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Excerpt
Pregnancy complicated by pheochromocytoma is potentially fatal because pregnancy and labor increase the risk of hypertensive crisis. Antepartum diagnosis could reduce both maternal and fetal mortality.
A 38-yr-old parturient was admitted at 21 wk gestation with progressive hypertension and headache. Her unstable blood pressure ranged from 132/94 to 220/128 mmHg. Plasma norepinephrine levels increased to 9.00 ng/mL at 22 wk gestation. An MRI scan revealed a mass in the left renal region and pheochromocytoma was diagnosed. Labetalol and doxazosin were started, after which her basal blood pressure ranged from 120/88 to 156/106 mmHg. Because of the size of the fetus and condition of the patient at 28 wk, the patient was scheduled for cesarean section combined with resection of the pheochromocytoma. Diazepam and famotidine were used for premedication; labetalol (150 mg) and doxazosin (2 mg) were given orally 3 h before anesthesia induction. The bispectral index value was maintained <60 during the surgery. After tracheal intubation, the arterial blood pressure increased to 230/120 mmHg. Sevoflurane with thiopental sodium, phentolamine (3 mg total) and a continuous nitroglycerin infusion (1.0 μg/kg/min) were given. After successful intubation, vecuronium was given; blood pressure decreased to 180/120 mmHg, and the operation was begun. Sevoflurane was stopped before the uterine incision was made. Nine minutes later, the infant was delivered. The infant required intubation and ventilation and was transferred to the NICU for normal care for all premature infants. Anesthesia was maintained after delivery with a propofol infusion (8 mg/kg/h) and intravenous fentanyl 175 μg. Nitroglycerin was discontinued and a prostaglandin E1 (PGE1) infusion was started.
After the abdominal wound from the cesarean section was closed, the tumor extraction was started. Blood pressure increased to 210/115 mmHg; fentanyl 50 μg and phentolamine 1 mg lowered the level to 150/70 mm Hg. When the tumor was massaged, arterial blood pressure and serum norepinephrine increased. Phentolamine 1 mg was again given. After the adrenal vein and artery were ligated, blood pressure decreased and PGE1 administration was stopped. Dopamine was started along with norepinephrine. One hour after the operation, the blood pressure was stable at 117/93 mmHg. The patient had no intraoperative memory. By postoperative day 7, the norepinephrine concentration decreased to 0.02 ng/mL. She was discharged on postoperative day 12 and her infant on postoperative day 81.
Preoperative, oral, -blocking drugs are the main therapy of hypertension induced by pheochromocytoma. They can be used safely during pregnancy, but used alone, can cause tachycardia. Combinations of - and -blocking drugs can be used to treat tachycardia and the current consensus supported the usefulness of this combination.
