The Anesthetic Management of Triplet Cesarean Delivery: A ...

The Anesthetic Management of Triplet Cesarean Delivery:
A Retrospective Case Series of Maternal Outcomes
Teresa Marino, MD*, Leonidas C. Goudas, MD, PhD†, Valery Steinbok, MD†,
Sabrina D. Craigo, MD*, and Ralph W. Yarnell, MD†
*Division of Maternal-Fetal-Medicine and †Department of Anesthesia, New England Medical Center and Tufts University
School of Medicine, Boston, Massachusetts
Spinal anesthesia for the cesarean delivery of triplets is
associated with an increased incidence of maternal hypotension
and placental hypoperfusion. We performed
a retrospective case series analysis between January
1992 and June 2000 to evaluate the effects of regional
anesthetic techniques for cesarean delivery in triplet
pregnancies on maternal and neonatal outcome. Spinal
and epidural anesthesia were compared with respect to
intraoperative hemodynamics and neonatal outcomes.
Ninety-six triplet pregnancies were delivered by cesarean
section, of which 91 received regional anesthesia. A
statistically significant decrease in systolic blood pressure
was demonstrated immediately after the induction
of spinal as compared with epidural anesthesia. The total
volume of IV crystalloid used was significantly
larger in the Spinal Anesthesia group. The number of
The use of spinal anesthesia for triplet cesarean
delivery is controversial. Spinal anesthesia has
been associated with an increased incidence of
maternal hypotension compared with epidural anesthesia
(1,2). The incidence of higher-order multiple
gestations has increased over the past decade, primarily
because of assisted reproductive technologies, increasing
from an incidence of 1 per 8000 births in 1950
to more than 1 in 1000 births more recently (3,4).
Because of the large number of triplet deliveries at our
institution, we performed a retrospective case-series
study to evaluate the effect of anesthetic technique on
maternal and neonatal outcomes in this high-risk
group of patients.
Supported in part by the Richard Saltonstall Charitable Foundation
(to LCG).
Presented in part at the 21st annual meeting of the Society for
Maternal-Fetal Medicine, Reno, NV, February 5–10, 2001. Published
in abstract form in the American Journal of Obstetrics and Gynecology
184:S169,2001.
Accepted for publication June 11, 2001.
Address correspondence and reprint requests to Teresa Marino,
MD, Division of Maternal-Fetal-Medicine, New England Medical
Center, 750 Washington, Box 360, Boston, MA 02111. Address
e-mail to tmarino@lifespan.org.
patients receiving more than 15 mg of ephedrine and
the cumulative dose of ephedrine was significantly
larger in the Spinal group compared with the Epidural
group. There were no differences in the rate of perioperative
complications between the Spinal and Epidural
Anesthesia groups. Neonatal Apgar scores were similar
in both groups. The data suggest that both epidural and
spinal anesthesia for triplet cesarean delivery are safe
techniques, but the latter is associated with a larger initial
decrease in systolic blood pressure. This decreasing
of systolic blood pressure, however, remained within
the physiological range and did not seem to be clinically
significant. The need for more crystalloid fluids and
ephedrine should be anticipated when spinal anesthesia
is used for these cases.
(Anesth Analg 2001;93:991–5)
The mode of triplet delivery remains controversial;
however, more than 60% of patients with triplets and
higher-order gestations are delivered by cesarean section
(5,6). At our institution, all triplet pregnancies at
viable gestational age are delivered by cesarean delivery.
Spinal anesthesia has become the anesthetic technique
of choice for singleton cesarean delivery, in part
because of the improved quality of surgical anesthesia
compared with epidural block (7). The introduction of
pencil-point spinal needles has reduced the incidence
of postdural puncture headache to 1%–2%, thus eliminating
a main disadvantage over epidural anesthesia
for surgery (1,8). However, the rapid onset of block
with spinal anesthesia may be associated with a more
intense initial hypotensive effect than that observed
after epidural anesthesia (1,7,8). The exaggerated aortocaval
compression associated with multifetal pregnancy
has been considered by some to be a contraindication
to spinal anesthesia. It is thought that
excessive hypotension in these cases might result in
fetal hypoxemia at delivery (8). This hypothesis has
not been confirmed, primarily because triplet delivery
has been too infrequent in the past to allow a comparison
of maternal and neonatal outcomes after spinal
©2001 by the International Anesthesia Research Society
0003-2999/01 Anesth Analg 2001;93:991–5 991

992 OBSTETRIC ANESTHESIA MARINO ET AL. ANESTH ANALG
ANESTHESIA FOR TRIPLETS 2001;93:991–5
versus epidural anesthesia. The objective of this retrospective
case-series analysis was to identify the risks
and benefits of these two neuraxial anesthetic techniques
for triplet cesarean delivery on the basis of
maternal and neonatal outcomes.
