Pheochromocytoma discovered in a pregnant woman: a case report]

A case of pheochromocytoma discovered at pregnancy is reported. The patient was a 27-year-old woman who had no symptoms before pregnancy. A sudden hypertensive attack occurred during vaginal examination at the 36th week of pregnancy. Magnetic resonance imaging (MRI) and ultrasonography showed a right adrenal mass. The level of catecholamine in blood and urine was beyond the normal limit. This patient was diagnosed as pheochromocytoma with pregnancy. Cesarean section was immediately done to avoid hypertensive crisis caused by spontaneous delivery. Blood pressure and blood volume were controlled by an alpha-blocker for one month after delivery, and, then the tumor was removed surgically. Pheochromocytoma with pregnancy is life-threatening for the mother and the fetus because of difficult diagnosis and complex clinical features. Early diagnosis and appropriate treatment are mandatory. Pathophysiological characteristics and the treatment of such specified statics are mainly discussed through our successful achievement.     

妊娠合并嗜铬细胞瘤的诊断与处理

目的 探讨妊娠合并嗜铬细胞瘤的诊断与处理方法.方法 妊娠合并嗜铬细胞瘤病例3例.年龄分别为41、28、32岁,均为妊娠期间出现高血压,并伴有头痛、心悸、多汗等症状,分别于妊娠27周+1,12周+4,14周+3就诊.24 h尿儿茶酚胺明显升高;肿瘤位于右肾上腺2例,双侧肾上腺1例,肿瘤直径4.5～10.0 cm,术前诊断"妊娠合并嗜铬细胞瘤".结果 例1于孕32周行全麻下剖宫产术,顺利分娩一健康女婴,同时行后腹腔镜下右肾上腺肿瘤切除术,切除7.0 cm肿瘤1枚.例2及例3均选择流产.例2行后腹腔镜下右肾上腺肿瘤切除术,切除右肾上腺4.5 cm肿瘤1枚.例3拒绝进一步治疗.例1及例2术后病理均证实为嗜铬细胞瘤.结论 对于妊娠早期出现高血压、典型发作性高血压或伴有头痛、心悸、大汗三联征,分娩后高血压仍未恢复正常的孕妇,应考虑嗜铬细胞瘤;及时诊断可显著降低母亲及胎儿死亡率;处理上应根据妊娠所处的时期及嗜铬细胞瘤的功能状态选择恰当的方式.妊娠中期是较理想的手术治疗时机.腹腔镜手术治疗妊娠嗜铬细胞瘤安全、有效.     

妊娠合并嗜铬细胞瘤的诊断与处理

目的 探讨妊娠合并嗜铬细胞瘤的诊断与处理方法.方法 妊娠合并嗜铬细胞瘤病例3例.年龄分别为41、28、32岁,均为妊娠期间出现高血压,并伴有头痛、心悸、多汗等症状,分别于妊娠27周+1,12周+4,14周+3就诊.24 h尿儿茶酚胺明显升高;肿瘤位于右肾上腺2例,双侧肾上腺1例,肿瘤直径4.5～10.0 cm,术前诊断"妊娠合并嗜铬细胞瘤".结果 例1于孕32周行全麻下剖宫产术,顺利分娩一健康女婴,同时行后腹腔镜下右肾上腺肿瘤切除术,切除7.0 cm肿瘤1枚.例2及例3均选择流产.例2行后腹腔镜下右肾上腺肿瘤切除术,切除右肾上腺4.5 cm肿瘤1枚.例3拒绝进一步治疗.例1及例2术后病理均证实为嗜铬细胞瘤.结论 对于妊娠早期出现高血压、典型发作性高血压或伴有头痛、心悸、大汗三联征,分娩后高血压仍未恢复正常的孕妇,应考虑嗜铬细胞瘤;及时诊断可显著降低母亲及胎儿死亡率;处理上应根据妊娠所处的时期及嗜铬细胞瘤的功能状态选择恰当的方式.妊娠中期是较理想的手术治疗时机.腹腔镜手术治疗妊娠嗜铬细胞瘤安全、有效.     

