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

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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 1. Reisner LS, Lin D. Anesthesia for cesarean section. In: Chestnut DH, ed. Obstetric anesthesia: principles and practice. 2nd ed. St. Louis: Mosby Inc, 1999:465–92. 2. Clark RB, Thompson CH. Prevention of spinal hypotension associated with cesarean section. Anesthesiology 1976;45:670–4. 3. Jewell SE, Yip R. Increasing trends of pleural births in the United States. Obstet Gynecol 1995;85:229–32. 4. Contribution of assisted reproductive technology and ovulation-inducing drugs to triplet and higher-order multiple 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.
ANESTH ANALG OBSTETRIC ANESTHESIA MARINO ET AL. 995 2001;93:991–5 ANESTHESIA FOR TRIPLETS 6. Wildschut HI, van Roosmalen J, van Leeuwen E, et al. Planned abdominal compared with planned vaginal birth in triplet pregnancies. Br J Obstet Gynaecol 1995;102:292–6. 7. Hawkins JL, Gibbs CP, Orleans M, et al. Obstetric anesthesia work force survey, 1981 versus 1992. Anesthesiology 1997;87: 135–43. 8. Shnider SM, Levinson G. Anesthesia for cesarean section. In: Shnider SM, Levinson G, eds. Anesthesia for obstetrics. 3rd ed. Williams and Wilkins, 1993:211–46. 9. Sangarlangkarn S, Klaewtanong V, Jonglerttrakool P, Khankaew V. Meperidine as a spinal anesthetic agent: a comparison with lidocaine-glucose. Anesth Analg 1987;66:235–40. 10. Yarnell RW, Polis T, Reid GN, et al. Patient-controlled analgesia with epidural meperidine after elective cesarean section. Reg Anesth 1992;17:329–33. 11. Hawkins JL, Koonin LM, Palmer SK, Gibbs CP. Anesthesiarelated deaths during obstetric delivery in the United States, 1979–1990. Anesthesiology 1997:86:277–84. 12. Hawkins JL, Beatty BR, Gibbs CP. Update on obstetrical anesthesia practices in the United States [abstract presented at The Society of Obstetric Anesthesia and Perinatology]. Anesthesiology 1999;(Suppl):A53. 13. Riley ET, Cohen SE, Macario A, et al. Spinal versus epidural anesthesia for cesarean section: a comparison of time efficiency, costs, charges, and complications. Anesth Analg 1995;80:709–12. 14. Jawan B, Lee JH, Chong ZK, Chang CS. Spread of spinal anaesthesia for caesarean section in singleton and twin pregnancies. Br J Anaesth 1993;70:639–41. 15. Jawan B, Lee JH. The effect of removal of CSF on cephalad spread of spinal with bupivacaine. Acta Anaesthesiol Scand 1990;34:452–4. 16. Malone FD, D’Alton ME. Multiple gestation: clinical characteristics and management. In: Creasy RK, Resnik R, eds. Maternalfetal medicine: principles and practice. 4th ed. Philadelphia: Saunders, 1998:598–615.
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