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Labor Analgesia for a Parturient with Untreated Acromegaly
Abstract Number: T-36
Abstract Type: Case Report/Case Series
Introduction: Acromegaly is a rare endocrine disorder with an incidence of 3 new cases per million people per year that is associated with infertility. With the development of medical therapies and infertility treatment, the anesthesiologist may provide intrapartum care for these patients. Medical and obstetrical comorbidities such as insulin resistance, hypertensive disorders and cardiovascular disease must be considered while developing a labor analgesic plan. Additionally during pregnancy, the pituitary gland undergoes global hyperplasia and increases by 45% due to escalation of lactotrophic cells. There is little data to describe concurrent pathologic growth of pituitary adenoma during pregnancy, but this has serious implications for neuraxial techniques. Before initiation of labor analgesia, intracranial imaging studies can elucidate tumor size and intracranial dynamics(1-2). However, that may not always be feasible or necessary. We report a case of successful lumbar epidural placement in a parturient with known acromegaly and insufficient imaging of a pituitary adenoma in preterm labor.
Case: Our patient is a 35 year old G2P1 parturient who presented in preterm labor at 34 weeks gestation. Her medical history included a pituitary adenoma and untreated acromegaly diagnosed 5 years prior during her previous pregnancy after vaginal delivery of an IUGR infant. Although the patient was compliant with antenatal visits, the patient failed to follow up for an MRI to evaluate her intracranial mass. On admission, she was normotensive and denied headache, nausea or visual disturbances. Physical exam revealed an obese woman with frontal bossing, coarse facial features, hirsutism and a Mallampati class 4 airway. In addition, the fetal heart tones were reassuring (category 1 tracing) and the uterine contraction pattern was adequate with oxytocin augmentation. After discussion of analgesic options with the patient, a lumbar epidural was placed uneventfully followed by successful vaginal delivery of a healthy infant.
Discussion: A known intracranial lesion associated with acromegaly, a rarity, may pose concerns for the anesthesiologist. In parturients with active acromegaly the incidence of clinically significant somatotrophic adenoma growth is 10%, even in the absence of treatment. Headache, a common surrogate marker of increased ICP, in this population can be attributed to withdrawal of somatostatin analogs, preeclampsia, or increased intracranial pressure from pathologic pituitary growth(1). History and physical exam may prompt additional work-up when necessary. As the patient was clinically asymptomatic, lumbar epidural was deemed safe and appropriate for this patient. This case supports the use of lumbar epidural for labor analgesia in parturients with untreated acromegaly.
1)Dias M et al. Eur J Endocrinol. 2013 Dec 21;170(2):303-12
2)Shah PN et al.Indian J Anaesth. 2011 Nov;55(6):618-20