Case report
Renal oncocytoma in pregnancy – an unusual presentation of secondary hypertension
Oncocitoma renal na gravidez – uma forma invulgar de hipertensão secundária
a Internato Médico em Ginecologia-Obstetrícia, Maternidade Dr. Alfredo da Costa, Lisboa, Portugal
b Departamento de Medicina Interna, Maternidade Dr. Alfredo da Costa, Lisboa, Portugal
c Serviço de Medicina Materno-Fetal, Maternidade Dr. Alfredo da Costa, Lisboa, Portugal
d Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
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A propósito de um caso clínico" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 567 "Ancho" => 2337 "Tamanyo" => 187560 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Transthoracic echocardiography: (A) end-diastolic apical 4-chamber view showing right ventricular dilatation, paradoxical septal wall motion and pulmonary artery systolic pressure of 65<span class="elsevierStyleHsp" style=""></span>mmHg; (B) parasternal short-axis view showing diastolic flattening of the ventricular septum due to pulmonary hypertension; (C) preserved right ventricular 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Maternidade Dr. Alfredo da Costa, Lisboa, Portugal" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal" "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Oncocitoma renal na gravidez – uma forma invulgar de hipertensão secundária" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1215 "Ancho" => 1583 "Tamanyo" => 148038 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Nuclear magnetic resonance image of renal oncocytoma – coronal view.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">The authors report the case of a 32-year-old woman, white, with no relevant medical, surgical or obstetric history. The current pregnancy arose through medically assisted techniques due to primary infertility.</p><p id="par0010" class="elsevierStylePara elsevierViewall">During the first half of the pregnancy, the patient developed hypertension that was difficult to control despite combined medical therapy with alpha-methyldopa 500<span class="elsevierStyleHsp" style=""></span>mg every <span class="elsevierStyleHsp" style=""></span>hours, propranolol 20<span class="elsevierStyleHsp" style=""></span>mg every 8<span class="elsevierStyleHsp" style=""></span>hours and nifedipine CR 30<span class="elsevierStyleHsp" style=""></span>mg once a day.</p><p id="par0015" class="elsevierStylePara elsevierViewall">At 24 weeks gestation, following further elevation of blood pressure (BP) (194/131<span class="elsevierStyleHsp" style=""></span>mmHg), visual disturbances, proteinuria and worsening renal function, the patient was transferred to a hospital with specialist perinatal support services and admitted to a maternal–fetal intensive care unit. The clinical setting and laboratory tests confirmed chronic hypertension with superimposed pre-eclampsia; intravenous perfusion of labetalol and magnesium sulfate was therefore begun and betamethasone was administered for fetal pulmonary maturation according to the department's protocol. On the third day of hospital stay, the patient's clinical condition worsened despite therapy, and she developed ascites, limb edema, periorbital edema and other signs of volume overload. Laboratory tests revealed hypoalbuminemia and worsening renal function (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Fetal ultrasound showed a good biophysical profile (8/8), despite fetal growth restriction and absent end-diastolic flow; ductus venosus Doppler was normal, and regular fetal monitoring was instituted.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">On the fourth day of hospital stay, a diagnosis of acute pulmonary edema in the context of hypertensive crisis was made and appropriate therapeutic measures were taken. On the sixth day, there was further worsening of the mother's pulmonary status requiring invasive mechanical ventilation, followed by fetal death; the patient was transferred to a general intensive care unit. The fetus was stillborn two days later, and the patient's condition slowly improved.</p><p id="par0025" class="elsevierStylePara elsevierViewall">A thorough etiological study was performed in the postpartum period, including renal and endocrine studies and investigation of hereditary and acquired thrombophilia.