• We s t e r n v i s a y a s m e d i c a l c e n t e r

• Department of anesthesiology

“Rara Sanguis”

An interesting case presentation

b y : e r w i n r . Ta l e n t o , m . d .
1st year resident
 G E N E R A L D ATA

• S. A.

• 31 year-old

• Female

• Married

• Roman Catholic

• Lambunao, Iloilo

• Labor pains
 H I S T O RY O F P R E S E N T I L L N E S S

• 8 months PTA

• Undocumented fever

• Vomiting

• Consult at a local district hospital

• Managed as UTI

• Became well until...

 H I S T O RY O F P R E S E N T I L L N E S S

• 7 months PTA

• Hypogastric pain radiating to the flank

• Fever and chills

• Dysuria

• Vomiting

• Dizziness
 H I S T O RY O F P R E S E N T I L L N E S S

• 7 months PTA

• Admitted at a LDH

• Markedly elevated WBC and low Hgb

• 8 weeks pregnant (twins)

• Referred to our institution

 H I S T O RY O F P R E S E N T I L L N E S S

• 5 months PTA

• Prenatal checkup

• Repeat CBC - same results

• Advised consult with a hematologist

• Did not comply

• Regular prenatal checkups - uneventful

 H I S T O RY O F P R E S E N T I L L N E S S

• 4 months PTA

• Consult with a hematologist

• Same CBC results

• Decreased S. K levels

• Admitted for “hydration”

• Oral potassium supplements

 H I S T O RY O F P R E S E N T I L L N E S S

• 2 months PTA

• Follow up with Hema

• Repeat CBC - Anemia

• Admitted for blood transfusion

• No other symptoms
 H I S T O RY O F P R E S E N T I L L N E S S

• 5 days PTA

• On and off fever

• No other symptoms
 H I S T O RY O F P R E S E N T I L L N E S S

• On the Day of Admission

• Persistence of fever

• Onset of labor pains

• Still with elevated WBC

• 35 2/7 weeks AOG

 PA S T M E D I C A L H I S T O R Y
FA M I LY H I S T O R Y

• Unremarkable
P E R S O N A L A N D S O C I A L H I S T O RY

• Housewife

• Non-smoker

• Non-alcoholic beverage drinker

O B S T E T R I C & M E N S T R U A L H I S T O RY

• Menarche at 10 years old

• 5 days duration

• Amount: Unknown

• Regular

• No associated symptoms
 REVIEW OF SYSTEMS

• No Anorexia

• No Weight loss

• No Loss of consciousness

• No Malaise
 REVIEW OF SYSTEMS

• No Myalgia/Arthralgia

• No Chest pain

• No Difficulty of breathing

• No Bowel changes

• No Vaginal bleeding
 P H Y S I C A L E X A M I N AT I O N

• General Survey

• Awake, alert, coherent, seated on bed. Appears healthy, no signs of distress, cooperative,
speech is understandable and logical, appropriate mood and affect

• Vital signs

• Temp = 37.1 degrees Celcius, afebrile

• CR = 88 bpm, regular

• RR = 21 cpm, regular, non-labored

• BP = 90/60 mmHg

• Weight = 60 kg

• Height = 5 ft
 P H Y S I C A L E X A M I N AT I O N

• Skin

• Skin is brown, with good turgor, warm to touch, no

significant lesions, pinkish nailbeds, no clubbing, hair
abundant and evenly distributed

• HEENT

• Round, normocephalic, no lumps, no lesions, areas of

tenderness or deformities, pinkish conjunctiva, nasal
septum at midline, patent nares, lips are moist, oral mucosa
pink and moist, no ulcers, tonsils not enlarged, no swelling
or ulceration
 P H Y S I C A L E X A M I N AT I O N

• Thorax and Lungs

• Symmetrical chest expansion, non-labored breathing, resonant

all lung fields, no adventitious sounds, clear breath sounds,
adynamic precordium, PMI at 5th ICS midclavicular line, no
heart murmur

• Abdomen and Back

• Fair in color, abdomen is gravid, no visible peristalsis, no skin

lesions, umbilicus at midline, normoactive bowel sounds,
tympanitic all quadrants, no lesions no mass noted, the spine
was at the midline, no tenderness
 P H Y S I C A L E X A M I N AT I O N

