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ANTERIOR MEDIASTINAL MASS IN A PARTURIENT WITH METASTATIC RENAL CELL CARCINOMA
Abstract Number: F-63
Abstract Type: Case Report/Case Series
Introduction: Care of the terminally ill parturient presents both medical and ethical challenges. We present the case of a patient with symptomatic anterior mediastinal mass secondary to malignancy, and discuss the ethical dilemma faced during the course of her labor and delivery.
Case Presentation: A 24 yo gravida 4 para 1 at 34.4 weeks gestation with a history of stage IV renal cell carcinoma presented for induction of labor due to worsening pulmonary status. In 2009, she was diagnosed with cancer and underwent a nephrectomy and chemotherapy. In 2010, she developed recurrence with pulmonary metastases. During this pregnancy, her respiratory status continued to decline with increasing oxygen requirements. A chest CT revealed nearly complete occlusion of the right bronchus intermedius, a pretracheal mass, and a mass compressing the left atrium. Upon presentation, she was unable to lie supine due to dyspnea, and had frequent coughing spells, during which her SpO2 would decrease to 70%.
After much discussion with the patient and obstetric team, neuraxial anesthesia was to be initiated early after induction of labor. If the patient required an emergent cesarean delivery prior to epidural placement, a spinal anesthetic was to be performed in lieu of general anesthesia as the patient did not wish to be intubated per her D.N.R. status. The patient understood that a spinal anesthetic would likely require additional time, potentially delaying the delivery of a fetus in distress. She also acknowledged that administration of anesthesia entailed risks that may cause maternal hemodynamic and respiratory compromise; in such an event, she agreed to temporarily rescind her D.N.R. status, and allow herself to be intubated and receive vasoactive drugs until an emergent cesarean delivery could be performed. The patient proceeded to have an uneventful intrapartum and postpartum course, delivered vaginally via forceps, and was discharged home after 4 days.
Discussion: While critically ill patients can present with ethical dilemmas, terminally ill parturients have the added consideration of a fetus. Bearing in mind a parturient’s values, discussions regarding both maternal and fetal well-being are needed to facilitate informed decision making. Our patient elected to defer general anesthesia for emergent cesarean delivery, accepting that spinal anesthesia could delay delivery and risk harm to the fetus. This was an autonomous decision bearing nonmaleficence in mind for the mother. Yet, in the event of iatrogenic cardiovascular collapse, our patient desired intervention to expedite delivery of the fetus, thereby placing the priority on the fetus. Ultimately, autonomous decisions must be respected when the interest of the mother and fetus diverge.
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2. ACOG Committee Opinion No. 321. Obstet Gynecol 2005;106:1127–37
3. Milliez J, et al. Best Prac Res Clin Obstet Gynaecol 2001;15:323-31