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Renal ultrasound showed a well-defined mass in the lower pole of the right kidney. Renal magnetic resonance imaging was performed to clarify its nature and relations, which showed a well-defined, macronodular mass measuring 85<span class="elsevierStyleHsp" style=""></span>mm at its widest point, with radial expression and a central necrotic scar with high contrast uptake, suggestive of renal oncocytoma (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Total right nephrectomy was subsequently performed and the surgical specimen was sent for pathoanatomical and immunohistochemical study. This confirmed a solid tumor measuring 85<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>70<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>65<span class="elsevierStyleHsp" style=""></span>mm, consisting of granular and eosinophilic cytoplasm, positive for Cam 5.2 and negative for CD10, and focally positive for CK7 and vimentin, compatible with a diagnosis of renal oncocytoma.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient's BP normalized in the postoperative period.</p><p id="par0045" class="elsevierStylePara elsevierViewall">After two years of clinical surveillance, the patient became pregnant again. The second pregnancy was monitored from the first trimester at our institution and was uneventful, with normal BP. At 36 weeks, it was decided to perform a cesarean section due to abnormal fetal presentation and oligamnios, resulting in the birth of a healthy boy weighing 2165<span class="elsevierStyleHsp" style=""></span>g, with an Apgar score of 7/10.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Renal oncocytoma accounts for 5–7% of primary renal neoplasms. It is usually diagnosed in asymptomatic patients following diagnostic exams for non-urological reasons.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">On histopathological study, renal oncocytoma presents as a well-defined, solid mass in the renal parenchyma with a central sclerosed area, although it should be remembered that this classical finding is present in only a third of cases.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> Diagnosis therefore requires thorough histopathological study to document the presence of tumor cells arranged in nests, cords, or tubules, with eosinophilic cytoplasm and no mitosis, and exclude the coexistence of a clear-cell tumor, found in 10–32% of cases in the literature.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4,5</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">This type of tumor usually has a benign behavior and excellent prognosis. Even large masses are encapsulated and as such are rarely invasive or associated with metastasis.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Diagnosis of renal oncocytoma during pregnancy is uncommon. In 1989, Fraser et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> published the first case report of a renal tumor diagnosed at 23 weeks gestation following investigation of right lower back pain in a healthy 31-year-old woman. This case had a good perinatal outcome despite pre-eclampsia.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In the case presented here, the renal oncocytoma was diagnosed following investigation of the cause of hypertension detected in the first half of the pregnancy that was refractory to combined therapy, culminating in early onset of severe pre-eclampsia associated with acute pulmonary edema requiring invasive ventilation, followed by fetal death.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Pre-eclampsia is defined as hypertension (BP of over 140/90<span class="elsevierStyleHsp" style=""></span>mmHg in two measurements at least 6<span class="elsevierStyleHsp" style=""></span>h apart) and proteinuria of over 300<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h. It is a complex maternal–fetal syndrome of early onset that results from inadequate trophoblast invasion. The complications associated with this syndrome include acute renal failure, eclampsia, acute pulmonary edema, placental abruption fetal growth restriction and fetal death. Such manifestations or the development of pre-eclampsia at early gestational ages are taken by some authors as a criterion of severe disease that justifies thorough investigation of the underlying causes.