CASE REPORT
At 35 weeks and two days gestation, a 28-year-old previously healthy
pregnant lady (gravida 2, para 1) presented to the obstetrical triage of
our tertiary care centre with one-week onset of severe hypertension
(>160/110 mmHg). She reported having previous episodes of
moderately high BP dating back to 25 weeks gestation that required no
treatment. She saw her primary care provider, 1 week before, complaining
of headache and right flank pain. Her BP was found to be 165/110 mmHg. A
series of investigations, including a CBC, electrolytes, BUN,
creatinine, liver enzymes and a random urine protein creatinine ratio
which all came back within normal range. A presumed diagnosis of
pregnancy-induced hypertension was made and she was prescribed Labetalol
200 mg BID. An obstetrical ultrasound and umbilical artery (UA) Doppler
were done and showed no signs of fetal growth restriction (FGR). Her
follow-up plan was twice daily BP measurement, twice weekly antenatal
visits and planned delivery at 38 weeks.
However, her BP was still labile on the given dose of Labetalol and her
right flank pain persisted, so an abdominal ultrasound was done to rule
out renal pathology. Surprisingly, the ultrasound showed a heterogeneous
right suprarenal solid mass measuring 6 x 4.5 cm as shown infigure (1). The patient was referred by her physician to our
hospital. Her BP upon presentation was fluctuating between 200/120 mmHg
above and 110/80 mmHg below. CBC, coagulation profile, liver profile,
electrolytes, urea, and creatinine were all normal. Urinary proteins
were 165 mg/24 hours, all of which made the diagnosis of preeclampsia
unlikely. Pheochromocytoma was suspected given the labile nature of the
patient’s blood pressure (BP) and the suprarenal mass discovered in
ultrasound. 24-hour urine collection was sent for metanephrine and
vanillylmandelic Acid (VMA) to confirm the diagnosis which came back
markedly elevated being 703 μmol/day and 82 μmol/day respectively. This
was followed by an abdominal MRI, revealing a 5.5 x 4 cm right adrenal
mass, a normal left adrenal gland, and no extra-adrenal tumours were
discovered.