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Cesarean Delivery in Patient with Labile Recurrent Pericaval Pheochromocytoma
Abstract Number: SU-29
Abstract Type: Case Report/Case Series
Perioperative management of pheochromocytoma presents an anesthetic challenge. Unpredictable catecholamine responses despite adrenergic blockade can lead to cardiovascular instability, which can be compounded in pregnancy.
A 28 y/o G1P0 was scheduled for a cesarean delivery (CD) at 37+4/7 weeks due to a symptomatic recurrent pheochromocytoma. Her history was significant for an adrenalectomy 8 years prior. At 13 weeks, she presented with paroxysmal hypertension, tachycardia, and markedly elevated urinary metanephrines. Magnetic resonance imaging showed recurrent right adrenal bed pheochromocytoma surrounding the inferior vena cava with possible hepatic invasion. Surgery would involve caval resection and possible hepatic segmentectomy. There were three options for management: 1) surgery while pregnant; 2) await fetal maturity and resect the tumor during CD; or 3) await fetal maturity, perform CD and delay surgery until normalization of the physiologic changes of pregnancy. Given the magnitude of the surgery, stable tumor size, and difficulty conceiving, she was medically managed with phenoxybenzamine and metoprolol until term gestation.
Intravenous and arterial access was established and 100 mcg intrathecal hydromorphone was given. General anesthesia was induced with fentanyl, propofol, and rocuronium. Central venous access was obtained and a propofol infusion was started in addition to inhaled sevoflurane. After uterine incision, sodium nitroprusside was initiated to treat escalating blood pressures. The fetus was delivered with gentle uterine fundal pressure. Vacuum-assisted delivery was had been planned, to avoid tumor manipulation but the surgeon was unable to engage the fetal head. Apgar scores were 2 and 7 at 1 and 5 minutes. The neonate was monitored in intermediate care nursery overnight for hypoglycemia and blood pressure management. After delivery total intravenous anesthesia (TIVA) with propofol was initiated and inhalational anesthetic was discontinued. Uterine tone was adequate after oxytocin administration. The patient was extubated in the operating room and monitored overnight in intensive care. Her pain was controlled and her postoperative course was uneventful. She underwent resection of the pheochromocytoma 9 weeks later.
We have presented an uneventful CD in a patient with a recurrent, symptomatic pheochromocytoma. Intrathecal hydromorphone was provided for postoperative analgesia. Local anesthetic was avoided to reduce the risk of hemodynamic collapse after sympathectomy in a patient with high baseline sympathetic tone (1). Vasoactive medication infusions are integral in being able to rapidly and effectively treat significant hemodynamic compromise. Optimized preoperative alpha and beta blockade combined with general anesthesia, TIVA, and intrathecal opioid provided hemodynamic stability, prevention of uterine atony, and adequate postoperative analgesia.
1. J ClinAnesth 2013;25(8):672-4