Anterior Mediastinal Mass in the Pregnant Patient: Management Considerations and Outcomes
Laura Lockard, MD1, Aditya Upadhyay, MD1, 2, Melissa Kreso, MD1
1University of Rochester Medical Center: Department of Anesthesiology & Perioperative Medicine, 2Vanderbilt University Medical Center
Introduction
Anterior mediastinal masses (AMMs) present substantial anesthetic challenges, as airway or vascular compression can lead to sudden and catastrophic cardiopulmonary collapse during both general and neuraxial anesthesia. Consequently, patients with AMMs require comprehensive preoperative assessment, meticulous risk stratification, and close multidisciplinary collaboration to ensure safe procedural planning. Pregnancy further amplifies these risks through physiologic adaptations that exacerbate respiratory and hemodynamic vulnerability, particularly during labor and delivery. Additionally, the need to defer or modify definitive oncologic therapies during pregnancy underscores the importance of coordinated, interdisciplinary care to preserve maternal stability, support fetal well-being, and facilitate timely postpartum treatment.
Case Description
Initial Presentation
•29-year-old G1P0 female at 35w1d with normal pregnancy presented with cough
•Chest radiograph showed mediastinal widening, subsequent MRI revealed an 11 x 5 x 11 cm anterior mediastinal mass
•Biopsy: precursor T-cell lymphoblastic leukemia/lymphoma
•Induction of labor initiated at outside hospital, transferred for a higher level of care
Clinical Findings
•Subjective: nonproductive cough, exertional dyspnea, neck swelling
•Vitals: BMI 29, BP 113/65, HR 99, RR 16, SpO2 98%
•Exam: Mallampati II, mild neck swelling, otherwise unremarkable
Imaging
•CT chest: Diffuse conglomerate lymphadenopathy encasing the mediastinum and mediastinal vasculature, with anterior extension into the retrosternal space. No vascular invasion or airway compression was seen, though there was external compression of the left and right brachiocephalic veins.
•TTE: LVEF 65% with normal LV/RV size and function, normal estimated RV systolic pressure, and a small circumferential pericardial effusion without evidence of tamponade.
Initial Management
•Obstetrics team paused induction of labor
•Coordinated multidisciplinary discussions between anesthesia, high risk obstetrics, oncology, interventional radiology
•Oncology recommended delivery to allow initiation of oncological workup and treatment as soon as possible, and the obstetrics team favored proceeding with vaginal delivery
Images
Clinical Management
•RUE PICC was placed by IR for central access
•OB resumed induction on labor and delivery; the patient was maintained in semi-upright position
•An epidural catheter was placed at L3-L4 early in labor
•Analgesia was initially unilateral; the epidural required two replacements before getting sufficient relief
•The patient had a spontaneous vaginal delivery; both mother and infant tolerated delivery well
•Patient transferred to the oncology service to initiate chemotherapy and radiation
Discussion
Although imaging showed no airway compression, the patient’s symptoms and vascular involvement placed her in the high-risk category, potentially complicating the use of general anesthesia or neuraxial techniques.2
Physiological changes in pregnancy further complicated anesthetic decision-making1,3
•Challenges with general anesthesia:
•Decreases preload and cardiac output and increases intrathoracic pressure, increasing the risk of cardiovascular collapse
•Reduces lung volumes, relaxes bronchial smooth muscle leading to greater airway compressibility and potentially difficult or impossible ventilation
•Challenges with spinal anesthesia:
•Causes abrupt sympathectomy and systemic vasodilation, risking sudden hemodynamic collapse
•Given the patient’s risk profile, early epidural placement with cautious titration was considered a safe neuraxial option, with spinal anesthesia and general anesthesia posing higher theoretical risks
Conclusions
•Patients with anterior mediastinal masses present unique anesthetic challenges, which are further complicated by the physiologic changes of pregnancy
•Interdisciplinary planning enabled a safe delivery and timely initiation of oncologic treatment without compromising maternal or fetal safety
•Thorough preoperative risk stratification, close communication among the care teams, and clear contingency planning were essential to achieving a successful outcome.
References
1.Slinger P, Ku CM. Anesthesia for Patients with Mediastinal Masses. Principles and Practice of Anesthesia for Thoracic Surgery. 1st ed. Springer Science+Business Media LLC; 2011. DOI 10.1007/978-1-4419-0184-2_14
2.Saffarazadeh A, Popescu WM, Detterbeck FC, Lie AX, Blasberg JD. Anesthetic Risk with Large Mediastinal Masses: A Management Framework Based on a Systematic Review. Ann Thorac Surg. 2024; 119(5): 967-979
3.Reeder CR, Hambright AA, Fortner KB. Dyspnea in Pregnancy: A Case Report of a Third Trimester Mediastinal Mass in Pregnancy. American Journal of Case Reports. 2018; 19: 1536-1540
