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Mediastinal Mass in a Parturient
Abstract Number: RF2AB-152
Abstract Type: Case Report Case Series
Mediastinal mass in a parturient is a rare but often incidental finding during workup of dyspnea. A large mediastinal mass encasing major vessels and the bronchial tree poses a potential risk of airway and cardiovascular collapse secondary to compression, particularly in the non-spontaneously breathing patient.1-2
A 29-year-old G1P0 at 32 gestational weeks with past medical history of Factor V Leiden mutation (heterozygote) presented with dyspnea and oxygen saturation in high 80’s. A computed tomography scan revealed a mediastinal mass (16 cm x 11cm x 14 cm) involving the middle, anterior, and superior mediastinum, surrounding the great vessels, ascending aorta and extending into the right paratracheal and aortopulmonary window with multiple pulmonary nodules (Figure 1). Lymph node biopsy revealed nodular sclerosis classic Hodgkins lymphoma and a diagnosis of stage IV disease was made. The patient was started on prophylactic enoxaparin, steroids, and chemotherapy consisting of Adriamycin, Bleomycin, Vinblastine and Dacarbazine (ABVD) which resulted in excellent clinical response.
Delivery at 37 gestational weeks was planned. A multidisciplinary meeting was held to discuss the delivery method. Given the risk of cardiopulmonary collapse in the peripartum period, a scheduled primary cesarean delivery (CD) seemed preferable, given the intricacies related to the coordination between multiple teams. Prophylactic arterio-venous extracorporeal membrane oxygenation (ECMO) cannulation before delivery was recommended. The patient discontinued enoxaparin 24 h prior. An arterial line was placed; epidural was performed at the L3-L4 level. After confirming our ability to obtain a T4 surgical level, ECMO cannulas were placed and heparin 1000 U IV was administered 1 h after epidural placement to avoid clotting of cannulas. Her intraoperative course was unremarkable, ECMO sheaths were removed and the patient was transferred to the ICU for observation overnight. Currently, the patient is still undergoing chemotherapy for her Hodgkin’s lymphoma (restaged IIB).
Patients with mediastinal mass poses many challenges to anesthesiologists. Although neither general anesthesia nor neuraxial anesthesia has been proven superior, a catheter-based technique has found preferable in case studies to avoid impairing spontaneous ventilation, which could lead to inability to ventilate and cardiovascular collapse.1-2
JA clinical reports. 2017;3(1):28
Curr Opin Anaesthesiol. 2007;20(1):1-3