to be a useful and safe agent to employ in cases of undiagnosed hypertensive obstetric emergencies.
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Affiliation(s)
- J R Golshevsky
- Department ofAnaesthesia, Goulbum Valley Health, Shepparton, Victoria, Australia.
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11
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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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12
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Ghalandarpoor-Attar SN, Ghalandarpoor-Attar SM, Borna S, Ghotbizadeh F. A rare presentation of pheochromocytoma in pregnancy: a case report. J Med Case Rep 2018; 12:37. [PMID: 29422092 PMCID: PMC5806440 DOI: 10.1186/s13256-017-1549-z] [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: 06/23/2017] [Accepted: 12/21/2017] [Indexed: 12/27/2022] Open
Abstract
Background Early diagnosis of pheochromocytoma and its proper management can lessen its mortality and morbidity. This case report describes a 24-year-old pregnant woman with an unusual presentation of pheochromocytoma. Case presentation An Iranian 24-year-old primigravid woman from Kordistan province was referred to our center with left flank pain at 37 weeks of gestation. She had a history of gestational diabetes mellitus since the 12th week of gestation which was managed by insulin administration. She also had a history of pulsatile bi-temporal headache for 2 years prior to her referral to us. She underwent complete abdominal and pelvic ultrasound imaging for her flank pain. This examination revealed a heterogeneous mass of 119 × 87 × 79 mm above her left kidney, highly suspicious of being an adrenal-originating tumor. Subsequently, we consulted an endocrinologist. She underwent abdominopelvic magnetic resonance imaging and her 24-hour urine metanephrine, normetanephrine, and vanillylmandelic acid were assessed. Finally, the diagnosis of pheochromocytoma was confirmed. She underwent a cesarean section and adrenal mass excision at the 40th week of gestation. This timely diagnosis resulted in her proper management and good maternal and neonatal treatment outcomes. Conclusions Our patient had pheochromocytoma during pregnancy. She had no complaints about hypertension before or during pregnancy until giving birth to her child; her only symptoms were a vague left flank pain, gestational diabetes, and headaches for the past 2 years. The unusual symptom of flank pain led to timely diagnosis and a good treatment outcome.
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Affiliation(s)
- Seyedeh Noushin Ghalandarpoor-Attar
- Obstetrics and Gynecology Department, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran. .,Valiasr Hospital, Imam Khomeini Hospital Complex, East Baqerkhan st, Chamran Highway, Tehran, 1419733141, Iran.
| | | | - Sedigheh Borna
- Obstetrics and Gynecology Department, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fahimeh Ghotbizadeh
- Obstetrics and Gynecology Department, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Orioli L, Debiève F, Donckier J, Mourad M, Lois F, Maiter D. Pheochromocytoma during pregnancy: Case report and review of recent literature. ANNALES D'ENDOCRINOLOGIE 2017; 78:480-484. [PMID: 28870709 DOI: 10.1016/j.ando.2017.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 04/15/2017] [Accepted: 05/29/2017] [Indexed: 01/22/2023]
Affiliation(s)
- Laura Orioli
- Department of endocrinology and nutrition, Cliniques universitaires Saint-Luc, UCL, avenue Hippocrate, 10, 1200 Woluwé-Saint-Lambert, Belgium.
| | - Frederic Debiève
- Department of obstetrics, Cliniques universitaires Saint-Luc, UCL, avenue Hippocrate, 10, 1200 Woluwé-Saint-Lambert, Belgium.
| | - Julian Donckier
- Department of endocrinology and diabetology, CHU UCL Namur, UCL, rue Dr.-Gaston-Therasse, 1, 5530 Yvoir, Belgium.
| | - Michel Mourad
- Department of abdominal transplantation, endocrine, general and bariatric surgery, Cliniques universitaires Saint-Luc, UCL, avenue Hippocrate, 10, 1200 Woluwé-Saint-Lambert, Belgium.
| | - Fernande Lois
- Department of anaesthesiology, Cliniques universitaires Saint-Luc, UCL, avenue Hippocrate, 10, 1200 Woluwé-Saint-Lambert, Belgium.
| | - Dominique Maiter
- Department of endocrinology and nutrition, Cliniques universitaires Saint-Luc, UCL, avenue Hippocrate, 10, 1200 Woluwé-Saint-Lambert, Belgium.
