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Emergent cesarean delivery for fetal indications in a patient with persistent hypertension after resection of pheochromocytoma
Abstract Number: SU-09
Abstract Type: Case Report/Case Series
We present the challenging case of a parturient who required emergent cesarean section for fetal distress in the setting of persistent, severe hypertension after surgical resection of a pheochromocytoma diagnosed earlier in pregnancy.
A 24 year-old G2P1 with a five-year history of palpitations, flushing, and headaches was referred to our institution with labile hypertension and elevated metanephrines at 17 weeks gestational age. MRI confirmed a 4.3x2.5x4.0 cm right adrenal mass consistent with pheochromocytoma. She was managed medically prior to an uneventful laparoscopic adrenalectomy at 18 weeks. Despite surgical margins suggesting complete resection, metanephrines failed to return to normal levels and the patient was readmitted for uptitration of her antihypertensives at 23 weeks. Her hypertension was refractory to a five-medication regimen and an urgent cesarean section was called at 25 weeks for nonreassuring fetal heart tones. Anesthetic management included a pre-induction arterial line and plan for a combined spinal-epidural which was converted to an intrathecal catheter after an accidental dural puncture. She received 0.3 ml of 0.75% hyperbaric bupivacaine followed by a total of 1.25 ml 0.5% bupivacaine to achieve an adequate surgical block. The patient required only intermittent doses of vasopressors for hypotension after delivery. She developed hypertension in PACU, which was treated, then became hypotensive and required a phenylephrine infusion and overnight ICU admission. The patient’s antihypertensives were de-escalated to a three-drug regimen and she was discharged home on postoperative day 6. Unfortunately, her male infant expired from multi-organ failure within the first month of life.
Pheochromocytoma, a rare catecholamine-secreting tumor of the adrenal medulla, occurs in less than 0.01% of pregnancies (1). The clinical picture is clouded by the fact that pheochromocytoma can mimic the more common preeclampsia as the cause of hypertension (2). The most serious risks involve patients with undiagnosed disease presenting late to care for emergent delivery, in which sudden hypotension and cardiovascular collapse result in fetal and/or maternal death. In this case, it was unclear whether the patient’s persistent hypertension was due to preeclampsia or residual extra-adrenal disease, though her antihypertensives were only able to be de-escalated after delivery. Nonetheless, despite timely medical and surgical management, ideal outcomes were not achieved.
1. Biggar MA. Br J Surg 2013; 100; 182-90.
2. Hundsmith JG. Int J Obstet Anesth 2006; 15; 240-5.