</p><p id="par0075" class="elsevierStylePara elsevierViewall">This case presented with hypertension before the 20th week of gestation that could not be controlled despite combined antihypertensive therapy, and was associated with significant maternal morbidity and fetal death. Thorough investigation to exclude a secondary cause led to a diagnosis of renal oncocytoma and resolution of the patient's hypertension.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0080" class="elsevierStylePara elsevierViewall">The clinical behavior of renal oncocytoma remains poorly characterized during pregnancy and may lead to an adverse maternal and fetal outcome despite its theoretically benign behavior.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The authors highlight the importance of excluding a secondary cause of hypertension in cases that are difficult to control.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres176188" "titulo" => array:4 [ 0 => "Abstract" 1 => "Introduction" 2 => "Case report" 3 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec164566" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres176189" "titulo" => array:4 [ 0 => "Resumo" 1 => "Introdução" 2 => "Caso clínico" 3 => "Conclusão" ] ] 3 => array:2 [ "identificador" => "xpalclavsec164565" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Conclusion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-08-22" "fechaAceptado" => "2011-10-11" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec164566" "palabras" => array:3 [ 0 => "Renal oncocytoma" 1 => "Pregnancy" 2 => "Hypertensive disorder" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec164565" "palabras" => array:3 [ 0 => "Oncocitoma renal" 1 => "Gravidez" 2 => "Patologia hipertensiva" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Renal oncocytoma accounts for 5–7% of primary renal neoplasms. It is usually diagnosed in asymptomatic patients and is characterized by a benign behavior without invasion of adjacent tissues or metastasis. Diagnosis during pregnancy is uncommon and to date there have been only a few cases reported in the literature.</p> <span class="elsevierStyleSectionTitle">Case report</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The authors present the case of a 32-year-old nulliparous woman with uncontrolled hypertension diagnosed at seven weeks gestation. She was referred to our institution at 24 weeks with superimposed pre-eclampsia complicated by acute pulmonary edema and hemodynamic instability requiring mechanical ventilatory support, fetal growth restriction and stillbirth. Etiological study of the hypertensive disorder performed in the postpartum period was consistent with renal oncocytoma.</p> <span class="elsevierStyleSectionTitle">Conclusion</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The clinical behavior of renal oncocytoma remains poorly characterized during pregnancy and may lead to an adverse maternal and fetal outcome despite its theoretically benign behavior. It is essential to exclude a possible secondary cause of hypertension in cases that are difficult to control.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span class="elsevierStyleSectionTitle">Introdução</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">O oncocitoma renal representa 5–7% das neoplasias primárias do rim, é diagnosticado em doentes assintomáticos e caracteriza-se por um comportamento benigno, sem invasão dos tecidos adjacentes ou metastização. O seu diagnóstico no decurso da gravidez é raro, havendo poucos casos descritos na literatura.</p> <span class="elsevierStyleSectionTitle">Caso clínico</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Os autores apresentam o caso de uma nulípara de 32 anos com hipertensão arterial de difícil controlo diagnosticada às sete semanas gestacionais com internamento às 24 semanas por quadro de hipertensão crónica agravada com pré-eclâmpsia sobreposta, edema agudo do pulmão e instabilidade hemodinâmica com necessidade de suporte ventilatório mecânico, restrição do crescimento fetal e morte fetal. O estudo etiológico do quadro hipertensivo efectuado no período pós-parto permitiu demonstrar a existencia de um tumor renal-oncocitoma.</p> <span class="elsevierStyleSectionTitle">Conclusão</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">O comportamento clínico do oncocitoma renal permanece mal caracterizado durante a gravidez, podendo associar-se, apesar do seu comportamento teoricamente benigno, a um desfecho materno e fetal adverso. É fundamental excluir uma possível causa secundária nos quadros hipertensivos de difícil controlo.