Journal of Obstetric Anaesthesia and Critical Care

CASE REPORT
Year
: 2017  |  Volume : 7  |  Issue : 2  |  Page : 97--99

Anesthesia for combined cesarean section and pheochromocytoma resection


Sadhana Kulkarni1, Sudhir Kulkarni2, Savani Futane3, Prashant Pachore1,  
1 Department of Anesthesiology, Govt. Medical College and Cancer Hospital, Aurangabad, India
2 Department of Nephrology, Mahatma Gandhi Mission Medical College Aurangabad, Aurangabad, Maharashtra, India
3 Consultant Anesthesiologist, Aurangabad, Maharashtra, India

Correspondence Address:
Sadhana Kulkarni
Adwait, 113 Tilak Nagar, Aurangabad - 431 005, Maharashtra
India

Abstract

Pheochromocytoma (PCC) is a rare cause of hypertension during pregnancy [1:54000 pregnancies]. Fetomaternal morbidity and mortality is about 58% if the diagnosis is missed. Administration of anesthesia to patients with PCC is challenging. Associated pregnancy adds to the problems. This is a case report of a patient having PCC diagnosed at 26 weeks of gestation. With medical management pregnancy was continued till 34 weeks. She was posted for cesarean section and resection of PCC. Patient underwent surgery lasting for 7 h due to inferior vena cava tear and had stormy intra as well as postoperative course. Mother and baby had uneventful recovery due to continuous invasive monitoring and a good teamwork, despite limited anesthetic resources.



How to cite this article:
Kulkarni S, Kulkarni S, Futane S, Pachore P. Anesthesia for combined cesarean section and pheochromocytoma resection.J Obstet Anaesth Crit Care 2017;7:97-99


How to cite this URL:
Kulkarni S, Kulkarni S, Futane S, Pachore P. Anesthesia for combined cesarean section and pheochromocytoma resection. J Obstet Anaesth Crit Care [serial online] 2017 [cited 2021 Jan 27 ];7:97-99
Available from: https://www.joacc.com/text.asp?2017/7/2/97/217774


Full Text

 Introduction



Incidence of pheochromocytoma (PCC) during pregnancy is 1 out of 54,000.[1] Patient may be misdiagnosed as having preeclampsia, leading to increased fetomaternal mortality (58%).[2] This can be reduced by antenatal diagnosis and proper treatment. Anesthetic management of a parturient posted for a cesarean section and PCC resection in a limited resource setting is described.

 Case Report



A 22-year-old fourth gravida, having PCC diagnosed at 26 weeks of gestation, was posted for elective cesarean section at 34 weeks. She was asymptomatic and had no pedal edema. Pulse rate was 84/min and blood pressure was 120/80 mm Hg. Her antihypertensive medication consisted of Nifedipine 10 mg TDS, Prazosin 1.5 mg QID, and Metoprolol 50 mg OD. Systemic examination did not reveal any abnormality. Hemoglobin was 9.5 gm%. Ultrasonography abdomen revealed right-sided suprarenal mass [7.6 cm × 5.4 cm]. Urinary vanillylmandelic acid was 30.4 mg (normal range: 2–7 mg) over 24 hours.[3]

There was no albuminuria. Electrolytes, blood sugar, uric acid, coagulation profile, liver, kidney and thyroid function tests, calcitonin levels, fundoscopy, ECG, two-dimensional Echo were within the normal limits.

Patient received oral 10 mg Diazepam and 50 mg Metoprolol at night. Last dose of Nifedipine (10 mg) and 1.5 mg Prazosin was administered 4 h before surgery. We planned epidural anesthesia for cesarean section followed by additional general anesthesia for tumor resection.[4]

Intravenous (IV) Ranitidine and Ondansetron were given. Preoperative Metoclopramide was avoided to prevent hypertensive crisis.[5]

Multiparamonitor was applied. Fetal heart surveillance (FHS) was 130/min. Internal jugular vein and radial artery cannulation was done after giving 50 μgm of Fentanyl and one mg of Midazolam. 500 ml of ringer lactate was administered for preloading. After negative aspiration, a test dose of 2 ml, 1.5% Lignocaine with Adrenaline [6] was administered epidurally, but she became drowsy and developed twitching of muscles with blood pressure of 170/130 mm Hg, 120/min pulse rate, and 90% SpO2. Suspecting accidental intravascular injection of Lignocaine with Adrenaline, 100% oxygen was administered along with 50 mg of Thiopentone, 1 mg Phentolamine, and 5 mg of Labetalol. After 5 min, the patient was fully conscious and SpO2 was 98% on air along with pulse rate 110/min, blood pressure 130/90 mm Hg, and there were no twitchings. FHS slowed down to 80/min. We planned for general anesthesia to avoid fetal distress. 100 mg Thiopentone, 50 mg Propofol, and 100 mg Suxamethonium were administered for induction and rapid sequence intubation. Oxygen, nitrous oxide, Halothane [0.5%], Vecuronium, and Fentanyl were used for maintenance. A baby (2 kg wt) with APGAR score 8 was delivered without applying fundal pressure and then shifted to neonatal intensive care unit (NICU) with APGAR score 10 (5 min) for monitoring. Patient received Oxytocin to control postpartum hemorrhage and blood transfusion was initiated.