• Genitals and Rectum

• Grossly female, urethra, vagina and rectum are patent,

reddish to brown discoloration at bilateral inguinal area

• Extremities/musculoskeletal system

• Symmetrical with full range of motion, no

fasciculations or weakness, no clubbing, CRT <2
seconds, peripheral pulses were regular and full
 ADMITTING IMPRESSION

G1P0 Pregnancy Uterine Twins 35 2/7 weeks Age of

Gestation, Cephalic-Breech in Labor; Chronic
Myelogenous Leukemia
L A B O R AT O R I E S
L A B O R AT O R I E S
 C O U R S E I N T H E WA R D S
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

VS q4 hrs
D5LR 1L x 8 hrs
PNSS 1L x KVO
(+) labor pains G1P0 Pregnancy Uterine
Labs: CBC, APC, blood typing, CT,
BP 100/70 Twin 35 2/7 weeks Age
BT, protime, APTT, Na, K, Ca, SGPT,
CR 80 of Gestation, Cephalic-
SGPT, BUN, Creatinine, urinalysis
RR 21 Breech in Labor, Chronic
Ampicillin-Sulbactam 750 mg IV q6h
T 36.5 Myelogenous Leukemia
Stat Primary Cesarean Section with
Bilateral Tubal Ligation for
malpresented twin
A N E S T H E S I A P R E - O P E R AT I V E E VA L U AT I O N
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

(+) labor pains

ASA 2E: (+) CML (Jan
2017)
(-) HPN, DM, BA, Anesthetic Plan: General Endotracheal
FDA Anesthesia
Wt = 60 kg G1P0 Pregnancy Uterine NPO
Mallampati Class: II Twin 35 2/7 weeks Age Pre-op Meds:
Hgb 10.3 of Gestation, Cephalic- 1. Ranitidine 50 mg IV 1 hr PTOR
Hct 0.26 Breech in Labor, Chronic 2. Metoclopramide 10 mg 1 hr PTOR
Plt 265 Myelogenous Leukemia
WBC 519 To OR with 1 unit PRBC, 2 units
100/70 FWB
CR 80
RR 21
T 36.5
 INTERNAL MEDICINE NOTES

• For ECG 12 leads

• May proceed with proposed procedure with intra-operative

monitoring

• Patient stratified as Moderate Risk on hematologic side

I N T R A - O P E R AT I V E C O U R S E
I N T R A - O P E R AT I V E C O U R S E
 P O S T- O P E R AT I V E D I A G N O S I S

G1P1 (0202) Pregnancy Uterine delivered to both live preterm

babies, Twin 1: Baby Boy cephalic AGA BW 1,975 g, AS 9,
10; Twin 2: Baby Girl frank breech SGA BW 1500 g AS 9, 10
by Primary low transverse Cesarean Section with Bilateral
Tubal Ligation under General Endotracheal Anesthesia,
Chronic Myelogenous Leukemia
 P O S T- O P E R AT I V E C O U R S E
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

Immediate Post-op Rapid K replacement: KCl 10 mEqs +

90 cc PNSS via soluset to run for 2 hrs
BP 110/70 mmHg x 5 cycles
CR 82 bpm Repeat S. K 1 hr after the last cycle
RR 22 cpm Pain Meds:
1. Parecoxib 40 mg IV ANST q12h x 2
O2 sat 98%
S/P Primary LTCS under doses
CBS
GETA 2. Paracetamol 600 mg IV q6h x 4
Soft abdomen doses
Well-contracted 3. Tramadol 50 mg IV q6h x 4 doses
uterus 4. Tramadol 50 mg IV q4h PRN for
Full pulses breaththrough pain
S. K = 2.97 mEqs/L For Blood transfusion
 P O S T- O P E R AT I V E C O U R S E
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

Methylergometrine maleate 1 amp IM

12 hours post-op now
Oxytocin 1 amp IM now
S/P Primary LTCS under
(+) Boggy uterus —> Transfuse 1 unit PRBC x 4 hrs
GETA
contracted uterus Furosemide 20 mg IV mid and post BT
EBL = 1,500 cc Patient was transferred back to wards
 P O S T- O P E R AT I V E C O U R S E
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

