Endocrine Abstracts

Case history: We report a case of a 36-year-old female. She was Para 1 and 10 years prior had a vaginal delivery of a normal sized infant after an uncomplicated pregnancy. She was subsequently diagnosed with hypertension managed with Ramipril-10mg. She booked in her second pregnancy at 12 weeks/gestation. Ramipril had been stopped at positive pregnancy test and booking blood pressure was 139/85. Labetalol was commenced and she was seen in the pregnancy hypertension clinic.

Investigations: Renal USS with anomaly scan Renal MRI scan Adrenal hormone panel Routine biochemistry

Results and treatment: The renal USS at 20 weeks showed a 6.5 cm echogenic area in the upper pole of left kidney and the MRI confirmed a 7.8 cm adrenal mass radiologically suspicious of a phaeochromocytoma. A phaeochromocytoma was diagnosed at 22 weeks gestation. She was seen jointly by Obstetrics/Endocrinology and given her advancing gestation and the need to adequately alpha-block prior to any surgery a decision was made to manage her medically with tumour resection post-delivery. She started on doxazosin and titrated to maintain a balance between control of maternal blood pressure and utero-placental flow. Mode of delivery was discussed in detail and a decision for an elective C-section was made. Scans showed normal fetal growth until 33+6 when placental growth hormone testing indicated an increased risk of placental disease. Worsening hypertension led to admission and elective C-section at 35+6. Delivery was complicated by a 2L post-partum haemorrhage and acute kidney injury secondary to period of relative hypotension, which required dialysis. PET and MRI imaging confirmed isolated adrenal pheochromocytoma and adrenalectomy was performed. She is currently off dialysis with an eGFR 43. Genetic screen- normal.

Conclusion and discussion: Phaeochromocytoma is very rare in pregnancy and carries significant risk of morbidity and mortality to mother and foetus. The optimum management strategies and mode of delivery have limited evidence. This case highlights the haemodynamic instability that can occur particularly around childbirth with the risk of haemorrhage. Investigation for secondary hypertension should be considered in all young hypertensives including in the pregnant population with diagnoses of chronic hypertension.