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Table of Contents
LETTER TO THE EDITOR
Year : 2013  |  Volume : 17  |  Issue : 3  |  Page : 540-541

Successful pregnancy outcome in a case of pheochromocytoma presenting as severe pre-eclampsia with normal urinary catecholamine level


Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication10-May-2013

Correspondence Address:
Jai Bhagwan Sharma
Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi - 29
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2230-8210.111696

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How to cite this article:
Sharma JB, Naha M, Kumar S. Successful pregnancy outcome in a case of pheochromocytoma presenting as severe pre-eclampsia with normal urinary catecholamine level. Indian J Endocr Metab 2013;17:540-1

How to cite this URL:
Sharma JB, Naha M, Kumar S. Successful pregnancy outcome in a case of pheochromocytoma presenting as severe pre-eclampsia with normal urinary catecholamine level. Indian J Endocr Metab [serial online] 2013 [cited 2019 Nov 14];17:540-1. Available from: http://www.ijem.in/text.asp?2013/17/3/540/111696

Sir,

Pheochromocytoma diagnosed during pregnancy is extremely rare. [1] However, this situation deserves mention because the outcome of undiagnosed pheochromocytoma during pregnancy can be fatal.

A 21-year-old primigravida presented at 38 week period of gestation (POG) with high BP and headache. There was no history of blurring of vision, epigastric pain, nausea or vomiting; however, on direct questioning she gave history of recurrent episodes of palpitation, tremor and profuse sweating for last 3 years. Her BP was never checked before pregnancy.

On admission, BP was 180/110; pulse rate 100/min. Systemic examination was within normal limit. Fundal height was corresponding to 32 week POG. Her urine albumin was 3+ dipstick. Diagnosis of severe pre-eclamsia was made and she was started on three oral anti-hypertensives viz., Alpha-methyle dopa, Labetolol and Nifedepine. Her PIH parameters were normal except elevated 24 hrs urinary protein (1 gm). Her 24 hrs urine catecholamine was normal (89.6 mcg) but abdominal USG showed a 5 × 5 cm. mass on right kidney.

On the third day after admission, we had to terminate her pregnancy because of poor bio-physical profile of fetus. She was taken for emergency cesarean section under general anesthesia in ICU and a 1.8 kg baby was delivered. Four hours after operation she had an episode of paroxysmal hypertension (BP-200/120, pulse rate-100/min). She was given two doses of Tab. Prazosin 2 mg one hour apart and later started on Tab. Prazosin 2 mg QID and Tab. Amlodipine 10 mg daily. CT abdomen confirmed right adrenal tumor [Figure 1]. On fifth post-op day, dose of prazosin was increased to 3 mg QID and Tab. Metoprolol 25 mg daily was added. After stabilizing BP, she was taken for laparotomy 20 days after her cesarean section. Intra op, there was a 4 × 4 cm. vascular tumor in upper pole of right kidney which was completely removed. Post-op, her BP came back to normal within few hours without any drug. Histopathological examination confirmed the diagnosis. She was discharged in stable condition.
Figure 1: CT abdomen showing enhancing mass over right kidney

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Pheochromocytoma can masquerade severe preeclampsia of pregnancy. Accurate diagnosis is important as delivery of the fetus will be beneficial in pre-eclampsia but catastrophic in undiagnosed pheochromocytoma. [2] The present case is unique as the patient presented with proteinuria and normal urinary catecholamine, thus creating a major diagnostic dilemma. Proteinuria in pheochromocytoma may indicate hypertensive nephropathy from long-standing undiagnosed hypertension. Normal urinary catecholamine was probably because of episodically secreting tumor. [3] In this case, on the basis of patient's symptoms and USG finding, we made the provisional diagnosis of pheochromocytoma and took the patient for emergency section rather than inducing labour in which case we could have lost her.

So, pheochromocytoma should always be kept as a differential diagnosis in pregnancy with uncontrolled hypertension. The tumor can present with unusual findings like proteinuria and normal urinary catecholamine. In suspected cases, MRI/USG abdomen should be done before terminating pregnancy. When diagnosed late and there is indication of emergency section, it should be done in ICU with all arrangements ready to deal with the hypertensive crisis. Definitive surgery should be done only after stabilizing the blood pressure.

 
   References Top

1.Wissler RN. Endocrine disorders. In: Chestnut DH, editor. Obstetric Anesthesia. Principles and Practice. 2 nd ed. New York: Mosby Year Book Inc; 1999.p. 828-32.  Back to cited text no. 1
    
2.Hudsmith JG, Thomas CE, Browne DA. Undiagnosed phaeochromocytoma mimicking severe preeclampsia in a pregnant woman at term. Int J Obstet Anesth 2006;15:240-5.  Back to cited text no. 2
    
3.Sinclair D, Shenkin A, Lorimer AR, Normal catecholamine production in a patient with a paroxysmally secreting pheochromocytoma. Ann Clin Biochem 1991;28:417-9.  Back to cited text no. 3
    


    Figures

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This article has been cited by
1 Impact of maternal pheochromocytoma on the fetus and neonate
Shigeo Iijima
Gynecological Endocrinology. 2019; : 1
[Pubmed] | [DOI]



 

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