Management of Labor Analgesia in a Patient with

Acute Myeloid Leukemia

Kelly G. Elterman, MD,* Jonathan R. Meserve, MD,* Martha Wadleigh, MD,†
Michaela K. Farber, MD,* and Lawrence C. Tsen, MD*

The anesthetic implications of acute leukemia in pregnancy have not been reported. We describe
the anesthetic management of a laboring primigravida at 34 weeks’ gestation with new-onset
acute myeloid leukemia. With multidisciplinary consultation, we recommend that neuraxial anes-
thesia be avoided in new-onset acute myeloid leukemia due to the risk of introducing malignant
cells into the central nervous system, which can spread the disease and complicate manage-
ment. We discuss the use of a fentanyl patient-controlled analgesia and dexmedetomidine as
a method of labor analgesia, and the potential benefits of the latter medication in the obstetric
population.  (A&A Case Reports. 2014;3:104–6.)

N
ewly diagnosed acute leukemia in pregnancy is
a rare and challenging event, the management of
which warrants collaboration among hematolo-
gists, obstetricians, and anesthesiologists. The incidence of
acute leukemia in pregnancy is estimated to be 1 in 75,000 to
100,000 pregnancies.1 Acute myeloid leukemia (AML) is the
most common acute leukemia in pregnancy, accounting for
more than two-thirds of all cases.2 Most frequently detected
in the second and third trimesters,2 acute leukemia in preg-
nancy presents unique challenges for the health care team;
the timing and mode of delivery relative to initiation of che-
motherapy with resulting pancytopenia as well as the deci-
sions regarding analgesic or anesthetic management require
an analysis of the maternal and fetal risks and benefits. We
present our anesthetic management of a patient with newly
diagnosed AML for whom neuraxial analgesia was contra-
indicated due to the presence of circulating leukemic blast
cells. Written consent was obtained from the patient to
­publish this report.
CASE DESCRIPTION
A 32-year-old primigravida at 34 weeks’ gestation was
admitted for leukocytosis, thrombocytopenia, and a periph-
eral blood smear with suspected blast (abnormal imma-
ture white blood cell) forms. Leukocytosis was detected on
routine blood work in her first trimester with subsequent
resolution on repeat evaluation. A hematologic consultation
had been recommended but not pursued. At 33 weeks’ ges-
tation, the patient complained of diffuse musculoskeletal
pain refractory to muscle relaxants and opioid analgesics.
After repeated pain evaluations by her local physician and
the emergency department, routine blood work revealed
From the *Department of Anesthesiology, Perioperative, and Pain Medicine,
Brigham and Women’s Hospital, Boston, Massachusetts; and †Hematology–
Oncology, Dana Farber Cancer Institute/Brigham and Women’s Hospital,
Boston, Massachusetts.
Accepted for publication May 1, 2014.
Funding: None.
The authors declare no conflicts of interest.
Address correspondence to Kelly G. Elterman, MD, Brigham and Women’s
Hospital, 75 Francis St., CWN-L1, Boston, MA 02115. Address e-mail to
kelterman@partners.org.
Copyright © 2014 International Anesthesia Research Society
DOI: 10.1213/XAA.0000000000000076
a prominent leukocytosis with new thrombocytopenia.
Review of the peripheral blood smear demonstrated imma-
ture monocytic forms consistent with leukemic blasts.
Upon admission, the patient reported several days
of night sweats, progressive fatigue, gingival bleeding,
and diffuse bone and muscle pain. Laboratory evalua-
tion revealed leukocytosis (39,000/μL), thrombocytopenia
(59,000/μL), and normochromic macrocytic anemia (hemo-
globin: 10.1 g/dL; mean corpuscular volume: 103.8 μm3).
A peripheral smear revealed abundant monocytic forms
in all stages of maturation with rare blast forms indica-
tive of acute monocytic leukemia. The patient underwent
an immediate bone marrow biopsy, and preliminary flow
cytometry revealed AML with monocytic features.
A multidisciplinary meeting with the patient, her fam-
ily, and the relevant health care teams (obstetrics, obstetric
anesthesia, and hematology/oncology) determined that
urgent delivery would be necessary to enable the induction
of chemotherapy. Initial discussions focused on a cesarean
delivery performed under spinal anesthesia; however, this
approach was ultimately abandoned due to the potential
for introduction of malignant cells into the central nervous
system (CNS) and resultant increased complexity of disease
management. General anesthesia was therefore determined
to be the safest option if a cesarean delivery was required.
The patient indicated a strong preference to avoid cesar-
ean delivery and general anesthesia, and thus labor was
induced with oxytocin with an anticipated vaginal deliv-
ery. Intravenous analgesic drugs were discussed with the
patient. Contingency planning included an emergent cesar-
ean delivery performed under general anesthesia, with the
intraoperative placement of an ultrasound-guided triple-
lumen central venous catheter for the postpartum initiation
of chemotherapy.
Labor analgesia was requested and achieved in the first
stage of labor with IV patient-controlled analgesia using
fentanyl (13 mcg bolus, 7-minute lockout, 300 mcg/4 h
maximal dose, no basal infusion). During the second stage
of labor, the patient experienced breakthrough pain and
requested additional analgesia. Dexmedetomidine 50 mcg
(0.5 mcg/kg) was administered IV over 10 minutes, with
sufficient analgesic effect for the remainder of the second
stage of labor; the patient did not require additional medi-
cation. She experienced no hypotension, bradycardia, or

