Cesarean delivery in a parturient with an anterior mediastinal mass
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Cesarean delivery in a parturient with an anterior mediastinal mass Amanda L. Roze des Ordons, MD • Jason Lee, MD • Erin Bader, MD • Les Scheelar, MD • Blaine Achen, MD • Jason Taam, MD • Roderick MacArthur, MD Derek R. Townsend, MD
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Received: 17 May 2012 / Accepted: 17 October 2012 / Published online: 7 November 2012 Ó Canadian Anesthesiologists’ Society 2012
To the Editor, Patients with a mediastinal mass are at risk of respiratory impairment, especially when general anesthesia is induced. Circulatory collapse may also occur because of a decrease in venous return.1,2 These effects might be accentuated when the physiologic changes of pregnancy are present. We report the case of a parturient with a mediastinal mass who presented for Cesarean delivery. The patient has provided written consent for publication of this report. A 24-yr-old G2P1 female at 39 weeks gestation presented for a repeat elective Cesarean delivery. At initial evaluation, she was dyspneic with pulsus paradoxus and a loud murmur. A transthoracic echocardiogram showed elevated right ventricular (RV) and pulmonary artery (PA) pressures, a left ventricular ejection fraction [ 65%, and a
A. L. Roze des Ordons, MD J. Lee, MD L. Scheelar, MD B. Achen, MD J. Taam, MD Department of Anesthesia and Pain Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada E. Bader, MD Division of Obstetrics and Gynecology, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada R. MacArthur, MD Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada D. R. Townsend, MD (&) Division of Critical Care Medicine, Department of Anesthesia and Pain Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada e-mail: [email protected]
pericardial effusion requiring urgent ultrasound-guided pericardiocentesis. A chest x-ray showed a widened mediastinum with tracheal and bronchial shift. A computed tomography scan (Figure) confirmed the presence of an anterior-superior mediastinal mass (14 x 11 x 12 cm) encasing the aorta and the PA, with obliteration of the superior vena cava (SVC) and mass effect on the trachea and bronchus. The mediastinal mass was thought to be most consistent with a lymphoma. Plans were made for the patient to be transferred to the local heart institute following a five-day course of methylprednisolone 500 mg iv daily to shrink the mass. At the heart institute, she was scheduled to undergo Cesarean delivery with cardiopulmonary bypass (CPB) backup. Two days after admission, the patient went into spontaneous labour and was transported to the heart institute for urgent Cesarean delivery. An epidural anesthetic was deemed the safest option, allowing for spontaneous ventilation, thereby avoiding collapse of the mediastinal mass and a potentially difficult obstetrical airway. Left radial arterial and upper extremity intravenous catheters were in place,
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