Wall blocks for breast cancer in pregnant patients: saving general anaesthesia also benefits foetal wellness

Wall blocks for breast cancer in pregnant patients: saving general anaesthesia also benefits foetal wellness | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF correspondence Wall blocks for breast cancer in pregnant patients: saving general anaesthesia also benefits foetal wellness Cristiano D’Errico, Annamaria Fabozzi, Giuseppe Sepolvere, Martino Trunfio, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6185604/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Although it is uncommon in general, breast cancer is the most commonly diagnosed cancer during pregnancy. Pregnant patients should receive treatment based on nonpregnant guidelines, with special adjustments for diagnosis, staging, oncology, and obstetrics. This situation is particularly concerning for the health of a long-awaited foetus, especially after medical intervention to aid fertilization. To ensure the baby's safety, it is best to conclude the pregnancy as soon as possible in many cases. We know this is not always possible. This case report discusses the application of the pecto-serratus plane block (PSP) in a patient at seven months gestation undergoing breast quadrantectomy due to the abrupt onset of breast cancer. This study is limited as it involves only one patient. However, it highlights the relevance of locoregional anaesthesia in para-physiological states such as pregnancy. fascial plane block pregnancy Figures Figure 1 Figure 2 Figure 3 Introduction Although it is uncommon in general, breast cancer is the most commonly diagnosed cancer during pregnancy. Treatment for pregnant patients should follow nonpregnant patient guidelines, with specific considerations for diagnosis, staging, oncological treatment, and obstetrical care. About 7 to 10% of women diagnosed with breast cancer are under 40. This subgroup of patients has different risk factors, cancer biology, clinical outcomes, and specific psychosocial issues, such as fertility preservation, family planning, and job reintegration 2 . Early full-term pregnancy has been shown to reduce the lifetime risk of breast cancer, whereas a later first full-term pregnancy increases the risk of breast cancer. This should be considered to assess the timing of intervention. The best time for surgery during pregnancy is the second trimester due to lower risks for both the fetus and preterm labor. The anaesthesia technique depends on the procedure duration, gestational age, and mother and child condition. Surgery for breast cancer during pregnancy follows treatment guidelines and is performed in any trimester regardless of anaesthesia preferences. Fascia blocks are considered a suitable choice today due to their benefits on the hypothalamic‒pituitary‒adrenal axis, which may reduce relapse risks for the mother, and their impact on the health of the unborn child by eliminating the risk of transplacental passage of anaesthetics. Anaesthetic agents commonly used for surgical procedures during pregnancy, such as barbiturates, propofol, benzodiazepines, opioids, and ketamine, do not show teratogenic effects when administered at clinical doses. Considering that fetal blood concentrations of muscle relaxants are only 10–20% of maternal concentrations, these drugs appear to have a substantial margin of safety when given to pregnant women during organogenesis. There is no evidence of teratogenicity with the clinical administration of local anaesthetic agents. Only maternal cocaine abuse is associated with congenital cardiac defects and facial, genitourinary, and gastrointestinal tract anomalies. Given that anaesthetics are currently deemed safe for unborn children, do you prefer to ensure your child's health by avoiding any drugs passing through the placenta? Considering the recent concerns regarding fascia blockage in oncological surgery, it is advisable, in cases of pregnancy complicated by breast cancer, to avoid general anaesthesia for pregnant patients. Whenever feasible, locoregional anaesthesia should be practiced. To execute this block, “written” consent was obtained from the patient for the publication of this case report. Case Overview We present a case of a Pectoserratus plane (PSP) block in a 45-year-old pregnant woman following the AMC technique. The patient had a quadrantectomy for a 2.2 cm cancer in the right upper outer quadrant and removal of the sentinel lymph node (Fig. 1) (Fig. 2 ). With no other pathologies, her ASA classification was I. A 100 mm 22 G needle was used for the PSP block, and 3 ml of NaCl (sodium chloride) was initially injected to confirm