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Torres, R. Oncocitoma renal na gravidez – uma forma invulgar de hipertensão secundária. Rev Port Cardiol 2012. <span class="elsevierStyleInterRef" href="doi:10.1016/j.repc.2011.08.002">doi:10.1016/j.repc.2011.08.002</span></p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1138 "Ancho" => 1587 "Tamanyo" => 117194 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Nuclear magnetic resonance image of renal oncocytoma – transverse view.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1215 "Ancho" => 1583 "Tamanyo" => 148038 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Nuclear magnetic resonance image of renal oncocytoma – coronal view.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">ALT: alanine aminotransferase; AST: aspartate aminotransferase; BP: blood pressure; DV: ductus venosus; Hb: hemoglobin; IDN: isosorbide dinitrate; MCA: middle cerebral artery; Mg<span class="elsevierStyleSup">2+</span>: magnesium; UA: umbilical artery.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Gestational age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Maternal syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Fetal syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Treatment \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Day 124 weeks 5 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BP 174/115<span class="elsevierStyleHsp" style=""></span>mmHg, proteinuria and lower limb edemaLaboratory results: Hb 11.9<span class="elsevierStyleHsp" style=""></span>mg/dl, leukocytes 13<span class="elsevierStyleHsp" style=""></span>000/μl, platelets 287<span class="elsevierStyleHsp" style=""></span>000/μl, urate 5.6<span class="elsevierStyleHsp" style=""></span>mg/dl, creatinine 0.8<span class="elsevierStyleHsp" style=""></span>mg/dl, AST 13, ALT 15, proteinuria 0.8<span class="elsevierStyleHsp" style=""></span>g/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Betamethasone, magnesium sulfate, labetalol, nifedipine, methyldopa \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Day 325 weeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Periorbital edema and ascitesLaboratory results: Hb 10mg/dl, leukocytes 17<span class="elsevierStyleHsp" style=""></span>100/μl, platelets 246<span class="elsevierStyleHsp" style=""></span>000/μl, urate 7.2<span class="elsevierStyleHsp" style=""></span>mg/dl, creatinine 0.9<span class="elsevierStyleHsp" style=""></span>mg/dl, AST 14, ALT 16, Mg<span class="elsevierStyleSup">2+</span> 5.6, proteinuria 0.4<span class="elsevierStyleHsp" style=""></span>g/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ultrasound:Pelvic presentation, estimated weight 587<span class="elsevierStyleHsp" style=""></span>gFlowmetry:Absence of diastolic flow in UA, normal DV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Furosemide, labetalol, nifedipine, methyldopa, magnesium sulfate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Day 425 weeks 1 day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dyspnea, bibasal crackling ralesLaboratory results: Hb 9.0<span class="elsevierStyleHsp" style=""></span>g/dl, leukocytes 14<span class="elsevierStyleHsp" style=""></span>900/μl, platelets 228<span class="elsevierStyleHsp" style=""></span>000/μl, urate 8.1<span class="elsevierStyleHsp" style=""></span>mg/dl, albumin 2.6<span class="elsevierStyleHsp" style=""></span>g/dl, AST 20, ALT 19, proteinuria 1<span class="elsevierStyleHsp" style=""></span>g/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Furosemide, labetalol, nifedipine, methyldopa, IDN, desalted human albumin \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Day 525 weeks 2 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dyspnea, bibasal crackling ralesLaboratory results: Hb 10.2 g/dl, leukocytes 16<span class="elsevierStyleHsp" style=""></span>000/μl, platelets 246<span class="elsevierStyleHsp" style=""></span>000/μl, urate 9.0<span class="elsevierStyleHsp" style=""></span>mg/dl, creatinine 0.9<span class="elsevierStyleHsp" style=""></span>mg/dl, albumin 2.9<span class="elsevierStyleHsp" style=""></span>g/dl, proteinuria 1.5<span class="elsevierStyleHsp" style=""></span>g/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Flowmetry:Reverse diastolic flow in UA, normal MCA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Furosemide, labetalol, nifedipine, methyldopa, IDN, desalted human albumin \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Day 625 weeks 3 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Acute pulmonary edema with hemodynamic instability (BP 160/110<span class="elsevierStyleHsp" style=""></span>mmHg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fetal death \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Invasive ventilation \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab268770.