one of the most important causes of hypertension in pregnancy is pheochromocytoma but its occurrence is rare . it has high morbidity and mortality for mother and fetus . due to the similarity to other forms of hypertension , diagnosis of pheochromocytoma diagnosis of pheochromocytoma is based on catecholamine 's concentration ( epinephrine , norepinephrine , dopamine , and vanillylmandelic acid [ vma ] ) in 24 h urine collection . sensitivity of the test would be increased if 24 h urine collection begins at onset of a paroxysm . sensitivity of abdominal computed tomography ( ct ) for diagnoses of adrenal pheochromocytoma is 93100% and extra - adrenal pheochromocytoma is 90% . other diagnostic techniques included metaiodobenzylguanidine imaging , positron emission tomography imaging , and somatostatin receptor scintigraphy . management of pheochromocytoma includes medical therapy ( phenoxybenzamine , propranolol ) and surgery . a 27-year - old woman para 1 live 1 admitted with chief complaint of sudden onset of headache , confusion , nausea and vomiting , shortness of breath , tachypnea , and hypertension 2 days after cesarean section . her cesarean section was performed at term pregnancy due to fetal distress under spinal anesthesia . her pulse rate was 125/min ; systolic blood pressure was labile ( 70230 mmhg ) and failed to respond to conventional treatment . antinuclear a antibodies and antineutrophil cytoplasmic antibody were normal ( nl ) , but epinephrine = 65.2 ( nl : 1.722.4 g/24 h ) , norepinephrine = 364 ( nl : 12.585.5 g/24 h ) , metanephrine = 2071 ( nl : 30180 mcg/24 h ) , normetanephrine = 1337 ( nl : 103390 mcg/24 h ) , and vma = 17.18 ( nl : 1.46.5 mg/24 h ) were increased in 24 h urine collection . the patient was given medical treatment with phenoxybenzamine and propranolol , but treatment was not effective ; hence , she underwent adrenalectomy . pheochromocytoma is a neuroendocrine tumor derived from adrenal chromaffin cells , and extra - adrenal paraganglioma could cause secondary hypertension . high amount of catecholamine 's release ( norepinephrine , epinephrine , and dopamine ) causes the typical manifestations of pheochromocytoma . vasoconstriction is one of the -receptors stimulation symptoms , whereas vasodilation is due to 2-receptors stimulation . increases in intra - abdominal pressure , fetal movement , uterine contraction , delivery process , abdominal surgical intervention , and even general anesthesia can make pheochromocytoma clinically overt in pregnancy . signs and symptoms in pheochromocytoma are similar to other forms of hypertension , including the new - onset hypertensive syndromes in pregnancy , gestational hypertension , and preeclampsia . hypertension can be insidious , and the pregnant women may even symptomatic till delivery . signs and symptoms of pheochromocytoma are nausea and vomiting , abdominal pain , severe constipation ( megacolon ) , chest pain , congestive heart failure , cardiac dysrhythmia , and conduction defects . preeclampsia is usually manifested by proteinuria , sudden weight gain , edema , rise in liver enzymes , and coagulation disorders . pregnant woman with pheochromocytoma rarely has proteinuria , liver or coagulation abnormalities , sudden weight gain , and edema . it should be started as soon as the -methyl - parathyrosine ( a tyrosine hydroxylase inhibitor ) diagnosis is established and should be given for 1014 days . the best treatment in pregnancy is phenoxybenzamine ( pregnancy class c ) . the -blockers should not prescribe before -blocker drugs because -blockers alone can rise blood pressure dramatically due to unopposed -adrenergic effects in patients with epinephrine - secreting tumors especially . in patients with intolerance to combine - and -blockers , we can use -methyl - parathyrosine but its safety during pregnancy is questionable . the surgery time is controversial depending on factors such as gestational age of pregnancy , clinical response to treatment , the accessibility of the tumor for surgery , and fetal condition . some physicians recommended surgical tumor removal after adequate medical treatment in early gestational age by laparoscopic adrenalectomy if tumor size is < 7 cm . after 24 weeks of gestation , an elective cesarean section done then surgical procedure is recommended . vaginal delivery is accompanied with higher mortality rate ( 31% ) as compared with cesarean section ( 19% ) . in pregnant women , early diagnosis and treatment of pheochromocytoma if appropriate management was done for pheochromocytoma , pregnancy loss is seen only in 11% of patients . catecholamines do not cross the placenta , but placental abruption due to paroxysmal hypertension and then rebound hypotension can cause severe hypoxia and fetal wastage . early diagnose and management has been attributed to improvement in maternal outcomes . with earlier diagnosis and presurgical preparation , maternal mortality has decreased to 2% from 48% in older literature . in patients with a suspicious family history of pheochromocytoma , paraganglioma , or evidence of genetic cause , genetic testing should be considered . one of the rare but important causes of hypertension in pregnancy is pheochromocytoma with high morbidity and mortality of mother and fetus . phenoxybenzamine is safe in pregnancy , but -adrenergic blockers must be initiated only if necessary because their association with intrauterine growth retardation . during the second trimester , resection of tumor can often be safe or tumor resection simultaneous with cesarean section in mature fetus . individualized approach for each patient is recommended . pheochromocytoma presentations are different in pregnancy , but in the second half of pregnancy , new - onset or superimposed preeclampsia may be mistaken with it . high clinical suspicion , early diagnosis and treatment , and collaboration among specialists are required for better management of patients and improved outcome .
pheochromocytoma is a catecholamine - producing tumor . 
 there are a very few reported cases of clinical pheochromocytoma . here , we report a 27-year - old woman para 1 live 1 with chief complaint of headache , confusion , nausea , and vomiting 2 days after cesarean section . 
 she was anxious and had palpitation . on physical examination , 
 fever , tachycardia , tachypnea , high blood pressure , and right thyroid nodule were found . 
 she was managed as pregnancy - induced hypertension at first . in laboratory data , epinephrine , 
 norepinephrine , metanephrine , normetanephrine , and vanillylmandelic acid were increased in 24 h urine collection . 
 an adrenal mass was detected in abdominal computed tomography . 
 regarding clinical and paraclinical findings , pheochromocytoma was diagnosed . 
 the patient received medical treatment , but it was not effective ; hence , she underwent adrenalectomy .