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Management of a Presumed Pheochromocytoma in the Parturient
Abstract Number: S 42
Abstract Type: Case Report/Case Series
Pheochromocytomas are rare during pregnancy, with an estimated incidence of 0.002-0.007% (1,2), but carry significant risk to both the mother and fetus, including maternal hypertensive crisis and uteroplacental insufficiency.
A 38-year-old G6P3 in the first trimester presented with episodes of palpitations and shortness of breath. Physical exam and vitals were unremarkable. A CT scan of the chest ruled out pulmonary embolus, but incidentally discovered a left adrenal mass. Further workup noted mildly elevated plasma metanephrines. The clinical picture was suggestive of pheochromocytoma.
Extensive multi-disciplinary pre-operative planning involving the obstetrician, anesthesiologist, endocrinologist, surgeon, and neonatologist led to the decision to proceed under the presumption of pheochromocytoma (see figure). The patient was admitted one week prior to surgery for volume expansion and alpha-blockade, followed by beta-blockade.
At 37 weeks gestation, she underwent c-section followed by laparoscopic adrenalectomy. Pre-operatively, a large bore IV, arterial line, and central line were placed. After her abdomen was prepped and draped, rapid-sequence induction and intubation was performed. The c-section and adrenalectomy were surgically uneventful, and a healthy baby was delivered. Intra-operatively, hypertension was never a problem, but multiple high-dose vasopressors were needed for hemodynamic support. However, by the end of the case, the patient was normotensive without pressor requirement and was extubated uneventfully. Pathology of the adrenal specimen was notable for a lymphangioma cyst with no evidence of pheochromocytoma.
Ultimately, this patient did not have a pheochromocytoma. However, this case stresses the importance of multi-disciplinary planning for the uncertain adrenal mass. When pheochromocytoma is suspected, we suggest that the parturient be treated as such, given the potential catastrophic complications associated with an unrecognized pheochromocytoma. More broadly, when uncertainty exists about a diagnosis in the parturient with such potential impact, a multi-disciplinary approach to care of the patient is recommended.
1. Wissler RN. Endocrine disorders. In: Chestnut DH (Ed.). Obstetric Anesthesia. Principles and Practice, 2nd ed, New York: Mosby Year Book Inc.;1999:828-32
2. Mannelli, M. Bemporad D. Diagnosis and management of phaeochromocytoma during pregnancy. J Endocrinol Invest 2002;25;567