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Maternal and fetal evolution in the maternal–fetal intensive care unit.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Giant renal oncocytoma: a case report and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. Akbulut" 1 => "A. Senol" 2 => "B. Cakabay" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1752-1947-4-52" "Revista" => array:5 [ "tituloSerie" => "Journal of Medical Case Reports" "fecha" => "2010" "volumen" => "4" "paginaInicial" => "52" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20205900" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Renal adenomas: pathological differential diagnosis with malignant tumors" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "F. Algaba" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Advances in Urology" "fecha" => "2008" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Renal oncocytoma in pregnancy: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "W. Fraser" 1 => "M. Auger" 2 => "R. Onerheim" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Canadian Journal of Surgery" "fecha" => "1989" "volumen" => "32" "paginaInicial" => "124" "paginaFinal" => "126" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Renal Oncocytoma: a clinicopathologic study of 70 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "B. Perez-Ordonez" 1 => "G. Hamed" 2 => "S. Campbell" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "American Journal of Surgical Pathology" "fecha" => "1997" "volumen" => "21" "paginaInicial" => "871" "paginaFinal" => "883" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9255250" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sub-typing of renal cell tumors; contribution of ancillary techniques" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D. Pradhan" 1 => "N. Kakkar" 2 => "A. Bal" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1746-1596-4-21" "Revista" => array:5 [ "tituloSerie" => "Diagnostic Pathology" "fecha" => "2009" "volumen" => "4" "paginaInicial" => "21" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19558708" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bilateral synchronous occurrence of three different histological types of renal tumor: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D. Radopoulos" 1 => "A. Tahmatzopoulos" 2 => "N. Kalinderis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1752-1947-3-6798" "Revista" => array:5 [ "tituloSerie" => "Journal of Medical Case Reports" "fecha" => "2009" "volumen" => "3" "paginaInicial" => "6798" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19830124" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Renal oncocytoma: multifocality, bilateralism, metachronous tumor development and coexistent renal cell carcinoma" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C.B. Dechet" 1 => "D.G. Bostwick" 2 => "M.L. Blute" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/00005392-199907000-00010" "Revista" => array:5 [ "tituloSerie" => "Journal of Urology" "fecha" => "1999" "volumen" => "162" "paginaInicial" => "40" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10379735" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Changing concepts in the management of renal oncocytoma" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D.H. Chao" 1 => "A. Zisman" 2 => "A.J. Pantuck" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Urology" "fecha" => "2002" "volumen" => "59" "paginaInicial" => "635" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11992832" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003100000005/v1_201305151729/S2174204912000402/v1_201305151729/en/main.assets" "Apartado" => array:4 [ "identificador" => "9919" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003100000005/v1_201305151729/S2174204912000402/v1_201305151729/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204912000402?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
