///2019 Abstract Details
2019 Abstract Details2019-07-13T07:45:15-05:00

Pulmonary Embolism and Occult Metastatic Pancreatic Cancer in a Parturient with Pre-Eclampsia: A Case Report

Abstract Number: RF7A10-135
Abstract Type: Case Report Case Series

Marguerite Hoyler MD1 ; Marguerite Hoyler MD2; Jon D. Samuels MD3; Danielle McCullough MD4

Case: A healthy 40yo G1P0 with remote history of tobacco and alcohol abuse was admitted for management of pre-eclampsia at 28w6d gestation. She was treated with magnesium and labetolol. On hospital day (HD) 4, she developed new-onset shortness of breath, with desaturations to 93% on room air (RA). Hemodynamics were unchanged (HR 70s-80s, BP 140s/90s). CXR showed pulmonary edema. The patient received 20mg IV furosemide with no clinical improvement.

On HD 5, the patient underwent emergent cesarean delivery for non-reassuring fetal heart tracings. There were no adverse intra-operative events. The patient received a spinal anesthetic and 200cc IVF. EBL was 800cc. HR was 60-80bpm and BP 120-155/80-110, with 1.1mg phenylephrine infused. Oxygen saturation ranged 92-96% on RA, and was 95% on transfer to PACU. In PACU, the patient desaturated to 88% on RA. There was no associated tachycardia or hypotension. Pulmonary embolism (PE) workup was initiated. Lower extremity dopplers confirmed femoral DVT. CT chest showed bilateral PEs, as well as numerous hepatic hypodensities. Anticoagulation was initiated. The patient was transferred to the ICU.

Subsequent MRI showed diffuse hepatic nodules, lymphadenopathy, and a pancreatic mass. Biopsy confirmed metastatic pancreatic adenocarcinoma. The patient was discharged home on HD10 without further complications related to pregnancy or PE, with close oncology follow-up.

Discussion: Pancreatic cancer is a rare but morbid disease, with 5 year survival rates below 5%.1 Modifiable risk factors include tobacco use, obesity, and possibly alcohol consumption.1 Among women, reproductive history has not been shown to affect pancreatic cancer risk.2 The medical literature contains few reports of pancreatic cancer in pregnancy.3 Here, we describe a parturient with metastatic pancreatic cancer discovered incidentally during workup for PE.

Pregnancy is a known thrombophilic state. However, in some parturients, attribution of PE to the physiologic changes of pregnancy is insufficient because there are other risk factors present. This case is a reminder that occult malignancy should be considered in the differential diagnosis for PE etiology. Although malignancy in pregnancy is rare,4 patient history often reveals risk factors. The patient described here had a history of tobacco use and alcohol abuse.

Regardless of identifiable risk factors for thrombophilia or malignancy, PE should be entertained early in the differential diagnosis of acute-onset dyspnea in the parturient, both due to the urgency of the diagnosis and its prevalence in this vulnerable population.5 PE may not present with tachycardia; particularly in pre-eclamptic patients on beta-blockade.

1. Hidalgo M, N Engl J Med, 2010.362(17):1605-17.

2. Perrin MC et al, BMC Med, 2007. 5:25.

3. Wakefield BW et al, Gyn Obstet Invest, 2018. 83(4):404-409.

4. Pereg D et al, Cancer Treat Rev, 2008. 34(4):302-12.

5. Righini M et al, Ann Intern Med, 2018. 169(11):766-773.

SOAP 2019