31-year-old lady for Hysteroscopy, D&C, Ablation, and Laparoscopic Bilateral Oophorectomy

Background

• Chronic pelvic pain, recurrent ovarian cysts
• Menorrhagia and anaemia, known to Gynaecologist for many years
• Multiple previous hysteroscopies and laparoscopies
• Decision to have oophorectomy made the day prior to clinic review via preoperative phoneconsult with proceduralist
• Recent referral to chronic pain specialist, review pending

Issues

• Partially Empty Sella syndrome – ACTH, TSH, and Prolactin deficiency
• On high-dose Hydrocortisone
• Previous Addisonian crisis perioperatively despite steroid replacement regime?
• Hypothyroidism
• Severe untreated GORD
• Procedure booked for private hospital with no onsite endocrinology support
• Very fit and healthy lady despite co-morbidities. DASI >10

Discussion

What is Partially Empty Sella?

• Empty sella – Radiological description. Pituitary gland shrinks/is compressed by CSF making the sella look empty.
• Partial empty sella – remnants of the pituitary gland visible on MRI
• Rare condition, congenital. Mainly affects women
• Hypopituitarism – mainly deficiencies of anterior pituitary hormones.
• Common manifestations are Central hypogonadism and female infertility.

Perioperative management of Addison’s

• Maintain hydration and regular steroid replacement
• Monitor electrolytes and BSL

Plan:

• IV hydrocortisone replacement at start of surgery – dose dependent on surgery and duration of fasting
• IV hydrocortisone replacement in first 24 hours after intermediate and major surgery
• Endocrinologist advice recommended. See attached BJA education paper

Suitable for Private Hospital?

• Consensus was no, surgery should be rescheduled to occur at JHH
• Endocrinologist in agreement, should be in hospital where they are available to consult

• Proceed at JHH
• Steroid replacement regime in conjunction with endocrine
• Recheck pathology including TFT’s
• Commence PPI
• See article Anaesthesia and Pituitary Disease doi:10.1093/bjaceaccp/mkr014