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Anesthesia for cesarean section in patient with a Functioning Metastatic Pancreatic Neuroendocrine Tumor
Abstract Number: F-24
Abstract Type: Case Report/Case Series
CASE PRESENTATION: A 29-year old G2P1, presented for an elective cesarean section (CS) at 34 weeks' gestation. She had a pancreatic islet cell tumor with severe liver metastases and a very enlarged liver compressing. CT/MRI also showed encroachment on the Inferior Vena Cava (IVC). A CS was planned because of severe hepatomegaly, hypoglycemia, shortness of breath, abdominal pain, raised intraabdominal pressure due to enlarged uterus and liver and severe lower extremity edema to the groin. An open liver biopsy and a possible liver resection were planned.
Her symptoms included abdominal pain, shaking, sweating and confusion with blood sugars 20-30 mg/DL necessitating frequent meals. She was placed on Octreotide (a somatostatin analog) for blood sugar maintenance and fentanyl PCA for abdominal pain. The Liver team (surgery and anesthesia), obstetric and the obstetric anesthesia teams evaluated her. After delivery, in addition to Octreotide, she would be placed on Everolimus, an antiproliferation immunosuppressive agent.
PREOPERATIVE COURSE: The patient weighed 76 kg with Class I airway. Her respiratory rate was 26/min, pulse rate 105, blood pressure 112/73. Chest was clear to auscultation. Room air oxygen saturation was 97% and hemoglobin 8.6g/DL. She received intravenous 10% dextrose solution fluid and Octreotide with frequent blood sugar measurement.
INTRAOPERATIVE COURSE: We decided to do general endotracheal anesthesia because of the respiratory distress and the possibility of liver resection. Arrangements for implementing massive transfusion protocol were made. She was positioned at 45 degrees semi-Fowler position with left uterine displacement. An arterial and CVP line were inserted. A rapid sequence induction and endotracheal intubation was performed and anesthesia maintained with desflurane and oxygen. An Octreotide infusion was continued with frequent blood sugar measurements. The baby was delivered with Apgars of 7 and 8. Multiple liver biopsies were obtained. Maternal and neonatal blood sugars at birth were respectively 116 and 43 mg /DL.
POSTOPERATIVE COURSE: was uneventful. Mother and baby did well. She continued to receive Octreotide. She received diuretics for tachypnea.
DISCUSSION: Insulinoma, is rare (1-4 cases/million). Nineteen cases have been reported in pregnancy with one fatality from a malignant tumor. Diagnosis may be missed because of confusion due to early pregnancy symptoms. Hypogycemia seen in early pregnancy improves later because of changing sensitivity to insulin throughout pregnancy. Frequently, the diagnosis is made only in the postpartum period. Metastatic insulinoma presents challenges for the anesthesiologist.
KEYWORDS: Glucose homeostasis, massive hemorrhage, a multidisciplinary approach and the choice of anesthesia.
1. Diaz AG, Herrera J, et al –American Society for Reproductive Medicine 2008;90:015-0282
2. Takacs AC, Krivak T, et al –Obs & Gyn Survey 2002:57:229-235