妊娠合并嗜铬细胞瘤的诊断与处理

目的 探讨妊娠合并嗜铬细胞瘤的诊断与处理方法.方法 妊娠合并嗜铬细胞瘤病例3例.年龄分别为41、28、32岁,均为妊娠期间出现高血压,并伴有头痛、心悸、多汗等症状,分别于妊娠27周+1,12周+4,14周+3就诊.24 h尿儿茶酚胺明显升高;肿瘤位于右肾上腺2例,双侧肾上腺1例,肿瘤直径4.5～10.0 cm,术前诊断"妊娠合并嗜铬细胞瘤".结果 例1于孕32周行全麻下剖宫产术,顺利分娩一健康女婴,同时行后腹腔镜下右肾上腺肿瘤切除术,切除7.0 cm肿瘤1枚.例2及例3均选择流产.例2行后腹腔镜下右肾上腺肿瘤切除术,切除右肾上腺4.5 cm肿瘤1枚.例3拒绝进一步治疗.例1及例2术后病理均证实为嗜铬细胞瘤.结论 对于妊娠早期出现高血压、典型发作性高血压或伴有头痛、心悸、大汗三联征,分娩后高血压仍未恢复正常的孕妇,应考虑嗜铬细胞瘤;及时诊断可显著降低母亲及胎儿死亡率;处理上应根据妊娠所处的时期及嗜铬细胞瘤的功能状态选择恰当的方式.妊娠中期是较理想的手术治疗时机.腹腔镜手术治疗妊娠嗜铬细胞瘤安全、有效.

Abstract：

Objective To discuss the diagnosis and management of pheochromocytoma in pregnancy. Methods Three cases of pheochromocytoma in pregnancy were managed from 2007- 2009.Case 1, a 41-year-old woman presented with paroxysmal hypertension during 27+1 weeks' gestation.The accompanied symptoms included dizziness, palpitation and sweating. Both B ultrasound and MRI revealed a right adrenal tumor about 7 cm in diameter. The 24-hour catecholamine was higher than normal. A diagnosis of right adrenal pheochromocytoma was made. Case 2, a 28-year-old woman presented with hypertension during 12+4 weeks' gestation. B ultrasound showed a right adrenal tumor about 5 cm in diameter. The 24-hour catecholamine was higher than normal. Case 3, a 32-year-old woman presented with hypertension during 14+3 weeks' gestation. B ultrasound revealed bilateral adrenal tumors. The 24-hour catecholamine was higher than normal. The diagnosis of bilateral adrenal pheochromocytomas was made. Results The first patient delivered a healthy female infant through cesarean section at 32 weeks' gestation. Laparoscopic resection of right adrenal pheochromocytoma was successfully performed at the same time. Both the second and third patients had elective abortion for fear of fetotoxicity. Case 2 accepted laparoscopic resection of right adrenal pheochromocytoma after 4 weeks' medical preparation. Case 3 rejected surgery. The histopathological findings proved pheochromocytoma in case 1 and case 2. Conclusions Pheochromocytoma should be included in the defferential diagnosis in hypertension occurring during pregnancy especially in the following situations:hypertension during early pregnancy; paroxymal hypertension accompanied by headache, palpitation and sweating; hypertension does not relieve after delivery. Early diagnosis and management with medical treatment followed by surgical removal usually results in good maternal and fetal outcomes. The second trimester is good timing of surgical management. Laparoscopic removal of pheochromocytoma is safe in pregnancy.     

