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

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).