Adrenal gland tumor surgery safe in pregnant woman: Case report

Laparoscopic adrenalectomy resolved Cushing's syndrome in patient, 28

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by Andrea Lobo |

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A pregnant woman underwent a successful laparoscopic adrenalectomy, a minimally invasive surgery to remove tumors in the adrenal glands, for Cushing’s syndrome which was caused by such a tumor and resolved, according to a case report.

Although it is the standard treatment for adrenal tumors, laparoscopic adrenalectomy is not commonly done in pregnant women due to the risk of general anesthesia and the procedure itself.

The specific surgical approach used in this case, called retroperitoneal approach, “should be chosen and performed between 14 and 30 weeks of pregnancy to prevent mother and fetal complications,” the researchers wrote.

The case was described in a report, “Cushing’s syndrome in pregnancy in which laparoscopic adrenalectomy was safely performed by a retroperitoneal approach,” published in the journal IJU Case Reports.

Cushing’s syndrome comprises a group of conditions characterized by excessive levels of the cortisol hormone. This often occurs due to a tumor in the brain’s pituitary gland — then called Cushing’s disease — that increases the production of the adrenocorticotropic hormone (ACTH), stimulating the adrenal glands (sitting on top of the kidneys) to produce cortisol.

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Surgery, anesthesia risks for pregnant women

Cortisol-producing adrenal tumors also can cause Cushing’s syndrome, and laparoscopic adrenalectomy is the standard treatment. However, “few pregnant women with adrenal [Cushing’s syndrome] undergo adrenalectomy” due to the risks associated with the surgery itself and general anesthesia, the researchers wrote.

Still, the laparoscopic approach, a minimally invasive procedure that allows a surgeon to access the inside of the abdomen without making large incisions in the skin, “is safe, and maternal and fetal complications were higher in women who did not undergo surgery,” the researchers wrote.

“Less postoperative pain, faster wound healing, and faster postoperative recovery are the main advantages of laparoscopic surgery,” they added.

In this report, a team of Japanese researchers described the case of a 28-year-old pregnant woman who developed Cushing’s syndrome due to a tumor in the adrenal gland and whose symptoms eased after laparoscopic adrenalectomy.

The woman, pregnant for the first time, had developed facial and leg swelling and more facial acne since her 12th week of pregnancy, in addition to gaining 6 kg (about 13 pounds) in one month. She also experienced bleeding under the skin in her arms, skin irritation in the abdomen, muscle weakness, palpitations, insomnia, and reduced vision.

She was referred to the hospital at 18 weeks of pregnancy, after her symptoms gradually worsened from week 14, to identify the cause of her symptoms.

Considering her Cushing’s signs, and the fact that she had high cortisol levels and low ACTH levels, she was suspected to have adrenal tumor-related Cushing’s.  Further examination revealed she had low blood levels of potassium and antibodies, and liver dysfunction.

Due to the rapidly worsening of the woman’s state and because she was pregnant, she was admitted to the hospital at 19 weeks of pregnancy for intensive testing. An MRI scan revealed a 38 mm tumor in her left adrenal gland, which was causing her Cushing’s syndrome.

She was started on metyrapone, a cortisol-lowering medication marketed under the brand name Metopirone. This increased her levels of sexual male hormones, or androgens, which are also produced by the adrenal glands.

The researchers considered it would be difficult to control her disease with medication alone and decided to perform surgery to remove the adrenal tumor.

“While the management of the cortisol levels is important, metyrapone is a risk factor for gestational [high blood pressure] and may [suppress] fetal cortisol production by crossing the placenta,” the researchers wrote. “In this case, because androgens were also elevated and drug management was expected to be challenging, the surgery was aggressively considered.”

Surgery successfully performed at 23 weeks of pregnancy

At 23 weeks of pregnancy, the woman underwent laparoscopic left adrenalectomy via a retroperitoneal approach. In this approach, the retroperitoneal space — the space in front of the lower back and behind the abdominal lining, where kidneys are located — is accessed with the patient placed in the right lateral position.

“In pregnant women, performing the surgery by the retroperitoneal approach in the lateral position is preferable to prevent putting pressure on the fetus during the surgery,” the team wrote.

During surgery, the woman’s blood pressure was carefully monitored, as well as fetal heart rate. The procedure occurred without complications. The analysis of the removed tissue showed the tumor was benign.

After surgery, she stopped taking metyrapone, and she experienced a reduction in cortisol levels, as well as in leg swelling, facial acne, fatigue, and muscle weakness.

From before the surgery to about three months after the baby was born, she received hydrocortisone to prevent post-adrenalectomy low cortisol. The baby was born by cesarean section at 38 weeks, without complications for both the mother and the baby.

“We present a case of a pregnant woman diagnosed with adrenal [Cushing’s syndrome] who underwent a unilateral laparoscopic adrenalectomy by a retroperitoneal approach without any problems,” the researchers wrote. “Adrenalectomy is a useful treatment when [Cushing’s syndrome] is difficult to control despite metyrapone and other medical support.”