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DEXMEDETOMIDINE AS AN ADJUNCT FOR ANALGESIA IN A LABORING PATIENT WITH ACUTE MYELOID LEUKEMIA AND CIRCULATING BLASTS
Abstract Number: T-22
Abstract Type: Case Report/Case Series
Newly diagnosed acute leukemia in pregnancy is a rare event that warrants multidisciplinary intervention. The incidence of acute leukemia in pregnancy is estimated to be 1 in 75,000-100,000 pregnancies.  Acute myelogenous leukemia (AML) is the most common hematologic malignancy in pregnancy, accounting for more than two thirds of cases.  Most frequently detected after the first trimester, acute leukemia in pregnancy presents unique challenges; the timing and mode of delivery relative to initiation of chemotherapy with resulting pancytopenia as well as decisions regarding analgesic or anesthetic management require an analysis of maternal and fetal risks and benefits. We present our management of a patient with newly diagnosed AML for whom neuraxial analgesia was contraindicated due to presence of circulating leukemic blasts.
A 32 year-old primigravida at 34 weeks’ gestation presented with an 8-day history of night sweats, fatigue, gingival bleeding, and diffuse musculoskeletal pain. Previously, her prenatal course had been uneventful. Laboratory evaluation revealed leukocytosis (39,000/µL), thrombocytopenia (59,000/µL), and normochromic macrocytic anemia (Hgb 10.1 g/dL; MCV: 103.8µm^3). A peripheral smear demonstrated abundant monocytic forms in all stages of maturation with rare blasts. Bone marrow flow cytometry confirmed AML with monocytic features.
A meeting was held with the patient, her family, and the relevant health care teams (obstetrics, obstetric anesthesia, and hematology/oncology) to facilitate a plan for delivery to enable induction of chemotherapy. Although initial discussion focused on neuraxial techniques, this approach was ultimately abandoned for concern of potential seeding of the central nervous system (CNS) with malignant cells, which has been observed to worsen patient outcome and increase complexity of disease surveillance. 
The patient wished to avoid cesarean delivery and general anesthesia, thus labor was induced for anticipated vaginal delivery. Contingency planning included cesarean delivery under general anesthesia and intraoperative placement of a central venous catheter for postpartum chemotherapy. Labor analgesia was requested and achieved with intravenous (IV) fentanyl patient-controlled analgesia (PCA; 13 mcg bolus, 7 min lockout, no basal infusion). Breakthrough pain in the second stage of labor was controlled with IV dexmedetomidine 50 mcg (0.5mcg/kg) infused over 10 minutes. Successful analgesia was achieved without adverse effect. The patient had an uncomplicated vaginal delivery and chemotherapy was initiated.
We present a management strategy for a parturient with new-onset AML and circulating blasts. In such patients, for whom neuraxial techniques are contraindicated, fentanyl PCA with dexmedetomidine infusion provide alternative analgesic options.
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