PRIMARY ALDOSTERONISM IN PREGNANCY

A CASE REPORT

Abstract

INTRODUCTION/BACKGROUND
Primary aldosteronism (PA) in pregnancy is a rare and potentially severe disorder that poses significant challenges for diagnosis and treatment. Compared to essential hypertension, PA is associated with increased risks of preterm delivery, fetal growth restriction, and preeclampsia due to hypertension and hypokalemia.

CASE
We present a 34-year-old primigravida with confirmed PA of ten years duration marked by recurrent episodes of hypokalemia and hypertensive urgency. Despite the initiation of mineralocorticoid receptor antagonist (MRA) treatment, the patient's blood pressure remained poorly controlled, and the patient also had irregular follow-up. She presented at 8 weeks of gestation with uncontrolled hypertension. She required multiple antihypertensive medications with maximal doses as pregnancy progressed, including methyldopa, labetalol, and nifedipine, but BP control remained suboptimal. Imaging revealed a left adrenal nodule, leading to retroperitoneoscopic adrenalectomy in the second trimester.

Postoperatively, her blood pressure improved moderately, but she developed severe preeclampsia at 26 weeks, necessitating an emergency caesarean delivery and her premature infant did not survive. She remained hypertensive post-adrenalectomy and postpartum, suggesting concomitant essential hypertension.

Managing PA in pregnancy is difficult because MRAs have adverse effects in pregnancy, and other antihypertensive drugs have limited ability to lower aldosterone-mediated hypertension. This case illustrates the problems of achieving tight blood pressure control in pregnancy and consequent maternal and fetal complications. Surgical adrenalectomy may not completely alleviate hypertension during pregnancy because of ongoing vascular remodelling from chronic aldosterone excess. Compared with essential hypertension, PA in pregnancy carries a larger risk of unfavourable outcomes, including preeclampsia, IUGR and placental insufficiency due to aldosterone's direct endothelial and pro-inflammatory effects. Despite adrenalectomy, this patient still developed preeclampsia, emphasizing the persisting vascular dysfunction even after surgery.

CONCLUSION
Careful management of primary aldosteronism (PA) during pregnancy is crucial to reduce complications. Adrenalectomy may improve blood pressure control, but it does not ensure protection from adverse outcomes. Multidisciplinary care and continuous monitoring are therefore necessary.