///2009 Abstract Details
2009 Abstract Details2018-05-01T17:45:11+00:00

Unexpected finding of a malignant endodermal sinus tumor resulting in massive blood loss during cesarean section

Abstract Number: 26
Abstract Type: Case Report/Case Series

Matthew W Martin MD1 ; Mythili A. Prabhu MD2

Introduction:

The incidence of neoplasm continues to climb in women of childbearing years in the United States. Germ cell tumors comprise 33% of these malignancies, often invading into the surrounding tissues and lymphatics. These malignancies, with highest prevalence in Asians often appear benign, making diagnosis difficult in pregnancy. It is important to recognize the risk of significant blood loss during resection of these tumors.

Case Report:

A 40yo, Japanese parturient, presented to the operating room for an urgent cesarean section under epidural. Her pregnancy was complicated by a right adnexal mass characterized as an "ovarian cyst" on ultrasound. After an uneventful cesarean delivery of a healthy baby girl, inspection of the right adnexal mass revealed features consistent with possible neoplasm. Given this finding, the patient was administered a GA allow adequate surgical exposure. The mass was found to be friable and adherent to the retroperitonium. Acute and massive hemorrhage ensued from the tumor mass during dissection. Immediate management included a radial arterial line, internal jugular Cordis placement, and multiple transfusions of PRBCs, FFPs, and platelets. Epinephrine, aminocaproic acid, and calcium infusions were initiated to maintain MAPs of 65mmHg and reduce blood loss. After an emergent hysterectomy and 15 liters of blood loss, vascular surgeons assisted in clamping the common iliac arteries to allow for tumor excision. The abdomen was packed, and the patient was transported to the surgical ICU intubated and sedated in stable condition. She had received a total of 27units RBCs, 17units FFPs, 15units Platelets, and 10units of Cryoprecipitate.

The patient returned to the operating room the following day for abdominal closure. She was extubated POD#1 and discharged home POD#10 with a diagnosis of Stage IIIc malignant endodermal sinus tumor. The patient underwent 4 rounds of chemotherapy and subsequent follow-up CT scan 4 months post-op showed her to be in complete remission.

Discussion:

While the majority of adnexal masses are benign, the prudent anesthesiologist must prepare for potential complications. Acute hemorrhage is a leading cause of maternal morbidity and mortality, accounting for 17% of maternal deaths in the United Stares from 1991-1999 . In this case, establishing large bore IV access, obtaining help with placement of invasive lines, starting antifibrinolytics, and correcting coagulopathy contributed to our successful outcome.

We report the first case of successful anesthetic management of massive hemorrhage from an unexpected malignant endodermal sinus tumor masking as a dermoid cyst during cesarean section. This outcome resulted from coordinated efforts between the anesthesiologists, surgeons, and the nursing team.

SOAP 2009