Placed in Trendelenburg position

FD 500 cc of present IVF (PLR)
Replace GI losses vol/vol
POST-OP DAY 1 For Stat Fecalysis, Na, K
Repeat CBC, APC in AM
BP 70/50 mmHg Apprised for FISH-BCR-ABL assay
(+) Loose BM x 5 Transfuse 1 unit PRBC
episodes IV Ampi-sul shifted to Sultamicillin 750
Dry lips and oral AGE with moderate mg/tab 1 tab BID x 7 days
mucosa dehydration MTV and ascorbic acid 1 tab OD
(+) soft abdomen Hydroxyurea 500 mg/cap 1 cap daily
Dry well-coaptated Allopurinol 300/tab 1 tab daily
wound Sodium bicarbonate 1 tab daily
Slightly pinkish Transfuse 1 unit PRBC, for rpt CBC post
conjunctiva BT
 Hema follow-up:
For FISH-BCR-
 P O S T- O P E R AT I V E C O U R S E
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

POST-OP DAY 2 For Stat Exploratory Laparotomy

For GS, CS, KOH of wound discharge
BP 90/60 mmHg For Stat S. K, Na, Crea, Ca
S/P Primary LTCS Rpt APTT, Protime
CR 100 bpm
under GETA
RR 21 cpm ECG 12 leads now
CML
(+) soft abdomen Request 3 units PRBC and 2 units FFP
AGE with some
Loose stools x 4 Referred to Nephro Service
dehydration
episodes Transfer to SICU post-op
Moist buccal mucosa Referred to Department of Surgery for
S. K 2.63 Central Venous Pressure (CVP) line
Crea 155.54 insertion
A N E S T H E S I A P R E - O P E R AT I V E E VA L U AT I O N
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

Anesthetic Plan: General

ASA 2E Endotracheal Anesthesia
Hgb 8.9 NPO
Hct 0.29 S/P Primary LTCS Pre-op Meds:
Plt 228 under GETA 1. Ranitidine 50 mg IV 1 hr PTOR
WBC 327 CML 2. Metoclopramide 10 mg 1 hr
Slightly pale PTOR
(+) loose stools To OR 3 units PRBC
 INTERNAL MEDICINE RISK
S T R AT I F I C AT I O N

• Patient is stratified as Moderate Risk to develop CP

complication while undergoing an intermediate risk
procedure

• Attach to cardiac monitor and pulse oximeter

• Repeat ECG 12 leads post-op

• For intraoperative monitoring

 NEPHRO NOTES
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

1,650 cc of GI Increase IVF rate to 150 cc/Hr

Losses Acute Kidney Injury, with PNSS 1L x 6 liters, then
u/o: 50-60 cc/Hr RIFLE-R secondary to
CBS AGE with Moderate 125 cc/Hr thereafter
Crea = 155 Dehydration Rpt Crea, Na, Ca in AM
(-) rales, DOB
 P O S T- O P E R AT I V E C O U R S E
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

POD 2, In PM:
Defer OR temporarily
BP 100/70 mmHg S/P Primary LTCS
CR 97 bpm under GETA
NPO
RR 21 cpm CML Omeprazole 40 mg IVTT OD
(+) soft abdomen Possible morbidities: Folks apprised of patient condition.
Loose stools x 1 • Elevated WBC Continue O2 support at 2-4 lpm via
episode • Bleeding on the face mask
Initial CVP reading: surgical site For X-ray supine upright
6 cmH2O • Persistence of loose For abdominal girth monitoring
X-ray supine stools
upright: Beginning Still for SICU transfer.
partial intestinal
obstruction
 P O S T- O P E R AT I V E C O U R S E
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

POD 3:
Paracetamol 300 mg IV now
In AM: Maintain on NPO
Omeprazole 40 mg IV now
T = 37.9 Metronidazole 500 mg
BP 100-110/60-70 Pip-Taz 2.25 g IV q6h
mmHg For rpt APPT, protime, T3, T4, TSH
CR 110 bpm -same-
CVP = 4 cmH2O determination
O2 sat 99% Fast drip 200 cc PLR now
(+) pallor For repeat S. Na, K, Ca, protime, CBC,
(+) bleeding at op-site apc in AM
app 200 cc Request another 2 units PRBC
Soft abdomen Complete bedrest without bathroom
Hgb 8.8
Hct 0.24
privileges
 P O S T- O P E R AT I V E C O U R S E
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

