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74 systoles&#46; She had no distal oedemas or other data of interest&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Supplementary tests</span></p><p class="elsevierStylePara">1&#46;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; Haemogram&#58; normal&#46;</p><p class="elsevierStylePara">2&#46;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; Biochemistry&#58; creatinine&#58; 0&#46;92mg&#47;dl&#59; glomerular filtration rate &#40;GFR&#41; calculated using MDRD-4 equation&#58; 67ml&#47;min&#59; sodium&#58; 140mEq&#47;l&#59; potassium&#58; 3&#46;3mEq&#47;l&#59; calcium&#58; 9&#46;7mg&#47;dl&#59; uric acid&#58; 4&#46;7mg&#47;dl&#59; GOT&#58; 26IU&#47;dl&#59; GPT&#58; 21IU&#47;dl&#59; LDH&#58; 337IU&#47;l&#59; total bilirubin&#58; 0&#46;3mg&#47;dl&#59; normal coagulation&#44; negative indirect Coombs test&#46;</p><p class="elsevierStylePara">3&#46;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; Venous gasometry&#58; normal&#46;</p><p class="elsevierStylePara">4&#46;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; Urine&#58; negative systematic and sedimentary tests&#44; microalbuminuria&#47;creatinine index&#58; 8&#181;g&#47;mg&#59; uricosuria&#58; 0&#46;3g&#47;24h&#46;</p><p class="elsevierStylePara">5&#46;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; Chest X-ray&#58; no pathological findings&#46;</p><p class="elsevierStylePara">6&#46;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; Electrocardiogram&#58; sinus rhythm&#44; no blockages or signs of ischaemia&#46;</p><p class="elsevierStylePara">7&#46;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; Funduscopy&#58; normal&#46;</p><p class="elsevierStylePara">8&#46;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; Anatomopathological exam of the placenta&#58; normal&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The abdominal ultrasound and renal Doppler scan were normal&#46; Drug treatment was started with calcium antagonists and doxazosin&#44; achieving better pressure control&#44; although it was insufficient&#46; A second analysis found plasma aldosterone of 1161pg&#47;ml and urinary aldosterone of 22&#46;68&#181;g&#47;24h&#44; with a plasma renin activity at baseline of 0&#46;6ng&#47;ml&#47;h and aldosterone&#47;renin rate of 193&#46;3&#46; The remaining parameters &#40;catecholamines in urine&#44; thyroid hormones and plasma cortisol&#41; were all normal&#46; Given the suspected primary hyperaldosteronism &#40;PHA&#41;&#44; a saline overload test was performed and 2 litres of physiological saline solution administered over 4 hours&#46; Previous treatment did not have to be modified&#44; however&#44; we do recommend suspending angiotensin-converting enzymes &#40;ACE&#41;&#44; angiotensin II receptor antagonists &#40;ARA-II&#41;&#44; beta-blockers and diuretics beforehand&#46;<span class="elsevierStyleSup">1</span> Following the saline overload&#44; aldosterone was not suppressed&#44; being 27&#46;6ng&#47;dl &#40;normal&#58; &#60;10ng&#47;dl&#41;&#46; PHA was confirmed as the cause of her secondary AHT and treatment with spironolactone was started&#44; achieving better blood pressure control and relieving her asthenia&#46; The examination was completed with a CT with contrast medium and magnetic resonance imaging&#44; which revealed a 1cm-adenoma in the left suprarenal gland &#40;Figure 1&#41;&#46;</p><p class="elsevierStylePara">At present&#44; BP is controlled with 50mg of spironolactone per day&#44; and the patient is waiting for a left suprarenalectomy to avoid complications in future pregnancies&#46;</p><p class="elsevierStylePara">This case illustrates the serious complications that are secondary to poorly controlled ATH during pregnancy&#44; such as miscarriage&#44; <span class="elsevierStyleItalic">abruptio placentae&#44; </span>and<span class="elsevierStyleItalic"> </span>delayed foetal growth&#44; which is likely to be related to vasoconstriction and placental endothelial dysfunction&#46;<span class="elsevierStyleSup">2</span> The differential diagnosis of ATH during pregnancy involves testing for essential hypertension&#44; pregnancy-related ATH&#44; pre-eclampsia