Successful near-term pregnancy outcome after repair of a dissecting thoracic aortic aneurysm at 14 weeks gestation

PURPOSE: We report the anesthetic management for a scheduled Cesarean section of a 29-yr-old female who previously had a repair of her dissecting thoracic aortic aneurysm during the 14th week of her pregnancy. CLINICAL FEATURES: A 29-yr-old female with a history of hypertension and previously diagnosed aortic dissection secondary to suspected Marfan's syndrome, presented to our institution for the first time after she became pregnant. A transesophageal echocardiogram revealed a dissecting aortic aneurysm greater than 8 cm in diameter beginning distal to the left subclavian artery and extending into the descending thoracic aorta. The patient was counseled in great detail about the risk of rupture with continuing pregnancy. She refused termination and chose elective repair of the aneurysm, with continuation of the pregnancy. Partial repair of the thoracic aneurysm was undertaken when the pregnancy was 13(5/7) weeks by ultrasound dates. She was subsequently maintained on labetolol and hydralazine for blood pressure control. A decision was made to proceed with a Cesarean section at 32 weeks. After placement of a radial artery catheter and two large peripheral iv catheters, she received a of 7 and 7 at one and five minutes was delivered. CONCLUSIONS: Aortic dissection in pregnancy may have catastrophic results. Undoubtedly, it presents unique challenges for anesthetic and obstetrical management. With appropriate care and surgical correction of the dissecting aneurysm early in pregnancy, a successful outcome for the pregnancy was possible.     

Variable hemodynamic fluctuations during resection of multicentric extraadrenal pheochromocytomas

PURPOSE: To report the perioperative management and the serious hemodynamic fluctuations during manipulation of an organ of Zuckerkandl tumour in a patient undergoing resection of multicentric extraadrenal pheochromocytomas. CLINICAL FINDINGS: A 28-yr-old man who had undergone at age 12 a laparotomy for excision of an extraadrenal pheochromocytoma complained of paroxysmal headache, occasional sweating and palpitations. The arterial blood pressure (BP) was 200/100 mmHg. A 24-hr-urine collection showed catecholamines 5076 microg x 24 hr(-1) (normal < 25 microg x 24 hr(-1)). Computed tomography of the abdomen revealed two retroperitoneal masses, one adjacent to the lower pole of the right kidney and a second larger mass located at the aortic bifurcation in the region of the organ of Zuckerkandl. The patient was scheduled for excision of multiple extraadrenal pheochromocytomas. He was prepared preoperatively for two weeks with prazosin 1 mg po q six hours and propranolol 10 mg tid. Manipulation of the infrarenal tumour was uneventful but manipulation of the Zuckerkandl tumour resulted in severe hypertensive episodes with BP ranging from 200/100 to 320/120 mmHg. Surgery was interrupted temporarily; the hypertensive crisis was controlled by the infusion of sodium nitroprusside and by iv phentolamine and esmolol. CONCLUSION: In a patient undergoing resection of recurrent multicentric extraadrenal pheochromoctyomas, severe hypertensive episodes occurred during manipulation of one tumour but not during manipulation of the other. This may be attributed to inadequate preparation of the patient, difficult surgical dissection of the large Zuckerkandl pheochromocytoma, and/or secondary to an excessive and different pattern of release of catecholamines during manipulation of the Zuckerkandl tumour.     

Idiopathic dilated cardiomyopathy presenting in pregnancy

PURPOSE: To describe the clinical course and management of a patient who presented with idiopathic dilated cardiomyopathy in early pregnancy. CLINICAL FEATURES: A 27 yr old, previously well, Chinese primigravida presented at 18 wk gestation with a history of irregular heart beat and decreased exercise tolerance. Echocardiography showed moderate left ventricular dysfunction with left ventricular ejection fraction of 35-40%. Idiopathic dilated cardiomyopathy was diagnosed. She declined termination of pregnancy and was managed medically with furosemide, digoxin and potassium supplements. Low molecular weight heparin was prescribed. Emergency Cesarean delivery was performed at 31 wk gestation because of deteriorating liver function and a non-reassuring fetal heart rate pattern. General anesthesia was given because of relative urgency, the patient's wish, and concerns about potential risk of spinal hematoma. Invasive monitoring with pulmonary and radial artery catheters was used and low dose inotropic support was given. Postoperatively, she was managed in the intensive care and coronary care units where she was treated with dobutamine, furosemide, digoxin, potassium, captopril, losartin and warfarin. Her postoperative course was complicated by a severe embolic stroke five weeks after delivery and she died five months later. CONCLUSION: Idiopathic dilated cardiomyopathy may rarely present in pregnancy. A multidisciplinary approach and close peripartum monitoring are important in management and termination of pregnancy should be considered. Thromboembolic complications are a major risk.     

