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Anesthetic Management of a Cesarean Section in a Parturient with New Onset Multiple Myeloma Complicated by a Sacral Plasmacytoma, a Case Report
Abstract Number: SU-04
Abstract Type: Case Report/Case Series
INTRODUCTION: Multiple myeloma (MM) involves the neoplastic growth of plasma cells which produce immunoglobulins. Only one prior case has addressed anesthetic considerations in pregnancy (1). We present the anesthetic management for delivery of a parturient with newly diagnosed MM, complicated by a sacral plasmacytoma.
CASE: A 26 year old G1P0 presented at 31 weeks EGA with 5 weeks of low back pain. Labs showed hypercalcemia (18.2 mg/dL) and acute renal failure (Cr 2.09 mg/dL). Pelvic MRI revealed a lytic mass in the right sacral ala (4.4 x 3.0 cm), extending across the SI joint, with extraosseous spread to adjacent soft tissue and marrow replacing lesions. X-rays found disease in the left humerus and femur. A CT guided biopsy showed CD 138+ plasma cells with kappa light chain restriction. Combined with high urine free kappa light chains, the diagnosis of MM was established. Following treatment, (IV fluids, diuretics, calcitonin, pamidronate, dexamethasone) a plan for vaginal delivery was formulated by a multidisciplinary team. However, PPROM, polyhydramnios, fetal edema, and uncontrolled pain necessitated operative delivery 2 weeks later. With no evidence of macro lesions in the lumbar vertebrae, we planned a spinal anesthetic. As sitting was too painful, we placed the spinal laterally at L3-4 and a cesarean section (C/S) was performed for a viable male infant. In anticipation of severe postoperative pain, 20 mL liposomal bupivacaine was injected incisionally and multimodal analgesia including hydromorphone, pregabalin, tramadol, and a lidocaine patch was utilized. Subsequently, she underwent radio (32Gy) and chemotherapy (bortezomib, dexamethasone); unfortunately, the plasmacytoma caused cauda equina syndrome requiring operative decompression. Her disease now involves the axial and appendicular spine.
DISCUSSION: The pathobiology of MM is complex, leading to replication of a malignant clone of plasma cells (2). It is responsible for up to 10% of hematologic malignancies. MM during pregnancy is rare as the median age at diagnosis is 66, with just 2% younger than 40. Of 32 cases during pregnancy since 1965 (3), only one discusses anesthetic considerations (1). Most delivered by C/S (82%) due to extensive disease and pelvic instability (3). Accepting the risk of pathological fracture, our patient elected for a vaginal birth to facilitate chemotherapy, but C/S became necessary. At maternal request, we chose a single injection spinal over GA (normal coagulation/platelets, no macro lumbar disease). A CSE or epidural were also possibilities, but intense pain limited prolonged positioning and we wished to avoid an indwelling catheter. We describe successful placement of a spinal for C/S in a parturient with rapidly progressing MM. This complicated patient required a collaborative multidisciplinary team for successful delivery.
References: 1. IJOA 2010;19:336-9. 2. Blood 2009;113:5412-17. 3. Hematol Oncol. 2014 Dec 10. doi: 10.1002/hon.2184