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van der Weerd K, van Noord C, Loeve M, Knapen MFCM, Visser W, de Herder WW, Franssen G, van der Marel CD, Feelders RA. ENDOCRINOLOGY IN PREGNANCY: Pheochromocytoma in pregnancy: case series and review of literature. Eur J Endocrinol 2017; 177:R49-R58. [PMID: 28381449 DOI: 10.1530/eje-16-0920] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 03/29/2017] [Accepted: 04/05/2017] [Indexed: 11/08/2022]
Abstract
Pheochromocytoma in pregnancy is extremely rare. Early recognition is crucial as antepartum diagnosis can largely decrease maternal and fetal mortality rates. As symptoms of pheochromocytoma are rather similar to those of other far more common causes of hypertension during pregnancy, timely diagnosis is a challenge. In pregnant patients, similar to non-pregnant patients, increased plasma and/or 24-h urine (nor)metanephrine concentrations most reliably confirm the diagnosis of pheochromocytoma. MRI and ultrasound are the only imaging modalities that can be used safely during pregnancy to localize the tumor. During pregnancy, pretreatment consists of alpha blockade as usual. However, dosing of α-adrenergic receptor blockers during pregnancy is a challenge as hypertension must be treated while preserving adequate uteroplacental circulation. When the diagnosis is made within the first 24 weeks of pregnancy, it is generally recommended to remove the tumor in the second trimester, while resection is generally postponed till after delivery when the diagnosis is made in the third trimester and medical pretreatment is sufficient. Both during and after pregnancy, laparoscopic surgery is the preferred approach for resection of the tumor. There is no consensus in literature about the preferred route and timing of delivery. Therefore, in our opinion, decisions should be made on an individual basis by an experienced and dedicated multidisciplinary team. Over the last decades, maternal and fetal prognosis has improved considerably. Further increasing awareness of this rare diagnosis and treatment of these patients by a dedicated team in a tertiary referral hospital are critical factors for optimal maternal and fetal outcome.
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Affiliation(s)
- K van der Weerd
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - C van Noord
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Internal Medicine, Maasstad Hospital, Rotterdam, The Netherlands
| | - M Loeve
- Department of Anesthesiology, Unit of Obstetric Anesthesiology
| | - M F C M Knapen
- Division of Obstetrics and Prenatal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Foundation Prenatal Screening Southwest Region of the Netherlands, Rotterdam, The Netherlands
| | - W Visser
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Division of Obstetrics and Prenatal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - W W de Herder
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - G Franssen
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - R A Feelders
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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15
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Remón-Ruiz P, Aliaga-Verdugo A, Guerrero-Vázquez R. Pheochromocytoma in neurofibromatosis type 1 during pregnancy. Gynecol Endocrinol 2017; 33:93-95. [PMID: 27908211 DOI: 10.1080/09513590.2016.1254181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Pregnant women with neurofibromatosis type 1 (NF-1) have increased complications during gestation, including hypertensive disorders that are sometimes caused by pheochromocytoma. Pheochromocytoma is an extremely rare condition during pregnancy, and the main clinical manifestation is hypertension. If not properly treated, pheochromocytoma has high maternal and fetal mortality rates. Early recognition and adequate clinical management before delivery have led to better outcomes in the last few decades. Despite the association of NF-1 and pheochromocytoma, there are few clinical reports of these two conditions in pregnant patients. We present a rare case of pheochromocytoma diagnosed during pregnancy in a patient with NF-1, and we describe the treatment and the obstetric and fetal outcomes. We also review other medical conditions related to NF-1 that complicated this patient's pregnancy.
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Affiliation(s)
- Pablo Remón-Ruiz
- a Department of Endocrinology and Nutrition , Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla , Seville , Spain
| | - Alberto Aliaga-Verdugo
- a Department of Endocrinology and Nutrition , Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla , Seville , Spain
| | - Raquel Guerrero-Vázquez
- a Department of Endocrinology and Nutrition , Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla , Seville , Spain
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16
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17
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Ramakrishna H. Pheochromocytoma resection: Current concepts in anesthetic management. J Anaesthesiol Clin Pharmacol 2015; 31:317-23. [PMID: 26330708 PMCID: PMC4541176 DOI: 10.4103/0970-9185.161665] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Pheochromocytoma represents very significant challenges to the anesthetist, especially when undiagnosed. These chromaffin tissue tumors are not uncommon in anesthetic practice and have varied manifestations. The perioperative management of these tumors has improved remarkably over the years, in conjunction with the evolution of surgical techniques (open laparotomy to laparoscopic techniques and now to robotic approaches in the present day). This review attempts to comprehensively address the intraoperative and postoperative issues in the management of these challenging tumors with an emphasis on hemodynamic monitoring and anesthetic technique.
