S001: NEURAXIAL ANESTHESIA FOR CESAREAN DELIVERY IN A PATIENT WITH NEWLY DIAGNOSED ACUTE MYELOID LEUKEMIA AND CIRCULATING BLASTS: A CASE REPORT
Daniel Montes de Oca, MD; Prudhvi R Budati, MD
Baptist Health South Florida
The diagnosis of cancer in pregnancies is estimated to occur in 0.1% of pregnancies and is the second most common cause of maternal death after gestation-related complications. We present a case of a patient with newly diagnosed Acute Myeloid Leukemia (AML) for whom neuraxial analgesia was determined to be the most appropriate option within the context of circulating leukemic blast cells.
Case report: The patient, a 33-year-old woman, initially presented at 22 weeks gestation after outpatient evaluation for a left neck mass. MRI and a core needle biopsy were performed for the neck mass and after flow cytometry from the biopsy revealed 12–15% circulating myeloblasts, consistent with acute myeloid leukemia (AML). Despite induction chemotherapy, day 21 marrow (1/12/2026) showed persistent disease. Due to the progression of leukemia and anticipation of the need for more intensive re-induction therapy (incompatible with the pregnancy), a multidisciplinary decision was made to proceed with expedited delivery. On 1/16/2026, at 26 weeks gestation, anesthesia supported the obstetric team for a repeat cesarean section. The patient received neuraxial anesthesia and underwent uneventful surgery.
Discussion: Specific evaluation was made as to whether general vs regional anesthesia was best for this specific situation. One case report reported that epidural anesthesia should be avoided given the risk of inadvertent CNS seeding with hematological blast cells. (3) This recommendation is further reinforced in the literature in the context of pediatric patients and the increased risk of seeding with traumatic lumbar punctures. (4). Conceptually this mechanism for iatrogenic spread into the CSF is clear. However, further research has demonstrated limited prognostic or clinical value in this possible risk. In pediatric patients, the prognostic effect of blasts in the CSF or traumatic lumbar puncture with blasts has varied in various clinical trials with no clear negative value. (4). Furthermore, using data from 11 ECOG-ACRIN trials there was no difference in the incidence of CNS involvement between the five trials in which a lumbar puncture (LP) was mandatory for all enrolled patients and the other trials (in which an LP was performed at the discretion of the investigator).
Hematology was naturally heavily involved in the patient’s care, and her oncologic treatment plan was an additional factor taken into consideration for her anesthetic planning. Due to the extramedullary spread of her AML, as demonstrated by the myeloid sarcoma in her neck, the hematology team decided it was prudent for the patient to receive intrathecal chemotherapy as part of her overall treatment. As such, the patient was to receive multiple lumbar punctures starting with the first one several weeks prior to the date of delivery, where she began her first treatment of intrathecal cytarabine. The fact that the patient was already exposed to several lumbar punctures as well as already receiving intrathecal chemotherapy further reinforced the belief that utilizing epidural anesthesia did not add any additional risk to the patient. Additionally, the patient was already receiving additional systemic chemotherapy reducing the peripheral blasts, further reducing the chances of CNS seeding via intrathecal anesthesia.