A case of pheochromocytoma with subsequent preeclampsia in a twin pregnancy

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: MON 37-82-Pheochromocytoma & Paraganglioma
Monday, June 17, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board MON-78
Daniel Alberto Cadena*1, Charise M Shively1, Vijayaratna Chockalingam1, Brandy Ann Panunti2 and Susana Laura Dipp3
1Ochsner Clinic Foundation, New Orleans, LA, 2Ochsner Med Cntr, New Orleans, LA, 3Ochsner Medical Foundation, New Orleans, LA
Pheochromocytoma is a rare cause of hypertension during pregnancy, with an incidence of  <0.2 per 10 000 pregnancies.  The mortality risk for untreated pheochromocytomas for mother and fetus is very high. In multifetal gestation uncontrolled hypertension is commonly due to preeclampsia. We are reporting the first case of pheochromocytoma with subsequent preeclampsia in a twin pregnancy.

28-year-old G2P1 African American female presented at 19 weeks gestation of a twin pregnancy with headaches, palpitations and uncontrolled hypertension of six months duration. At the time of evaluation, her blood pressure was 230/120mmHg. She had no peripheral edema and a 24 hr urine done to exclude preeclampsia was normal (<0.7 mg/dl (0-15mg/dl)). Evaluation for secondary hypertension included a renal ultrasound that incidentally showed a right adrenal mass. Biochemical evaluation indicated markedly elevated 24 hr urine normetanephrine levels of 9674 nmol/dl (ref 273 – 3548 nmol/dl) and norepinephrine levels of 402 nmol/dl (0-100 nmol/dl). MRI of the abdomen confirmed a 4.6 x 3.9 x 4.2cm heterogenous right adrenal mass with marked hyperintensity on T2-weighted images. She was pretreated with phenoxybenzamine, labetalol and hydralazine. Due to persistently elevated blood pressures (153/111 mmHg) a nicardipine drip was used to normalize her blood pressure (113/84mmHg). A laparoscopic right adrenalectomy was performed but conversion to open resection was required due to vascularity of the tumor and bleeding. Pathology report confirmed pheochromocytoma. Three days postoperatively she developed systolic cardiac dysfunction EF 40% (55-70%), associated with worsening hypertension and massive proteinuria 15000 mg/dl in 24 hr urine collection (0-15mg/dl).  Labor was induced at 23 weeks, due to presence of preeclampsia with both babies dying after delivery.

Discussion. Whether a multifetal gestation or a reduced utero-placental blood flow after controlling HTN in a case of pheochromocytoma contributed to the development of preeclampsia is unknown. In the management of pheochromocytomas during pregnancy, careful monitoring and avoidance of aggressive normalization of blood pressure should be considered.

Oliva R, Angelos P, Kaplan E, Bakris G. Pheochromocytoma in pregnancy: a case series and review. Hypertension. 2010 Mar;55(3):600-6.

Nothing to Disclose: DAC, CMS, VC, BAP, SLD

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