Endocrine Abstracts

Case history: This 32-year-old lady was found to have a 23 × 17 mm bladder mass incidentally identified on a first trimester scan and confirmed with renal tract ultrasound. Urine collections showed mildly raised normetadrenaline 4.32 umol/24 h (normal range 0–3.0), plasma normetanephrine 1339 pmol/l (120–1180), no metastases were identified on MRI and genetic screening was negative. The patient had two previous normal pregnancies and deliveries. BP in the current pregnancy was mildly elevated at 10 weeks gestation (140/71 mmHg) but remained normal during pregnancy and she was otherwise asymptomatic. Despite normotension low dose alpha blockade with doxazosin was used to try to prevent marked BP fluctuations and in preparation for delivery, however the patient was non-compliant due to side effects. A multidisciplinary decision was taken to induce labour at 41 weeks with alpha blockade prior to labour given caesarean section would require significant bladder manipulation. The patient attended in spontaneous labour at 40+5, an epidural was sited and labour progressed normally. Two minutes after delivery the mother experienced sudden severe headache and BP was recorded as 151/62 mmHg. Headache and BP improved without treatment and syntocinon was given (rather than syntometrine which includes ergotamine and can cause hypertensive crises). Mother and daughter were discharged on day 2 post delivery with the patient on prazocin 5 mg bd. She is shortly to be seen by endocrinology and urology for planned resection of the paraganglioma.

Prevalence of paraganglioma in the urinary bladder is <1% and those associated with pregnancy are extremely rare. Recommended management is based upon case reports, small case series and expert opinion with traditional recommendation that vaginal delivery is best avoided due to risk of hypertensive crisis from active labour. Although bladder paragangliomas often present with hypertension and symptoms of catecholamine excess our case is consistent with a small case series highlighting pregnancies with paragangliomas may be at lower risk of adverse outcome than those with phaechromocytomas (Wing JCEM 2015). This rare case exhibits a positive outcome due to early recognition, investigation and initiation of treatment with a multidisciplinary approach.