Year : 2015 | Volume
: 5 | Issue : 1 | Page : 33--35
Anaesthetic consideration for caesarean delivery of a parturient without 'The Master Gland'
Tuhin Mistry, Sushil Bhati, Chandra Sekhar Chatterjee, Rama Chatterjee
Department of Anaesthesiology and Critical Care, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
Dr. Tuhin Mistry
Room No: A-92, Resident Doctor«SQ»s Hostel, Sawai Man Singh Medical College, JLN Marg, Jaipur - 302 004, Rajasthan
We are presenting the management of a patient posted for elective caesarean delivery who conceived after ovulation induction and in vitro fertilisation, 20 years after postsurgical hypopituitarism. She had uneventful pregnancy and delivered a healthy baby by caesarean section under general anaesthesia.
|How to cite this article:|
Mistry T, Bhati S, Chatterjee CS, Chatterjee R. Anaesthetic consideration for caesarean delivery of a parturient without 'The Master Gland'.J Obstet Anaesth Crit Care 2015;5:33-35
|How to cite this URL:|
Mistry T, Bhati S, Chatterjee CS, Chatterjee R. Anaesthetic consideration for caesarean delivery of a parturient without 'The Master Gland'. J Obstet Anaesth Crit Care [serial online] 2015 [cited 2020 Nov 26 ];5:33-35
Available from: https://www.joacc.com/text.asp?2015/5/1/33/155198
Pregnancy after complete loss of hypophyseal function is rare and precious. It is considered as "high-risk pregnancy" as it is associated with greater risk of miscarriages, fetal demise, intrauterine growth restriction, prematurity, inability to breast-feed and early elective caesarean section is almost inevitable.  Successful outcome requires proper management during pregnancy and delivery which needs a team effort consisting of endocrinologist, obstetrician and anaesthesiologist.
A 32-year-old female, primigravida, weighing 60 kg and height of 162 cm with 37 weeks of gestation was posted for elective lower segment caesarean section (LSCS). She had history of Craniopharyngioma for which she underwent total hypophysectomy at the age of 12 years. After surgery, she received radiotherapy as well as chemotherapy with bleomycin, etoposide and carboplatin. She received growth hormone (GH) for 3 years which was stopped after attaining height in acceptable normal range. Since the onset of disease, she has no vision in left eye with 40% vision in right eye. She was on life long replacement therapy with hydrocortisone, levothyroxin and desmopressin and cyclic substitution therapy with oestrogen and progesterone for primary amenorrhoea. At 30 years of age, she consulted for fertility treatment and underwent an ovulation induction with gonadotropins, followed by in vitro fertilisation and embryo transfer which resulted in a successful singleton pregnancy. She was followed-up regularly and no changes in the doses of hydrocortisone (10 mg), desmopressin nasal spray & levothyroxine (100 mcg) were required and the antenatal period was uneventful. Fetal well-being was assessed in terms of serial ultrasonography (USG) screening throughout the pregnancy and she was subjected to elective LSCS at 37 weeks of gestation. Her haematological, biochemical and hormonal investigations were unremarkable.
Patient's refusal debarred us from using neuraxial block. On the day of surgery, she took morning dose of the ongoing medication. Aspiration prophylaxis was given 30 minutes prior. Standard monitors (pulse oximeter, noninvasive blood pressure, 5-lead electrocardiogram and EtCO 2 with facemask) were attached. Patient was preoxygenated for 5 minutes. Rapid sequence induction with Sellick's manoeuvre was performed using ketamine, propofol and succinylcholine. At the time of induction 100 mg hydrocortisone was given intravenously. Intravenous (IV) lignocaine 1.5 mg/kg was used to suppress the stress response. Laryngoscopy was done using Mccoy blade size 3 and her trachea was intubated with 7.0 mm internal diameter cuffed endotracheal tube. Anaesthesia was maintained with controlled ventilation, isoflurane inhalation and muscle relaxant atracurium. A 3.14 kg baby boy was delivered with Apgar score of 8 at birth. After the delivery, 20 U of oxytocin were added to the one litre of IV fluid. All the vitals, blood loss and urine output were monitored thoroughly. At the end of surgery, bilateral USG guided transversus abdominis plane block was performed with bupivacaine(0.25%, 0.6 ml/kg with half the volume on either side) for postoperative analgesia. After complete reversal of muscle relaxant, IV lignocaine 1.5 mg/kg was used for smooth emergence and the trachea was then extubated. Oxytocin drip was continued slowly for 6 hours. The monitoring was continued postoperatively for 3 days. Subsequently, injectable steroids were tapered and overlapped with oral steroids. Postoperative period was uneventful.
