Figure (1): Abdominal ultrasound showing a right suprarenal mass
The patient was admitted to the obstetrical intensive care unit (ICU) for close monitoring of her blood pressure. The decision was to deliver the patient via Caesarean section in the attendance of general surgery team for concurrent adrenalectomy, after optimization of her BP with alpha-adrenergic blockade using Phenoxybenzamine 30 mg TID and subsequent beta-blockade with Metoprolol 50 mg BID for 14 and 10 days respectively. Patient’s past medical history and family history were negative for features suggestive of multiple endocrine neoplasia (MEN) syndromes.
On the night of the scheduled surgery, the patient developed a generalized tonic clonic (GTC) seizure that was aborted by 2 mg of Lorazepam. There were no post-ictal neurological lateralizing signs and urgent CT brain was done to rule out intracranial hemorrhage and was negative. MRI stroke protocol was also done and revealed no signs suggestive of ischemic stroke. Possible metabolic causes of seizures were also excluded. Exceptionally, as reported in a few cases in the literature, seizures were found to be a rare presenting symptom of pheochromocytoma. Thus, this episode may have directly been related to the patient’s condition.
After optimization of the patient’s condition, Caesarean section via midline skin incision with intrapartum adrenalectomy was performed under general anesthesia (GA). A #20 gauge radial arterial line, PAC, and 5-lead ECG were used for intra-operative monitoring. Prior to being induced, Remifentanil (0.1 mcg/kg/min) with Nitroprusside (0.5 mcg/kg/min) were commenced for baseline BP control. Intermittent BP fluctuations were also controlled by boluses of Labetalol 10 mg IV (total 40 mg) (systolic BP 175 mmHg lowered to 115 mmHg pre-induction). The patient was wedged in a position where her uterus was displaced to the left. A 5-mg defasciculating dose of Rocuronium was given, and after three minutes of pre-oxygenation, a rapid sequence induction with 100 mg Lidocaine, 280 mg thiopental, and 120 mg succinylcholine was conducted under cricoid pressure.
After delivery of the baby, closure of the uterus and ensuring haemostasis, general surgery team scrubbed in and performed right adrenalectomy via an open transabdominal approach upon which there was a dramatic decline in patient’s BP to 95/60 mmHg necessitating the discontinuation of Nitroprusside infusion. The patient was transferred back to the ICU for postoperative care. The excised right adrenal gland was sent for histopathological examination and the results came back consistent with the diagnosis of benign pheochromocytoma. The patient had a smooth postoperative course with normalization of her BP. She was discharged home 6 days following the surgery.