A 33-year-old previously healthy woman, gravida 1, para 0, presented during her first trimester with palpitations and an increase in sweating. Her symptoms began at approximately 10 weeks’ gestation and increased at 12 weeks’ gestation. At this time, she noticed a flushing of her face, headaches and worsening palpitations. She attributed the changes to normal features associated with pregnancy.
On examination, at 12 weeks’ gestation, her blood pressure (BP) was noted to be 130/80 mm Hg; pulse, 102 beats per minute (bpm); and BMI, 24.7. Fetal heart rate was detected at 150 bpm. A urinalysis was obtained, which revealed the absence of proteinuria. She was told to return in 1 week for repeat BP monitoring.
At 13 weeks’ gestation, her BP was elevated at 150/95 mm Hg, and a repeat urinalysis revealed no protein. In the setting of palpitations, headaches and hypertension, a biochemical investigation was performed, which revealed a plasma fractionated total metanephrines level of 3,083 pg/mL (normal, <205 pg/mL), normetanephrines level of 3,020 pg/mL (normal, <148 pg/mL) and metanephrines level of 63 pg/mL (normal, <57 pg/mL). A subsequent 24-hour vanillylmandelic acid level (VMA) was obtained, which was elevated at 18.9 mg/24 hours (normal, <6 mg/24 hours), and a 24-hour urinary metanephrine level was elevated at 7,119 mcg/24 hours (normal, 122-676 mcg/24 hours).
Concern for a pheochromocytoma was increased, and an MRI of the abdomen was obtained at 15 weeks’ gestation, which revealed a well-circumscribed left adrenal mass measuring 3.3 cm x 3.4 cm x 3.5 cm.
The patient was started on an alpha-blocker (phenoxybenzamine) preoperatively with a beta-blocker subsequently added 10 days later in the setting of persistent tachycardia. At 17 weeks’ gestation, a laparoscopic resection of a left adrenal mass was performed with close intraoperative monitoring and no complications. The pathology was consistent with a pheochromocytoma.