The pituitary gland or hypophysis is considered as the "master gland" of the endocrine system as it acts as a coordinating centre for control of many downstream endocrine glands. Physiologically, the pituitary gland is divisible into two distinct portions: The anterior pituitary or adenohypophysis secretes thyroid stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), lutenizing hormone, follicle-stimulating hormone, GH and prolactin and the posterior pituitary or neurohypophysis secretes arginine-vasopressin or antidiuretic hormone (ADH) and oxytocin. 
Normally, subphysiological target hormone levels stimulate the pituitary gland to increase trophic hormone production. When the pituitary gland is removed, the target gland hormone production is reduced because of a lack of trophic stimulus (disruption of hypothalamic-pituitary-adrenal [HPA] axis) which results in progressive secondary failure of the target glands. So, pituitary hormone replacement therapy needs to be taken into consideration to maintain the metabolic milieu of human body.
Pregnancy after hypophysectomy is no doubt a "precious pregnancy." So, it requires an early obstetric intervention in the form of elective caesarean section. Overton et al. carried out an audit concerning the outcome of 18 pregnancies in nine women with panhypopituitarism, attending a single fertility clinic over 20 years and concluded that, these are high-risk pregnancies perhaps because of uterine defects secondary to endocrine deficiency and early elective caesarean section is recommended. 
C-section being a major abdominal surgery is a very stressful condition. The stress response to surgery is portrayed by an array of hormonal changes initiated by neuronal activation of HPA axis which ultimately results in release of cortisol, the "stress hormone" along with other endocrine, autocrine and some paracrine substances. Dimopoulou et al. concluded that, at an early phase following major surgery, elevated cortisol is associated with high ACTH.  Wakim and Sledge et al. showed that patients undergoing surgery having low levels of ACTH are at an increased risk for cardio-vascular collapse.  Cortisol influences, regulates or modulates many of the changes that occur in the body in response to stress. The response plays as a compensatory mechanism and provides maximum chances of survival because of the increased cardio-vascular functions, fluid preservation and supply of the increased demands for energy generating substrates. Low cortisol level during surgery generally impairs the patient's ability to combat surgical stress which is manifested by significant drop in blood pressure. A stress dose of steroids given preoperatively and continuation of current steroid dose before and after surgical intervention will help to prevent cardio-vascular collapse.  In case of major surgery, in addition to usual corticosteroid dose, Salem et al. recommended 100-150 mg of hydrocortisone IV every 8 h for 48-72 h, Nicholson et al. recommended 25 mg of hydrocortisone at induction of anaesthesia followed by 100 mg/day for 48-72 h whereas Jabbour recommended 100 mg hydrocortisone at induction of anaesthesia followed by 100 mg every 8 h for 24 h with gradual tapering. ,,
Central hypothyroidism is characterized by low levels of serum free T4 and TSH which may predict unpropitious surgical outcome in terms of impaired cardiac contractility with decreased cardiac output, increased peripheral vascular resistance, and decreased blood volume as well as involvement of respiratory, hematopoietic, and renal organ systems. Thyroxine supplement has to be continued till the morning of surgery. Antisialagogue and antiemetic premedication is helpful since these patients may have decreased GIT motility and bradycardia. It is better to avoid sedative and narcotic premedication. Ketamine is the better induction agent in hypothyroidism because it will not produce hypotension and bradycardia. Inhalation agents can increase the severity of already existent myocardial depression and bradycardia. Recovery from general anesthesia may be delayed in hypothyroid patients by hypothermia, respiratory depression or reduced rate of drug biotransformation. All of these factors can contribute to a patient having cardio-vascular collapse with surgical stress.
In hypophysectomised patient, the lack of ADH results in diabetes insipidus (DI). The body cannot reabsorb an appropriate amount of water. A patient urinates large amounts and can become dehydrated, hypernatremic, and hypotensive. Most individual's kidneys will eventually adjust and control this absorption problem over time. Preoperative treatment of DI consists of restoring normal intravascular volume by replacing urinary losses, by using nasal desmopressin, and by giving daily fluid requirements intravenously. If DI is suspected during a case, monitoring of sodium levels and serum osmolality will help to prevent the problems associated with it.
A careful review of all medications, lab reports, patient's medical history and current vital signs or symptoms with any deviation from normal should be checked preoperatively. Although neuraxial techniques are the preferred method of providing anaesthesia for caesarean delivery but maternal refusal remains a contraindication. The local anaesthetics when used intrathecally or epidurally, abolishes the stress response to a great extent, particularly in lower abdominal operations. General anaesthesia does not abolish the response completely. These responses can be modified in the pre, peri and postoperative period. The prevention of stress response during laryngoscopy, intubation and skin incision protects the myocardium. Stabilization of depth of anaesthesia and hemodynamics peri-operatively reduces this response.
To conclude, a patient of hypophysectomy remains on lifelong replacement therapy with many hormones. A proper control of hormonal level is essential for safe outcome and may require involvement of an endocrinologist. General and regional anaesthesia both can be safely given to these patients though regional anaesthesia is more preferable.
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