Maintain in NPO
POD 3:
Insert NGT, attach to drain
In PM: Meds:
BP 110/70 mmHg 1. Pip-Taz 2.25 g IV q8h
CR 112 bpm 2. Metronidazole 500 mg IV q6h
T 38.3 3. Omeprazole 40 mg IV OD
O2 sat 97% -same- 4. Paracetamol 300 q4h IV RTC
CVP: 9 cmH2O 5. Tranexamic acid 1 g IV now then q8h
CBS Transfuse 1 unit PRBC
S. K 2.64 Dec Rapid K replacement x 8 cycles,
Albumin 15.18 Dec incorporate 40 mEqs KCl to present IVF
Crea 102.7 Request 50 cc if 20% human albumin x 2
Awake, with minimal
bottles
bleeding
 P O S T- O P E R AT I V E C O U R S E
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

POD 3:

In late PM:
BP 100-110/60-70
mmHg
-same-
CR 115 bpm Continue present management.
Afebrile
Tachypneic 26 cpm
O2 sat 97%
HBS > Left base
s/p 4 units of blood
 P O S T- O P E R AT I V E C O U R S E
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

POD 4:

GCS 15
BP 120/70 mmHg
CR 120’s
RR 21 Continue present management
Febrile episodes Patient refused NGT reinsertion
(+) pinkish conjunctiva -same- Decrease IVF rate to 80 cc/Hr
HBS For rpt S. K
Soft abdomen For whole abdomen ultrasound
(+) wound dehiscence
~2x2 cm lower portion
of op-site
Minimal bleeding opsite
Hgb 9.3, Hct 0.25, plt
282
 P O S T- O P E R AT I V E C O U R S E
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

POD 5:
GCS 15
BP 110/80 mmHg
CR 90’s
RR 23
Imp: Sepsis sec to:
O2 sat 99% 1. Surgical site
Afebrile infection For possible CVP pullout
NGT drain: Yellowish to
brownish 2. Cannot rule out For reverse isolation
CBS HAP
(+) breast engorgement
CML
IM Infectious Service:
(+) soft abdomen
(+) minimal bleeding at surgical AKI secondary Vancomycin 1 g IV OD in 100 cc
site
Electrolyte imbalance PNSS to run for 2 hrs
(+) BM x 3 episodes, greenish,
mucoid Anemia
CS: Specimen: Wound
discharge
Final Result: Heavy
Growth of Staphylococcus
klosii
 P O S T- O P E R AT I V E C O U R S E
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

POD 6: Imp: Sepsis sec to:

Awake, conversant 1. Surgical site
BP 100/70 mmHg infection
CR 90’s 2. Cannot rule out Shift O2 face mask to nasal cannula
O2 sat 99%
Afebrile
HAP at 4 lpm
HBS CML Present meds were continued
NGT drain: billous AKI secondary Rapid K x 7 cycles
(+) min bleeding on Electrolyte imbalance
surgical site Anemia
S. K 2.6
 P O S T- O P E R AT I V E C O U R S E
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

POD 7-8:
GCS 15
BP 110/80 mmHg
CR 90’s Still on NPO
O2 sat 99% For pelvic ultrasound
Afebrile
Pinkish conjunctiva Omeprazole 80 mg IV bolus now
-Same-
Soft abdomen Start Omeprazole Drip: PNSS 90 cc
NGT with coffee-ground
drain
+ Omeprazole 40 mg to run for 10
Minimal wound discharge hrs x 72 hours
(+) mucoid loose stools Continue Present medications
u/o 80 cc/Hr
Vanco D2-3, Pip-Taz D5-
6, Metro D4-5
 P O S T- O P E R AT I V E C O U R S E
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

POD 9:

GCS 15
BP 110-120/70 mmHg
CR 70-80’s
O2 sat 98-99% Still on NPO
Soft abdomen
NGT decreased coffee- Continue Omeprazole Drip
-Same-
ground drain Increase Tranexamic acid 1 IVTT to
Decreased wound q6h
discharge
Vanco D3, Pip-Taz D5+1, Rapid K x 5 cycles
Metro D6+1
I: 3,700, O: 3,260
Hgb 10.5
WBC 436.9
S. K 2.3
 P O S T- O P E R AT I V E C O U R S E
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