Methods
All cases of triplet pregnancies delivered by cesarean
section at New England Medical Center from July
1992 to June 2000 were reviewed. Patients were identified
from our triplet database and confirmed from
our delivery room logbook. Data were collected from
the patients’ prenatal, anesthetic, and discharge
records. The neonatal records for each triplet were
also reviewed.
Antenatal maternal complications were documented.
The anesthetic management, perioperative
maternal hemodynamics, and neonatal outcomes
were compared between groups on the basis of the
type of regional anesthesia performed. Patients who
delivered before 24 wk gestation, those with a demise
of one or more fetuses, or those who delivered vaginally
were excluded. Decisions regarding the choice of
anesthetic technique, anesthetic drugs, perioperative
IV fluid administration, and the frequency of vasopressor
use were made by the anesthesiologist involved
in the case. Lidocaine 2% with epinephrine
(1:200,000) was the local anesthetic used in all epidural
cases and was supplemented with fentanyl or meperidine.
Hyperbaric bupivacaine (0.75% in dextrose) was
used in all the spinal anesthetics, with meperidine
10–20 mg added to the solution in all cases (9,10).
Sensory block extending from T4 to T6 by pinprick
was confirmed before the incision. The small number
of patients in the General Anesthesia group (n 5)
were included for demographic comparison only.
Data in tables and figures are presented as percentage
or mean sem. Statistical analysis of continuous
variables was performed with multiple analysis of
variance (ANOVA) followed by post hoc analysis, with
Dunn’s test for pairwise comparison between groups.
Dichotomous variables were compared by using the
2 test. The Apgar scores are presented as binomials.
The statistical comparison of Apgar scores was performed
at 1 and 5 min for the same neonate in the
order of delivery between the groups using Kruskal-
Wallis one-way ANOVA on ranks. Differences were
considered statistically significant at P 0.05.
Results
From January 1992 to June 2000, there were 96 triplet
cesarean deliveries at New England Medical Center, a
tertiary care center. Seventy-one patients had spinal,
20 had epidural, and 5 had general anesthesia. Maternal
age, maternal weight, and mean gestational age at
time of cesarean delivery were similar between
groups. Eighty-six of the 96 (89.6%) triplet pregnancies
were the result of assisted reproductive technology.
The indications for delivery did not differ significantly
between regional anesthesia groups (Table 1). There
were no cases of general anesthesia or epidural anesthesia
after 1997 (Fig. 1). In this 8-yr period, there was
one case of regional anesthesia failure (both epidural
and spinal approaches attempted) followed by general
anesthesia. Indications for general anesthesia included
severe preeclampsia with coagulopathy and nonreassuring
fetal heart rate tracing (Table 1).
Of the 96 women with triplet pregnancies, 83
(86.5%) required antenatal admission for longer than
24 h. The most common complication of triplet pregnancy
was preterm labor, occurring in 81.2% of patients.
Pregnancy-induced hypertension was also common,
occurring in 32.3% of our admitted patients. Of
the patients diagnosed with pregnancy-induced hypertension,
more than 50% met criteria for severe preeclampsia,
HELLP syndrome (hemolysis, elevated
liver tests, and low platelets), or coagulopathy (Table
2). Acute fatty liver of pregnancy occurred in 4.2% of
our patients.
