Review article
Primary aldosteronism and pregnancy

https://doi.org/10.1016/j.preghy.2015.08.003Get rights and content

Highlights

  • Primary aldosteronism is associated with significant fetal and maternal morbidity and mortality.

  • It is likely that primary aldosteronism is underdiagnosed in pregnancy.

  • The diagnosis of primary aldosteronism may be obscured by physiological changes in the renin–angiotensin–aldosterone axis during pregnancy.

  • Hypertension and hypokalemia may resolve during pregnancy and recur postpartum as a result of the anti-mineralocorticoid effect of progesterone.

  • The optimal management of primary aldosteronism in pregnancy is unclear.

Abstract

Primary aldosteronism is the most common cause of secondary hypertension. Less than 50 cases of pregnancy in women with primary aldosteronism have been reported, suggesting the disorder is significantly underdiagnosed in confinement. Accurate diagnosis is complicated by physiological changes in the renin–angiotensin–aldosterone axis in pregnancy, leading to a risk of false negative results on screening tests. The course of primary aldosteronism during pregnancy is highly variable, although overall it is associated with a very high risk of fetal and maternal morbidity and mortality. The optimal management of primary aldosteronism during pregnancy is unclear, with uncertainty regarding the safety of mineralocorticoid antagonists and amiloride, their relative efficacy compared with the antihypertensive medications commonly used during pregnancy, and as to whether prognosis is improved by laparoscopic adrenalectomy where an adrenal adenoma can be demonstrated.

Section snippets

1. Introduction

Chronic hypertension is estimated to complicate approximately 1.8% of pregnancies, and is associated with significant foetal and maternal morbidity and mortality [1]. Secondary causes of hypertension are estimated to complicate approximately 0.24% of pregnancies. Primary aldosteronism (PA) is the most common cause of secondary hypertension in non-pregnant subjects, accounting for approximately 7.4% of cases of secondary hypertension in subjects between the age of 18 and 40 years [2]. Excluding

2. Methods and materials

A search was conducted of the National Library of Medicine’s MEDLINE/PubMed with the objective of identifying all articles published in English language between January 1960 and May 2015 with “pregnancy” and “aldosteronism” or “aldosterone” in the title or abstract. The reference lists of all articles identified by this search strategy were examined and selected those manuscripts judged to be relevant. All pertinent reports were retrieved and the relative reference lists were systematically

3. Cases

Five pregnancies to 4 women with primary aldosteronism are described, and the literature reviewed.

4. Literature review and discussion

In previously reported cases of pregnancy in women with PA the age of subjects varied between 17 and 40 years at diagnosis [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18]. Thirty-two per cent of the subjects had been diagnosed with hypertension prior to conception, 41% were noted to be hypertensive for the first time in second trimester, and 27% were first noted to have hypertension in the peripartum period. The underlying cause of PA was available in 32 cases.

5. Diagnosis

Pregnancy is a state of hyperreninemic hyperaldosteronism. Progesterone levels increase throughout gestation due to placental production [24]. Progesterone acts as an antagonist at the mineralocorticoid receptor and as a result aldosterone levels rise in parallel with the changes in progesterone. Plasma aldosterone increases 3–8-fold during gestation plateauing in third trimester. Plasma renin activity (PRA) rises by approximately 4-fold by 8 weeks gestation and 7-fold at term due to oestrogen

6.1. Surgical

Nine subjects with PA underwent laparoscopic adrenalectomy between 14 and 24 weeks gestation [9], [13], [15], [17]. Despite biochemically documented cure of hyperaldosteronism these pregnancies were associated with significant foetal morbidity and mortality. One case of IUFD occurred at 26 weeks gestation, there were two deliveries at 26 weeks gestation because of IUGR associated with foetal distress, and one delivery at 34 weeks gestation. There were 5 term deliveries. Adrenalectomy during

7. Conclusion

It is likely that PA is significantly underdiagnosed in pregnancy. PA should be considered and ARR measured in all women with hypertension pre-conception or during pregnancy, especially where hypokalaemia or proteinuria is present, the onset of hypertension occurs prior to 20 weeks gestation, or where there is the development or exacerbation of hypertension postpartum. Physiological changes in serum aldosterone and PRA in pregnancy may result in falsely negative ARR in pregnant women with PA in

Funding

No funding received for this manuscript.

Conflict of interest

No conflict of interest.

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