30 year old patient diagnosed with primary hyperaldosteronism after presenting with severe hypertension and hypokalemia. On the next clinic visit to discuss further diagnostic tests and therapy, patient was found to be pregnant. How can this case be approached?
Since spironolactone is contraindicated during pregnancy, a case report on primary hyperaldosteronism during pregnancy reported a favourable outcome for both mother and baby after switching to amiloride.
https://www.ncbi.nlm.nih.gov/m/pubmed/22712170/
Mineralocorticoid receptor antagonists (MRAs) are the first choice for medical treatment of PA. Unfortunately, spironolactone is classified as FDA pregnancy category C: animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans. In the FDA report of aldactone, teratology studies on mice, rats, and rabbits are mentioned (http:// www.accessdata.fda.gov/drugsatfda_docs/label/2013/ 012151s071lbl.pdf, 30 May 2014).
Eplerenone, on the other hand, is classified as pregnancy category B: no adequate and well-controlled studies in pregnant women are available. In animal models, no teratogenic effects were observed (FDA report Inspra Eplerenone, http:// www.accessdata.fda.gov/drugsatfda_docs/label/2008/ 021437s006lbl.pdf, 30 May 2014)
If hypertension or hypokalemia are not controlled before conception or during the first trimester, possible to use of eplerenone as a selective MRA. In patients with APA, adrenalectomy could be considered if hypokalemia and hypertension are uncontrollable . In these cases, a laparoscopic approach in the second trimester is recommended. PA patients could be treated again in the second and third trimesters with MRAs if necessary.
Treatment of PA in pregnancy is challenging. Before planning pregnancy, it is highly recommended to perform adequate subtype differentiation by adrenal vein sampling (AVS). If APA is diagnosed, surgical cure by adrenalectomy should be aspired before planning pregnancy to avoid complications during pregnancy.
Please see this guidelines:
Hypertension in pregnancy: diagnosis and management (2010) NICE guideline CG107
and
Hypertension Canada’s 2018 Guidelines for the Management of Hypertension in Pregnancy
https://www.nice.org.uk/guidance/cg107/resources/surveillance-report-2017-hypertension-in-pregnancy-diagnosis-and-management-2010-nice-guideline-cg107-pdf-3546403325413
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