Refractory hypotension during spinal anesthesia for Cesarean delivery due to undiagnosed pheochromocytoma

Profound hypotension and resistance to conventional vasopressor therapy following administration of spinal anesthesia for Cesarean delivery occurred in a multiparous parturient. Postpartum evaluation for secondary hypertension showed a diagnosis of pheochromocytoma. Pheochromocytoma was mistaken for preeclampsia with significant vasopressor requirement to treat hypotension from spinal anesthesia. If pheochromocytoma is diagnosed during pregnancy and Cesarean delivery is required, spinal anesthesia may not be the optimal choice of anesthesia.     

Craniotomy for suprasellar meningioma in a 28-week pregnant woman without fetal heart rate monitoring

PURPOSE: To illustrate the anesthetic management of a craniotomy for suprasellar meningioma in a 28-week pregnant woman and to review the considerations for fetal monitoring during surgery. CLINICAL FEATURES: A 33-yr-old woman presented at 28 weeks of gestation with rapidly deteriorating vision in her right eye. Neuroradiological investigations revealed a large suprasellar meningioma extending into the frontal lobe. She underwent a craniotomy for excision of the tumour at 28 weeks gestation because of the risk of irreversible blindness. Anesthetic management was tailored for pregnancy and an intracranial tumour. Intraoperative blood pressure was maintained within 10% of baseline and respiratory variables were stable. No fetal heart rate monitoring was used during the surgery, as there was no plan to perform an emergency Cesarean delivery even in the event of change in fetal monitoring. The aim was to treat the mother aggressively for any untoward events. She made a good neurological recovery after the procedure and had a spontaneous vaginal delivery at 40 weeks of gestation without any neonatal complications. CONCLUSIONS: Anesthetic management of a brain tumour during pregnancy should be tailored to the individual patient according to the circumstances. It is possible to perform this type of procedure without fetal heart rate monitoring. The decision regarding fetal monitoring should be based on the consensus of the multidisciplinary care team and the mother.     

General anesthesia with remifentanil for Cesarean section in a parturient with an acoustic neuroma

PURPOSE: To describe the anesthetic management of a parturient with a large acoustic neuroma undergoing general anesthesia with remifentanil for Cesarean section. CLINICAL FEATURES: A near-term parturient presented with a large intracranial mass. Cesarean section under general anesthesia was elected one week prior to craniotomy for tumour resection. Remifentanil infusion, 0.2-1.0 microg x kg(-1) x min(-1), was used from induction to emergence of general anesthesia. The neonate was born seven minutes after the remifentanil infusion was started. She had normal umbilical cord pH and her Apgar scores were 7 and 8, at one and five minutes respectively. Although the neonate received supplemental oxygen, she did not require naloxone. Both mother and neonate made an uneventful recovery. CONCLUSION: Remifentanil was effective in producing stable hemodynamic conditions, without severe neonatal respiratory depression, during induction and maintenance of general anesthesia for a Cesarean delivery in a parturient with a large intracranial tumour.     

