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Obstetric anesthetic management of a parturient with fetal sacrococcygeal teratoma
Abstract Type: Case Report/Case Series
Sacrococcygeal teratomas are extragonadal tumors consisting of tissues from all three germ layers that arise from the presacral area and can extend exteriorly or into the pelvis and abdomen(1). These tumors can be large and have significant vascularity. Delivery of the infant requires multidisciplinary expertise to provide appropriate care for this challenging patient.
A 22-year-old G2P0202 parturient at 28+6 weeks presented for primary classical cesarean delivery due to a rapidly enlarging fetal sacrococcygeal teratoma (15.4 x 10.6 x 6.8cm) and massive polyhydramnios. Overall, the perioperative goals included minimal fetal sedation, complete uterine relaxation to facilitate atraumatic delivery, and preparation for management of possible maternal or fetal hemorrhage.
On the morning of delivery, two 18g intravenous lines and a right radial arterial line were placed. A lumbar epidural catheter was inserted and dosed with 30ml of preservative-free 2% lidocaine with epinephrine in divided doses. Uterine relaxation was achieved with a nitroglycerin infusion initiated at 25mcg/kg/min and titrated up to 200mcg/kg/min with a bolus dose of 150mcg at the time of uterine exposure. Subsequent hypotension was treated with phenylephrine. Once the fetus was delivered, the nitroglycerin infusion was discontinued and an oxytocin infusion was started. Excellent uterine tone was obtained without additional uterotonics. Following delivery, the infant was cyanotic, apneic, and bradycardic. She was intubated, given a fluid bolus, and started on high frequency oscillatory ventilation prior to transfer. Surgical excision of the sacrococcygeal teratoma was attempted on day of life #4. Massive uncontrollable hemorrhage was encountered and the infant expired intraoperatively.
The anesthetic goals of this delivery included administering neuraxial anesthesia to minimize fetal sedation after delivery, providing optimal conditions for delivery of the fetus and teratoma, preparing for the possibility of prolonged surgery, and ensuring the safety of the parturient. Ultimately, intubation and ventilatory support were required given severe fetal pulmonary hypoplasia and restrictive pathophysiology associated with this teratoma. Despite the ultimate demise of the infant, the multidisciplinary plan was effective in providing a safe delivery for both parturient and fetus while avoiding the risks of general anesthesia.
1) Gucciardo L et al. Prenat Diagn 2011. 31:678-8