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Affiliation(s)
- Harish Ramakrishna
- Department of Anesthesiology, Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
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18
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WITHDRAWN: Healthy pregnancy outcome with aggressive emergency management of neuroendocrine tumor in early pregnancy. Am J Emerg Med 2014. [DOI: 10.1016/j.ajem.2014.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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19
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Dong D, Li H. Diagnosis and treatment of pheochromocytoma during pregnancy. J Matern Fetal Neonatal Med 2014; 27:1930-4. [DOI: 10.3109/14767058.2014.880883] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
A pheochromocytoma in a pregnant patient is one of the most threatening medical conditions for mother, fetus, and physician. Although extraordinarily rare with a frequency of 0.002% of all pregnancies, this tumor is notorious for its devastating consequences. As in non-pregnant patients, the signs and symptoms are quite variable but not specific, with hypertension being one of the most prominent signs. Confusion with the much more prevalent forms of pregnancy-related hypertension is the main cause of overlooking the diagnosis. If undiagnosed, maternal and fetal mortality is around 50%. Conversely, early detection and proper treatment during pregnancy decrease the maternal and fetal mortality to <5 and 15% respectively. For the biochemical diagnosis, plasma or urinary metanephrines are the tests of first choice since they have a nearly maximal negative predictive value. For reliable localization, only magnetic resonance imaging is suitable, with a sensitivity of more than 90%. When the tumor is diagnosed in the first 24 weeks of gestation, it should be removed by laparoscopic adrenalectomy after 10-14 days of medical preparation with the same drugs as in non-pregnant patients. If the tumor is diagnosed in the third trimester, the patient should be managed until the fetus is viable using the same drug regimen as for regular surgical preparation. Cesarean section with tumor removal in the same session or at a later stage is then preferred since vaginal delivery is possibly associated with higher mortality. Despite all technical diagnostic and therapeutic progress over the last decades, the key factor for further reduction of maternal and fetal mortality is early awareness and recognition of the potential presence of a pheochromocytoma in a pregnant patient with hypertension.
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Affiliation(s)
- Jacques W M Lenders
- Division of General Internal Medicine, Department of Medicine, Radboud Adrenal Centre, St Radboud University Nijmegen Medical Centre, PO Box 9101, 6500HB Nijmegen, The Netherlands.
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21
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Därr R, Lenders JWM, Hofbauer LC, Naumann B, Bornstein SR, Eisenhofer G. Pheochromocytoma - update on disease management. Ther Adv Endocrinol Metab 2012; 3:11-26. [PMID: 23148191 PMCID: PMC3474647 DOI: 10.1177/2042018812437356] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Pheochromocytomas are rare endocrine tumors that can present insidiously and remain undiagnosed until death or onset of clear manifestations of catecholamine excess. They are often referred to as one of the 'great mimics' in medicine. These tumors can no longer be regarded as a uniform disease entity, but rather as a highly heterogeneous group of chromaffin cell neoplasms with different ages of onset, secretory profiles, locations, and potential for malignancy according to underlying genetic mutations. These aspects all have to be considered when the tumor is encountered, thereby enabling optimal management for the patient. Referral to a center of specialized expertise for the disease should be considered wherever possible. This is not only important for surgical management of patients, but also for post-surgical follow up and screening of disease in patients with a hereditary predisposition to the tumor. While preoperative management has changed little over the last 20 years, surgical procedures have evolved so that laparoscopic resection is the standard of care and partial adrenalectomy should be considered in all patients with a hereditary condition. Follow-up testing is essential and should be recommended and ensured on a yearly basis. Managing such patients must now also take into account possible underlying mutations and the appropriate selection of genes for testing according to disease presentation. Patients and family members with identified mutations then require an individualized approach to management. This includes consideration of distinct patterns of biochemical test results during screening and the appropriate choice of imaging studies for tumor localization according to the mutation and associated differences in predisposition to adrenal, extra-adrenal and metastatic disease.
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22
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Abstract
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.
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Affiliation(s)
- A Lansdown
- Centre for Endocrine and Diabetes Sciences, School of Medicine, Cardiff University, UK.
