Cesarean delivery in a parturient with an anterior mediastinal mass

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. 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 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, and a large-bore intravenous catheter was placed in the lower extremity. After insertion of an epidural catheter at the L2-L3 interspace, the patient was placed in a left lateral position with a 45 horizontal tilt. The catheter was then injected with 2% lidocaine 12 mL and 8.4% bicarbonate 1 mL. The cardiac surgeon placed left femoral CPB guidewires, a right femoral arterial line, and a Cordis venous line in preparation for CPB if needed. A vigorous baby boy was delivered. Throughout the procedure, 2L of crystalloid was infused, and phenylephrine was titrated at 100-500 lg min to maintain a mean arterial pressure within 10% of baseline. After delivery, an oxytocin infusion was started, with the addition of norepinephrine 0.010.15 lg kg min to maintain hemodynamic stability. 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