Endocrine Abstracts

Introduction : Despite being the most frequent cause of secondary hypertension, primary aldosteronism (PA) is only sporadically reported (< 80 case reports) in pregnancy (1). We present a case of a 29 year old woman in whom PA was diagnosed during pregnancy.

Case presentation: A 29 year old woman with an uncomplicated singleton pregnancy of a female foetus presented at the emergency department at 18 weeks of gestation (second trimester) with severe hypertension (200/126mmHG). Before pregnancy, she did not have hypertension. Blood sampling showed a normal kidney and liver function, but a severe hypokalaemia (2.5 mmol/l; reference range 3.5-5.1 mmol/l). Plasma aldosterone was elevated (1512 pmol/l) and direct renin concentration was suppressed (0.60 mIU/l) resulting in an aldosterone/ renin ratio of 2516.1 pmol/l/mIU/l. 24-hour urine cortisol, catecholamines and metanephrines were normal. Screening for hypertensive complications was negative. The tentative diagnosis of primary aldosteronism was made and patient was treated with intravenous potassium suppletion (80 meq KCl/ 24h) and 2 antihypertensives (Labetalol Methyldopa). In consult with the gynaecologist, Spironolactone at a dose of 50 mg BID was associated and the patient was referred to the Antwerp University Hospital at 19 weeks of gestation. Spironolactone was switched to Eplerenone because of limited more information regarding safety during pregnancy (1-6). The patient could be discharged on potassium gluconate 46 mEq daily, Eplerenone 25 mg once daily and 2 other antihypertensives (Labetalol, Nifedipine retard). However, the patient was readmitted after 2.5 weeks because of uncontrolled hypertension, oedemas and the development of mild proteinuria. The dose of Eplerenone was increased to 50 mg BID and MRI of the adrenals was performed, revealing an adenoma at the left adrenal (maximum diameter 1.9 cm). At 24 weeks of pregnancy, the patient underwent a laparoscopic left adrenalectomy. Pathology confirmed an adrenocortical adenoma. Postoperatively, potassium suppletion could be stopped and antihypertensive drugs could be tapered from 5 to 2 antihypertensives. Eplerenone was stopped. During further admission the patient was infected with COVID 19. Unfortunately, an urgent caesarean section was indicated at 24 weeks and 6 days of gestation because of foetal distress. The female neonate weighted 0.530 kg and was admitted to the neonatal intensive care unit (Apgar score 4-7-10).

Conclusion: We presented the case of a 29 year old female, who developed hypertension and hypokalaemia during the second trimester pregnancy and was diagnosed with PA. Blood pressure and potassium were not under control despite treatment with 5 antihypertensive drugs including Eplerenone 50 mg BID. At 24 weeks of pregnancy, she underwent a laparoscopic left adrenalectomy. The course was complicated with mild proteinuria and foetal distress necessitating caesarean section at 24 weeks of gestation. PA is a very rare etiology of secondary hypertension during pregnancy and is associated with increased maternal and foetal morbidity and mortality. Diagnosis is challenging due to the physiological changes during pregnancy with an increase of all the components of the renin angiotensin-aldosterone system. Suggestive features include hypertension before 20 weeks of gestation, worsening of hypertension as pregnancy progresses and hypokalaemia. Currently, no guidelines for the treatment of PA during pregnancy exist. The benefit of adrenalectomy is unclear and evidence supporting the choice of medical treatment with Eplerenone is anecdotal (1-6). A review of 13 cases with PA, diagnosed during pregnancy, revealed a poor outcome considering blood pressure was controlled in only 3 cases and 3 neonates deaths.

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