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23
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Lata I, Sahu S. Management of paroxysmal hypertension due to incidental pheochromocytoma in pregnancy. J Emerg Trauma Shock 2011; 4:415-7. [PMID: 21887038 PMCID: PMC3162717 DOI: 10.4103/0974-2700.83876] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Accepted: 11/30/2010] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Indu Lata
- Department of Maternal and Reproductive Health, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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24
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Gainder S, Raveendran A, Bagga R, Saha SC, Dhaliwal LK, Bhansali AK. Phaeochromocytoma in pregnancy can mimic severe hypertensive disorders. J OBSTET GYNAECOL 2011; 31:539-41. [DOI: 10.3109/01443615.2011.587909] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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25
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Sarathi V, Bandgar TR, Menon PS, Shah NS. Pheochromocytoma and medullary thyroid carcinoma in a pregnant multiple endocrine neoplasia-2A patient. Gynecol Endocrinol 2011; 27:533-5. [PMID: 20672905 DOI: 10.3109/09513590.2010.507285] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE We describe a rare combination of pheochromocytoma and medullary thyroid carcinoma (MTC) during pregnancy. METHODS Twenty-three-years old lady, primigravida, was detected to be hypertensive at 12 weeks of gestation and was found to have left adrenal mass on routine obstetric scan. She had a goitre on examination which was proven to be MTC on fine needle aspiration cytology. Twenty-four hours urinary vanillyl mandelic acid and serum calcitonin levels were elevated. After adequate α and β blockade she underwent left adrenalectomy during second trimester of gestation with no significant perioperative complications. Twelve days later she underwent total thyroidectomy. RESULTS Adrenal mass was confirmed to be pheochromocytoma while MTC was confirmed in the thyroidectomy specimen. Post-operatively, she was normotensive and delivered a healthy female baby at term. Both mother and the baby tested positive for germline RET mutation (C634W) in exon 11. CONCLUSION We describe a rare case of pregnant multiple endocrine neoplasia-2A patient with pheochromocytoma and MTC.
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MESH Headings
- Adrenal Gland Neoplasms/diagnosis
- Adrenal Gland Neoplasms/genetics
- Adrenal Gland Neoplasms/physiopathology
- Adrenal Gland Neoplasms/surgery
- Adult
- Amino Acid Substitution
- Carcinoma, Medullary/diagnosis
- Carcinoma, Medullary/genetics
- Carcinoma, Medullary/physiopathology
- Carcinoma, Medullary/surgery
- Carcinoma, Neuroendocrine
- Female
- Humans
- Hypertension, Pregnancy-Induced/etiology
- Live Birth
- Multiple Endocrine Neoplasia Type 2a/diagnosis
- Multiple Endocrine Neoplasia Type 2a/genetics
- Multiple Endocrine Neoplasia Type 2a/physiopathology
- Multiple Endocrine Neoplasia Type 2a/surgery
- Mutation
- Pheochromocytoma/diagnosis
- Pheochromocytoma/genetics
- Pheochromocytoma/physiopathology
- Pheochromocytoma/surgery
- Pregnancy
- Pregnancy Complications, Neoplastic/diagnosis
- Pregnancy Complications, Neoplastic/genetics
- Pregnancy Complications, Neoplastic/physiopathology
- Pregnancy Complications, Neoplastic/surgery
- Pregnancy Trimester, First
- Proto-Oncogene Proteins c-ret/genetics
- Thyroid Neoplasms/diagnosis
- Thyroid Neoplasms/genetics
- Thyroid Neoplasms/physiopathology
- Thyroid Neoplasms/surgery
- Young Adult
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Affiliation(s)
- Vijaya Sarathi
- Department of Endocrinology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India.
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26
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Sarathi V, Lila AR, Bandgar TR, Menon PS, Shah NS. Pheochromocytoma and pregnancy: a rare but dangerous combination. Endocr Pract 2010; 16:300-9. [PMID: 20061281 DOI: 10.4158/ep09191.ra] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Vijaya Sarathi
- Department of Endocrinology, Seth Gordhandas Sunderdas Medical College & King Edward Memorial Hospital, Mumbai, Maharashtra, India
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27
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Thomas AA, Thomas AZ, Campbell SC, Palmer JS. Urologic emergencies in pregnancy. Urology 2010; 76:453-60. [PMID: 20451969 DOI: 10.1016/j.urology.2010.01.047] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2009] [Revised: 01/17/2010] [Accepted: 01/19/2010] [Indexed: 11/26/2022]
Abstract
The management of urological emergencies during pregnancy presents unique clinical challenges for the treating physician. Clinical signs and symptoms are often subtle while diagnostic and therapeutic options are limited in treating patients to avoid fetal morbidity. A high index of suspicion with early diagnosis and treatment are essential for the management of genitourologic emergencies in pregnant women. It is essential for patients to be managed on an individual basis using a multidisciplinary approach.