or secondary aetiology&#46;<span class="elsevierStyleSup">3 </span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Essential ATH&#46; </span>It is difficult to diagnose it during pregnancy if the patient has not been diagnosed with ATH previously or has not had any BP readings&#46; Pregnant patients diagnosed with chronic ATH present with BP equal or above 140&#47;90mm Hg on two occasions before the twentieth week of the pregnancy&#44; which continues to persist 6 weeks postpartum&#46; Our patient claimed that she had no history of ATH and no lesions to the target organ were found due to ATH&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Pregnancy-related ATH&#46; </span>It is the main cause of hypertension during pregnancy&#44;<span class="elsevierStyleSup">4</span> and appears during the second half of the pregnancy in patients that were previously normotensive&#46; It is not usually associated with oedemas or proteinuria and BP normalises after the birth&#44; although high BP levels can persist up to 10 days following delivery&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Pre-eclampsia&#46; </span>It is a pregnancy-related disorder&#44; which develops from the 20<span class="elsevierStyleSup">th</span> week&#46; The patient has arterial hypertension and proteinuria above 0&#46;3g&#47;24h&#46;<span class="elsevierStyleSup">5</span> Proteinuria may become apparent in advanced phases of the pregnancy&#44; meaning that in principle&#44; pre-eclampsia should not be ruled out when there is no sign of proteinuria&#44; especially if ATH is diagnosed after 20 weeks of pregnancy&#44; with headaches&#44; oedemas or altered laboratory findings &#40;thrombocytopaenia&#44; altered hepatic enzymes&#44; hyperuricaemia&#41;&#46; New low calciuria levels has been reported to be an early pre-eclampsia marker&#46;<span class="elsevierStyleSup">6 </span>The patient in this case&#44; had ATH before 20 weeks&#44; no analytical alterations were found which would suggest pre-eclampsia&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Secondary ATH&#46; </span>Some authors recommend assessing metanephrine and normetanephrine levels and performing an ultrasound scan of the suprarenal gland for patients with recently diagnosed ATH&#46;<span class="elsevierStyleSup">5</span> This is because a pheochromocytoma could be completely asymptomatic and fatal if not diagnosed before the birth&#46; In our study&#44; having dismissed previous essential ATH and pre-eclampsia&#44; we investigated the possibility of secondary ATH&#44; and finally diagnosed primary hyperaldosteronism from the supplementary tests mentioned above&#46;</p><p class="elsevierStylePara">The treatment of choice for ATH secondary to PHA is eplerenone or spironolactone but both of them should not be used during pregnancy due to the potential feminising effect that aldosterone has on male foetuses&#46;<span class="elsevierStyleSup">7</span> We have found very little evidence of eplerenone use during pregnancy&#46;<span class="elsevierStyleSup">8 </span>Alpha-methyldopa&#44; labetalol and amlodipine can be used as alternative treatments&#46; Surgery should only be indicated during pregnancy for cases that are refractory to conventional treatment<span class="elsevierStyleSup">9</span><span class="elsevierStyleSup"> </span>or if patients have adenomas more than 4cm in diameter&#46;<span class="elsevierStyleSup">9</span> New laparoscopic surgical techniques during pregnancy have lead to greater effectiveness and less surgical risk for the mother and the baby&#46; The retroperitoneal approach has more advantages than the transperitoneal one&#44; given that organ movement is more restricted during the surgical procedure and because it uses much lower intraabdominal pressure&#46;<span class="elsevierStyleSup">10&#44;11</span></p><p class="elsevierStylePara">To conclude&#44; PHA diagnosis is very rare during pregnancy&#44; but it must be taken into consideration because early treatment could reduce severe complications related to poor blood pressure control&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10677&#95;108&#95;15831&#95;en&#95;10677&#95;18107&#95;11652&#95;es4881b5&#46;jpg" class="elsevierStyleCrossRefs"><img src="10677_108_15831_en_10677_18107_11652_es4881b5.jpg" alt="MR of left adrenal gland"></img></a></p><p class="elsevierStylePara">Figure 1&#46; MR of left adrenal gland</p>"
