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Designing a Plan for the Parturient with an Anterior Mediastinal Mass
Abstract Number: RF2AB-156
Abstract Type: Case Report Case Series
Introduction: The parturient with an anterior mediastinal mass poses a unique challenge to the anesthesiologist. A physical exam, assessing for shortness of breath when supine and any rescue position that provides symptom resolution, combined with imaging that shows any vascular or pulmonary compromise can help to predict anesthetic risk.1 We present a case of a woman with a newly diagnosed anterior mediastinal mass at 19 weeks gestational age (GA).
Case: A 32 year old G2P1 at 19 weeks GA presented to the emergency room with neck swelling. Ultrasound revealed a right internal jugular vein thrombus, and anticoagulation therapy was initiated with enoxaparin. Further imaging showed a large (16.2 cm x 5.2 cm) anterior mediastinal mass with encasement of the right innominate, subclavian, and bilateral carotid arteries, a pericardial effusion, and bronchial compression. Biopsy confirmed Hodgkin’s lymphoma, and she was started on an abbreviated course of bleomycin-containing chemotherapy. A multidisciplinary team planned for repeat cesarean delivery and bilateral tubal ligation at 36 2/7 weeks to coincide with a gap in her chemotherapeutic regimen.
Given the complexities inherent in managing this patient, detailed plans were made for a number of scenarios. Our system has multiple locations, with service lines important for this patient’s care located in different hospitals. Separate plans addressed emergent presentation with maternal compromise, fetal compromise, or both. The obstetric and cardiac anesthesia teams met with the patient, and worked with maternal fetal medicine, oncology, otolaryngology, and the extracorporeal membrane oxygenation (ECMO) teams to ensure that care could be provided in a safe, timely, and organized fashion. Planning was complicated by therapeutic anticoagulation, important to consider given the peril of managing this patient emergently.
Fortunately the patient presented as scheduled. She received a combined spinal-epidural, with 6 mg bupivacaine, 15 mcg fentanyl, and 150 mcg morphine. She was gradually moved from sitting to supine with an incline of 20 degrees, and 2% lidocaine was dosed through the epidural in 2-3 mL aliquots to obtain a T5 level. A perfusionist was available for initiation of ECMO. During the procedure, she developed chest pain and shortness of breath, which resolved by increasing her incline.
Discussion: An extensive pre-anesthetic workup and multidisciplinary approach is essential when caring for a parturient presenting with an anterior mediastinal mass. Knowledge of the anatomic implications of the mass, previous treatment, delivery plan, and rescue position are keys to success.2 Intimate knowledge of the processes in place at our health system allowed our team to design detailed plans in advance for several of the most likely delivery scenarios, which we then disseminated to her care team.
1Blank RS & de Souza DG. Can J Anes (2011) 58:853
2Kanellakos GW. Anesthesiol Clin (2012) 30:749-58