The IV fluid volume used before the induction of
anesthesia (preload) did not differ between the Spinal
and Epidural groups. The total volume of IV crystalloid
used was 2.5 0.09 L in the Spinal group and 2.1
0.1 L in the Epidural group (P 0.05). After the
induction of regional anesthesia, systolic blood pressure
was 110.3 2.5 in the Spinal Anesthesia group
and 127.3 4.0 in the Epidural group at the same time
point (P 0.05) (Fig. 2A). These differences were not
clinically significant. No other differences in systolic
blood pressures were noted between the regional
groups. There were no differences in mean arterial
pressures, diastolic pressures, or heart rate between
the regional anesthesia groups. Ephedrine was successfully
used as a pressor drug at the time of surgery
when necessary to maintain blood pressure. The number
of patients who required the administration of
more than 15 mg of ephedrine over the entire case was
larger in the Spinal Anesthesia group than the Epidural
Anesthesia group (50 vs 6 patients, P 0.0011).
In addition, the total dose of ephedrine was significantly
larger in the Spinal Anesthesia group compared
with the Epidural group (20 21.3 mg vs 4.75
8.37 mg, P 0.001).
There were no intraoperative anesthesia complications
recorded for any of the groups. Postoperative
complications were similar among the three anesthesia
groups. The total estimated blood loss was similar
in the Spinal and Epidural Anesthesia groups (0.98
0.04 L vs 0.94 0.06 L).

ANESTH ANALG OBSTETRIC ANESTHESIA MARINO ET AL. 993
2001;93:991–5 ANESTHESIA FOR TRIPLETS
Table 1. Indications for Cesarean Delivery
Indication Spinal (n 71) Epidural (n 20) General (n 5)
Preterm labor 33 (47.8) 11 (55) 0
Premature rupture of membranes 8 (11.3) 3 (15) 0
Preeclampsia 13 (18.3) 4 (20) 0
Preeclampsia with coagulopathy 0 0 2 (40)
Acute fatty liver 3 (4.2) 0 1 (20)
Term gestation a
7 (9.9) 2 (10) 0
Nonreassuring fetal HR tracing 6 (8.5) 0 2 (40)
Data are presented as n (%).
HR heart rate.
a Patients delivered at 37 wk gestation.
Figure 1. Number of patients that received spinal, epidural, or
general anesthesia for triplet delivery with cesarean section from
July 1992 through June 2000 at New England Medical Center Hospital.
Each bar represents the number of triplet deliveries performed
with cesarean section during a 1-yr period starting in July and
ending with June.
There were no differences in gestational age at delivery
or birth weight between the two groups. Apgar
scores at 1 and 5 min were compared for all neonates
between each anesthetic group and for subgroups of
neonates according to the order of delivery (first, second,
or third). There was no statistically significant
difference in the Apgar scores at 1 and 5 min. Of the
samples measured, there was no difference in umbilical
cord blood pH results between the two groups.
However, because the umbilical cord gases were collected
in fewer than half of these cases, these were
excluded from any further analysis.
Discussion
There is a growing preference for regional anesthesia
for cesarean birth in the United States (7), not only
because it avoids the risks of failed intubation and
aspiration, but also because these patients prefer to be
awake, experience less sedation and better analgesia
postoperatively (10), and to participate in the delivery
Table 2. Complications of Triplet Gestations
Complication n (%)
Antenatal complications 83 (86.5)
Preterm labor (34 wk) 78 (81.2)
Premature rupture of membranes 17 (17.7)
Pregnancy-induced hypertension 31 (32.3)
Mild preeclampsia 18 (18.8)
Severe preeclampsia 18 (18.8)
HELLP syndrome 5 (5.2)
Eclampsia 1 (1)
Acute fatty liver of pregnancy 4 (4.2)
Gestational diabetes 7 (7.3)
Anemia 15 (15.6)
Supraventricular tachycardia 3 (3.1)
Pruritic urticarial plaques and papules of
pregnancy
4 (4.2)
Acute lumbar disc prolapse 1 (1)
Postpartum complications 23 (24.0)
Endometritis 14 (14.9)
Hemorrhage 6 (6.2)
Disseminated intravascular coagulopathy 2 (2)
Postpartum readmission 8 (8.3)
Pneumonia 2 (2)
HELLP hemolysis, elevated liver tests, and low platelets.
of their newborns. The increased safety of regional
anesthetic techniques was demonstrated by Hawkins
et al. (11), who reported that from 1985 to 1990, the
case fatality rate directly attributed to anesthesia was
approximately 17-fold more frequent with general anesthesia
as compared with regional anesthesia. The
fact that fewer than 10% of cesarean deliveries are now
performed under general anesthesia (12) underscores
the strong preference for regional blocks among caregivers
and patients alike. This is the first case series of
triplet deliveries that supports the safe use of both
spinal and epidural anesthetic techniques in these
cases.
