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

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.
References
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associated with cesarean section. Anesthesiology 1976;45:670–4.
3. Jewell SE, Yip R. Increasing trends of pleural births in the
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4. Contribution of assisted reproductive technology and
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births: United States, 1980–1997. MMWR Morb Mortal Wkly
Rep 2000;49:535–8.
5. Malone FD, Kaufman GE, Chelmow D, et al. Maternal morbidity
associated with triplet pregnancy. Am J Perinatol 1998;15:
73–7.