Primary aldosteronism in pregnancy

Abstract

Primary aldosteronism (PA) is the most common form of secondary hypertension. Although hypertensive disorders seem to affect around 5–10% of pregnancies worldwide, literature counts less than 80 cases of PA diagnosed during the peri-partum period. In this review we discuss about current knowledge on pathophysiology, natural history, diagnosis and treatment of PA in pregnancy. Because of the physiologic changes in the renin–angiotensin–aldosterone system (RAAS) and the contraindication to both confirmatory test and subtype differentiation, diagnosis of PA during pregnancy is challenging and relies mostly on detection of low/suppressed renin and high aldosterone levels. The course of pregnancy in patients with PA is highly variable, ranging from progesterone-induced amelioration of blood pressure (BP) control to severe and resistant hypertension with potential maternal and fetal complications. Mineralcorticoid receptor antagonists (MRA) are the recommended and most effective drugs for treatment of PA. As the anti-androgenic effect of spironolactone can potentially interfere with sexual development, their prescription is not recommended during pregnancy. On the other side, eplerenone, has proven to be safe and effective in 6 pregnant women and may be added to conventional first line drug regimen in presence of resistant hypertension or persistent hypokalemia. Ideally, patients with unilateral forms of PA should undergo adrenalectomy prior to conception, however, when PA is diagnosed during pregnancy and medical therapy fails to adequately control hypertension or its complications, adrenalectomy can be considered during the second trimester in case of unilateral adrenal mass at MRI-scan.

Analysis of serum calcium, sodium, potassium, zinc, and iron in patients with pre‐eclampsia in Bangladesh: A case–control study

“…In Pearson's correlation analysis, Hemoglobin and potassium ( r = 0.397, p < 0.05) showed positive relation in the patient group, and a significant negative correlation was shown between creatinine and potassium ( r = −0.490, p < 0.05). Elevated plasma concentrations of aldosterone and other mineralocorticoids may contribute to hypokalemic alterations seen during a healthy pregnancy, an also increase in glomerular filtration rate, 49 and inadequate potassium conservation by kidney & alimentary canal; Potassium lost in feces may be higher than that lost via urine, 50 and a similar hypothesis also suggested by Bera et al 48 and Yussif et al 51 Their predictive analysis show that pregnant women with hypertension had lower blood potassium levels than pregnant women with normotension. Their speculations depicted a possible link between hypertensive pregnancies and low potassium levels.…”

Pheochromocytoma

“…Optimal management strategies vary by cause. 4 , 5 , 6 , 7 , 8 In nonpregnant patients, resistant hypertension should be considered when blood pressure remains elevated at maximum or maximally tolerated doses of 3 agents, typically including a long acting calcium-channel blocker, a renin-angiotensin system (RAAS) blocker, and a diuretic agent. 3 The diagnosis is more complicated in pregnancy because RAAS blockers are contraindicated and diuretic agents are not frequently used.…”

Approach to the Patient: Reninoma

“…Spironolactone is a nonselective MRA used since the 1960s that also confers antagonistic action at the androgen receptor. Exposure in early pregnancy, during genital differentiation, has been associated with feminization of males and atypical genitalia ( 51 ). Isolated case reports of its use in late pregnancy after confirmation of female fetus have not been associated with complications ( 52 ).…”

“…Eplerenone is a selective MRA and therefore not associated with antiandrogen activity. However, it is a newer agent than spironolactone and experience in pregnancy is limited to 6 published cases ( 51 ).…”

“…Use of amiloride, a sodium epithelial channel blocker, in pregnancy has been described in 8 cases of PA ( 51 ). Its use has not been recommended because of concern about hypovolemia and, while animal models are reassuring for fetal safety, evidence for its use clinically remains lacking.…”