Anesthetic management of combined cesarean section and excision of pheochromocytoma

Cesarean section at 28 weeks' gestation with resection of pheochromocytoma: perioperative antihypertensive management

Pregnancy complicated by pheochromocytoma is potentially fatal. Pregnancy and labor increase the risk of hypertensive crisis as it may occur with the sudden release of catecholamine accompanying uterine contractility and straining. However, antepartum diagnosis reduces both maternal and fetal mortality, allowing for safe cesarean section and resection of tumor. We describe the management of perioperative hypertension for combined cesarean section and pheochromocytoma resection.

Anesthesia for combined cesarean section and extra-adrenal pheochromocytoma resection: a case report and literature review

Pheochromocytoma during pregnancy is unusual, with approximately 250 cases now reported in the literature. The current case describes the anesthetic management of a patient with a large extra-adrenal pheochromocytoma who underwent a combined cesarean section and tumor removal in which perioperative hemodynamic control was difficult despite high-dose a-adrenergic blockade. In this case it is believed that difficulty in perioperative hemodynamic management was related to mechanical stimulation of the tumor by the gravid uterus. Review of published case reports since 1980 reveals that a pheochromocytoma during pregnancy may be diagnosed in an extra-adrenal location relatively more commonly compared to non-pregnant patients. Established criteria exist for the adequacy of alpha- and beta-adrebergic blockade for the management of pheochromocytoma in the non-pregnant patient. We discuss how these criteria apply to pregnant patients with pheochromocytoma, and suggest possible modifications to the criteria.

[Anesthesia for cesarean section and excision of pheochromocytoma caused by Sipple's syndrome]

A case of a 23-year-old primigravida with a tumour of the left adrenal gland and a medullary thyroid carcinoma is reported. Her blood pressure remained at about 100/60 mmHg throughout pregnancy. She was scheduled for elective Caesarean section combined with removal of both adrenal glands. Anaesthesia was carried out using 10 micrograms.kg-1 alfentanil, 5 mg.kg-1 thiopentone, 1.5 mg.kg-1 succinylcholine and 0.5 vol % enflurane. A single hypertensive crisis (190/100 mmHg) occurred intraoperatively, during dissection of the left adrenal gland. This responded well to 1 mg.min-1 phentolamine. The postoperative course was uneventful for both the mother and the child. Total thyroidectomy with block dissection of the lymph nodes was to be carried out within three weeks after the Caesarean section. Only two similar cases of multiple endocrine neoplasia associated with pregnancy have previously been published.

Phaeochromocytoma in pregnancy. Five cases and a review of the literature

We report five patients with phaeochromocytoma associated with pregnancy and review the 42 other cases reported in the literature from 1980 to 1987. The overall maternal mortality was 17% and the fetal loss 26%; antenatal diagnosis of phaeochromocytoma reduced the maternal mortality to zero and the fetal loss to 15%, but was made in only 53% of the patients. Although phaeochromocytoma is rare, a high index of clinical suspicion must be maintained and all those at risk investigated if earlier diagnosis and improved outcome are to be achieved. Once the diagnosis is confirmed, alpha-blockade is essential and beta-blockade may be required. CT scan or magnetic resonance imaging may be used to localize the tumour during the antenatal period. In the first and second trimesters, tumour resection has a good fetal outcome; in later pregnancy, delivery by elective caesarean section followed by tumour resection is recommended.

Use of magnesium sulphate in the anaesthetic management of phaeochromocytoma in pregnancy

The anaesthetic management of two patients with phaeochromocytoma complicating pregnancy is presented. In one patient, the operative delivery was followed by elective tumour resection at a later stage. Magnesium sulphate was used as an adjunct to all three anaesthetics, with notable success on two occasion. In one of the operative deliveries, it proved impossible to achieve adequate blood levels of magnesium, due to severe pre-existing magnesium deficiency. Hypomagnesaemia is likely to be present in such cases and must be corrected preoperatively. Magnesium sulphate is a useful adjunct to the anaesthetic management of the pregnant patient with a phaeochromocytoma provided that adequate serum levels of magnesium can be established.

Pregnancy and functional paraganglioma

The association of pregnancy with a catecholamine-secreting tumor is rare. The high maternal and fetal mortality rate is significantly reduced when the diagnosis is made antepartum and adequate management is started. In 1979 Burgess reviewed 42 cases with antepartum diagnosis, demonstrating the benefits of alpha-blockade (Obstet Gynecol 1979; 53:266-270). When diagnosis was made in the third trimester of pregnancy, a combined procedure of cesarean section and tumor resection was best. The best surgical approach in first- and second-trimester diagnosis, however, remains controversial. A case with second-trimester diagnosis is described. Following a period of alpha- and beta-blockade, a combined surgical procedure in the third trimester resulted in a healthy mother and infant. Follow-up procedures included a meta-iodobenzylguanidine scan of the mother. Postpartum, ultrasonography of the child's brain revealed periventricular leucomalacia. The prognosis associated with this finding is poor. Some more recent information about certain aspects of these tumors is also discussed.

Cerebral haemorrhage in a pregnant woman with a multiple endocrine neoplasia syndrome (type 2A or Sipple's syndrome)

We present the case history of a 30-yr-old woman who suffered a cerebral haemorrhage toward the end of pregnancy (at 35 wk). The pregnancy was terminated by Caesarean section because aggravation of cerebral bleeding was feared. Extensive studies revealed that the patient was suffering from a multiple endocrine neoplasia syndrome (type 2A or Sipple's syndrome) with bilateral pheochromocytomas and a medullary thyroid carcinoma. She made an uneventful recovery. The relevant literature is discussed.

Phaeochromocytoma and pregnancy--an updated appraisal

Phaeochromocytoma in pregnancy carries a considerable risk to the mother and is even more dangerous to the fetus. It should, therefore, be kept in mind as a possible cause of hypertension in pregnancy and appropriate laboratory tests undertaken. The data presented in the literature indicate that the early diagnosis of phaeochromocytoma in pregnancy decreases maternal mortality markedly and fetal mortality less significantly. Diagnostic measures to localize the tumour before delivery are limited; radiation exposure to the fetus will be minimized by the adjunctive use of ultrasound and CAT scanning. If the diagnosis is made before 20-24 weeks, the tumour should be excised without delay and pregnancy interrupted or allowed to continue, depending on circumstances. After the 24th week, the pregnancy should usually be continued under adequate adrenergic blockade until fetal maturity is achieved. Labour and vaginal delivery should generally be avoided. Caesarean section and careful removal of the tumour at the same time are recommended.