Malignant recurrent pheochromocytoma during pregnancy: case report and review of the literature

Pheochromocytoma is an uncommon disorder associated with significant morbidity and mortality. When the disorder is discovered during pregnancy the risks are much greater. Malignant lesions represent only 10% of these tumors. Malignancy associated with pregnancy is even more rare. We present the fourth case of malignant pheochromocytoma and pregnancy to be reported in the literature. Surgery remains the mainstay of therapy. If the disorder is diagnosed early in pregnancy, surgical exploration should be considered after rapid medical control. If diagnosis is made later in pregnancy, medical control for the duration of the pregnancy should be attempted. Labor and vaginal delivery should be avoided because of an associated high morbidity and mortality. Cesarean section is recommended, once fetal maturity has been reached. Localization and definitive resection may be performed after delivery if exploration was not performed at the time of cesarean section. Although the prognosis of patients with malignant pheochromocytomas remains poor, there is hope of improving this prognosis in the future with use of new radiopharmaceutical agents and, possibly, new chemotherapy. Currently, aggressive surgical management not only appears to offer excellent palliation but likely prolongs survival of patients with malignant pheochromocytomas in selected cases.     

Pregnancy, labour and delivery in a Jehovah’s Witness with esophageal varices and thrombocytopenia

PURPOSE: An increasing number of women with cirrhosis are conceiving and carrying their pregnancies to term. However, the maternal mortality rate remains high (10-61%). This case report describes the management of a parturient with esophageal varices and thrombocytopenia. She was also a Jehovah's Witness. CLINICAL FEATURES: A 25-yr-old Jehovah's Witness parturient with portal hypertension and esophageal varices secondary to cryptogenic cirrhosis was referred to our obstetrical unit at eight weeks gestation. In addition she was thrombocytopenic with platelet counts ranging from 42,000-67,000 x microl(-1). Her esophageal varices were banded prophylactically on three occasions during her pregnancy. Magnetic resonance imaging at 32 wk gestation showed extensive caput medusa and dominant midline varix. Therefore, the planned mode of delivery was changed from Cesarean section which could result in massive hemorrhage, to elective induction of labour with an assisted second stage. The patient refused any blood product transfusion except acute hemodilution and cell saving if necessary during labour and delivery. Despite elaborate preparations for a planned vaginal delivery, she underwent an unanticipated rapid labour. Spinal analgesia was provided to facilitate smooth assisted vacuum delivery. CONCLUSION: Multidisciplinary care is the key for a successful outcome in parturients with cirrhosis. Periodic examination and banding of esophageal varices is recommended during pregnancy. Active consideration should be given to availing of the benefits of regional anesthesia.     

Anesthesia for Cesarean section and posterior fossa craniotomy in a patient with von Hippel-Lindau disease

PURPOSE: To describe the care of a pregnant woman with von Hippel-Lindau disease (VHLD) and intracranial mass lesions. CLINICAL FEATURES: A 30-yr-old primigravida with VHLD at 35 weeks gestation was seen at the obstetric anesthesia clinic because she wished an epidural analgesia during labour. She had a history of headaches and dizziness. Further investigations showed an enlarged cerebellar hemangioblastoma with significant local mass effects. A combined Cesarean section delivery and posterior fossa craniotomy was performed at 37 weeks gestation. A general anesthetic with fentanyl, rocuronium, nitrous oxide, oxygen and isoflurane was given for Cesarean section delivery. After delivery, isoflurane was reduced and propofol infusion at 4-8 mg x kg(-1) x hr(-1) was initiated. The patient had an uneventful operative course and recovery. CONCLUSIONS: Patients with VHLD may have worsening of preexisting lesions or develop other lesions during pregnancy. Some asymptomatic lesions can increase the risk for anesthesia complications. These patients need comprehensive assessment before administration of anesthesia.     

