JS-NG-9: PRIMARY HYPERALDOSTERONISM IN A TRIPLET PREGNANCY: CONSIDERATIONS FOR INTRA-PARTUM DIAGNOSIS AND MANAGEMENT
Notice bibliographique
Résumé
Primary aldosteronism (PA) is an uncommon etiology of hypertension. We report the first known case of PA in a triplet pregnancy to describe the intra-partum considerations in diagnosis, investigation and management of PA. A 33-year-old female G3P0A2 at 10 weeks gestation with triplet pregnancy was admitted for hyperemesis gravidarum and hypertension. Her comorbidities include chronic hypertension, uterine fibroids, and two previous pregnancy losses. Home medications are labetalol 100 mg BID. On presentation, the patient complained of nausea, vomiting and epigastric pain and headache. On examination, her blood pressure was 161/90 and heart rate of 75. The rest of the cardiopulmonary exam was normal. Laboratory values were notable for potassium:2.9 mmol/L (n 3.5–5mmol/L) and bicarbonate 26 mmol/L (n 24–31mmol/L). The platelets, liver function tests and renal function tests were normal. Despite continuous high dose oral and parenteral high dose potassium supplementations, she had hypokalemic episodes (nadir 2.7mmol/L). She remained hypertensive at 140/90 on labetalol 200 mg QID and nifedipine XL 30 mg q12 hours. PA was suspected and testing revealed aldosterone 1280 (n 166–2885), renin 0.49 (n 0.10–1.10), aldosterone-renin ratio (ARR) 2615 (n < 1500), which is indeterminate. Abdominal MRI demonstrated right adrenal mass, measuring 2.7 x 5.2 x 2.9 cm. Repeat testing revealed aldosterone 11,000, renin 0.34, ARR > 30,000, which is highly suggestive of PA. The uterus was too bulky with the triplet pregnancy and uterine fibroids to safely proceed with adrenalectomy. The patient consented to receive eplerenone 25 mg BID for medical management of PA in addition to nefidipine XL 60 mg BID and oral potassium supplementation. She re-presented to hospital at 31 weeks with spontaneous rupture of membranes. She had an emergency caesarian section and delivery three healthy male infants. At one month postpartum, she was switched to spironolactone 25 mg BID from eplerenone, in addition to nefidipine and potassium supplementation, and maintained blood pressure of 130–140/80–90. At five months postpartum, she had testing on doxazosin 4 mg daily, hydralazine 10 mg TID and potassium supplementations, which revealed aldosterone 2360 pmol/L, renin < 2, ARR > 1200. Adrenal vein sampling demonstrated marked lateralization of aldosterone production to the right adrenal gland. A right laparoscopic adrenalectomy was completed and she achieved normotension on post-operative day 2. She was discharged on no antihypertensive medication or potassium supplementation. At 8 months post-adrenalectomy, her blood pressure is 120/96 potassium is 4mmol/L and her aldosterone levels remain low at 252 on no medications. In this case of triplet pregnancy, the diagnosis of PA was difficult to establish given the impact of pregnancy on the renin-angiotensin-aldosterone-system. Treatment with eplerenone resulted in improvement of hypertension and good pregnancy outcome. Postpartum, adrenalectomy resulted in rapid and sustained improvement in hypertension and reversal of hypokalemia.
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Prédiction distillée sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Apprise à partir de 10 348 étiquettes directes de Codex et de 10 348 étiquettes directes de Gemma. Le mode candidate est l'union des têtes enseignantes seuillées; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont ni des étiquettes humaines ni des étiquettes directes de modèles de pointe.
Scores Codex et Gemma par catégorie
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,000 | 0,000 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,000 | 0,000 |
| Bibliométrie | 0,000 | 0,000 |
| Études des sciences et des technologies | 0,000 | 0,000 |
| Communication savante | 0,000 | 0,000 |
| Science ouverte | 0,000 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,000 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,000 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule tête enseignante, pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».