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Affiliation(s)
- Anil A Thomas
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
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28
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Bierlaire D, Péa D, Monnier F, Delbreil JP, Bessout L. Phéochromocytome et grossesse : prise en charge anesthésique, à propos de deux cas. ACTA ACUST UNITED AC 2009; 28:988-93. [DOI: 10.1016/j.annfar.2009.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2009] [Accepted: 08/20/2009] [Indexed: 10/20/2022]
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29
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Pregnancy and coma. HANDBOOK OF CLINICAL NEUROLOGY 2008. [PMID: 18631830 DOI: 10.1016/s0072-9752(07)01717-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register]
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30
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Junglee N, Harries S, Davies N, Scott-Coombes D, Scanlon M, Rees D. Pheochromocytoma in Pregnancy: When is Operative Intervention Indicated? J Womens Health (Larchmt) 2007; 16:1362-5. [DOI: 10.1089/jwh.2007.0382] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- N. Junglee
- Centre for Endocrine and Diabetes Sciences, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales
| | - S.E. Harries
- Department of Anaesthetics, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales
| | - N. Davies
- Department of Obstetrics and Gynaecology, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales
| | - D. Scott-Coombes
- Department of Surgery, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales
| | - M.F. Scanlon
- Centre for Endocrine and Diabetes Sciences, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XN, Wales
| | - D.A. Rees
- Centre for Endocrine and Diabetes Sciences, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XN, Wales
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31
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Abstract
Urologic tumors during pregnancy are rare. Presenting symptoms of malignancies may be mistaken as typical symptoms in pregnancy. Evaluation and treatment of tumors of the adrenal gland, kidney, ureter, bladder, and urethra are reviewed based upon stage and type of tumor and stage of pregnancy.
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Affiliation(s)
- Frances M Martin
- Division of Urology, Department of Surgery, University of Kentucky College of Medicine, University of Kentucky Chandler Medical Center, 800 Rose Street, Room MS-283, Lexington, KY 40536, USA
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32
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Abstract
Hypertension during pregnancy is a common problem, causing significant maternal and fetal morbidity and mortality. Pre-eclampsia is by far the most common cause, affecting 5-10% of primigravid women. Phaeochromocytoma is a rare endocrine tumour causing hypersecretion of noradrenaline, adrenaline and/or dopamine. It is extremely rare during pregnancy and may be misdiagnosed with potentially catastrophic consequences. Delayed diagnosis remains a significant source of maternal and fetal morbidity and mortality. Recognition is critical, as the majority of maternal deaths have occurred when the diagnosis has been overlooked. Diagnosis of phaeochromocytoma is achieved by detecting increased catecholamines and metabolites (metanephrine and normetanephrine) on 24-h urine collection, as these levels are unaffected by pregnancy or pre-eclampsia. Definitive treatment of phaeochromocytoma is surgical and the laparoscopic approach has been shown to be safe and is preferred for most phaeochromocytomas. Medical preparation and treatment of hypertension is essential for safe surgery. Timing of adrenalectomy is either during the second trimester or as a staged procedure after Caesarean section delivery.
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Affiliation(s)
- S Grodski
- Department of Surgey, St Vincent's Hospital, Melbourne, Victoria, Australia.
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33
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Moretti A, Minuto M, Berti P, Bernini GP, Mannelli M, Miccoli P. Unusual association of adrenal pheochromocytoma and para-aortic neurofibroma in pregnancy. J Endocrinol Invest 2006; 29:738-41. [PMID: 17033264 DOI: 10.1007/bf03344185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The association of pheochromocytoma (PHEO) and pregnancy is uncommon and life threatening for both the fetus and the mother. Early diagnosis and treatment is essential to decrease maternal and fetal mortality and to differentiate the disease from the more common pre-eclampsia. While medical treatment should be started immediately after diagnosis, the timing of surgical treatment is still debated. We describe the case of a 27-yr-old woman in the 18th week of pregnancy who showed a biochemical pattern typical of PHEO and, by imaging studies, 2 tumors with the same characteristics: the first localized on the right adrenal gland, the second at the right renal hilum. The patient underwent surgery because of suspicion of malignant PHEO with local metastasis, while histology revealed a rare association of a solitary PHEO and para-aortic neurofibroma, both tumors embryologically deriving from a common cell precursor.