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| 2024 November | 9 | 7 | 16 |
| 2024 October | 108 | 36 | 144 |
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| 2024 May | 52 | 26 | 78 |
| 2024 April | 49 | 25 | 74 |
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| 2024 February | 51 | 26 | 77 |
| 2024 January | 61 | 21 | 82 |
| 2023 December | 59 | 31 | 90 |
| 2023 November | 75 | 36 | 111 |
| 2023 October | 60 | 20 | 80 |
| 2023 September | 45 | 22 | 67 |
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| 2023 May | 57 | 31 | 88 |
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| 2022 December | 68 | 32 | 100 |
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| 2022 July | 62 | 38 | 100 |
| 2022 June | 70 | 31 | 101 |
| 2022 May | 71 | 35 | 106 |
| 2022 April | 51 | 36 | 87 |
| 2022 March | 65 | 53 | 118 |
| 2022 February | 84 | 46 | 130 |
| 2022 January | 90 | 32 | 122 |
| 2021 December | 40 | 31 | 71 |
| 2021 November | 54 | 38 | 92 |
| 2021 October | 55 | 51 | 106 |
| 2021 September | 49 | 36 | 85 |
| 2021 August | 76 | 33 | 109 |
| 2021 July | 38 | 26 | 64 |
| 2021 June | 39 | 35 | 74 |
| 2021 May | 46 | 41 | 87 |
| 2021 April | 66 | 81 | 147 |
| 2021 March | 70 | 18 | 88 |
| 2021 February | 72 | 24 | 96 |
| 2021 January | 40 | 13 | 53 |
| 2020 December | 44 | 15 | 59 |
| 2020 November | 54 | 21 | 75 |
| 2020 October | 40 | 11 | 51 |
| 2020 September | 78 | 23 | 101 |
| 2020 August | 38 | 8 | 46 |
| 2020 July | 58 | 9 | 67 |
| 2020 June | 48 | 18 | 66 |
| 2020 May | 57 | 9 | 66 |
| 2020 April | 60 | 11 | 71 |
| 2020 March | 60 | 12 | 72 |
| 2020 February | 85 | 70 | 155 |
| 2020 January | 40 | 11 | 51 |
| 2019 December | 43 | 7 | 50 |
| 2019 November | 57 | 9 | 66 |
| 2019 October | 37 | 5 | 42 |
| 2019 September | 63 | 9 | 72 |
| 2019 August | 51 | 6 | 57 |
| 2019 July | 57 | 11 | 68 |
| 2019 June | 47 | 20 | 67 |
| 2019 May | 56 | 10 | 66 |
| 2019 April | 52 | 11 | 63 |
| 2019 March | 127 | 9 | 136 |
| 2019 February | 103 | 12 | 115 |
| 2019 January | 89 | 7 | 96 |
| 2018 December | 100 | 15 | 115 |
| 2018 November | 81 | 7 | 88 |
| 2018 October | 158 | 13 | 171 |
| 2018 September | 73 | 16 | 89 |
| 2018 August | 48 | 14 | 62 |
| 2018 July | 31 | 5 | 36 |
| 2018 June | 56 | 7 | 63 |
| 2018 May | 53 | 6 | 59 |
| 2018 April | 57 | 12 | 69 |
| 2018 March | 69 | 9 | 78 |
| 2018 February | 50 | 5 | 55 |
| 2018 January | 77 | 2 | 79 |
| 2017 December | 73 | 7 | 80 |
| 2017 November | 71 | 13 | 84 |
| 2017 October | 70 | 15 | 85 |
| 2017 September | 62 | 11 | 73 |
| 2017 August | 63 | 18 | 81 |
| 2017 July | 47 | 10 | 57 |
| 2017 June | 60 | 10 | 70 |
| 2017 May | 60 | 18 | 78 |
| 2017 April | 37 | 13 | 50 |
| 2017 March | 39 | 5 | 44 |
| 2017 February | 67 | 4 | 71 |
| 2017 January | 32 | 3 | 35 |
| 2016 December | 42 | 8 | 50 |
| 2016 November | 40 | 4 | 44 |
| 2016 October | 46 | 11 | 57 |
| 2016 September | 33 | 2 | 35 |
| 2016 August | 14 | 1 | 15 |
| 2016 July | 28 | 2 | 30 |
| 2016 June | 8 | 2 | 10 |
| 2016 May | 13 | 2 | 15 |
| 2016 April | 41 | 2 | 43 |
| 2016 March | 55 | 7 | 62 |
| 2016 February | 71 | 20 | 91 |
| 2016 January | 71 | 13 | 84 |
| 2015 December | 64 | 9 | 73 |
| 2015 November | 42 | 10 | 52 |
| 2015 October | 65 | 12 | 77 |
| 2015 September | 45 | 9 | 54 |
| 2015 August | 45 | 11 | 56 |
| 2015 July | 29 | 9 | 38 |
| 2015 June | 26 | 5 | 31 |
| 2015 May | 45 | 9 | 54 |
| 2015 April | 40 | 13 | 53 |
| 2015 March | 35 | 5 | 40 |
| 2015 February | 38 | 7 | 45 |
| 2015 January | 52 | 10 | 62 |
| 2014 December | 49 | 7 | 56 |
| 2014 November | 40 | 11 | 51 |
| 2014 October | 67 | 12 | 79 |
| 2014 September | 45 | 8 | 53 |
| 2014 August | 44 | 11 | 55 |
| 2014 July | 55 | 11 | 66 |
| 2014 June | 31 | 5 | 36 |
| 2014 May | 39 | 20 | 59 |
| 2014 April | 53 | 13 | 66 |
| 2014 March | 77 | 18 | 95 |
| 2014 February | 68 | 24 | 92 |
| 2014 January | 83 | 24 | 107 |
| 2013 December | 64 | 12 | 76 |
| 2013 November | 67 | 19 | 86 |
| 2013 October | 51 | 16 | 67 |
| 2013 September | 66 | 18 | 84 |
| 2013 August | 67 | 27 | 94 |
| 2013 July | 83 | 21 | 104 |
| 2013 June | 66 | 20 | 86 |
| 2013 May | 59 | 18 | 77 |
| 2013 April | 78 | 30 | 108 |
| 2013 March | 70 | 26 | 96 |
| 2013 February | 62 | 28 | 90 |
| 2013 January | 75 | 25 | 100 |
| 2012 December | 70 | 17 | 87 |
| 2012 November | 50 | 25 | 75 |
| 2012 October | 45 | 16 | 61 |
| 2012 September | 25 | 7 | 32 |
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