Management of a Ruptured Cavernous Hemangioma in Late Pregnancy followed by Precipitous Vaginal Delivery under General Anesthesia
Abstract Number: F-58
Abstract Type: Case Report/Case Series
Cavernous hemangiomas are vascular anomalies containing aberrant networks of thinly walled blood vessels which are prone to rupture. Pregnancy appears to be associated with both the development and progression of these lesions.
A 39 year-old woman presented 31 weeks into her second pregnancy with right upper quadrant pain resulting from a contained rupture of a hepatic hemangioma. She was hemodynamically stable and the cardiotocograph tracing was unremarkable upon presentation. Over the following thirty-six hours, she developed ventilator dependent respiratory failure and a consumptive coagulopathy that persisted despite replacement of two blood volumes. Imaging showed a 21cm vascular lesion arising from the right hepatic artery. A multidisciplinary meeting determined that surgical resection was not feasible until after delivery, while a cesarean section also presented a significant risk given the uncorrectable coagulopathy and preterm fetus. A temporizing embolization was undertaken in the interventional radiology suite.
General anesthesia was provided with isoflurane and rocuronium. We employed uterine displacement and an abdominopelvic radiographic shield. Fetal heart tones were monitored continuously and contingency was made for an emergent cesarean section in the angiography suite. Both a 6F femoral venous and 5F arterial sheath were present intraoperatively. Provision for massive transfusion was in place in the event of uncontrollable re-bleeding or the need for emergent cesarean section. The lesion was ultimately amenable to endovascular treatment.
Eight hours after successful embolization, the patient had spontaneous rupture of membranes, advanced cervical dilation and regular uterine contractions. Given the need for mechanical ventilation, the remote location of the ICU from obstetrical support staff and the need for possible cesarean section, she was moved to an operating room. While revisiting the optimal mode of delivery, she complained of labor pain which was unrelieved by intravenous morphine and general anesthesia was administered. The infant presented precipitously and was delivered vaginally.
While hemangiomas can rupture at any time, the most frequent precipitating factor is sudden cardiovascular stress. Increases in cardiac output, a rapid change in blood volume and intra-abdominal pressure were hypothesized to have the potential to provoke rebleeding. Therefore, allowing the patient to continue to labor was undesirable. Simultaneously, a cesarean section would have necessitated a significant transfusion burden to treat the previously uncorrectable coagulopathy. Given the short labor course, the coagulopathy precluding neuraxial anesthesia and the precipitous delivery, we employed general anesthesia for vaginal delivery.
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