Pregnancy and cesarean section delivery in a patient with panhypopituitarism
Abstract Number: 30
Abstract Type: Case Report/Case Series
Introduction: Endocrine disorders frequently make it difficult for a patient to conceive and successfully maintain a pregnancy. Lack of pituitary function can result in devastating complications during a delivery or cesarean section if the anesthesiologist is unprepared. This case describes how panhypopituitarism complicated a pregnancy.
Case Presentation: A 30 year old G2P1001 with longstanding panhypopituitarism from previous trauma presented for scheduled cesarean section. Her twin pregnancy was a result of in vitro fertilization. She experienced increased thirst and urination during pregnancy, and was diagnosed with diabetes insipidus. Home medications prior to pregnancy were synthroid and hydrocortisone. DDAVP was added once pregnant. Prior to surgery, her home medications were given in addition to oral bicitra and hydrocortisone 100mg IV. An epidural was placed at L3-4; and dosed with 15ml of lidocaine 1.5% in addition to 50mcg of fentanyl. A cesarean section was performed. Blood pressure following epidural placement was consistently low (90/50), with no response to multiple doses of phenylephrine. A vasopressin drip was initiated with blood pressure increasing to 100s/60s. Oxytocin 10U was given and the patient was transferred to PACU without need for additional vasopressor treatment.
Discussion: Failure to diagnose and institute proper therapy in a parturient with panhypopituitarism can have lethal consequences for both mother and fetus (1). One study of women with Sheehan syndrome reported women who were not on hormone replacement experienced a 42% rate of fetal abortions and up to 27% rate of maternal death (vs. 13% abortions and 0 maternal deaths in women on therapy). (2)
Treatment of this condition includes L-thyroxine and cortisol (or prednisone). Pregnancy frequently leads to new onset diabetes insipidus since placental enzymes increase clearance of vasopressin. Adequate hydration and continuation of hormonal replacement is essential during labor. (1)
Lack of pituitary function can be devastating during the stress of labor or surgery. Acute adrenal crisis can lead to hypotension unresponsive to traditional pressors. Lack of thyroid therapy can limit metabolic rate and ability to maintain core temperature, and can produce severe hypothermia (3). Hyponatremia and hypovolemia due to impaired renal function can lead to a prolonged or unpredictable response to anesthesia (3). In this case report, an understanding of these potential problems led to a successful outcome for both mother and her twins.
1. Creasy R, Resnik R, Iams J, Lockwood C, Moore T. Maternal-Fetal Medicine, Principles and Practice, 6th ed.
2. Grimes HG, Brooks MH. Obstet Gynecol Surv 1980; 35:481.
3. Pillai P, Spears FD. Anaesthesia 2005; 60(9)924-927.