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Affiliation(s)
- A Moretti
- Department of Internal Medicine, University of Pisa, 56100 Pisa, Italy
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34
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Bembo SA, Elimian A, Waltzer W, Carlson HE. Pheochromocytoma in a Pregnant Woman with a History of Intracerebral Aneurysms. Am J Med Sci 2005; 329:317-9. [PMID: 15958874 DOI: 10.1097/00000441-200506000-00012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Pheochromocytoma in pregnancy is rare; if unrecognized, potentially fatal hypertensive crises may occur. We report a case of a 35-year-old woman with a history of two intracerebral aneurysms who presented at 26 weeks' gestation with tachycardia, hypertension, and pulmonary edema. Laboratory data revealed elevated 24-hour urinary catecholamine and metanephrine levels, and abdominal sonography showed a 10-cm right adrenal mass. After stabilization with phenoxybenzamine and metoprolol, cesarean section was successfully performed at 36 weeks' gestation. Postpartum abdominal computed tomography scanning confirmed a 10-cm right adrenal mass. A benign pheochromocytoma was removed without incident. This case illustrates the importance of early diagnosis and management of pheochromocytoma in pregnancy and is also an example of the rare association of pheochromocytoma with intracerebral aneurysms.
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Affiliation(s)
- Shirley A Bembo
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Stony Brook University, Stony Brook, New York 11794-8154, USA
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35
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Tong C, England P, de Crespigny PC, Millar R, Conn J. Diabetes mellitus as the only manifestation of occult phaeochromocytoma prior to acute haemorrhage in pregnancy. Aust N Z J Obstet Gynaecol 2005; 45:91-2. [PMID: 15730379 DOI: 10.1111/j.1479-828x.2005.00344.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Carol Tong
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Australia
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36
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Browne I, Brady I, Hannon V, McKeating K. Anaesthesia for phaeochromocytoma and sickle cell disease in pregnancy. Int J Obstet Anesth 2005; 14:66-9. [PMID: 15627545 DOI: 10.1016/j.ijoa.2004.07.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2004] [Indexed: 11/15/2022]
Abstract
A 33-year-old woman (G(1)P(0)) presented to a maternity hospital at 36 weeks' gestation. She suffered from sickle cell disease with three acute crises in the previous five months of her pregnancy. She also had a phaeochromocytoma with inadequately controlled hypertension. This report describes the multi-disciplinary work-up and peri-operative management necessary to optimise her medical condition before caesarean section at 39 weeks' gestation and subsequent removal of a malignant phaeochromocytoma.
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Affiliation(s)
- I Browne
- Departments of Anaesthesia, St. Vincent's University Hospital, Dublin 4, Ireland.
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37
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Phupong V, Witoonpanich P, Snabboon T, Tharavej C, Ultchaswadi P. Bilateral pheochromocytoma during pregnancy. Arch Gynecol Obstet 2004; 271:276-9. [PMID: 15221327 DOI: 10.1007/s00404-004-0654-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2004] [Accepted: 05/05/2004] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Vorapong Phupong
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Pathumwan, Bangkok 10330, Thailand.
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38
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Dugas G, Fuller J, Singh S, Watson J. Pheochromocytoma and pregnancy: a case report and review of anesthetic management. Can J Anaesth 2004; 51:134-8. [PMID: 14766689 DOI: 10.1007/bf03018772] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Geoff Dugas
- Department of Anesthesia and Perioperative Medicine, St. Joseph's Health Care, University of Western Ontario, London, Ontario, Canada
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39
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Abstract
A case of phaeochromocytoma which presented post partum is reported. Uneventful pregnancy and delivery of a healthy infant were followed by acute respiratory and cardiovascular deterioration of the mother. Despite intervention our patient died 36 h after first presentation. Diagnosis of phaeochromocytoma was confirmed post mortem.
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40
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Abstract
Laparoscopic adrenalectomy has become the procedure of choice for the surgical management of most adrenal tumors, including functional and non-functional lesions. The role of laparoscopic adrenalectomy in the management of malignant adrenal tumors is controversial and most adrenocortical cancers are generally treated by open adrenalectomy. Laparoscopic adrenalectomy can be performed by both the anterior or lateral trans-abdominal approach and by the lateral or posterior retro-peritoneal approach, with each method being suitable for specific indications. Although there are no randomized trials comparing laparoscopic with open adrenalectomy, the laparoscopic approach is associated with shorter hospital stay, reduced pain and improved cosmesis. This review discusses the indications and contraindications, technique and outcomes for laparoscopic adrenalectomy.
