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

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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
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