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Cesarean delivery under neuroaxial anestheisa for patient with large thoracic mass
Abstract Number: S-38
Abstract Type: Case Report/Case Series
Introduction: Mediastinal mass in pregnancy is rare. We present a woman admitted in her third trimester with severe orthopnoea, dysphonia and dysphagia who had an emergency cesarean delivery under neuraxial anesthesia.
Case report: A 26-year-old Afro-Caribbean woman (G1P0) of 37+5 weeks gestation presented with sudden onset of dyspnoea when lying flat and dysphagia following a two week history of hoarse voice. Medical and obstetric history was unremarkable. Examination showed a bulky neck and no stridor. Nasendoscopy demonstrated left-sided vocal cord palsy. Oxygen saturations and respiratory rate when sitting were normal. Blood tests were unremarkable. Sitting bedside echocardiogram showed no vessel compression. PA chest radiograph showed an abnormality of the left upper mediastinal contour consistent with an anterior mediastinal mass. A CAT scan was advised after delivery. Given her worsening symptoms and orthopnoea, a multidisciplinary team decision (MDT) led to category 3 cesarean delivery. She had a combined spinal and epidural (CSE) in the sitting position (intrathecal dose of 2 milliliters plain marcaine 0.5% with 300 micrograms diamorphine). Block height was adequate and no epidural top up was required. The operative procedure took place in a 30-degree head up position with both consultant anesthesiologist and obstetrician present. There was minimal blood loss and the patient remained asymptomatic throughout. The post-operative period was uneventful and investigations were consistent with lymphoma, which was treated with chemotherapy.
Discussion: Mediastinal mass remains an anesthetic challenge with variable clinical presentation ranging from lack of symptoms to severe cardio respiratory compromise. General anesthesia can lead to loss of muscle tone and tumor compression syndrome obstructing the mediastinum causing either airway obstruction or reduction in venous return and loss of cardiac output with sudden cardiac arrest.1 We decided on neuraxial anesthesia to avoid these risks. Inability to lie flat is often cited as a contraindication to regional anesthesia for cesarean delivery however both good operating conditions and patient comfort were achieved in a 30-degree head up tilt using CSE anesthesia with plain marcaine. An MDT approach is required for these rare complicated patients.
1. Erdös G, Tzanova I. Perioperative anaesthetic management of mediastinal mass in adults. Eur J Anaesthesiol. 2009 Aug;26(8):627