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Diagnosis of secondary hypertension causing miscarriage during the first trimester of pregnancy
Diagnóstico de una hipertensión arterial secundaria en una gestante en el primer trimestre como causa de un aborto espontáneo
O.. Fikri Benbrahima, R.. García Agudoa, F.. Cazalla Cadenasa, A.. Martínez Caleroa, J.. González-Spínolab
a Sección de Nefrología, Hospital La Mancha Centro, Alcázar de San Juan, Ciudad Real,
b Servicio de Radiología, Hospita La Mancha Centro, Alcázar de San Juan, Ciudad Real,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44; </span></p><p class="elsevierStylePara">Uncontrolled arterial hypertension &#40;AHT&#41; during pregnancy compromises correct gestation development&#46; We describe the case of a 41-year-old pregnant woman who was referred to our unit after having suffered a miscarriage in the tenth week of gestation&#46;</p><p class="elsevierStylePara">The patient had no personal or family history of interest&#44; and ATH was detected in the eighth week of pregnancy&#46; She visited the emergency department on several occasions due to metrorrhagia and asthenia&#44; with blood pressure &#40;BP&#41; at around 160-170&#47;100-110mm Hg&#46; Alpha-methyldopa was prescribed at 500mg every 8 hours&#44; gradually increasing doses but without adequately controlling AHT&#46; In the tenth week of pregnancy&#44; the patient had a miscarriage and was referred to the outpatient nephrology unit&#46;</p><p class="elsevierStylePara">In the physical examination BP was 162&#47;100mm Hg and heart rate &#40;HR&#41; 74 systoles&#46; She had no distal oedemas or other data of interest&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Supplementary tests</span></p><p class="elsevierStylePara">1&#46;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; Haemogram&#58; normal&#46;</p><p class="elsevierStylePara">2&#46;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; Biochemistry&#58; creatinine&#58; 0&#46;92mg&#47;dl&#59; glomerular filtration rate &#40;GFR&#41; calculated using MDRD-4 equation&#58; 67ml&#47;min&#59; sodium&#58; 140mEq&#47;l&#59; potassium&#58; 3&#46;3mEq&#47;l&#59; calcium&#58; 9&#46;7mg&#47;dl&#59; uric acid&#58; 4&#46;7mg&#47;dl&#59; GOT&#58; 26IU&#47;dl&#59; GPT&#58; 21IU&#47;dl&#59; LDH&#58; 337IU&#47;l&#59; total bilirubin&#58; 0&#46;3mg&#47;dl&#59; normal coagulation&#44; negative indirect Coombs test&#46;</p><p class="elsevierStylePara">3&#46;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; Venous gasometry&#58; normal&#46;</p><p class="elsevierStylePara">4&#46;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; Urine&#58; negative systematic and sedimentary tests&#44; microalbuminuria&#47;creatinine index&#58; 8&#181;g&#47;mg&#59; uricosuria&#58; 0&#46;3g&#47;24h&#46;</p><p class="elsevierStylePara">5&#46;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; Chest X-ray&#58; no pathological findings&#46;</p><p class="elsevierStylePara">6&#46;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; Electrocardiogram&#58; sinus rhythm&#44; no blockages or signs of ischaemia&#46;</p><p class="elsevierStylePara">7&#46;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; Funduscopy&#58; normal&#46;</p><p class="elsevierStylePara">8&#46;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; Anatomopathological exam of the placenta&#58; normal&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The abdominal ultrasound and renal Doppler scan were normal&#46; Drug treatment was started with calcium antagonists and doxazosin&#44; achieving better pressure control&#44; although it was insufficient&#46; A second analysis found plasma aldosterone of 1161pg&#47;ml and urinary aldosterone of 22&#46;68&#181;g&#47;24h&#44; with a plasma renin activity at baseline of 0&#46;6ng&#47;ml&#47;h and aldosterone&#47;renin rate of 193&#46;3&#46; The remaining parameters &#40;catecholamines in urine&#44; thyroid hormones and plasma cortisol&#41; were