Laparoscopic Adrenalectomy on a Patient with Primary Aldosteronism during Pregnancy

Abstract

Abstract. A pregnant 26-year-old woman was referred for evaluation and management of progressive hypertension and hypokalemia at 14 weeks of gestation. Her plasma aldosterone level was markedly elevated and magnetic resonance imaging showed a right adrenal tumor. Primary aldosteronism due to an aldosterone producing-adenoma was diagnosed. Because of progressive severe hypertension, a laparoscopic adrenalectomy was performed at 17 weeks of gestation. The procedure was completed without complication, and plasma aldosterone and potassium levels rapidly improved postoperatively. However, her hypertension persisted and the growth retardation of the fetus was found. Regrettably, intrauterine fetal death was confirmed at 26 weeks of gestation. Histological examination of the placenta revealed that the placental artery had very thick walls which had apparently caused a critical failure in fetal blood flow. The optimal timing of laparoscopic surgery during pregnancy and perioperative management were subsequently discussed. PRIMARY aldosteronism is not a rare cause of hypertension [1], and its association with pregnancy has been reported. However, we found that only 23 cases have been described in the literature published in English since the first report of primary aldosteronism in pregnancy described by Crane et al. in 1964 [2]. A recent evolution in adrenal surgery, including minimally invasive laparoscopic surgery, has largely improved modality and QOL of patients with primary aldosteronism. As of yet, however, there has been little discussion of performing laparoscopic adrenalectomy on a pregnant woman. We report a case of primary aldosteronism during pregnancy that was treated by a laparoscopic adrenalectomy and discuss the feasibility of this procedure on pregnant women. Case ReportA 26-year-old Japanese woman was hypertensive when she registered for prenatal care at 14 weeks and 4 days of gestation. She had been healthy before becoming pregnant; however, the initial laboratory assessment revealed low potassium and high plasma aldosterone levels. She was told three years ago that she had mild hypertension that could be controlled

Outcomes after laparoscopic adrenalectomy

“…Both patients had benign neoplasms. Three case reports of LA in pregnant patients, primarily for cortical adenomas, have been published [33,34]. One of these reports describes using a retroperitoneal approach, whereas the others describe using a transperitoneal approach.…”

PROGRESS IN PRIMARY ALDOSTERONISM: Mineralocorticoid receptor antagonists and management of primary aldosteronism in pregnancy

“…However, assuming that w10% of all hypertensive disorders are caused by PA, 0.6-0.8% of all pregnant women would suffer from PA. Indeed, to our knowledge, only 41 PA patients with 47 pregnancies (excluding familial forms) have been published in the literature regarding PA and pregnancy (20,21,22,33) (methods for literature review, see Supplementary data, see section on supplementary data given at the end of this article). PA is mostly caused by idiopathic bilateral hyperplasia of the adrenal gland (IAH) or APA, whereas APA might be more frequent than IAH as shown in the PAPY study and in our own data (34,35).…”

“…If hypertension or hypokalemia are not controlled before conception or during the first trimester, we recommend the use of eplerenone as a selective MRA. In patients with APA, adrenalectomy could be considered if hypokalemia and hypertension are uncontrollable (22,26,44). In these cases, a laparoscopic approach in the second trimester is recommended.…”

Secondary Hypertension in Pregnancy

“…Hypokalemia and hypertension may be difficult to control in PAP and are associated with poor fetal outcomes [43]. Symptomatic management with aldosterone receptor antagonists is problematic, as their safety in pregnancy has not been established.…”