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.