POD 10: Still on NPO

Continue Omeprazole Drip
In AM: Start Parenteral feeding; Cabiven to
GCS 15 run for 36 hours
BP 100-120/70-70 Suggest referral to Gastro Service
mmHg To consider Upper GI
For Rpt CBC, APC, S. Albumin, PT,
CR 80-140’s, RR 23- Bleed
24 cpm APTT, Na, K, Crea
T 37-38, O2 sat 99% For D-Dimer
Soft abdomen Request 2 units of PRBC
(+) Bloody NGT drain Omeprazole drip revised to 80 mg +
Decreased wound equal amounts of PNSS to make 100
discharge cc solution x 12H
 P O S T- O P E R AT I V E C O U R S E
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

POD 10:

In PM:
Tachycardic,
-Same- Patient & folks apprised of patient’s
afebrile
present status
(+) DOB;
(+) Melena;
(+) coffee-ground
NGT drain
 P O S T- O P E R AT I V E C O U R S E
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

Patient intubated on CAB at 10 LPM

POD 10: Start Norepinephrine drip 16 mg in
500 cc D5W at 10 gtts/min, titrate to
In late PM maintain SBP >90 mmHg
(3:40pm): -Same- Start Dobutamine drip: D5W 250 cc
plus 2 amps Dobutamine at
(+) Gasping 5gtts/min, titrate to maintain SBP >
(+) Melena 90 mmHg
BP Palpatory Give voluven, fast drip now
 P O S T- O P E R AT I V E C O U R S E
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

POD 10:
Hypovolemic CPR now
In late PM Epinephrine 1 amp IV now
Shock secondary
(3:40pm):
to Acute massive (with a total of 7 amps were
GCS 3
blood loss, ARF administered)
(+) Fixed dilated type IV secondary
pupils
 P O S T- O P E R AT I V E C O U R S E
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

POD 10:

In late PM Folks apprised

(3:45pm) -Same- ECG long lead II
BP 0
CR 0
 P O S T- O P E R AT I V E C O U R S E
SUBJECTIVE/OBJE
ASSESSEMENT PLAN
CTIVE

POD 10:

In late PM
(4:00 PM) Patient pronounced dead.
Fixed dilated
-Same- Post-mortem care done.
pupils
BP 0, CR 0, RR 0
ECG Long lead
II: Flat
 FINAL DIAGNOSES

• G1P1 (0202) Pregnancy Uterine delivered to both live preterm

babies, twin 1: baby boy cephalic AGA BW 1,975 g, AS 9, 10,
Twin 2: Baby girl frank breech SGA BW 1500 g AS 9, 10 by
Primary low transverse Cesarean Section with Bilateral Tubal
Ligation under General Endotracheal Anesthesia

• Chronic Myelogenous Leukemia

• Hypovolemic Shock secondary to Gastrointestinal bleeding

secondary to Chronic Myelogenous Leukemia; Acute
Respiratory Failure Type IV Secondary; Electrolyte Imbalance
(Hypokalemia), s/p Intubation
CASE DISCUSSION
 CHRONIC MYELOGENOUS
LEUKEMIA (CML)

• A myeloproliferative disorder characterized by the BCR-

ABL oncogene, which results from a reciprocal t(9; 22)
chromosomal translocation.

• CML constitutes 15% of adult leukemia.

• Incidence rates vary from 0.6 to 2.0 cases per 100,000

persons, increase with age and are higher in men than in
women.
 CHRONIC MYELOGENOUS
LEUKEMIA (CML)

• The median age at diagnosis is 64 years old.

• CML accounts for 15% of adult leukemias

• Only 10% of cases are diagnosed during childbearing age.

• CML occurs in 10% of all pregnancy-associated leukemias

and the annual incidence ranges between 1 in 75,000 and 1 in
100,000 pregnancies.
 CHRONIC MYELOGENOUS
LEUKEMIA (CML)

• The diagnosis of CML during pregnancy may be made more

complicated .

• However, the diagnostic approach of CML in pregnant

females is identical to that in non-pregnant patients.
 SIGNS AND SYMPTOMS

• The clinical manifestations of CML are insidious.

• 3 phases (chronic, accelerated, and blast).

