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Anesthetic Management of a Gravid Patient with AML
Abstract Number: F-57
Abstract Type: Case Report/Case Series
Introduction: The incidence of pregnancy associated acute myeloid leukemia is low, and guidelines for the management of these patients are not established yet. We report the case of a 29 year old pregnant woman diagnosed with AML with blast crisis at 33 weeks, who underwent a C-section in order to get induction chemotherapy. We also highlight the central role of the anesthesiology team in facilitating treatment discussions and decision making in a multidisciplinary approach.
Case report: A 29 year old G1P0 woman, presented at 33 weeks with 4 weeks of increasing dyspnea, subjective fevers, night sweats and progressive submandibular and cervical lymphadenopathy. PMHx included DMII and hypothyroidism. Physical exam was pertinent for dyspnea and tachypnea, bilateral submandibular and cervical non tender 2cm lymph nodes, airway with poor dentition and gingival hypertrophy, MP I, Thyromental distance >3cm. Labs revealed severe leukocytosis, thrombocytopenia, anemia [WBC 202, PLT 35, Hgb 6.1 (with WBC and PLT wnl 3 months prior)], and reported monoblasts on peripheral blood smear. Uric Acid 10 and LDH 1000 suggested spontaneous tumor lysis. CXR showed R basilar opacity which was concerning for infection vs. leukostasis. Hematology, Transfusion, Oncology and Critical Care services were consulted by Obstetrics, with the Anesthesiology team playing a central role in coordinating treatment discussions and decisions between the multidisciplinary services. Decision was made to initiate leukapharesis, with the goal to improve oxygenation, and optimize the patient for C-section under general anesthesia—spinal anesthesia contraindicated with PLT 36— followed by chemotherapy induction. Though the patient’s WBC decreased to 80 s/p leukapharesis, patient remained dyspneic and tachypneic with saturations of 95% on non-rebreather mask. In light of her AML, the anesthesiology team requested a CT-PE protocol, which was negative for PE. The CT Thorax also enabled evaluation of the thorax for potential lymph nodes obstructing the bronchial trees or the mediastinum, but no enlarged mediastinal lymph nodes were seen.
Patient underwent a C-section under general anesthesia, with RSI, using propofol/fentanyl/succinylcholine and administration of blood products. Vital signs were stable during the procedure, and patient was transferred intubated to the ICU.
Conclusions: Though data on pregnancy-associated AML is scarce, a retrospective analysis of case reports showed that pregnant women diagnosed with AML carry a worse prognosis than non-pregnant women their age. To improve survival rate, the goal is to initiate chemotherapy as soon as possible, and thus possibly C-section the patient. AML pulmonary and cardiac involvement need to be considered prior to establishing an anesthetic plan. Furthermore, the anesthesiologist often acts as leader and facilitator in the setting of a multidisciplinary approach to treatment decision.
References: Henig et al. 2013.Blood:122 (21).