Our aim to maintain mean arterial pressure (MAP) in the range of 70–100 mm Hg, heart rate 80–110/min, central venous pressure (CVP) 8–10 mm Hg was achieved by using phentolamine, metoprolol, and fluid administration. No additional drugs were required to maintain the parameters. Sodium nitroprusside (SNS) drip was added after delivery of baby.

There was a rent in inferior vena cava (IVC) during resection. IVC repair required 5 h and tumor resection another 2 h during which there were a lot of fluctuations in MAP (68–150 mm Hg), heart rate (80–150/min), and CVP (4–12 mm Hg).

Blood loss during this period was about 3000 ml. She required 3500 ml of crystalloids, 500 ml of hydroxy ethyl starch 6%, and 1800 ml of whole blood. Urine output and blood sugar level were within the normal limits.

After resection, CVP was 10 mm Hg but MAP was 40 mm of Hg for which infusion of noradrenalin (1 μg/kg/min) was started. At the end of surgery, while artificial ventilation was still continued, airway pressures progressively increased over 30 min (peak 28 cm and plateau pressure 24 cm) along with fall in SpO2 90% (FiO2 1). There were bilateral crepitations in chest. Pink, frothy secretions were seen through endotracheal tube. Blood pressure was 120/90 mm Hg, with pulse rate of 140/min and 14 mm Hg CVP. 60 mg Furosemide was administered and gradually 10 cm PEEP was instituted in stages. Noradrenalin was gradually tapered over 40 min. SpO2 improved to 100% (FiO2 0.5) and MAP was stable (60 mm Hg without vasopressor). Two packed cell volumes of blood were administered over 2 h as hemoglobin was 6 gm%. She developed hypoglycemia (50 mg%) during this period, which was promptly treated with 50 ml 50% dextrose and 100 ml/hour 5% dextrose maintenance drip. She was electively ventilated in ICU for 10 hours using Midazolam (1 mg/h) and Vecuron (1micrgm/kg/min) infusion. Postoperative analgesia was provided with 8 hourly IV 100 mg Tramadol and 75 mg diclofenac infusion as the epidural catheter was blocked due to blood clot. As her pulse rate (80–90/min) and MAP (70–80 mm Hg) were stable for next 4 h, she was extubated. Baby was shifted from NICU after 24 hours. Mother was discharged on 12th postoperative day.

 Discussion



Goals of management of PCC during pregnancy are early diagnosis, control of blood pressure, and definitive surgery to reduce fetomaternal mortality (<5%).[7]

Hypertension in our patient was controlled with Prazosin, a selective α-1 antagonist. Its short duration helped in titration of dose,[8] without adverse effects on fetus.[9] Nifedipine helped to reduce vasospasm.[10] Terazosin and Doxazosin can also be used.[2] Phenoxybenzamine is commonly used but long duration of action predisposes to postoperative hypotension and needs monitoring of newborn.[11] Our patient had less than 20 mm orthostatic hypotension which assured adequate alpha blockade.[5] Tachycardia was treated with Metoprolol. Other beta-blockers [12] can be used after adequate alpha blockade.

Timing and mode of surgery remains controversial. PCC should be resected in second trimester or after delivery.[13] Cesarean section is preferred over vaginal delivery [14] and PCC should be resected simultaneously or after delivery.[12] Laparotomy is recommended for PCC resection,[12] after 24 weeks of gestation. So we planned cesarean section along with PCC resection.[15],[16] If only cesarean section is performed, there can be postoperative hypertensive crisis. There are reports of PCC resection in postpartum period at interval as localization of tumor might be difficult during pregnancy.[17]

These patients may develop hypertension during shifting, induction, intubation, fundal pressure during cesarean section, tumor handling, and hypotension due to hemorrhage and following tumor resection.

Almost every possible anesthetic technique has been advocated by Hull.[17] Anesthetic technique does not have a major impact on surgical outcome.[6] Epidural, general anesthesia, or combined can be used for cesarean section and PCC resection.

We planned epidural for cesarean section to minimize chances of hypertensive crises.[4],[18] Test dose of Lignocaine with Adrenalin can be administered as usual.[6] Three ml plain Bupivacaine can also be used. However, we had to switch to general anesthesia in anticipation of impending fetal distress as fetal heart rate decreased following accidental intravascular injection of Lignocaine with Adrenaline (140–80/min).

We added Propofol for induction to reduce intubation pressor response.[19] Rapid sequence intubation was done using Suxamethonium.[20] Fasciculation can compress tumor and stimulate autonomic ganglia.[6] But we had no other option at that time. As time was crucial, prior Magnesium sulfate (2 mg/kg over 10 min) could not be tried. Prior Phentolamine, Labetalol, and Propofol might have prevented hypertension after Suxamethonium in our patient. Rocuronium can be used but may cause hypertensive crises.[21]

Maintenance was done with Halothane 0.5%[22],[23] but its usage in patients with PCC is controversial due to its arrhythmogenic property.[12] But that was the only volatile agent available with us 12 years back. All other volatile agents except desflurane can be used. Desflurane produces sympathetic stimulation.[5] Fentanyl was used for our patient. Remifentanyl is preferred due to its shorter half-life in neonates.

