surgery for malignancy in the last trimester of pregnancy is uncommon and challenging for anesthesiologists . the onus of safety of two lives lies with them , which extends beyond the intraoperative period . we present management of a 30-week pregnant patient with advanced breast malignancy scheduled for surgery and chemotherapy with favorable outcomes for maternal disease and fetus , possible by multidisciplinary effort and active postoperative monitoring . a 32-year - old multiparous , 30 weeks pregnant parturient presented with a 4  3 cm lump in her left breast . on examination , lump was hard , immobile , and non - tender with palpable axillary lymph nodes . fine needle aspiration cytology revealed the lump to be infiltrating ductal carcinoma and estrogen receptor and progesterone receptor negative . abdominal ultrasound ruled out metastasis in liver . to avoid radiation hazards to fetus and due to financial constraints , computed tomography scan of brain or spine was not done . a treatment plan was formulated following discussion among oncologist , surgeon , anesthesiologist , gynecologist , neonatologist , and patient . it was decided that patient would undergo modified radical mastectomy , followed by chemotherapy after wound healing . labor would be induced before starting chemotherapy if patient did not deliver normally by then , to allow time for fetal maturity . after weighing pros and cons , and due to technical constraints it was agreed that fetal heart rate ( fhr ) would not be monitored intraoperatively . patient was administered 12 mg betamethasone intramuscularly 1 hour prior to surgery as advised by neonatologist for foetal lung maturity in case of preterm labor . half an hour prior to surgery , anti - aspiration prophylaxis with ranitidine 150 mg was given . in the operating room , patient was positioned supine with a wedge under right hip to avoid aortocaval compression . initial monitoring included non - invasive blood pressure , electrocardiogram , pulse oximeter , and capnography . patient was preoxygenated for 5 min . a modified rapid sequence induction with cricoid pressure using fentanyl 100 g , thiopentone 200 mg , and trachea was intubated and anesthesia maintained on 50% oxygen and nitrous , sevoflurane , and intermittent doses of fentanyl and rocuronium . hemodynamic and respiratory variables were stable through the surgery with mean arterial blood pressure between 70 and 85 mm of mercury , heart rate 70 - 85 beats per minute , spo2 99%-100% , and etco2 at 35 . surgery lasted for 4 h. blood loss was minimal . toward end of surgery , antiemetic ondansetron neuromuscuar blockade was reversed with neostigmine and glycopyrrolate and trachea extubated after patient was fully awake . analgesia was maintained with tramadol 75 mg intravenously thrice daily and paracetamol 1 g intravenously as rescue analgesic . she was monitored for uterine contractions by tocography which showed 4 - 5 contractions in a 10 min period with no significant fhr variations . breast cancer is becoming increasingly common during pregnancy with an incidence of approximately 15 - 35 per 100,000 deliveries . the diagnosis of breast cancer during pregnancy is expected to rise due to delay in child bearing by women . our patient presented with stage 3 , ( t4n1m0 ) according to american joint committee on cancer staging of breast cancer . treatment options in third trimester of gestation with advanced stage of cancer include surgery followed by chemotherapy . although chemotherapy is considered to be safe during third trimester , our patient was not willing to undergo chemotherapy . oncologist opined that she should undergo surgery followed by chemotherapy as soon as possible due to advanced nature of disease . parturients are at an increased risk of aspiration pneumonitis after 16 weeks of gestation due to progesterone reducing lower esophageal sphincter tone . hence , anti - aspiration prophylaxis is recommended . 15 - 30 uterine tilt is recommended to avoid supine hypotension that can occur after 20 weeks of pregnancy . introperatively , it is important to maintain normothermia , normocarbia , and avoid maternal hypoxia and hypotension . regional anesthesia avoids airway manipulation and risk of teratogenic effects of anesthetic drugs but carries risk of hypotension , pneumothorax , and intravascular local anesthetic injections . we were not comfortable performing these regional techniques in an obese anxious pregnant patient , hence decided to administer general anesthesia . monitoring of fhr and fetal heart variability is possible after 16 and 26 weeks of gestation , respectively . but , there is considerable controversy regarding fhr monitoring , as it is technically difficult when surgery is in progress and requires the presence of an additional trained personnel for interpretation in the operating room . american college of obstetricians and gynecologists recommend fhr monitoring when technically feasible , availability of trained obstetrician and neonatologist with infrastructure back up , and a minimum of fhr monitoring pre- and postsurgery when fhr monitoring is not feasible intraoperatively . intraoperative fhr monitoring was not technically feasible in our setup , but fhr was checked pre- and postoperatively . preterm delivery is associated with complications like low - birth weight , lung immaturity , and should be avoided . preoperative use of tocolytics is associated with maternal complications like hypotension , tachycardia , and are best avoided unless uterus is handled . ritodrine , a beta 2 agonist , is associated with palpitations , tremors , tachycardia , and pulmonary edema . it 's use has declined over the past few years but according to royal college of obstetricians and gynecologists it is still used in uk and many other parts of the world . use of safer tocloytics such as calcium channel blockers ( e.g. , nifedipine ) and oxytocin receptor antagonist ( atosiban ) has been advocated . another important issue in these patients is the risk of surgical site infection as these patients are immunocompromised and often malnourished in developing countries . prophylactic antibiotics should be administered within 60 min of starting surgery and continued in postoperative period . since these patients require chemotherapy postoperatively , insertion of hickman 's chemoport by open / percutaneous method can be considered . radiation exposure is not an issue in the third trimester but should be discussed with the patient . however , the risk of surgical scar healing and infection should also be discussed by the entire team and patient preoperatively . cohen - kerem et al . , reviewed 54 articles and found incidence of premature labor in pregnant patients undergoing nonobstetrical surgeries to be 8.3% . a total of 75% of the data were gathered from patients undergoing appendectomy in the second trimester . mazze and kallen , conducted a retrospective study of 5405 patients to study reproductive outcomes after anesthesia . they concluded that if pregnancy continues beyond the first postoperative week , the incidence of premature labour is no higher than in nonsurgical patients . the study does not mention whether risk of preterm labor increases with advanced stage of pregnancy , maternal disease , or duration of surgery . there is insufficient literature to estimate the risk and duration of persistence of risk of premature labor in postoperative period in patients undergoing major surgeries in third trimester . more studies are required to estimate risk of premature labor in the postoperative period and accordingly guidelines need to be formulated regarding the infrastructural set up , frequency and duration of postoperative monitoring . in the presence of little evidence that is available , emotional stress of cancer could have possibly contributory in triggering preterm labor in our patient . in hindsight , inclusion of a psychiatrist could have helped her cope with pregnancy and trauma of cancer .
surgery for advanced breast malignancy in the last trimester of pregnancy is uncommon . 
 we present successful management of a 32-year - old woman , 30 weeks pregnant with stage 3 breast malignancy , for surgery followed by normal labor and chemotherapy . 
 surgery and intraoperative period were uneventful . 
 patient had uterine contractions 36 h postsurgery , which were managed timely with active interventions and tocolytics . 
 risk of premature labor following nonobstetric surgery in pregnant patients is estimated to be 8.3% , but majority of the studies have been carried out in second trimester following appendectomy . 
 there is insufficient data in literature regarding the estimation and duration of persistence of risk of premature labor in these patients . 
 no guidelines are available regarding how long they need to be monitored for premature labor . 
 there is some evidence , although little that risk of premature labor persists for 7 days postsurgery . in the absence of convincing studies and guidelines , 
 we recommend postoperative monitoring for at least 7 days in patients undergoing major surgeries for malignancies in last trimester . 
 multidisciplinary approach is required to manage these patients .