Anaesthetic management for planned caesarean delivery under general anaesthesia in a pregnant patient with multiple myeloma at 32 weeks' gestation: a case report.
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We report on the management of a 34-year-old primigravida diagnosed with multiple myeloma during the third trimester of pregnancy. Multiple myeloma is a plasma cell malignancy usually seen in older men, with less than 50 reported cases occurring in the perigestational period. Common complications include skeletal lesions, anaemia and renal impairment. The presenting symptoms of our patient were painful, palpable bony lesions in the thorax and scalp alongside anaemia with a haemoglobin level of 5.1 g/dL, for which she was transfused with five red blood cell units. After diagnosis confirmation with serum protein electrophoresis and bone marrow biopsy, oral dexamethasone was initiated as a myeloma treatment. Caesarean delivery was planned at 32 weeks to balance the risk from rapidly progressing skeletal disease and anticipated need for chemotherapy with moderate prematurity, in the setting of reassuring fetal monitoring. General anaesthesia was primarily chosen due to axial skeletal involvement, suspected spinal instability and limited mobility complicating positioning for neuraxial techniques. The estimated blood loss was 1000 mL and she was administered a unit of red blood cells and a total of 20 units of oxytocin, remaining haemodynamically stable throughout surgery. Perioperative analgesia consisted of intravenous paracetamol and morphine, under close monitoring. Due to low birth weight, the baby was admitted to the special care unit and discharged on day five in good condition. The rarity of cases in pregnant population underlines the need for anaesthesiologists to remain aware of the relevant intraoperative considerations and perioperative management recommendations.