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Laparoscopic Pheochromocytoma Resection at 23 Weeks of Gestation: Fetal and Maternal Considerations.
Abstract Number: SA-54
Abstract Type: Case Report/Case Series
Pheochromocytoma during pregnancy is an extraordinarily rare (0.002%) and life-threatening condition. If undiagnosed the tumor carries a nearly 40-50% mortality rate for both the mother and fetus. Management during pregnancy depends on gestational age, tumor size and accessibility, as well as maternal and fetal well-being. While the second trimester is the safest period for performing surgery, fetal monitoring may be challenging and a plan for neonatal resuscitation must be established should fetal distress arise. Case: 29 year-old female G6P2032 was referred to our hospital at 22nd week gestational age with uncontrolled blood pressure, diaphoresis, severe headaches, blurred vision and episode of suicidal ideation. Laboratory data revealed elevated 24-hour urine epinephrine and norepinephrine. MRI showed 2.8 X 2.2 cm left suprarenal lesion consistent with pheochromocytoma. Multidisciplinary team decided to perform left laparoscopic adrenalectomy at the 23rd week of gestation after hemodynamic optimization using alpha-adrenergic blocker terazosin. After premedication with midazolam and fentanyl, an arterial line was cannulated for hemodynamic monitoring and the patient placed in left uterine displacement. To minimize the risk of aspiration the patient received famotidine and sodium citrate prior to procedure. After preoxygenation, cricoid pressure was applied and anesthesia was induced with fentanyl (100mcg), lidocaine (50mg), propofol (200mg) and rocuronium (70mg). After tracheal intubation, anesthesia was maintained with sevoflurane and continuous infusion of remifentanil. Magnesium sulfate and nitroglycerine infusions were used to achieve cardiovascular stability. Nitroglycerine (total 1740mg), esmolol (total 210mg) and remifentanil (240mcg) were bolused during laryngoscopy, intubation and tumor manipulation. After ligation of the tumor’s venous drainage phenylephrine infusion was initiated. At the end of the surgery phenylephrine drip was weaned off and patient was uneventfully extubated. Immediate postoperative period complicated by hypoglycemia treated with dextrose. Doppler monitor was used for fetal heart monitoring prior and immediately after surgery. Subsequent postoperative course was uncomplicated for both mother and fetus, with complete resolution of maternal hypertension.
Discussion: Multidisciplinary approach for management pheochromocytoma in pregnant patient requires close co-ordination between anesthesiologist, surgeon, obstetrician and endocrinologist. Fetal monitoring, as well as risk of emergent delivery and goals of neonatal resuscitation at 23rd week of gestation in case of fetal distress should be discussed with parents prior to procedure. Anesthetic considerations during pheochromocytoma resection in pregnant patient include perioperative hemodynamic optimization, airway management and effect of drugs and anesthetic agents on uterine activity and fetus.