Pheochromocytoma during Pregnancy: Laparoscopic and Conventional Surgical Treatment of Two Cases

Abstract

Pheochromocytoma is a rare entity. When it presents during pregnancy, rapid recognition and diagnosis are crucial in order to avoid the maternal and fetal morbidity and mortality associated with severe, uncontrolled hypertension. Difficulties arise from the differential diagnosis of pre-eclampsia. We report two patients operated on for pheochromocytoma during pregnancy. The first patient developed new-onset hypertension in early pregnancy. Prior to presentation, there had been non-specific signs of endocrine disorder, namely a mild diabetes, but no hypertension requiring medication. The second patient sought medical care for irregular heartbeat, shortness of breath, and fatigue during the 6th week of pregnancy. She was found to be hypertensive; diagnostic evaluation revealed substantially increased catecholamine levels. The diagnosis was made by elevated urinary catecholamines and by MRI scan as well as ultrasonography, both of which demonstrated an adrenal mass. Both patients underwent surgical extirpation of the affected adrenal gland. The procedure was performed laparoscopically in the case of the second patient. Pre-operatively, both patients were pre-treated with alpha-blockade followed by secondary beta-blockade. Patient two also received methyldopa for control of hypertension. Both patients were readily weaned from antihypertensive medications post-operatively, with complete resolution of hypertension within a few hours. Each pregnancy progressed normally to term.

Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy

“…Laparoscopic adrenalectomy during pregnancy has proven effective in the management of primary hyperaldosteronism [129], Cushing's syndrome [130][131][132], and pheochromocytoma [133][134][135][136][137][138]. Laparoscopic splenectomy has also become an increasingly accepted surgical approach in pregnancy [139].…”

Diagnosis and laparoscopic treatment of surgical diseases during pregnancy: an evidence-based review

“…After successful laparoscopic management of appendicitis and gallbladder disease in pregnancy, surgeons began exploring laparoscopy in the management of other surgical diseases that arise in pregnancy. Laparoscopic adrenalectomy during pregnancy has proven effective in the management of primary hyperaldosteronism [122], Cushing's syndrome [123][124][125], and pheochromocytoma [126][127][128][129][130][131]. Laparoscopic splenectomy has also become an increasingly accepted surgical approach in pregnancy [132].…”

Pheochromocytoma in a Pregnant Woman With Prior Traumatic Aortic Injury

“…27 Failure to control BP or evidence of malignancy should prompt definitive surgical intervention, regardless of gestational age. 28 Given the low risk of perioperative loss in the second trimester, 29 tumor removal should be considered with diagnosis before 24 weeks of gestation. 7,21,30,31 With later diagnosis, extended medical management is advocated for fetal benefit, 11,16 yet becomes increasingly challenging, because pressure from the gravid uterus, fetal movements, or contractions can precipitate catecholamine release and exacerbate hypertensive crisis.…”

“…7,21,30,31 With later diagnosis, extended medical management is advocated for fetal benefit, 11,16 yet becomes increasingly challenging, because pressure from the gravid uterus, fetal movements, or contractions can precipitate catecholamine release and exacerbate hypertensive crisis. 24 When resection is planned, laparoscopic adrenalectomy is the procedure of choice 28,32,33 ; although in advanced gestations, laparotomy after cesarean delivery may be more feasible. 3,28,33 With adequate medical treatment and vaginal delivery, postpartum interval laparoscopy is reasonable.…”