• Signs and symptoms in the chronic phase:

• Fatigue, weight loss, loss of energy, decreased exercise

tolerance

• Low-grade fever and excessive sweating

• Elevated white blood cell (WBC) count or

splenomegaly
 SIGNS AND SYMPTOMS

• Signs and symptoms in the chronic phase:

• Early satiety and decreased food intake

• Left upper quadrant abdominal pain

• Hepatomegaly
 SIGNS AND SYMPTOMS

• The following are signs and symptoms of progressive

disease:

• Bleeding, petechiae, and ecchymoses during the

acute phase

• Bone pain and fever in the blast phase

• Increasing anemia, thrombocytopenia, basophilia,

and a rapidly enlarging spleen in blast crisis
 DIAGNOSIS

• Histopathologic findings in the peripheral blood

• Philadelphia (Ph) chromosome in bone marrow cells

 DIFFERENTIAL DIAGNOSES

• Essential Thrombocytosis

• Myelodysplastic Syndrome

• Myeloproliferative Disease

• Polycythemia Vera

• Primary Myelofibrosis
 ANESTHETIC MANAGEMENT

• A study from International Journal of Obstetric Anesthesia

entitled "Chronic myeloid leukemia in pregnancy: an
absolute contraindication to neuraxial anesthesia?" by J. N.
Owsiak

• Anesthetic management of a patient with CML and

blast cells in the circulation who required cesarean
delivery.

• General anesthesia was chosen.

• High morbidity and mortality

 ANESTHETIC MANAGEMENT

• Highlights of the study:

• Chronic myeloid leukemia in pregnancy is rare.

• Poorly controlled chronic myeloid leukemia may lead to the

presence of circulating blast cells.

• Neuraxial anesthesia may cause central neurological blast cell

seeding.

• A central nervous system blast crisis is associated with a high

mortality rate.

• A multi-disciplinary approach to assist with anesthetic planning

is vital.
 ANESTHETIC MANAGEMENT

• A Canadian Journal: Cesarean delivery in a parturient with chronic myeloid

leukemia by Rashmi Datt, Ajay Sharma

• A case of newly diagnosed CML in a patient’s third trimester.

• Treated for two weeks with hydroxyurea prior to lower uterine segment
Cesarean delivery.

• General endotracheal anesthesia was administered uneventfully, and a

normal healthy baby was delivered uneventfully.

• Two weeks later, the patient was started on molecular targeted therapy.

• Both mother and child were doing well after two years of follow-up.
 ANESTHETIC MANAGEMENT

• A Canadian Journal: Cesarean delivery in a parturient with chronic myeloid

leukemia by Rashmi Datt, Ajay Sharma

• One important consideration for choosing general anesthesia in this

case was the potential for blast crisis (BC).

• Blast crisis is defined as the presence of a high blast count, 30%

blasts cells, in the blood/marrow or, presence of extramedullary
blastic infiltrates.

• Although rare, leukemic infiltration of meninges and brain,

including nerves, can occur even while on therapy.
 ANESTHETIC MANAGEMENT

• A Canadian Journal: Cesarean delivery in a parturient with chronic myeloid

leukemia by Rashmi Datt, Ajay Sharma

• Lower section Cesarean delivery can be conducted under general

anesthesia or under a subarachnoid block.

• A traumatic puncture cannot be ruled out.

• It was decided to administer general anesthesia for this patient as a

means to avoid potential introduction of leukemic blasts from the
systemic circulation into the CSF.
U P D AT E O N T H E M A N A G E M E N T O F
CML IN PREGNANCY

• Two scenarios may occur:

• The first is when a woman with CML treated with

imatinib or other tyrosine kinase inhibitors wishes to
become pregnant;

• The other is when CML is newly diagnosed during

pregnancy.
U P D AT E O N T H E M A N A G E M E N T O F
CML IN PREGNANCY

• Imatinib exposure in pregnancy poses an increased risk

for significant congenital malformations.

• It is debatable whether imatinib should be stopped, since

discontinuation of therapy may be associated with an
elevated risk of disease progression.

• The decision should be individualized for each patient.

U P D AT E O N T H E M A N A G E M E N T O F
CML IN PREGNANCY

• Two major reports evaluating interferon therapy during

pregnancy described 40 patients, eight of them treated
during the first trimester.

• There were no cases of fetal malformation when

interferon was administered as monotherapy.

• Therefore, IFN-α should be considered for newly

diagnosed CML patients during pregnancy.
U P D AT E O N T H E M A N A G E M E N T O F
CML IN PREGNANCY

• Patients in the second or third trimesters who do not

tolerate interferon may be treated with hydroxyurea or
possibly imatinib.

