marta zanon, valentina tommasi, vanessa fiorentino ... case italy.pdf · lc, a 30 years old woman,...
TRANSCRIPT
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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)
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WHAT IS GOING ON?
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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?
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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
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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
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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
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PET-CT scan
PET-CT scan showed hypermetabolism at the left adrenal mass that presented hypometabolic center.
IMAGING TESTS
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Laparoscopic left adrenalectomy wasperformed
Histological examination showed an adrenocorticaladenoma.
TREATMENT
Blood pressure rapidly normalized after surgery
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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
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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
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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
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CONCLUSION
….What is essential is invisible to the eye…..