placement. (Fig. 3 ). Based on the presence of the Double-V sign, 150 mg of ropivacaine 0.75% combined with dexamethasone 2 mg was administered. Local anaesthetics spread evenly and dynamically through the fascia. The patient was lightly sedated with 0.03 mg/kg midazolam and di-isopropilphenol via a targeted controlled infusion of 1 mcg/ml and spontaneously breathed with nasal cannulas. No opioids were administered. No haemodynamic changes were reported, and no signs or symptoms associated with brain lesions were detected. The patient was prematurely discharged from the hospital within the next eight hours; only intravenously, 1 g of paracetamol was prescribed as a numeric rating scale (NRS) < 2. Fetal echocardiography was done before and after the intervention. Discussion The use of a loco-regional anesthesia technique is now widely used in breast surgery. Although it is equally well know how the trans- placentar passage of drugs for general anesthesia can put at risk the new born, there are no works in Literature that have highlighted the use of loco-regional anesthesia for breast cancer. This case report highlights the importance of fascia blocks in pregnant woman Glossary of terms PSP: pecto-serratus plane block NaCl: sodium chloride AMC (assisted medical creation) Declarations The authors have no conflicts of interest. The authors haven’t no funding Clinical trial number not applicable Author Contribution C.D. wrote the main manuscriptF.A. was the gynecologistG.S. prepared figures 1-3M.T and M.L. performmed intervetionC.M . D.P.A and R.A. found bibliographyAll authors reviewed the manuscript References Boere I, Lok C, Poortmans P, Koppert L, Painter R, Vd Heuvel-Eibrink MM, Amant F. Breast cancer during pregnancy: epidemiology, phenotypes, presentation during pregnancy and therapeutic modalities. Best Pract Res Clin Obstet Gynaecol. 2022 Jun;82:46-59. doi: 10.1016/j.bpobgyn.2022.05.001. Epub 2022 May 9. PMID: 35644793. Eskandari A, Alipour S. Aspects of Anaesthesia for Breast Surgery during Pregnancy. Adv Exp Med Biol. 2020;1252:107-114. doi: 10.1007/978-3-030-41596-9_14. PMID: 32816269. El-Boghdadly K, Desai N, Halpern S, Blake L, Odor PM, Bampoe S, Carvalho B, Sultan P. Quadratus lumborum block vs. transversus abdominis plane block for caesarean delivery: a systematic review and network meta-analysis. Anaesthesia. 2021 Mar;76(3):393-403. doi: 10.1111/anae.15160. Epub 2020 Jul 4. PMID: 32621529. D’Errico C., Fusco P. , Tedesco M, Sepolvere G. The dynamic “Tsunami-sign” to replace the “Double-v” sign for an effective interfascial block. A case of interfascial block in breast lymphoma. Annals of Research in Oncology. 2023 Sep; 3(3):128-31 doi:10.48286/aro.2023.71 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 30 Aug, 2025 Reviews received at journal 29 Jul, 2025 Reviewers agreed at journal 16 Jun, 2025 Reviewers agreed at journal 14 Jun, 2025 Reviewers invited by journal 07 Apr, 2025 Editor assigned by journal 12 Mar, 2025 Submission checks completed at journal 11 Mar, 2025 First submitted to journal 08 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6185604","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"correspondence","associatedPublications":[],"authors":[{"id":472115981,"identity":"da329ee3-18b7-4aba-a03e-81f05b6e12f2","order_by":0,"name":"Cristiano 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in contact with the fourth rib in the pectoserratus plane\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6185604/v1/d52fd1ce91265e48051a9ae3.png"},{"id":87243381,"identity":"a1fbf719-6714-4538-9e23-39fd653e6dd1","added_by":"auto","created_at":"2025-07-22 02:00:45","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1133483,"visible":true,"origin":"","legend":"\u003cp\u003eupper left quadrantectomy\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6185604/v1/3c541de378ac058a60bc3deb.png"},{"id":87244048,"identity":"bfaac697-d5b8-42f7-ae9c-90a7cbea39c2","added_by":"auto","created_at":"2025-07-22 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Treatment for pregnant patients should follow nonpregnant patient guidelines, with specific considerations for diagnosis, staging, oncological treatment, and obstetrical care. About 7 to 10% of women diagnosed with breast cancer are under 40. This subgroup of patients has different risk factors, cancer biology, clinical outcomes, and specific psychosocial issues, such as fertility preservation, family planning, and job reintegration\u003csup\u003e2\u003c/sup\u003e. Early full-term pregnancy has been shown to reduce the lifetime risk of breast cancer, whereas a later first full-term pregnancy increases the risk of breast cancer. This should be considered to assess the timing of intervention.