///2017 Abstract Details
2017 Abstract Details2019-08-02T15:54:53-06:00

Metastatic Femur Fracture in Pregnancy: Obstetric and Anesthetic Considerations

Abstract Number: SAT-64
Abstract Type: Case Report/Case Series

Kathleen Coy MD1 ; Patricia Dalby MD2; Susan McElroy DO3; Joseph Derenzo MD4; Erica Coffin MD5; Thomas Vernon MD6

Metastatic Femur Fracture in Pregnancy: Obstetric and Anesthetic Considerations

A 34 year old presented at 31 weeks gestation to the ER with back and rib pain. Exam was normal except for exquisite chest wall tenderness. A CT scan of the chest was negative for pulmonary emboli, but showed multiple lucent lesions throughout the chest wall, and collapse of the T8 vertebral body. Oncology diagnosed stage 4 metastatic invasive ductal breast carcinoma. CT revealed lytic lesion of the femoral meta-diaphysis requiring intramedullary (IM) nail stabilization. Metastatic involvement of multiple bones, impending pelvic/femur fractures, and vertebral body metastatic processes were found. Pelvic MRI showed innumerable lesions in the pelvis and femurs. MRI brain showed areas of osseous metastases to the calvarium and skull base. CT liver showed metastatic disease. A lumbar spine MRI was performed. It revealed multifocal metastatic lesions involving the the T12-L3 vertebral bodies and sacrum without retropulsion of bone into epidural space. She was started on a weekly chemotherapeutic regimen of paclitaxel and DVT prophylaxis with enoxaparin. Palliative care was consulted for pain management.

Debate occurred as to the proper timing for the femur stabilization and delivery given the risks of a combined procedure and the risk of delaying chemotherapy further than necessary. Multidisciplinary planning between Maternal-Fetal Medicine, Orthopedic Surgery, Pediatrics, and Anesthesiology took place. It was determined that the patient was a candidate for neuraxial anesthesia/analgesia. A combination cesarean delivery at 38 weeks followed immediately by IM nail was planned and undertaken.

Anesthetic management concerns were many. Unanticipated post-partum hemorrhage could be more difficult to diagnose during the IM nail procedure, and could complicate intraoperative management. Careful positioning in the lateral decubitus position and avoidance of rollerboard transfers would be paramount given spine fractures and vertebral metastases. Postoperative and cancer pain required multimodal pain management strategies.

Cesarean delivery was performed with uncomplicated spinal anesthesia. After delivery general endotracheal anesthesia was induced for length of procedure and patient toleration. Total intravenous anesthesia technique was used to avoid uterine relaxation from volatile anesthetics. Competing perioperative considerations are presented.

SOAP 2017