Anesthesia for cesarean section in two patients with brain tumours

PURPOSE: To describe two patients with brain tumours where general anesthesia was used for cesarean sections under emergency and urgent conditions. CLINICAL FEATURES (CASE #1): The first patient presented at 38 wk gestation with an acute intracranial tumour herniation, requiring emergency craniotomy and simultaneous cesarean section. General anesthesia was induced with thiopental and vecuronium, maintained with enflurane 1% in O2 100%. Maternal P(ET)CO2 was maintained at 25 mmHg. After delivering a healthy infant, she was given syntocinon, mannitol and dexamethasone i.v. anesthesia was maintained with fentanyl, nitrous oxide 50% in O2 and isoflurane 1% during frontal-lobe tumour resection. CLINICAL FEATURES (CASE #2): The second patient presented at 37 wk gestation for urgent cesarean section because of placental insufficiency. She had had a brain tumour resection four years earlier. An increase in intracranial pressure necessitated craniotomy for decompression at 20 wk gestation. She was further treated with dexamethasone, carbamazepine and radiation for control of cerebral oedema at 34 wk. Cesarean section was performed under general anesthesia; rapid-sequence-induction with thiopental and succinylcholine, followed by isoflurane 1% in O2 100%. Syntocinon, fentanyl and atracurium i.v. were administered after delivery of a healthy infant. Although neurosurgeons stood by, their intervention was unnecessary. CONCLUSION: General anesthesia remains safe and dependable for operative delivery in parturients with intracranial tumour. Tracheal intubation allows maternal hyperventilation thereby controlling raised intracranial pressure. Hemodynamic stability is readily achieved to maintain cerebral perfusion. However, a multidisciplinary-team approach is critical for successful patient management.     

Lessons learned from anesthetic management of pheochromocytoma resection: a report of three cases

The anesthetic management of patients with pheochromocytoma, in which drastic hemodynamic changes may occur, is still a challenge to even the most experienced anesthesiologist, although the perioperative mortality has been reduced remarkably. We report three patients who developed unexpected major complications during elective resection of a pheochromocytoma. The Case 1 patient was a 46 year-old woman who developed ventricular tachycardia immediately after administration of ephedrine for transient hypotension induced by excessive phentolamine. Even a mild beta adrenergic agent may cause extraordinary stimulation to myocardium under alpha blockade. The Case 2 patient was a 44 year-old man who needed intensive vasodilating therapy due to an exaggerated cardiovascular response to intraoperative surgical stress. He developed severe metabolic acidosis resembling hyperdynamic shock before resection of the tumor, although blood pressure was controlled within the expected range. The Case 3 patient was a 60 year-old woman who did not receive preoperative alpha blocker therapy because she lacked cardiovascular symptoms. However, she revealed a high level of systemic vascular resistance after induction of general anesthesia and needed moderate inotropic support to compensate for an abrupt reduction of vascular resistance after resection of the tumor. The pathophysiology of the disease is complex and anesthetic care must be tailored in accordance with each patient's situation.     

Cesarean section in a patient with familial cardiomyopathy and a cardioverter-defibrillator

PURPOSE: To describe the impact of maternal automatic implantable cardioverter-defibrillator (AICD) therapy on pregnancy outcome, and discuss the clinical rationale for regional anesthesia in parturients with AICDs. CLINICAL FEATURES: A 20-yr-old primigravida with a history of familial cardiomyopathy and AICD placement presented at 39 weeks gestational age for elective labour induction. Ultimately, the patient underwent a Cesarean section for a failed induction. Her AICD was deactivated during the peripartum period, although the pacing function remained active as she had an underlying heart rhythm of less than 34 beat.min(-1). The patient had continuous electrocardiogram monitoring via an external defibrillating unit to which she remained connected by external defibrillator pads. Labour analgesia and surgical anesthesia were provided with a lumbar epidural dosed with varying concentrations of bupivacaine. This management resulted in an excellent maternal and fetal outcome. CONCLUSIONS: Automatic implantable cardioverter-defibrillators are being utilized more frequently in the obstetric population, and appear compatible with good fetal outcomes. Experience with the anesthetic management of these patients is markedly limited - primarily involving reports of general anesthesia for Cesarean section. Epidural anesthesia, however, offers distinct advantages in this patient population including easy conversion from labour analgesia to surgical anesthesia, preservation of fetal-maternal hemodynamics, prevention of increases in plasma catecholamines due to labour or operative pain, and, finally, possible direct suppression of arrhythmias by pharmacologically-active plasma levels of local anesthetic.     