all normal&#46; Given the suspected primary hyperaldosteronism &#40;PHA&#41;&#44; a saline overload test was performed and 2 litres of physiological saline solution administered over 4 hours&#46; Previous treatment did not have to be modified&#44; however&#44; we do recommend suspending angiotensin-converting enzymes &#40;ACE&#41;&#44; angiotensin II receptor antagonists &#40;ARA-II&#41;&#44; beta-blockers and diuretics beforehand&#46;<span class="elsevierStyleSup">1</span> Following the saline overload&#44; aldosterone was not suppressed&#44; being 27&#46;6ng&#47;dl &#40;normal&#58; &#60;10ng&#47;dl&#41;&#46; PHA was confirmed as the cause of her secondary AHT and treatment with spironolactone was started&#44; achieving better blood pressure control and relieving her asthenia&#46; The examination was completed with a CT with contrast medium and magnetic resonance imaging&#44; which revealed a 1cm-adenoma in the left suprarenal gland &#40;Figure 1&#41;&#46;</p><p class="elsevierStylePara">At present&#44; BP is controlled with 50mg of spironolactone per day&#44; and the patient is waiting for a left suprarenalectomy to avoid complications in future pregnancies&#46;</p><p class="elsevierStylePara">This case illustrates the serious complications that are secondary to poorly controlled ATH during pregnancy&#44; such as miscarriage&#44; <span class="elsevierStyleItalic">abruptio placentae&#44; </span>and<span class="elsevierStyleItalic"> </span>delayed foetal growth&#44; which is likely to be related to vasoconstriction and placental endothelial dysfunction&#46;<span class="elsevierStyleSup">2</span> The differential diagnosis of ATH during pregnancy involves testing for essential hypertension&#44; pregnancy-related ATH&#44; pre-eclampsia or secondary aetiology&#46;<span class="elsevierStyleSup">3 </span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Essential ATH&#46; </span>It is difficult to diagnose it during pregnancy if the patient has not been diagnosed with ATH previously or has not had any BP readings&#46; Pregnant patients diagnosed with chronic ATH present with BP equal or above 140&#47;90mm Hg on two occasions before the twentieth week of the pregnancy&#44; which continues to persist 6 weeks postpartum&#46; Our patient claimed that she had no history of ATH and no lesions to the target organ were found due to ATH&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Pregnancy-related ATH&#46; </span>It is the main cause of hypertension during pregnancy&#44;<span class="elsevierStyleSup">4</span> and appears during the second half of the pregnancy in patients that were previously normotensive&#46; It is not usually associated with oedemas or proteinuria and BP normalises after the birth&#44; although high BP levels can persist up to 10 days following delivery&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Pre-eclampsia&#46; </span>It is a pregnancy-related disorder&#44; which develops from the 20<span class="elsevierStyleSup">th</span> week&#46; The patient has arterial hypertension and proteinuria above 0&#46;3g&#47;24h&#46;<span class="elsevierStyleSup">5</span> Proteinuria may become apparent in advanced phases of the pregnancy&#44; meaning that in principle&#44; pre-eclampsia should not be ruled out when there is no sign of proteinuria&#44; especially if ATH is diagnosed after 20 weeks of pregnancy&#44; with headaches&#44; oedemas or altered laboratory findings &#40;thrombocytopaenia&#44; altered hepatic enzymes&#44; hyperuricaemia&#41;&#46; New low calciuria levels has been reported to be an early pre-eclampsia marker&#46;<span class="elsevierStyleSup">6 </span>The patient in this case&#44; had ATH before 20 weeks&#44; no analytical alterations were found which would suggest pre-eclampsia&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Secondary ATH&#46; </span>Some authors recommend assessing metanephrine and normetanephrine levels and performing an ultrasound scan of the suprarenal gland for patients with recently diagnosed ATH&#46;<span class="elsevierStyleSup">5</span> This is because a pheochromocytoma could be completely asymptomatic and fatal if not diagnosed before the birth&#46; In our study&#44; having