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Pulmonary Carcinoid in Pregnancy Treated with IR Embolization and Surgical Resection
Abstract Number: RF7B10-553
Abstract Type: Case Report Case Series
Carcinoid tumors are slow growing neuroendocrine tumors. The incidence of pulmonary carcinoid in pregnancy is unknown. Management of carcinoid tumors in the pregnant patient has no clear guidelines and can be complex given the variability in location, symptoms, and treatment preferences for these rare tumors.
We report the case of a 33 year old primigravid woman who presented at 25 weeks gestation with large volume acute on chronic hemoptysis, found to have a 2.5 x 1.4 cm mass in the right lower lobe bronchus concerning for carcinoid. Patient had no carcinoid symptoms (flushing, wheezing, diarrhea) or evidence of metastases. Initial management consisted of IR embolization of the bronchial artery supplying the mass to reduce risk of further hemoptysis and pulmonary compromise. Based on perinatology’s recommendation to place maternal wellbeing first, the cardiothoracic tumor board recommended definitive surgical resection. We proceeded with urgent surgery at 27 weeks gestation to decrease risk of further physiologic changes of pregnancy compromising maternal morbidity and preterm labor. The patient underwent a right open thoracotomy with right lower lobe lobectomy under general anesthesia with single lung ventilation and thoracic epidural. Anesthetic goals included maintaining maternal and placental perfusion, uterine relaxation and optimizing surgical exposure. The patient received pre-induction fetal monitoring, hourly intraoperative monitoring of FHR and uterine tone, and continuous fetal heart monitoring for 4-6 hours post-op. Indomethacin PR was given prior to extubation for post-op tocolysis. Patient tolerated the procedure well and post-op fetal monitoring was unremarkable. Post-op course was unremarkable, with the patient planning a vaginal delivery. Intraoperative pathology was consistent with carcinoid and negative margins.
This case highlights the need for multidisciplinary discussion (perinatology, CT surgery, pulmonology and IR) for management of complex patients. Our multi-site, university affiliated hospital posed a challenge regarding perioperative care as the maternal and pediatric units are greater than 1 mile from the primary CT surgery site. L&D and neonatal teams were on stand-by in the event of emergent peri-operative delivery.
Indications for peri-operative delivery need to be extensively discussed with patients and conveyed to all care teams involved. In this situation, continuous fetal monitoring was deferred because of the patient’s wishes for emergent delivery only for maternal indications. Intermittent intra-op fetal monitoring every hour was used to help guide anesthetic management, with the idea that fetal bradycardia or contractions may be signs of inadequate placental perfusion or need for additional uterine relaxation.