What? Prone Position in a Very Pregnant Patient
Abstract Number: SU-10
Abstract Type: Case Report/Case Series
This is the case of a 42-yo G12 P8 female with a 28 week IUP and a large posterior thigh mass. This case posed unique positioning and monitoring challenges. A MRI of the left thigh showed a large hemorrhagic mass in the adductor magnus muscle. Needle biopsy was positive for leiomyosarcoma. Her life activities were greatly affected by pain and she was scheduled for an excision of the mass. She was obese (BMI 40.3) with a history of depression. She was a former Jehovah’s Witness, but on discussion of her situation she accepted blood products. Alternatives for surgical positioning were discussed with the surgeon who insisted on an approach to remove the mass by the prone position. The obstetrical team recommended pre and post procedural monitoring of fetal heart tones. A separate maternal fetal medicine agreed that intraoperative fetal monitoring was not needed as well difficult to perform.. It was decided to position her prone position on an open frame modular table system. This table had a spinal surgery top to allowed for individual positioning pads. There was an open area that would accommodate her gravid abdomen freely. See picture.
General anesthesia was induced supine and the patient was turned onto the spinal frame for surgery. During operation, the patient had a rapid blood loss of 1 liter with mass removal, which the surgeon initially claimed was old blood and “Tumor Juice”. However, Preoperative Hgb was 10.3 with repeat intraoperative Hgb values of 6.8/6.8/6.2. She received 1U PRBCs in the OR along with vasopressor and fluid resuscitation. Postoperatively upon resumption of supine position with LLUD, fetal heart tones (FHT) were decreased, and the patient was transferred to the labor suite PACU for prolonged fetal monitoring. A second unit PRBCs was soon given and FHT recovered to 100-110s. She also reported painful contractions in the PACU, so the decision was made to start tocolytic therapy with indomethacin and to give betamethasone for fetal lung maturity. Patient's contractions ceased and she and fetus made uneventful recovery.
Two months later she presented in labor and delivered a healthy infant with a labor epidural. However, repeat tumor scans showed recurrent soft tissue mass and a chest CT suggested metastasis. Two weeks later, she was admitted with shortness of breath, back pain, and anorexia. In hospital treatment was by palliative care, psychiatry, and hematology/oncology with planned chemotherapy of gemcitabine/docetaxel.