104 cases-anesthesia-analgesia.org October 15, 2014 • Volume 3 • Number 8

oxyhemoglobin desaturation (continuous pulse oximetry
remained 98%–99% with 4 L oxygen face mask). Ninety
minutes later, a healthy male neonate was delivered with
1- and 5-minute Apgar scores of 9 and 9, respectively.
DISCUSSION
Acute leukemia, either myeloid or lymphoid, is one of the
most common malignancies to occur in pregnancy and
should be treated immediately to optimize maternal prog-
nosis.2 When diagnosed in the first trimester, patients are
often advised to terminate the pregnancy due to the toxic-
ity of chemotherapeutic drugs and the frequent need for
stem cell transplantation.1 In the second and third trimes-
ters, chemotherapy is often initiated because the risk of
teratogenicity is decreased,3 but the timing of delivery and
post-chemotherapeutic pancytopenia remain of concern.
Importantly, the neurodevelopmental outcomes of children
with intrauterine chemotherapy exposure appear no differ-
ent than that of the general population.4,5 However, when
the age of the fetus is closer to term, minimizing fetal che-
motherapy exposure by early delivery is accepted as a pru-
dent management strategy.
The anesthetic management of a patient with chronic
neutrophilic leukemia during pregnancy was recently
reported,6 but to our knowledge the peripartum man-
agement of a patient with acute leukemia has not been
described. While both acute and chronic leukemia may
predispose patients to both hemorrhage and thrombosis,7
due to thrombocytopenia and the presence of malignancy,
respectively, chronic leukemia does not typically present
with thrombocytopenia until later stages.8 Thus, acute leu-
kemia is more likely to present an unpredictable bleeding
risk. Whether the presence of concurrent AML and preg-
nancy, itself a hypercoagulable state,9 increases the risk of
venous thromboembolism has not been reported. However,
other myelodysplastic conditions, such as essential throm-
bocytosis and polycythemia vera, present an increased risk
for venous and arterial thrombosis with pregnancy.10
Patients with acute leukemia, or blast crisis phase of
chronic leukemia, often present with severe thrombocyto-
penia, which enhances the risk for postpartum hemorrhage
and increases the risk for epidural hematoma with neurax-
ial techniques. While there are no strict guidelines regarding
a minimal platelet count necessary for a neuraxial tech-
nique, anesthesiologists often avoid neuraxial techniques in
patients with platelet counts <75,000/μL. Although platelet
transfusions before neuraxial techniques can theoretically
attenuate the risk of epidural hematomas in patients with
thrombocytopenia, neuraxial techniques in patients with
AML present the risk of introducing malignant cells into the
CNS from an inadvertent or intentional dural puncture.
The introduction of malignant cells into the CNS is
concerning for 2 reasons. First, it can alter disease staging
because the presence of blasts in the cerebrospinal fluid
indicates advanced disease. Second, it may worsen disease
outcome; in studies of children with acute lymphoblastic
leukemia undergoing diagnostic lumbar punctures and
concurrent administration of intrathecal chemotherapy,
those with a traumatic lumbar puncture, defined in one
study as a sample containing >10 red blood cells per micro-
liter, had worse event-free survival than their counterparts
October 15, 2014 • Volume 3 • Number 8
without CNS disease. While the reasons for these worse
outcomes are unclear, several groups have attributed the
increased mortality to the introduction of hematogenously
circulating blast cells into the cerebrospinal fluid at the
time of lumbar puncture.11–14 Thus, while the risk of spinal
anesthesia in the patient with untreated AML is unknown,
these studies would suggest that resultant worsening of
oncologic outcome is possible. Although the epidural tech-
nique per se should not increase this risk, inadvertent dural
puncture occurs in approximately 0.19% to 3.6% of epidural
techniques in laboring women.15
Due to these considerations, and in consultation with our
obstetric and hematologic colleagues, we decided to man-
age labor analgesia with an IV fentanyl patient-controlled
analgesia with dexmedetomidine for breakthrough pain
relief. Although dexmedetomidine has received only limited
clinical evaluation during pregnancy, when compared with
clonidine, it has an 8-fold greater α-2 selectivity,16 less fetal
transfer in an in vitro placental model,17 and minimal, if any,
effects on fetal physiology during labor.18 Dexmedetomidine
may also offer several benefits to obstetric patients. First,
animal studies have demonstrated analgesic synergism
between fentanyl and α-2 agonists.19 Additionally, while
opioids and local anesthetics may decrease the effectiveness
of in vitro uterine contractions,20 α-2 agonists have been
observed in in vitro studies to increase the frequency and
amplitude of human myometrial contractions.21 Although
not currently approved for use during pregnancy, dexme-
detomidine has been used successfully in parturients for
labor analgesia,22 general anesthesia for cesarean delivery,22
and nonobstetric surgery.23
CONCLUSIONS
Our case illustrates the importance of a multidisciplinary
approach to the pregnant patient with a newly diagnosed
acute hematologic malignancy. While AML in pregnancy is
rare, the risks of inadvertent CNS seeding and subsequent
prognostic implications are relative contraindications to the
performance of neuraxial techniques. E
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A & A case reports