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.