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Metastatic Cancer in the Parturient
Abstract Number: T-41
Abstract Type: Case Report/Case Series
Introduction: Management of the parturient with metastatic cancer requires a multidisciplinary approach with appraisal of the clinical and ethical risks and benefits unique to this patient population. This is a discussion of the physiologic, pharmacologic, and ethical management of a 31 year-old G5P1 diagnosed with stage IV gastric cancer.
Case: An otherwise-healthy female was diagnosed with stage IV gastric cancer at 19 weeks gestation after presenting with nausea, dysphagia and neck pain. Enoxaparin, for treatment of a RIJ thrombus and a course of palliative chemotherapy were initiated. At 34 weeks she presented with dyspnea and crushing chest pain. A chest CT revealed a large left-sided pleural effusion, which was treated with thoracentesis and pleural catheter placement. At 35 weeks, an external cephalic version was attempted for breech presentation, but was unsuccessful. She strongly desired to avoid a prolonged recovery from cesarean delivery given her uncertain lifespan, and so underwent induction of labor at 35 weeks for a vaginal breech delivery. Induction of labor also helped avoid further respiratory and physical decompensation and allowed appropriate cessation of anticoagulation for neuraxial anesthesia. She received an early placement of a combined spinal-epidural to avoid catecholamine surges that could lead to physical decompensation. She was moved to the operating room for vaginal breech delivery. Chloroprocaine 3% and IV nitroglycerin were available in anticipation of possible head entrapment. The patient had an uncomplicated vaginal delivery and postoperative course. Her baby girl was healthy with no ill effects from chemotherapy. One year postpartum, she is alive undergoing palliative chemotherapy.
Discussion: Approximately 1 in 1000 pregnancies are affected by a comorbid malignancy, the most common cancers being breast, cervical, lymphoma, and melanoma.1 Physiologic changes of pregnancy may diminish a woman’s ability to cope with the complications and treatments of the malignancy. Restrictive lung physiology of pregnancy may be worsened by malignant ascites and pleural effusions, which may make a high sensory level from neuraxial anesthesia poorly tolerated. Labor or recovery in the postpartum period may be poorly tolerated due to underlying malnutrition and deconditioning. Both malignancy and pregnancy represent hypercoagulable states, so time off anticoagulation should be limited. Neuraxial anesthesia timing may be complicated by anticoagulation regimens or thrombocytopenia from myelosuppression.2 Lastly, the complex end of life discussions related to cancer and pregnancy may lead to uncommon obstetric scenarios such as vaginal breech delivery and necessitate a thoughtful appraisal of risks and benefits with regard to obstetric and anesthetic management.
1 Voulgaris et al. Surgical Oncology. 2011. 20(4): e175-e185.
2 Pentheroudakis and Pavlidis. European Journal of Cancer. 2006. 42(2): p. 126-140.