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Laparascopic Resection of a Pheochromocytoma in a 15 week Gestational Pregnancy
Abstract Number: SU-39
Abstract Type: Case Report/Case Series
A 27 year old female G2 p1001 @ 7 week gestation was referred to our institution without obstetric services for persistent hypertension, palpitations, headache, lightheadedness, and fatigue and a family history of pheochromocytoma. Initial 24 hour urine revealed elevated dopamine, epinephrine and plasma norepinephrine levels. An abdominal MRI showed a 1.9 x 2.2 cm mass in the right adrenal gland along with several enlarged epigastric lymph nodes. The patient was started on phenoxybenzamine and labetalol. A laparoscopic adrenalectomy was planned at 15 week gestation pending stable hemodynamics. Surgery planned to have gastroenterology do an upper endoscopy with biopsy of the epigastric lymph nodes a week prior to her surgery, however, at the insistence of the obstetric anesthesiologist, the endoscopic procedure was scheduled at the time of the laparoscopy. Endocrinology was followed her vital signs on an outpatient basis prior to surgery, which required an increase in alpha and beta blockade due to continued elevations in blood pressure (BP) (140's/90's) and heart rate (HR) (90's to 100's). The gynecologic service was consulted to monitor the fetus pre- and post-operatively.
At 15 week gestation the patient underwent a laparoscopic right adrenalectomy along with an upper endoscopy and epigastric lymph node biopsy. After induction with propofol and succinylcholine, anesthesia was maintained with isoflurane and vecuronium. Post induction, an arterial line and right internal jugular line were placed. Phenylephrine and vasopressin infusions were started due to intermittent hypotension after induction with BP ranging from 66/50 to 150/90's and occasional increase in HR to 115 bpm requiring esmolol boluses. Fluid administration for the procedure included 3 liters of crystalloid and 750 ml of albumin. The patient was extubated in the operating room and transported to the ICU where an abdominal ultrasound showed fetal activity and a fetal heart rate over 140 bpm. The patient was eventually weaned off vasopressin and phenylephrine infusions and she was dischared 2 days following surgery. Pathology confirmed the presence of a pheochromcytoma with benign reactive inflammatory lymph nodes.
The patient underwent a repeat cesarean section under spinal anesthesia at 39 weeks gestation at her home institution with delivery of a viable male infant weighing 3,977g and Apgars of 8 and 9. Patient was told she had wide fluctuations in blood pressure during the procedure, but otherwise had an unremarkable course and was monitored overnight in the ICU.
Pheochromocytoma in pregnancy is very rare, and difficult to differentiate due to the more common manifestations of pregnancy-induced hypertension. If undiagnosed, maternal and fetal mortality is high, at 5 and 15% respectively. Early diagnosis and treatment, including surgery in the second trimester decrease the potential morbidity and mortality as depicted in this case.
Lenders, JW Eur J Endocrinol 166: 143, 2012