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Metastatic Malignant Melanoma in Pregnancy: Considerations for Neuraxial Anesthesia
Abstract Number: F3C-4
Abstract Type: Case Report/Case Series
Malignant melanoma has become a major cause of cancer death in women of childbearing age. Melanoma accounts for 8% of all malignant tumors arising during pregnancy and is the only malignant disease that can cross the placenta and metastasize to the fetus.1 We report a case of metastatic melanoma diagnosed in the third trimester of pregnancy and discuss potential implications for neuraxial anesthesia for labor pain management.
A 28 year old G2P1 at 33 weeks was transferred for evaluation of left thigh mass and 3 weeks of cough and shortness of breath. Chest CT revealed pulmonary and pleural nodules, left pleural effusion, and mediastinal and pericardiophrenic lymphadenopathy. Left thigh mass biopsy confirmed malignant melanoma. Brain MRI revealed no intracranial abnormalities and total spine MRI revealed diffuse osseous metastatic disease without cord compromise. An indwelling thoracic catheter system was placed for symptomatic management of her recurrent pleural effusions. Decision was made to induce labor due to maternal deterioration and poor prognosis.
During preliminary discussions, the patient requested a non-medicated delivery similar to her prior labor. The patient utilized nitrous oxide at 50/50 admixture and IV fentanyl early in labor and later requested an epidural during active labor. At this time, there were discussions about the appropriateness of placing an epidural catheter in the presence of known metastatic osseous spine disease and the patient had a precipitous normal spontaneous vaginal delivery which precluded placement of a labor epidural. Palliative care services were coordinated after her delivery and the patient was discharged home with hospice care.
Spine involvement of metastatic melanoma is rare in pregnancy but its presence can have significant implications when considering neuraxial anesthesia for labor. Intrathecal and epidural anesthesia have been reported to cause paraplegia in the presence of metastatic disease impinging on the spinal cord.2,3 There is also theoretical concern for metastatic seeding of the epidural space and intrathecal sac, as well as risk of brainstem herniation in patients with elevated intracranial pressure. At this time, there is no general consensus for management of pregnant patients with metastases affecting the spine. Given the potential risks of neuraxial anesthesia in these patients, we advocate for referral of these patients to high-risk obstetric anesthesia clinics when possible for comprehensive evaluation to determine the best anesthetic plan for their delivery. Lastly, there must be extensive discussions about risks and benefits of neuraxial anesthesia with these patients even when they are opting for a non-medicated labor to facilitate appropriate informed consent prior to the onset of labor.
1. Ernstoff MS et al. Am Soc Clin Oncol 2003
2. Miskovic AM et al. Int J Obstet Anesth 2013
3. Cherng YG et al. Acta Anaesthesiol Taiwan 2008