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Anterior mediastinal mass in a pregnant patient: the importance of multidisciplinary delivery planning
Abstract Number: F3C-2
Abstract Type: Case Report/Case Series
Careful perioperative planning is essential for parturients with an anterior mediastinal mass (AMM). General anesthesia can cause worsening of both mass effect and pre-existing compression of intrathoracic structures. Patients at highest risk for hemodynamic collapse on induction are those with severe postural symptoms, >50% tracheal compression, pericardial effusion, and SVC syndrome (1). Physiologic changes of pregnancy further increase perioperative risks; these include an increased risk of difficult intubation, decreased respiratory reserve, aortocaval compression, and acute blood loss at the time of delivery (2).
We present the case of a patient with diffuse large B-cell lymphoma diagnosed at 23 weeks gestation. She presented with severe dyspnea and was found to have a large pericardial effusion, internal jugular vein DVT and 14.3cm anterior mediastinal mass compressing the SVC, left PA, trachea and left main stem bronchus. A multidisciplinary team, including obstetricians, obstetric anesthesiologists, oncologists, neonatologists, cardiologists, cardiothoracic surgeons, and nurses participated in the patient’s plan of care. Chemotherapy with rituximab, etoposide, prednisolone, vincristine, cyclophosphamide, and doxorubicin was initiated immediately after diagnosis, and anticoagulation for the DVT was started. After completion of 4 cycles and 3 months of anticoagulation, a follow-up CT scan showed a decrease in the size of the mass to 7.6cm, with complete resolution of the DVT, pericardial effusion, and compression of intrathoracic structures. Labor was induced at 35.2 weeks, after the chemotherapy nadir, and prior to the 5th chemotherapy cycle. CT surgeons, cardiac anesthesiologists, and a perfusion team were on standby for the duration of labor, and a primed cardiopulmonary bypass circuit was present on the labor and delivery floor should emergency c-section be required. An epidural was placed successfully for labor analgesia. The neonate was delivered via uncomplicated vaginal delivery with Apgar scores of 8 and 9, at 1 and 5 minutes. Her postpartum course was uneventful after which she completed 2 more cycles of chemotherapy. Follow up PET CT revealed complete response to therapy.
A review of literature for management of parturients with AMM consists mainly of case reports, and none have reported a patient successfully undergoing vaginal delivery. For patients with a symptomatic mass causing compression of intrathoracic structures, cesarean section is usually preferred to avoid increases in intrathoracic and intraabdominal pressure with contractions and to allow for a controlled delivery. However, we have demonstrated that vaginal delivery can occur safely after chemotherapy treatment under close monitoring and with emergency equipment and personnel readily available.
1. Blank RS et al. Can J Anaesth 2011; 58:853-867
2. Kanellakos GW. Anesthesiol Clin 2012; 30(4):749–58