The use of spinal anesthesia for singleton cesarean
delivery has increased significantly over the past several
years, partly because of the introduction of atraumatic,
pencil-point spinal needles (1,7,8). Figure 1 demonstrates
a similar trend in this series of triplet cesarean deliveries.
Spinal anesthesia has the benefit of producing regional
anesthesia more rapidly and perhaps more reliably than
epidural anesthesia for cesarean delivery (13). Patients

994 OBSTETRIC ANESTHESIA MARINO ET AL. ANESTH ANALG
ANESTHESIA FOR TRIPLETS 2001;93:991–5
Figure 2. Perioperative changes in arterial blood pressures. Systolic
(SAP) (A) and mean (MAP) (B) arterial pressure. After the induction
of regional anesthesia, there was a significant decrease of the systolic
blood pressure in the Spinal Anesthesia group compared with
the Epidural group at the same time point. Data are presented as
mean sem (one-way analysis of variance, post hoc Dunn’s test for
pairwise comparisons, *P 0.05).
receiving spinal anesthesia are more comfortable during
surgery and require less supplemental intraoperative
analgesia (12). The incremental dosing of the epidural
catheter during the initiation of epidural anesthesia may
enable better control of the dermatomal distribution of
the sympathetic block and produces a slower onset of
action (8,12). These factors may reduce the incidence and
severity of maternal hypotension compared with spinal
block (12). In addition, spinal anesthesia produces a
greater spread of block with multifetal pregnancy as
compared with singleton patients undergoing cesarean
delivery (14). This may also contribute to an increase of
maternal hypotension and uterine hypoperfusion in
multifetal pregnancy. Proposed mechanisms accounting
for the greater increase in anesthetic spread observed in
multifetal pregnancies include obstructed venous return,
larger reduction of cerebrospinal fluid volumes, and increased
concentrations of progesterone (14,15). Some investigators
suggest that the spinal anesthetic technique is
associated with fewer complications and is more cost
effective in singleton pregnancies (13).
Our observations suggest that with adequate hydration
and the administration of ephedrine, hypotension
after spinal block for triplet birth can be safely managed.
Brief episodes of hypotension were not associated
with any significant effect on the neonates, and
no significant difference in Apgar scores was noted
between the two groups. It should be stressed that the
retrospective analysis in the present case series cannot
exclude the possibility of a deliberate use of increased
prehydration in women who received spinal anesthesia.
The need for increased IV crystalloid fluids and
ephedrine to avoid maternal hypotension should be
anticipated when spinal anesthesia is used (1,8).
The last general anesthetic performed in this series
was in April 1997. This may represent narrowing indications
for general anesthesia in obstetrics, as well as
earlier preemptive management of maternal and fetal
antenatal complications, thereby preventing urgency
or other contraindications to regional anesthesia.
The incidence of maternal comorbidity with triplet
gestations is substantially more frequent than in singleton
pregnancy (5,16) (Table 2). Pregnancy-induced
hypertension, the most common maternal antenatal
complication in our patients, carries a 7% incidence in
singleton pregnancy and up to 20% incidence in twin
gestations (16). Thus, it is not surprising that the incidence
of pregnancy-induced hypertension in our triplet
case series was 32.3%. Acute fatty liver of pregnancy,
a potentially life-threatening condition that
occurs with an incidence of approximately 1 in
10,000 deliveries (16), occurred in 4.2% of our patients.
This review of our experience with triplet birth is
subject to the usual criticisms of retrospective reviews.
Lack of randomization may have introduced bias, particularly
in the choice of patients receiving each type
of anesthesia. Lack of standardization of anesthetic
techniques may have introduced unmeasured confounders.
The passage of time may have introduced
changes in obstetric and anesthetic approaches that
have influenced these results (7,8).
This is the largest case series of anesthetic experience
with triplet cesarean birth and demonstrates the
safety of spinal and epidural anesthetic techniques in
this patient population.
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