An Unusual Cause for Hypertensive Crisis After Cesarean Section

Abstract

INTRODUCTION: Hypertensive crisis during pregnancy is potentially dangerous for mother and fetus. We present a case of hypertensive crisis after cesearean section initially mistaken for pre-eclampsia. CASE PRESENTATION: A 39 year old african american Gravida1 Para1 female with hypertension and gestational diabetes underwent a cesarean section after failed induction of labor. Intraoperatively she developed nausea, chest pain and palpitations. Her blood pressure rose to 250/150 mmHg and heart rate to 140 bpm with sinus tachycardia. She was treated with intravenous hydralazine, nitroglycerin, labetalol and magnesium sulfate. In the ICU her oxygen requirements increased, a CT angiogram was done which showed no pulmonary embolism but a 9 cm × 6 cm X 7 cm mass in the left adrenal gland with possible hemorrhage. Urine cathecholamines were elevated, including urine epinephrine 4664 mcg/24hr, urine norepinephrine 29195 mcg/24hr and urine dopamine 3467mcg/24hr. An MRI abdomen confirmed the mass and ruled out hemorrhage. She was treated with doxazosin for preoperative alpha blockade and propanolol for tachycardia. She underwent laparoscopic left adrenalectomy without complications. Pathology showed pheochromocytoma with negative margins. DISCUSSION: Pheochromocytoma is a rare catecholamine-secreting tumor, occurring in 0.007 % of pregnancies. Recognising pheochromocytoma antenatally is difficult because it may mimic pre-eclampsia or gestational hypertension. The effects of excessive circulating catecholamines may result in lethal complications if not diagnosed and/or treated early. Surgery is the definitive treatment. The timing remains a challenging and controversial issue. Current experience suggests that removal of the pheochromocytoma in a timely fashion following diagnosis leads to best outcomes. This can be achieved safely even during pregnancy if the diagnosis and necessary preparations can be made before 23 weeks of gestation. After 23 weeks, medical management as a bridge to surgery should continue until the later stages of pregnancy when fetal maturity is reached and the delivery can be undertaken in a controlled and planned fashion with subsequent removal of the pheochromocytoma. CONCLUSIONS: Pheochromocytoma is a rare but important cause of hypertension in pregnant and post partum patients because of its high morbidity and mortality to both mother and fetus. Management requires close collaboration among the obstetrician, hypertension specialist, endocrine surgeon, anesthesiologist, and pediatrician.