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Affiliation(s)
- Geeta Lal
- UCSF/Mt. Zion Medical Center, 1600 Divisadero Street, suite c347, San Francisco, CA 94143-1674, USA
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41
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Abstract
Although the presence of pheochromocytoma in pregnancy is extremely rare, this association deserves much attention as the tumor constitutes a very high risk for both mother and fetus. Any pregnant woman with hypertension, especially if paroxysmal or labile, or with so far unexplained "spells", should induce the clinician to consider the possibility of a pheochromocytoma. Maternal and fetal survival depend a lot on an early diagnosis, a correct medical therapy and a correct timing of delivery and surgery. In this respect, a strict collaboration between obstetricians, endocrinologists, anesthesiologists and surgeons is pivotal.
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Affiliation(s)
- M Mannelli
- Department of Clinical Pathophysiology, University of Florence, Italy.
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42
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Pace DE, Chiasson PM, Schlachta CM, Mamazza J, Cadeddu MO, Poulin EC. Minimally invasive adrenalectomy for pheochromocytoma during pregnancy. Surg Laparosc Endosc Percutan Tech 2002; 12:122-5. [PMID: 11948301 DOI: 10.1097/00129689-200204000-00011] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Pheochromocytoma during pregnancy is a very rare condition; fewer than 200 cases have been reported in the literature. We present the case of a 24-year-old pregnant woman found to have a pheochromocytoma during investigation of abdominal pain. This is the second reported case of laparoscopic adrenalectomy for pheochromocytoma detected during pregnancy. After appropriate radiologic investigation and medical management, a laparoscopic left adrenalectomy was performed at the beginning of the second trimester. There were no complications, and she was delivered of a healthy baby at term. We review the management of pheochromocytoma in pregnant patients and discuss the role of laparoscopy.
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Affiliation(s)
- David E Pace
- Center for Minimally Invasive Surgery, St. Michael's Hospital, University of Toronto, Ontario, Canada
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43
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Feocromocitoma y gestación. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2002. [DOI: 10.1016/s0210-573x(02)77176-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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44
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Biccard BM. Phaeochromocytoma: an unusual cause of hypertension in pregnancy. Anaesthesia 2001; 56:706-7. [PMID: 11437777 DOI: 10.1046/j.1365-2044.2001.02137-25.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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45
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Abstract
A primiparous, full-term, 28-year-old woman underwent an emergency lower segment Caesarean section under epidural anaesthesia for failure to progress in the first stage. Despite an uneventful pregnancy and delivery, she developed a hypertensive crisis in the postoperative period complicated by acute pulmonary oedema requiring ventilation for 48 h in the intensive care unit. Intravenous magnesium sulphate infusions and hydralazine boluses were used to control the blood pressure, which was associated with clonus, hyperreflexia, tachycardia and profuse sweating. The patient made a good recovery. Later measurement of urinary catecholamines in the recovery phase showed greatly elevated levels of norepinephrine, dopamine and vanillyl mandelic acid. Further investigations included a normal abdominal computed tomography scan and a I-123 meta-iodo-benzyl-guanidine scintigraphy scan which revealed a 3- to 4-cm irregular tumour located at the level of the lower pole of the right kidney and further liver hot spots. Intravenous magnesium sulphate infusion proved successful in controlling hypertension caused by a phaeochromocytoma in the postpartum period.