dismissed previous essential ATH and pre-eclampsia&#44; we investigated the possibility of secondary ATH&#44; and finally diagnosed primary hyperaldosteronism from the supplementary tests mentioned above&#46;</p><p class="elsevierStylePara">The treatment of choice for ATH secondary to PHA is eplerenone or spironolactone but both of them should not be used during pregnancy due to the potential feminising effect that aldosterone has on male foetuses&#46;<span class="elsevierStyleSup">7</span> We have found very little evidence of eplerenone use during pregnancy&#46;<span class="elsevierStyleSup">8 </span>Alpha-methyldopa&#44; labetalol and amlodipine can be used as alternative treatments&#46; Surgery should only be indicated during pregnancy for cases that are refractory to conventional treatment<span class="elsevierStyleSup">9</span><span class="elsevierStyleSup"> </span>or if patients have adenomas more than 4cm in diameter&#46;<span class="elsevierStyleSup">9</span> New laparoscopic surgical techniques during pregnancy have lead to greater effectiveness and less surgical risk for the mother and the baby&#46; The retroperitoneal approach has more advantages than the transperitoneal one&#44; given that organ movement is more restricted during the surgical procedure and because it uses much lower intraabdominal pressure&#46;<span class="elsevierStyleSup">10&#44;11</span></p><p class="elsevierStylePara">To conclude&#44; PHA diagnosis is very rare during pregnancy&#44; but it must be taken into consideration because early treatment could reduce severe complications related to poor blood pressure control&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10677&#95;108&#95;15831&#95;en&#95;10677&#95;18107&#95;11652&#95;es4881b5&#46;jpg" class="elsevierStyleCrossRefs"><img src="10677_108_15831_en_10677_18107_11652_es4881b5.jpg" alt="MR of left adrenal gland"></img></a></p><p class="elsevierStylePara">Figure 1&#46; MR of left adrenal gland</p>"
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Article information
ISSN: 20132514
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2022 September 87 29 116
2022 August 102 53 155
2022 July 76 53 129
2022 June 122 30 152
2022 May 111 41 152
2022 April 106 62 168
2022 March 99 36 135
2022 February 152 37 189
2022 January 131 37 168
2021 December 130 47 177
2021 November 106 40 146
2021 October 138 54 192
2021 September 102 46 148
2021 August 168 49 217
2021 July 153 50 203
2021 June 143 35 178
2021 May 158 42 200
2021 April 385 36 421
2021 March 222 35 257
2021 February 207 26 233
2021 January 196 25 221
2020 December 141 25 166
2020 November 137 14 151
2020 October 101 17 118
2020 September 125 8 133
2020 August 101 16 117
2020 July 133 16 149
2020 June 115 11 126
2020 May 116 18 134
2020 April 210 20 230
2020 March 182 11 193
2020 February 180 24 204
2020 January 183 19 202
2019 December 167 27 194
2019 November 156 29 185
2019 October 132 8 140
2019 September 166 21 187
2019 August 174 17 191
2019 July 181 32 213
2019 June 127 16 143
2019 May 128 15 143
2019 April 167 43 210
2019 March 102 12 114
2019 February 70 18 88
2019 January 81 19 100
2018 December 139 33 172
2018 November 163 14 177
2018 October 178 18 196
2018 September 91 17 108
2018 August 78 16 94
2018 July 62 14 76
2018 June 69 6 75
2018 May 72 17 89
2018 April 79 8 87
2018 March 86 6 92
2018 February 70 4 74
2018 January 79 11 90
2017 December 95 8 103
2017 November 52 11 63
2017 October 54 11 65
2017 September 61 12 73
2017 August 66 10 76
2017 July 66 16 82
2017 June 57 14 71
2017 May 72 18 90
2017 April 84 7 91
2017 March 50 38 88
2017 February 83 7 90
2017 January 46 8 54
2016 December 66 10 76
2016 November 63 7 70
2016 October 111 8 119
2016 September 127 4 131
2016 August 193 7 200
2016 July 167 6 173
2016 June 141 0 141
2016 May 140 0 140
2016 April 106 0 106
2016 March 104 0 104
2016 February 125 0 125
2016 January 107 0 107
2015 December 124 0 124
2015 November 93 0 93
2015 October 91 0 91
2015 September 66 0 66
2015 August 73 0 73
2015 July 69 0 69
2015 June 37 0 37
2015 May 60 0 60
2015 April 5 0 5
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¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?