Peripartale Aortendissektion

A 29-year-old primagravida developed severe chest pains during labor. An emergency caesarean section was performed as the symptoms persisted. Imaging diagnosis immediately after delivery revealed an acute proximal (type A) aortic dissection. The patient was transferred to the nearest cardiothoracic surgery centre and successful emergency surgical aortic repair was performed. The perioperative course of a type A aortic dissection during pregnancy and labor is complicated by time pressure, diagnostic restrictions until delivery and potentially fatal uterine bleeding during cardiopulmonary bypass and hypothermic cardiac arrest. This case report describes the diagnosis and the surgical, anesthesiological and gynecological management of this life-threatening peripartum complication.     

Bladder paraganglioma (pheochromocytoma): report of a new case

The authors report one case of vesical paraganglioma, not suspected in a 50-years-old female patient who presented gross hematuria as only symptom. The patient was not hypertensive. Radiologic and endoscopic investigations revealed a trigonal submucosal tumour. Complete transurethral resection of the tumor was performed with no intraoperative complications. The histopathological diagnosis indicated pheochromocytoma. Blood pressure was stable. There has been no recurrence for 18 months after transurethral resection.     

Use of inhaled nitric oxide for emergency Cesarean section in a woman with unexpected primary pulmonary hypertension

PURPOSE: Use of inhaled nitric oxide (iNO) could be of importance in emergency cases of primary pulmonary hypertension (PPH) in pregnant patients during labour and delivery. iNO acts as a selective pulmonary bed vasodilator avoiding systemic hemodynamic effects due to its ease of administration. Pulmonary bed vasodilation improves right ventricular function directly and left ventricular function indirectly. CLINICAL FEATURES: We report the case of a pregnant patient with unexpected PPH in whom an emergency Cesarean section (CS) had to be performed. PPH was diagnosed on admission as she arrived in active labour at 34 weeks gestational age. An emergency CS was performed under epidural anesthesia for breech presentation . All along labour, delivery and the first 24 hr, iNO was administered via a noninvasive ventilation device. CS was uneventful. A severe pulmonary hypertensive crisis was observed 12 hr after delivery and resolved with an increase of iNO concentration and administration of isoprenalin. The patient and baby returned home on day ten. CONCLUSION: The ease of administration of iNO allowed the optimal control of pulmonary arterial hypertension. No interaction with epidural anesthesia was observed. Use of iNO can improve the management of urgent CS in women with unexpected PPH.     

Anesthetic management of Cesarean delivery in a patient with hypoplastic anemia and severe pre-eclampsia

PURPOSE: To describe the anesthetic management of Cesarean delivery in a patient with hypoplastic anemia and severe pre-eclampsia. CLINICAL FEATURES: A 28-yr-old parturient with a history of thrombocytopenia was admitted with signs of pre-eclampsia (blood pressure of 140/90 mmHg, heavy proteinuria and moderate bilateral ankle edema) at 25 weeks of gestation. Laboratory studies revealed pancy-topenia (hemoglobin 6.4 g.dL(-1), white cell count 3.43 x 10(9).L(-1), platelet count 20 x 10(9).L(-1)) and bone marrow biopsy showed hypoplastic anemia. As pre-eclampsia worsened, a Cesarean delivery was performed at 27 weeks with prophylactic platelet transfusion and meticulous blood pressure control. The procedure was uneventful, conducted under general anesthesia with an estimated blood loss of around 600 mL and a live female baby was delivered. Postoperatively her blood pressure and neurological symptoms improved but thrombocytopenia remained at discharge. CONCLUSIONS: Hypoplastic anemia is rare in pregnancy but it poses an increased risk for both mother and fetus. The mother is at risk of life-threatening episodes of bleeding and infection and a multidisciplinary team approach (obstetrician, anesthesiologist, hematologist and pediatrician) is essential. An accurate assessment of the hematological condition should be made and abnormalities corrected before surgery. Regional anesthesia may not be possible in this circumstance.