• Leukapheresis may also be used as a transient tool for

leukoreduction.
GASTROINTESTINAL BLEEDING IN CML

Gastrointestinal bleeding in a chronic myeloid leukaemia patient precipitated by

dasatinib-induced platelet dysfunction: Case report by Louise Kostos,
Kate Burbury, Gaurav Srivastava H. Miles Prince

• Bleeding in patients with CML receiving dasatinib is a well-

documented side effect, occurring in up to 24% of patients
• Secondary grade 3 or 4 thrombocytopaenia.
• Platelet dysfunction precipitated by dasatinib has been
demonstrated in multiple in vitro and in vivo studies
GASTROINTESTINAL BLEEDING IN CML

Gastrointestinal bleeding in a chronic myeloid leukaemia patient precipitated

by dasatinib-induced platelet dysfunction: Case report by Louise Kostos,
Kate Burbury, Gaurav Srivastava H. Miles Prince

• Significant gastrointestinal bleeding secondary to angiodysplasia

in the absence of a severe thrombocytopaenia
• Upon cessation of dasatinib, platelet function normalised and the
bleeding resolved without further intervention.
GASTROINTESTINAL BLEEDING IN CML

A case of bleeding jejunal ulcer due to vasculitis from hydroxyurea vasculitis

from hydroxyurea by Yousuf Khurshid MD, Kathula S MD, Hillman N MD,
Pacheco J MD, Barde C.J MD, FACG Gopalswamy N MD, FACG
• 54-year-old Caucasian male presented with melena and
dizziness.
• He was on hydroxyurea for myelofibrosis.
• Patient was hemodynamically unstable.
• Rectal exam revealed bright red blood.
• Platelet count, PT and PTT were normal.
GASTROINTESTINAL BLEEDING IN CML

A case of bleeding jejunal ulcer due to vasculitis from hydroxyurea by Yousuf

Khurshid MD, Kathula S MD, Hillman N MD, Pacheco J MD, Barde C.J MD,
FACG Gopalswamy N MD, FACG

• Exploratory laparotomy with intraoperative enteroscopy, a

5mm shallow bleeding ulcer was found in the distal jejunum.
• Wedge resection of the ulcer was done.
• Microscopic exam revealed ulceration with features
compatible with hypersensitivity vasculitis.
• Hydroxyurea was discontinued and no further bleeding was
noted.
 P R O G N O S I S & M O RTA L I T Y

Causes of death in chronic myeloid leukemia. Analysis of 109 patients by

Cervantes F1, Sanz C, Bosch F, Rozman C.

• The cause of death 109 cases of Ph'-positive CML who died in a

15-year period.
• Eight patients (7.3%) died during the chronic phase of the
disease, 7 (6.4%) in the accelerated phase, and 94 (86.3%) in the
blastic crisis.
• Most of the deaths appearing in the accelerated phase were due to
infection or haemorrhage
• In the blastic crisis, deaths were mainly due to infection (54 of
the 94 cases), followed by haemorrhage and leucostasis.
 CONCLUSION

• Pregnant women have a prognosis similar to that of age-

matched nonpregnant women.

• The concepts in the management of CML in pregnancy are

evolving.

• Treatment for every female patient should be individualized.

• Counseling and a considered approach to disease monitoring.

 REFERENCES

Chronic myeloid leukemia in pregnancy: an absolute contraindication to neuraxial

anesthesia?" by J. N. Owsiak

Noa Lavi, MD; Netanel A. Horowitz, MD; Benjamin Brenner, MD: An Update on
the Management of Hematologic Malignancies in Pregnancy

AMIT BHANDARI, KATRINA ROLEN and BINAY KUMAR SHAH:

Management of Chronic Myelogenous Leukemia in Pregnancy
Louise Kostos, Kate Burbury, Gaurav Srivastava H. Miles Prince
Gastrointestinal bleeding in a chronic myeloid leukaemia patient precipitated by
dasatinib-induced platelet dysfunction: Case report
Yousuf Khurshid MD, Kathula S MD, Hillman N MD, Pacheco J MD, Barde C.J
MD, FACG Gopalswamy N MD, FACG: A case of bleeding jejunal ulcer due to
vasculitis from hydroxyurea
Cervantes F1, Sanz C, Bosch F, Rozman C.: Causes of death in chronic myeloid
leukemia. Analysis of 109 patients by
Thank you!