Marta Zanon, Valentina Tommasi, Vanessa Fiorentino ... case Italy.pdf · LC, a 30 years old woman,...

CLINICAL CASE PRESENTATION

Marta Zanon, Valentina Tommasi, Vanessa Fiorentino, Graziella Privitera

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LC, a 30 years old woman, was admitted in ourDepartment from Gynecology Department after atherapeutic abortion during the 19th week ofpregnancy for a Persistent Hypertension.

CLINICAL CASE

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9th July 2013: She was admitted in Gynecology Departmentfor uterine bleeding and high values of blood pressureduring the 16th week of pregnancyobstetric ultrasound: “membrane sweeping with hematiceffusion”.

Cardiological examination: BP: 170/90 mmHg, HR: 80 bpm.

Metyldopa 250 mg 1 cp for three times a day wasrecommended”.

MEDICAL HISTORY (I)

High blood pressure levels (150/90) were observed at 4 weeks’ gestation, Metyldopa 250 mg bid was prescribed.

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22nd July 2013: She was again admitted in the GynecologyDepartment for uterine bleeding and persistance of highblood pressure levels (170/90), at 19 weeks’ gestation:

Echocardiography: “Hypertrophy of left ventriculum

(diastolic IVS 20 mm) with normal systolic function and no

defects of segmental kinetic”.

Treatment: beta blockers and Ca-antagonists therapy was

started”.

MEDICAL HISTORY (II)

WHAT IS GOING ON?

Brown MA et al. Hypertens Pregnancy. 2001;20(1):IX-XIV.

HYPERTENSIVE DISORDERS IN PREGNANCY

DEFINITION: SBP ≥140 mmHg and/or DBP ≥90 mmHg. The blood pressure readings should be documented in at least two occasions.

CLASSIFICATION:

PREECLAMPSIA: high blood pressure reported after the 20th gestational week associated with proteinuria;

CHRONIC HYPERTENSION: hypertension detected before the 20th week of pregnancy;

PREECLAMPSIA SUPERIMPOSED TO CHRONIC HYPERTENSION;

GESTATIONAL HYPERTENSION: high blood pressure reported after the 20th gestational week without proteinuria

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Vital Parameters: BP: 176/100 mmHg, HR 74 bpm

During the second admission in Ginecology Department

Hb 10 g/dl MCV 88 fl

PTL 74000/mm3

AST 96 UI/LALT 179 UI/LGGT 214 UI/LALP 413 UI/L

Total bilirubin 1,9 g/dl Direct bilirubin: 0,4 mg/dl

LDH: 417 UI/L Aptoglobin: 1 mg/dl

Proteinuria/24 h: 470 mg/lGFR 122 ml/min

Potassium: 2,4 mmol/l Sodium: 137 mmol/l

Laboratory tests:

HELLP SYNDROME

PREECLAMPSIA

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THERAPEUTIC ABORTION

PREECLAMPSIA SUPERIMPOSED TO CHRONIC HYPERTENSION

HELLP SYNDROME

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• canreonate potassium 50 mg 1 cp/day• nebivolol 5 mg 1 cp/day• methyldopa 500 mg 1 cp x 4/day• nifedipine20 mg 1 cp x 3/day• doxazosin 4 mg x 2/day• isosorbide-5-mononitrate 20 mg 1 cp x 3/day• enalapril 20 mg 1 cp/day

ADMISSION AT OUR DEPARTMENT

• Despite the interruption of pregnancy and the anti-hypertensive treatments

• After pregnancy interruption an improvement of clinical condition and biochemical parameters was observed

High blood pressure persisted What is missing?

Physical Examination:

• BP 164/90 mmHg, HR 70 bpm, satO2 99% (FiO2 21%)

• Moon face, capillary fragility with widespread petechiae anda superficial hematoma, a thin skin, thin and sparse hair,hirsutism, muscle wasting at arms and legs,

• Globular abdomen, and striae rubrae in the right quadrantof the abdomen.

• She showed tremor spread, deflected mood, emotionallability, and anxiety

AT ADMISSION IN OUR DEPARTMENT

WHAT DO YOU THINK?

Could it be a Secondary Hypertension?

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• plasma renin activity (PRA) and aldosterone supine, baselineand after 50 mg oral captopril challenge Normal

• Thyroid function Normal• 24-h urinary catecholamines Negative

1 mg overnight dexamethasone suppression test:- Plasma cortisol levels h 8:00: 784 nmol/l

Secondary Hypertension Screening

•24 h urinary cortisol excretion: 1258 nmol/24h (normal values 16-168 nmol/24h)

•Plasma Cortisol levels h 8:00 816 nmol/L (normal values 250-550 nmol/l)

•Plasma Cortisol levels h 16:00 325 nmol/L (normal values 50-100 nmol/l)

•ACTH <5 ng/L (normal values 10-70 ng/l)

CUSHING SYNDROME

Abdominal CT scan

Abdominal CT imaging showed a left adrenal adenoma, solid, irregular, capsulated (size 87 mm × 70 mm × 70 mm)

IMAGING TESTS NEXT STEP

PET-CT scan

PET-CT scan showed hypermetabolism at the left adrenal mass that presented hypometabolic center.

IMAGING TESTS

Laparoscopic left adrenalectomy wasperformed

Histological examination showed an adrenocorticaladenoma.

TREATMENT

Blood pressure rapidly normalized after surgery

Lekarev O, New MI.Best Pract Res Clin Endocrinol Metab. 2011 Dec;25(6):959-73.16

• Approximately 140 cases of Cushing’s syndrome inpregnancy have been reported.

Pituitary adenoma

CUSHING SYNDROME DURING PREGNANCY

Lekarev O, New MI.Best Pract Res Clin Endocrinol Metab. 2011 Dec;25(6):959-73.

• Adrenal disorders in pregnancy are not common, but a timelydiagnosis is imperative because these disorders can lead to significantmaternal and fetal morbidity.

• Placental Corticotropin Releasing Hormone (CRH) as well as Bothmaternal and placental ACTH and cortisol levels rise during pregnancy.In addition the difficulty of diagnosis is related to the fact CSsynthoms/signs such as central weight gain, oedema, fatigue,emotional upset, hypertension and glucose intolerance, bruising, andhirustism are also common to pregnancy.

• The diagnostic test is the overnight dexamethasone suppression test

CUSHING SYNDROME DURING PREGNANCY

TAKE HOME MESSAGE

• Pregnancy is a particular condition that can hide underling diseases

• A multidisciplinary approach can make the difference

• When the therapeutic strategy doesn’t reach the expected results let’s start from the beginning

• The importance of early diagnosis

CONCLUSION

….What is essential is invisible to the eye…..