\u003c/p\u003e\u003cp\u003eThe best time for surgery during pregnancy is the second trimester due to lower risks for both the fetus and preterm labor.\u003c/p\u003e\u003cp\u003eThe anaesthesia technique depends on the procedure duration, gestational age, and mother and child condition. Surgery for breast cancer during pregnancy follows treatment guidelines and is performed in any trimester regardless of anaesthesia preferences. Fascia blocks are considered a suitable choice today due to their benefits on the hypothalamic‒pituitary‒adrenal axis, which may reduce relapse risks for the mother, and their impact on the health of the unborn child by eliminating the risk of transplacental passage of anaesthetics. Anaesthetic agents commonly used for surgical procedures during pregnancy, such as barbiturates, propofol, benzodiazepines, opioids, and ketamine, do not show teratogenic effects when administered at clinical doses. Considering that fetal blood concentrations of muscle relaxants are only 10\u0026ndash;20% of maternal concentrations, these drugs appear to have a substantial margin of safety when given to pregnant women during organogenesis. There is no evidence of teratogenicity with the clinical administration of local anaesthetic agents. Only maternal cocaine abuse is associated with congenital cardiac defects and facial, genitourinary, and gastrointestinal tract anomalies. Given that anaesthetics are currently deemed safe for unborn children, do you prefer to ensure your child's health by avoiding any drugs passing through the placenta?\u003c/p\u003e\u003cp\u003eConsidering the recent concerns regarding fascia blockage in oncological surgery, it is advisable, in cases of pregnancy complicated by breast cancer, to avoid general anaesthesia for pregnant patients. Whenever feasible, locoregional anaesthesia should be practiced.\u003c/p\u003e\u003cp\u003eTo execute this block, \u0026ldquo;written\u0026rdquo; consent was obtained from the patient for the publication of this case report.\u003c/p\u003e"},{"header":"Case Overview","content":"\u003cp\u003eWe present a case of a Pectoserratus plane (PSP) block in a 45-year-old pregnant woman following the AMC technique. The patient had a quadrantectomy for a 2.2 cm cancer in the right upper outer quadrant and removal of the sentinel lymph node (Fig.\u0026nbsp;1) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). With no other pathologies, her ASA classification was I.\u003c/p\u003e\u003cp\u003eA 100 mm 22 G needle was used for the PSP block, and 3 ml of NaCl (sodium chloride) was initially injected to confirm placement. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Based on the presence of the Double-V sign, 150 mg of ropivacaine 0.75% combined with dexamethasone 2 mg was administered.\u003c/p\u003e\u003cp\u003eLocal anaesthetics spread evenly and dynamically through the fascia.\u003c/p\u003e\u003cp\u003eThe patient was lightly sedated with 0.03 mg/kg midazolam and di-isopropilphenol via a targeted controlled infusion of 1 mcg/ml and spontaneously breathed with nasal cannulas. No opioids were administered.\u003c/p\u003e\u003cp\u003eNo haemodynamic changes were reported, and no signs or symptoms associated with brain lesions were detected. The patient was prematurely discharged from the hospital within the next eight hours; only intravenously, 1 g of paracetamol was prescribed as a numeric rating scale (NRS)\u0026thinsp;\u0026lt;\u0026thinsp;2.\u003c/p\u003e\u003cp\u003eFetal echocardiography was done before and after the intervention.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe use of a loco-regional anesthesia technique is now widely used in breast surgery. Although it is equally well know how the trans- placentar passage of drugs for general anesthesia can put at risk the new born, there are no works in Literature that have highlighted the use of loco-regional anesthesia for breast cancer. This case report highlights the importance of fascia blocks in pregnant woman\u003c/p\u003e"},{"header":"Glossary of terms","content":"\u003cp\u003ePSP: pecto-serratus plane block\u003c/p\u003e\n\u003cp\u003eNaCl: sodium chloride\u003c/p\u003e\n\u003cp\u003eAMC (assisted medical creation)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003eThe authors haven\u0026rsquo;t no funding\u003c/p\u003e\n\u003cp\u003eClinical trial number not applicable\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eC.D. wrote the main manuscriptF.A. was the gynecologistG.S. prepared figures 1-3M.T and M.L. performmed intervetionC.M . D.P.A and R.A. found bibliographyAll authors reviewed the manuscript\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBoere I, Lok C, Poortmans P, Koppert L, Painter R, Vd Heuvel-Eibrink MM, Amant F. Breast cancer during pregnancy: epidemiology, phenotypes, presentation during pregnancy and therapeutic modalities. Best Pract Res Clin Obstet Gynaecol. 