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• W2001552661 abstract "SECTION EDITOR: DAVID J. BIRNBACH. Grand multifetal pregnancies (four or more), which may result from the use of new ovulation-induction techniques, present challenges to the anesthesiologist. We describe the anesthetic management of a patient with sextuplet gestation. Case Report A 27-yr-old primigravida nulliparous woman with menotropins-induced sextuplet gestation was admitted to the hospital at 26 3/7 wk gestational age (EGA) for observation secondary to cervical shortening without contractions. She was placed at bedrest with bathroom privileges. A multidisciplinary meeting among obstetrics, anesthesiology, the neonatal intensive care unit (NICU), and nursing staff outlined the issues regarding timing and mode of delivery, anesthesia, and organization of resources. Delivery by cesarean section was planned. The timing of delivery would be based on obstetric indications such as poor fetal growth, advanced cervical change, labor or rupture of membranes, or maternal compromise, such as preeclampsia. The patient was otherwise healthy and had undergone uncomplicated general anesthesia for laparoscopy 2 yr before this admission. She had gained 23 kg during her pregnancy, weighed 85 kg, and was 5[prime]6[double prime] tall with a Mallampati class I airway. Her blood pressure (BP) was 110/60 mm Hg, and her heart rate (HR) was 80 bpm. She had no edema or respiratory compromise. She did not require any tocolytics. All laboratory values were within normal limits, including a hematocrit of 38%. Despite this relatively high hematocrit, there was no evidence of preeclampsia. All fetuses were growing well. The patient was more comfortable sitting upright but was able to tolerate the supine position with left uterine displacement (LUD) for short periods. Epidural anesthesia was thought to be a reasonable option for this patient, and she preferred this. During her admission, her BP ranged from 100/60 to 120/82 mm Hg. At 29 wk EGA, the patient complained of mild rectal pressure and was noted to have cervical change; cesarean section was planned. A 16-gauge IV catheter was placed. She received 30 mL of sodium citrate orally and metroclopramide 10 mg IV. Her initial BP was 130/80 mm Hg, HR 85 bpm. A lumbar epidural catheter was easily placed at the L3-4 interspace via a midline approach with the patient in the sitting position. A test dose of 3 mL of lidocaine 1.5% with epinephrine 1:200,000 was negative. After providing 20[degree sign] LUD, a T4 level was slowly obtained over 25-30 min using 20 mL of 0.5% bupivacaine with 100 [micro sign]g of fentanyl in divided doses. Our operating Table allowsselective positioning of the back, and we were able to slowly lower the patient to a supine position with LUD while raising our level. The patient tolerated this well. During this time, 1000 mL of lactated Ringer's solution (LR) was infused, oxygen was administered via face mask, and intermittent fetal monitoring was performed with ultrasound. The patient's BP remained stable without vasopressors, with a low of 110 mm Hg systolic before delivery of the infants. Her oxygen saturation was 99%-100% throughout the surgery, and she voiced no subjective complaints of respiratory compromise. Babies A-F were delivered 7-11 min after skin incision (Table 1 and Table 2). A separate neonatal team was present for each baby.Table 1: Baby DataTable 2: Cord Blood GasesAfter delivery, oxytocin 30 U was added to 1 L of LR. The uterus contracted well. Estimated blood loss was 1000 mL, and the patient received a total of 1800 mL of LR. Preservative-free morphine 5 mg was injected via the epidural catheter, and the patient was transferred to the recovery room in stable condition. Five of the babies required tracheal intubation in the delivery room, and all six were transferred to NICU in stable condition (Table 1). The mother's hematocrit on Postoperative Day 1 was 32.7%, and her subsequent course was unremarkable. All of the babies have been discharged home in good condition. Discussion Multifetal pregnancies present many challenges for the anesthesiologist. Maternal complications, such as preeclampsia, anemia, edema, and excessive weight gain, are more common than in singleton pregnancies. A review of the births of three or more infants showed an 18%-19% incidence of pregnancy-induced hypertension [1,2] and a 14% incidence of anemia [2]. The presence of a large gravid uterus predisposes the mother to significant respiratory compromise, aortacaval compression resulting in hypotension, and increases the incidence of uterine atony and postpartum hemorrhage. The incidence of preterm labor is 66%-88% [1-3]; therefore, patients may present for cesarean section while receiving tocolytic therapy, which has side effects such as fluid retention, pulmonary edema [4,5], hyperglycemia [6], and cardiac arrhythmias [7]. Fetal considerations are equally important in the anesthetic management of these parturients. The incidence of prematurity is very high [3]-the mean gestational age has been reported to be 32.4 wk for triplets, 30 wk for quadruplets, and 29 wk for quintuplets, although the numbers are small for the latter two groups [8]. Premature infants are prone to intracerebral hemorrhage and are more sensitive to anesthetic drugs secondary to immature organ development. Birth weights for twins are below the mean for singletons at 32 wk and below the 10th percentile after 36 wk [9]. Compared with twins, triplets are significantly more likely to demonstrate intrauterine growth restriction and discordant growth (66.7% vs 13%) [10]. Furthermore, for twins with a weight difference of 25% or more, there is a higher incidence of perinatal and intrauterine mortality [11,12]. Abnormal fetal presentations may necessitate uterine relaxation to facilitate timely delivery of all fetuses. Finally, the importance of adequate interdisciplinary preparation and cooperation cannot be overemphasized. While the anesthesia team was preparing the mother for surgery, nursing teams from labor and delivery and the NICU were preparing all three of our operating rooms for resuscitation of the babies. Additional nursing staff was made available to properly identify the babies, the placentas, and the umbilical cord gases. There is no ideal anesthetic technique for every patient. There is adequate support in the literature for both regional and general anesthesia [13-18]. The advantages of regional anesthesia include fewer airway problems [19], minimal neonatal depression, and parental participation in the birth. Lack of uterine relaxation associated with regional anesthesia is not a significant disadvantage because nitroglycerin can be used to provide rapid, short-acting uterine relaxation [20]. However, technical difficulties in performing the block due to exaggerated lordosis and edema, and the risk of hematoma associated with coagulopathy and preeclampsia, may make regional anesthesia unsuitable in some patients. Furthermore, in some patients, it is almost impossible to avoid aortacaval compression during the administration of regional anesthesia. Patients with respiratory distress and pulmonary edema will require positive pressure ventilation. Compared with spinal anesthesia, epidural anesthesia is more appropriate for the patient with grand multifetal gestation, because it allows for slow titration of the anesthetic level, thus minimizing hypotension secondary to sympathetic blockade. Furthermore, a gradual onset of anesthesia allows the patient to better tolerate the dyspnea often associated with the supine position. In an emergency, spinal anesthesia has the advantage of rapid onset of surgical anesthesia. However, because advanced planning is almost always necessary for the delivery of these patients, adequate time for epidural placement should be available. Our patient tolerated epidural anesthesia extremely well, and we have used the technique successfully for the delivery of several sets of quadruplets as well. In summary, we report the use of epidural anesthesia for cesarean section of sextuplets with successful maternal and neonatal outcome. The important anesthetic considerations for patients with multifetal gestation are presented." @default.
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• W2001552661 title "Successful Epidural Anesthesia for Cesarean Section for Sextuplets" @default.
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