Primary aldosteronism (PA) in pregnancy is a rare case. In connection with the risks associated with pharmacotherapy and surgical intervention in pregnancy, making clinical decisions in such situations is difficult. We report the case of short-term use of eplerenone for the treatment of arterial hypertension and hypokalemia in association with UA during pregnancy
A woman at the age of 31 was hospitalized on the tenth month of her fifth pregnancy. She had a complicated obstetric history: after a normal pregnancy at age 22, she had successively stillbirth at week 32, a spontaneous abortion at week 15, and neonatal fetal death after an urgent cesarean section for pre-eclampsia at week 34. Arterial hypertension was diagnosed during the second pregnancy, but information about the disease is limited, as the patient previously lived in Ghana.
In laboratory studies, we detected hypokalemia (2.1 mmol / L, range of reference values 3.5-5.1), plasma renin activity <0.2 pmol / ml per hour (1.1-2.7), and the plasma aldosterone concentration was 750 pmol / l (135-400). The results clearly spoke in favor of the PA. Echocardiography was used to determine left ventricular hypertrophy, hypertensive retinopathy and proteinuria. An MRI image of the left adrenal gland showed the formation of 1.2 × 8 mm, with a high content of lipid-like substances, with a reduced signal intensity corresponding to the signs of the adenoma. An ultrasound study conducted at week 16 of pregnancy showed a healthy mobile male fetus.
Treatment with amiloride, methyldopa, doxazosin and high doses of potassium preparations for oral administration was started. But uncontrolled hypertension and hypokalemia persisted. After discussion and informed consent, at the 18th week of gestation, a treatment regimen was added eplerenone, the initial dose was 50 mg with a rapid increase to 200 mg per day (in 2 divided doses). Hypokalemia was quickly eliminated, but the mean arterial pressure remained elevated, representing a serious obstetric risk.
Uncomplicated laparoscopic adrenalectomy on the left was performed at the 20th week of gestation after the application of eplerenone for 2 weeks. Arterial hypertension persisted after removal of the adrenal gland, but was easily controlled by methyldopa and doxazosin. The level of potassium in the serum remained normal. Histological examination confirmed adrenal adenoma.
H 28 week of pregnancy developed pre-eclampsia, which required urgent cesarean section. The newborn boy was significantly behind in growth, but he showed no signs of feminization. After 3 months of prolonged treatment, the newborn died of sepsis. The patient refused endocrinological observation. Four years later during the sixth pregnancy, despite good control of hypertension with three drugs, she developed pre-eclampsia. As a result of urgent cesarean section, a healthy girl was born.
As indicated, the clinical outcome of our case was unfavorable. Episodes of pre-eclampsia in previous and subsequent pregnancies, requiring urgent interventions, suggest rather that the problems were caused more by hypertension, rather than by eplerenone.The purpose of this report is to supplement the world experience of short-term use of eplerenone for fighting hypertension and maintaining potassium homeostasis during pregnancy.
As far as we know, this was the fourth report on the use of eplerenone in pregnancy and only the second - its use for these indications. During the previous case, a healthy boy was born at 35 weeks of gestation, the mother received eplerenone therapy for 8 weeks (50 mg twice a day).