We have used phentolamine prior to delivery of baby. Although low-dose SNP infusion (<1 μg/kg/min)[12] is considered safe, keeping possibility of fetal cyanide toxicity, sodium nitroprusside was added later during tumor resection. Postoperative hypotension in our patient could be due to fall in catecholamine levels and due to blood loss. Sudden reductions in catecholamines also lead to hypoglycemia.[5] Pulmonary edema might be due to increased permeability of pulmonary vessels during pregnancy, IV fluids, and noradrenalin. Patient responded to addition of PEEP and furosemide. Gradual tapering of noradrenalin reduced systemic vascular resistance and preload.

PCC is a rare but treatable cause of hypertension during pregnancy leading to high fetomaternal morbidity and mortality. Multidisciplinary approach helps for better outcome. Anesthetic management is challenging and needs a good teamwork.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Sarathi V, Lila AR, Bandgar TR, Menon PS, Shah NS. Pheochromocytoma and pregnancy: A rare but dangerous combination. Endocr Pract 2010;16:300-9.
2Oliva R, Angelos P, Kaplan E, George B. Pheochromocytoma in pregnancy: A case series and review. Hypertension 2010;55:600-6.
3Memon MA, Aziz W, Abbas F. Surgical management of pheochromocytoma in a 13-week pregnant woman. BMJ Case Rep 2014;2014.
4Takahashi K, Sai Y, Nosaka S. Anesthetic management for caesarean section combined with removal of pheochromocytoma. Eur J Anaesthesiol 1998;15:364-8.
5Harish R. Pheochromocytoma resection: Current concepts in anesthetic management. J Anaesthesiol Clin Pharmacol 2015;31:317-23.
6Bajwa SJ, Bajwa SK. Implications and considerations during pheochromocytoma resection: A challenge to the anesthesiologist. Indian J Endocrinol Metab 2011;15:S337-44.
7Schenker JG, Chowers I. Pheochromocytoma and pregnancy: Review of 89 cases. Obstet Gynecol Surv1971;26:739-47.
8Davi Rittori P, Cinthia C, Claudio M, Rubia M. Pheochromocytoma and pregnancy: A case report and review. J Bras Nefrol 2015;37:496-500.
9Bourget P, Fernandez H, Ribou F, Edouard D, Frydman R. Weak transplacental passage of prazocin [Alpress] during third trimester of pregnancy – 3 cases. J Gynecol Obstet Biol Reprod 1993;22:871-4.
10Lehmann HU, Hochrein H, Witte E, Mies SHW. Hemodynamic effects of calcium antagonists. Hypertension 1983;5:1166-73.
11Santeiro ML, Stromquist C, Wyble L. Phenoxybenzamine placental transfer during the third trimester. Ann Pharmacother 1996;30:1249-51.
12Lenders JW. Pheochromocytoma and pregnancy: A deceptive connection. Eur J Endocrinol 2012;166:143-50.
13Mannelli M. Management and treatment of pheochromocytomas and paragangliomas. Ann N Y Acad Sci 2006;1073:405-16.
14Junglee N, Harries S, Davies N, Scott-Coombes D, Scanlon MF, Rees DA. Pheochromocytoma in pregnancy: When is operative intervention indicated? J Women's Health [Larchmt] 2007;16:1362-5.
15Oh YS, Lee JJ, Cho GT. Anesthetic management of a patient with pheochromocytoma in pregnancy. Korean J Anesthesiol 1993;26:581-6.
16Doo AR, Kim D, Cha KN, Han YJ, Kim DC. Anesthetic management of a pregnant woman undergoing laparoscopic surgery for pheochromocytoma-A case report. Korean J Anesthesiol 2013;64:373-5.
17Hull CJ. Phaeochromocytoma: Diagnosis, pre-operative preparation, and anesthetic management. Br J Anaesth 1986;58:1453-6.
18Hopkins PM, Macdonald R, Lyons G. Caesarean section at 27 weeks gestation with removal of pheochromocytoma. Br J Anaesth 1989;63:121-4.
19Virendrakumar RB. Comparison of presser response to induction and endotracheal intubation with thiopentone and propofol –prospective randomized study. IJBAR 2012;3:9.
20Agarwal A, Khanna P, Narayanawamy S, Ganga Prasad, Borle A. Anaesthetic management for emergency caesarean section in a patient with an untreated recently diagnosed phaeochromocytoma. IJA 2011;55:614-7.
21Jeong CW, Lee HG, Kim WM, Shin SH, Bae HB. Was a hypertensive crisis in a patient with pheochromocytoma caused by rocuronium? – A case report. Korean J Anaesthesiol 2009;57:249-53.
22Kim JC, Jeon JK. Halothane anesthesia for pheochromocytoma. Korean J Anesthesiol 1981;14:453-8.
23Cooperman LH, Engelman K, Mann PE. Anesthetic management of pheochromocytoma employing halothane and beta adrenergic blockade. Anesthesiology 1969;30:29-36.