Neurosurgical anesthesia for a pregnant woman with macroprolactinoma

Abstract

Rationale:Being required to perform neurosurgery on a pregnant woman is rare, but occasionally unavoidable. In these cases, clinical anesthesiologists are confronted with conflicting information and few evidence-based guidelines.Patient concerns:Here, we describe the successful anesthetic management of a 24-week pregnant woman with macroprolactinoma who underwent endonasal transsphenoidal resection of pituitary adenoma.Diagnoses:According to the prolactin (PRL) level and magnetic resonance imaging (MRI) results, the patient was diagnosed with macroprolactinoma and kept stable after taking the regular bromocriptine treatment. However, after stopping the drug by herself because of pregnancy, her tumor increased in size and she suffered from vision loss. Surgery was recommended as soon as possible to lessen the compression in the eye. However, the anesthetic management was a considerable risk due to the increased chance of maternal mortality, intrauterine growth restriction, or preterm labor.Interventions:We held a multidisciplinary meeting before the operation and made a detailed plan for how to proceed. During the operation, our team ensured intensive monitoring, provided adequate oxygen, and achieved haemodynamic stability. Anesthetics like sufentanyl, rocuronium, propofol, and desflurane were carefully chosen in order to ensure the safety of both the mother and fetus.Outcomes:Under the careful and successful anesthetic management, the pregnant woman underwent the surgery smoothly and neither the mother nor baby experienced any pre- or postoperative complications. At the 38th week of gestation, the patient received a cesarean section and the baby had developed normally.Lessons:Neurosurgeries in pregnancy are sparse, and careful planning with cross-disciplinary specialists was needed in advance of the operation. Moreover, when dealing with such surgeries, we should consider the safety of both the mother and fetus, which is challenging but important.

ESE Clinical Practice Guideline on functioning and nonfunctioning pituitary adenomas in pregnancy

“…We included 28 studies on transsphenoidal surgery of pituitary adenomas during pregnancy (28,49,124,135,153,157,168,169,170,171,172,173,174,175,176,177,178,179,180,181,182,183,184,185,186,187,188,189), see Appendix 5 Table 1 for the GRADE evidence, and Appendix 5 Table 2 for study details. Pituitary surgery was performed in 33 cases during pregnancy.…”

Management of sellar and parasellar tumors becoming symptomatic during pregnancy: a practical algorithm based on multi-center experience and systematic literature review

“…The main elements to be considered in deciding whether or not attempting surgery are the mother conditions (i.e. symptoms type and progression), the fetus gestational age and vital parameters, and the predicted outcome of the procedure, since neurosurgical procedures during pregnancy can compromise blood flow to the fetus and induce premature labor [ 12 , 20 , 21 ].…”

Clinical Features and Surgical Management of Pituitary Adenoma During Pregnancy: Case Series and Literature Review

“…The overall malformation incidence in pregnancy is 2%, compared with 3.9% in the rst trimester, and the incidence of neural tube defects and preterm delivery is highest in the third trimester [56]. In our study, most patients also underwent surgery in the second trimester [16,18,19,23,24,27,29,33,[35][36][37][51][52][53][54][55]. Therefore, the second trimester is the best time for PA surgery [11-13, 57, 58].…”

“…Here, the three most common clinical symptoms of these patients were visual eld defects (68.3%) [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34], headaches (65.9%) [15, 16, 18-24, 26-36], and vision loss (48.8%) [17-23, 25, 26, 28, 29, 31, 32, 35, 37]. Previous studies showed that the two most common clinical symptoms of PA patients with apoplexy during pregnancy were headaches and visual impairment [18,33], which is similar to our study.…”