2022 Jun;82:46-59. doi: 10.1016/j.bpobgyn.2022.05.001. Epub 2022 May 9. PMID: 35644793.\u003c/li\u003e\n \u003cli\u003eEskandari A, Alipour S. Aspects of Anaesthesia for Breast Surgery during Pregnancy. Adv Exp Med Biol. 2020;1252:107-114. doi: 10.1007/978-3-030-41596-9_14. PMID: 32816269.\u003c/li\u003e\n \u003cli\u003eEl-Boghdadly K, Desai N, Halpern S, Blake L, Odor PM, Bampoe S, Carvalho B, Sultan P. Quadratus lumborum block vs. transversus abdominis plane block for caesarean delivery: a systematic review and network meta-analysis. Anaesthesia. 2021 Mar;76(3):393-403. doi: 10.1111/anae.15160. Epub 2020 Jul 4. PMID: 32621529.\u003c/li\u003e\n \u003cli\u003eD\u0026rsquo;Errico C., Fusco P. , Tedesco M, Sepolvere G. The dynamic \u0026ldquo;Tsunami-sign\u0026rdquo; to replace the \u0026ldquo;Double-v\u0026rdquo; sign for an effective interfascial block. A case of interfascial block in breast lymphoma. Annals of Research in Oncology. 2023 Sep; 3(3):128-31 doi:10.48286/aro.2023.71\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-anesthesia-analgesia-and-critical-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Journal of Anesthesia, Analgesia and Critical Care](https://janesthanalgcritcare.biomedcentral.com/)","snPcode":"44158","submissionUrl":"https://submission.nature.com/new-submission/44158/3","title":"Journal of Anesthesia, Analgesia and Critical Care","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"fascial plane block, pregnancy","lastPublishedDoi":"10.21203/rs.3.rs-6185604/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6185604/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAlthough it is uncommon in general, breast cancer is the most commonly diagnosed cancer during pregnancy. Pregnant patients should receive treatment based on nonpregnant guidelines, with special adjustments for diagnosis, staging, oncology, and obstetrics. This situation is particularly concerning for the health of a long-awaited foetus, especially after medical intervention to aid fertilization.\u003c/p\u003e\u003cp\u003eTo ensure the baby's safety, it is best to conclude the pregnancy as soon as possible in many cases. We know this is not always possible.\u003c/p\u003e\u003cp\u003eThis case report discusses the application of the pecto-serratus plane block (PSP) in a patient at seven months gestation undergoing breast quadrantectomy due to the abrupt onset of breast cancer. This study is limited as it involves only one patient. However, it highlights the relevance of locoregional anaesthesia in para-physiological states such as pregnancy.\u003c/p\u003e","manuscriptTitle":"Wall blocks for breast cancer in pregnant patients: saving general anaesthesia also benefits foetal wellness","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-22 01:44:40","doi":"10.21203/rs.3.rs-6185604/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-08-30T20:56:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-29T12:52:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"65235905301575959735855965069541104799","date":"2025-06-16T16:32:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"308399216944592479593733905522357280982","date":"2025-06-14T15:23:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-07T09:38:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-12T08:38:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-11T10:30:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Anesthesia, Analgesia and Critical Care","date":"2025-03-08T18:56:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-anesthesia-analgesia-and-critical-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Journal of Anesthesia, Analgesia and Critical Care](https://janesthanalgcritcare.biomedcentral.com/)","snPcode":"44158","submissionUrl":"https://submission.nature.com/new-submission/44158/3","title":"Journal of Anesthesia, Analgesia and Critical Care","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dc37e8bb-e6c7-4aa9-af47-152f72d8a67e","owner":[],"postedDate":"July 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-08T09:09:08+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-22 01:44:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6185604","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6185604","identity":"rs-6185604","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}