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Anesthetic management of quaternary C/S in a patient with diffuse, destructive metastatic lesions
Abstract Number: F5C-9
Abstract Type: Case Report/Case Series
A 41 year-old G11P7 presented to L&D at 32 weeks gestation after seeing her primary doctor with severe proptosis of the right eye as well as new-onset dyspnea. An MRI revealed a small soft tissue mass behind the right globe, which proved to be metastatic breast cancer. Further studies revealed widespread metastases to multiple organ systems, including liver metastases causing immense ascites, lung metastases causing severe dyspnea, lytic lesions at thoracic vertebrae, and multiple metastases to the brain. The patient was to undergo a caesarean delivery at 32 weeks-gestation so that she would sooner receive postpartum chemo- and radiation therapy.
After obtaining the patient's pertinent history, physical, laboratory and radiographic studies, we planned for neuraxial anesthesia with a single shot spinal. Preoperatively, two large bore IV's were placed, and both blood products and uterotonic agents were made immediately available. An uncomplicated spinal anesthetic was performed with hyperbaric bupivacaine, fentanyl, and preservative-free morphine. Intraoperatively, 6 liters of ascites were drained, which resulted in mild hypotension that was treated with phenylephrine and ephedrine as well as volume expansion with 3L of LR and 1.25L of 5% albumin. 30 minutes into the procedure, a healthy neonate with high Apgar scores was delivered. The remainder of her postoperative course was unremarkable, and the patient went on to receive further anti-cancer treatment.
Breast cancer remains the most common malignancy in pregnant and postpartum patients, with an incidence of 1 in 3,000. Here we present an extremely rare case of stage IV breast cancer in a pregnant multiparous woman with diffuse metastases. Our decision to use a spinal anesthetic was based on several factors, including the lack evidence of increased intracranial pressure on preoperative scans, and to mitigate the risk of aspiration with airway manipulation given the patient's profound ascites. We aimed to maintain euvolemia and stable hemodynamics using a combination of crystalloids, colloids, and vasopressors. Ultimately we were able to achieve our goal of allowing for the safe delivery of the patient's neonate while avoiding general anesthesia for the patient herself.
1. Katz, Cancer in pregnancy. Obst Gyn Surv 1996. 2. Leffert, Neuraxial Anesthesia in Parturients with Intracranial Pathology. Anes 2013. 3. Pierson, Invasive mechanical ventilation. Clin Resp Med. 2004.