Phaeochromocytoma: an unusual cause of hypertension in pregnancy

Abstract

SummaryA primiparous, full-term, 28-year-old woman underwent an emergency lower segment Caesarean section under epidural anaesthesia for failure to progress in the first stage. Despite an uneventful pregnancy and delivery, she developed a hypertensive crisis in the postoperative period complicated by acute pulmonary oedema requiring ventilation for 48 h in the intensive care unit. Intravenous magnesium sulphate infusions and hydralazine boluses were used to control the blood pressure, which was associated with clonus, hyperreflexia, tachycardia and profuse sweating. The patient made a good recovery. Later measurement of urinary catecholamines in the recovery phase showed greatly elevated levels of norepinephrine, dopamine and vanillyl mandelic acid. Further investigations included a normal abdominal computed tomography scan and a I-123 meta-iodo-benzyl-guanidine scintigraphy scan which revealed a 3-to 4-cm irregular tumour located at the level of the lower pole of the right kidney and further liver hot spots. Intravenous magnesium sulphate infusion proved successful in controlling hypertension caused by a phaeochromocytoma in the postpartum period.

Management of pheochromocytoma: Old ideas and new drugs

“…[15,16] It has been reported that calcium channel blockers can prevent the cathecholamine coronary spam as well. [16] Other drugs, including clonidine (0.1-1.2 mg), dexmedetomidine, [17] and magnesium, [18][19][20][21][22] have also been used to achieve suitable degrees of α-adrenergic blockade before surgery. Clonidine is a well-known presynaptic α2-adrenoreceptors agonist.…”

“…[23,24] The role of magnesium sulfate has been re-evaluated. [18][19][20][21][22] It can decrease catecholamine release, reducing anesthetic drugs, and dilate the bronchial tree. Magnesium is predominantly an arteriolar dilator, reducing afterload but with minimal effects on venous return and preload.…”

Anaesthetic management for emergency caesarean section in a patient with an untreated recently diagnosed phaeochromocytoma

“…It may cause potentially fatal hypertensive crises precipitated by catecholamine surge during vaginal delivery, the mechanical effects of the gravid uterus, uterine contractions and even vigorous foetal movements. [2] Antenatal recognition and subsequent pharmacological or surgical therapy is important for better maternal and foetal outcome. Management requires close co-ordination between the obstetrician, anaesthesiologist, paediatrician and the endocrinologist.…”

“…If the diagnosis is confirmed before 24 weeks gestation, medical management is initiated and the tumour should be excised after adequate adrenergic blockade (prazosin with or without beta blockers). [2] After the 24 th week, the pregnancy is usually allowed to continue until foetal maturity is attained and hypertension controlled with adequate alpha followed by beta blockade. Elective caesarean section followed by removal of the tumour should subsequently be performed in the third trimester.…”

Magnesium sulphate for phaeochromocytoma crisis

“…There is extensive literature on the efficacy of magnesium sulphate in the management of hypertension and arrhythmias during surgical removal of phaeochromocytoma, often without preceding alpha‐blockade. Several case reports describe its successful use in individuals with phaeochromocytoma crisis, including catecholamine cardiomyopathy, where phentolamine and nitroprusside were unsuccessful 4,5 …”