Doxorubicin-induced cardiomyopathy during pregnancy: three case reports of anesthetic management for cesarean and vaginal delivery in two kyphoscoliotic patients.

Abstract

WITH childhood cancer survival rates on the rise, increasing numbers of female pediatric cancer patients are reaching childbearing age. The long-range effects of childhood chemotherapy can have significant clinical implications for these women. The toxicity of an antineoplastic drug given to the pediatric patient may not be fully apparent until other physical conditions in adulthood, such as pregnancy, force the issue. Pregnancy imposes significant physiologic changes and cardiovascular stress. The cardiotoxicity of one chemotherapeutic agent in particular, doxorubicin, is frequent in young females, potentially severely limiting myocardial growth in childhood, leading to a lifelong reduction in myocardial mass, which may result in a significantly decreased cardiac reserve in the child as she grows. 1,2 Pregnancy can unmask the cardiovascular damages caused by doxorubicin even from the remote past in otherwise asymptomatic patients. When these women require an anesthetic for vaginal or cesarean delivery, anesthesiologists should be aware of the possibility of cardiac failure, even in asymptomatic pregnant patients, if they have previously been treated with doxorubicin. The interaction of the long-term cardiotoxic effect of doxorubicin with pregnancy and anesthetic management has not been well described. We present two cases in which regional anesthesia, particularly combined spinal-epidural (CSE) technique, was used successfully for cesarean delivery and vaginal delivery in kyphoscoliotic patients with doxorubicin-induced cardiomyopathy. To our knowledge, this is the first report of the successful use of epidural and combined spinal-epidural technique in kyphoscoliotic pregnant patients with doxorubicin-induced cardiomyopathy presenting during pregnancy.