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Affiliation(s)
- A Bullough
- Specialist Registrar and Consultant Anaesthetist, Department of Anaesthesia, Princess Margaret Hospital, Swindon SN1 4JU, UK
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Joseph JV, Harrison R, Davis RS. Multiple endocrine neoplasia type IIA (Sipple's syndrome) presenting in pregnancy. Aust N Z J Obstet Gynaecol 2000; 40:473-4. [PMID: 11194443 DOI: 10.1111/j.1479-828x.2000.tb01188.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- J V Joseph
- Department of Urology, University of Rochester Medical Center, New York 14642, United States of America
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47
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Brown MA, Hague WM, Higgins J, Lowe S, McCowan L, Oats J, Peek MJ, Rowan JA, Walters BN. The detection, investigation and management of hypertension in pregnancy: full consensus statement. Aust N Z J Obstet Gynaecol 2000; 40:139-55. [PMID: 10925900 DOI: 10.1111/j.1479-828x.2000.tb01137.x] [Citation(s) in RCA: 235] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- M A Brown
- Australasian Society for the Study of Hypertension in Pregnancy, Sydney NSW, Australia
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48
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Ahlawat SK, Jain S, Kumari S, Varma S, Sharma BK. Pheochromocytoma associated with pregnancy: case report and review of the literature. Obstet Gynecol Surv 1999; 54:728-37. [PMID: 10546277 DOI: 10.1097/00006254-199911000-00025] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED We report on a young woman with pheochromocytoma associated with pregnancy and review 41 other cases reported in the literature from 1988 to 1997. This review reveals that the overall maternal mortality was 4 percent and the fetal loss 11 percent; antenatal diagnosis of pheochromocytoma reduced maternal mortality to 2 percent; however, fetal loss was 14 percent. Diagnosis of pheochromocytoma was made antepartum in 83 percent of the cases. Although pheochromocytoma associated with pregnancy is rare, a high index of clinical suspicion must be kept and all those at risk must be investigated to achieve an early diagnosis and improved outcome. Once the diagnosis is confirmed, alpha-adrenergic blockade is essential and beta-blockade may be required. Magnetic resonance imaging and computerized tomography scan may be used to localize the tumor during the antenatal period. In early pregnancy, i.e., before 24 weeks, both tumor resection and medical treatment are associated with good fetal outcome; in later pregnancy, elective cesarean delivery followed by tumor resection results in favorable maternal and fetal outcome. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this article, the reader will be able to understand the clinical manifestations of a pheochromocytoma during pregnancy, how to make the diagnosis of a pheochromocytoma during pregnancy, and to know the medical and surgical management of a pheochromocytoma during pregnancy.
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Affiliation(s)
- S K Ahlawat
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Kothari A, Bethune M, Manwaring J, Astley N, Wallace E. Massive bilateral phaeochromocytomas in association with Von Hippel Lindau syndrome in pregnancy. Aust N Z J Obstet Gynaecol 1999; 39:381-4. [PMID: 10554962 DOI: 10.1111/j.1479-828x.1999.tb03425.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We report a rare case of large bilateral phaeochromocytomas in pregnancy, found coincidentally by ultrasonography at 26 weeks' gestation, in a woman with a family history of Von Hippel Lindau syndrome. Further, we report maternal and fetal serum and amniotic fluid phenoxybenzamine levels from this case.
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Affiliation(s)
- A Kothari
- Women's Health Care Program, Monash Medical Centre, Melbourne, Victoria
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50
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Finkenstedt G, Gasser RW, Höfle G, Lhotta K, Kölle D, Gschwendtner A, Janetschek G. Pheochromocytoma and sub-clinical Cushing's syndrome during pregnancy: diagnosis, medical pre-treatment and cure by laparoscopic unilateral adrenalectomy. J Endocrinol Invest 1999; 22:551-7. [PMID: 10475154 DOI: 10.1007/bf03343608] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The coexistence of pheochromocytoma and primary adrenal Cushing's syndrome of the same adrenal gland has rarely been reported. We describe here the case of a female patient presenting with mild Cushing's stigmata, hypertension and diabetes mellitus in whom we diagnosed a pheochromocytoma of the left adrenal gland with coexisting non-ACTH-dependent cortisol hypersecretion. While hormonal work-up was still in progress, the patient became pregnant and wanted to carry her pregnancy to full-term. A laparoscopic adrenalectomy in the 17th week of gestation was decided upon and the patient accordingly prepared for surgery by pre-treatment with phenoxybenzamine. Successful surgery--the first ever reported laparoscopic resection of a pheochromocytoma in pregnancy--without perioperative complications was performed under general anesthesia, with the patient receiving peri- and post-operative hydrocortisone substitution. Pathohistological examination revealed a pheochromocytoma with positive immunostaining for interleukin-6 (IL-6) and negative immunostaining for ACTH, vasoactive intestinal polypeptide (VIP) and cytochrome P450, and with no signs of malignancy. A paracrine stimulation of the ipsilateral adrenal cortex by IL-6 produced by the pheochromocytoma, leading to cortical hyperplasia and subclinical Cushing's syndrome, is suggested by the positive immunostaining for IL-6 and the MRI findings. Post-operatively, secondary adrenal insufficiency ensued, necessitating continuing hydrocortisone replacement over 12 months. Hypertension resolved after surgery, and diabetes after the uncomplicated vaginal delivery at term.
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Affiliation(s)
- G Finkenstedt
- Department of Internal Medicine, University of Innsbruck, Austria.
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