Anesth Analg 2001;93:991-995
© 2001 International Anesthesia Research Society
OBSTETRIC ANESTHESIA
The Anesthetic Management of Triplet Cesarean Delivery: A Retrospective Case Series of Maternal Outcomes
Teresa Marino, MD*,
Leonidas C. Goudas, MD PhD
,
Valery Steinbok, MD,
Sabrina D. Craigo, MD*, and
Ralph W. Yarnell, MD
*Division of Maternal-Fetal-Medicine and Department of Anesthesia, New England Medical Center and Tufts University School of Medicine, Boston, Massachusetts
Address correspondence and reprint requests to Teresa Marino, MD, Division of Maternal-Fetal-Medicine, New England Medical Center, 750 Washington, Box 360, Boston, MA 02111. Address e-mail to tmarino{at}lifespan.org
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Abstract
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Spinal anesthesia for the cesarean delivery of triplets is associated with an increased incidence of maternal hypotension and placental hypoperfusion. We performed a retrospective case series analysis between January 1992 and June 2000 to evaluate the effects of regional anesthetic techniques for cesarean delivery in triplet pregnancies on maternal and neonatal outcome. Spinal and epidural anesthesia were compared with respect to intraoperative hemodynamics and neonatal outcomes. Ninety-six triplet pregnancies were delivered by cesarean section, of which 91 received regional anesthesia. A statistically significant decrease in systolic blood pressure was demonstrated immediately after the induction of spinal as compared with epidural anesthesia. The total volume of IV crystalloid used was significantly larger in the Spinal Anesthesia group. The number of patients receiving more than 15 mg of ephedrine and the cumulative dose of ephedrine was significantly larger in the Spinal group compared with the Epidural group. There were no differences in the rate of perioperative complications between the Spinal and Epidural Anesthesia groups. Neonatal Apgar scores were similar in both groups. The data suggest that both epidural and spinal anesthesia for triplet cesarean delivery are safe techniques, but the latter is associated with a larger initial decrease in systolic blood pressure. This decreasing of systolic blood pressure, however, remained within the physiological range and did not seem to be clinically significant. The need for more crystalloid fluids and ephedrine should be anticipated when spinal anesthesia is used for these cases.
IMPLICATIONS: A large retrospective case series of the effects of spinal and epidural anesthesia on maternal hemodynamic profile during cesarean delivery for triplet gestation was performed. Our findings suggest that spinal anesthesia results in outcomes comparable to epidural anesthesia for both mother and newborns.
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Introduction
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The use of spinal anesthesia for triplet cesarean delivery is controversial. Spinal anesthesia has been associated with an increased incidence of maternal hypotension compared with epidural anesthesia (1,2). The incidence of higher-order multiple gestations has increased over the past decade, primarily because of assisted reproductive technologies, increasing from an incidence of 1 per 8000 births in 1950 to more than 1 in 1000 births more recently (3,4). Because of the large number of triplet deliveries at our institution, we performed a retrospective case-series study to evaluate the effect of anesthetic technique on maternal and neonatal outcomes in this high-risk group of patients.
The mode of triplet delivery remains controversial; however, more than 60% of patients with triplets and higher-order gestations are delivered by cesarean section (5,6). At our institution, all triplet pregnancies at viable gestational age are delivered by cesarean delivery. Spinal anesthesia has become the anesthetic technique of choice for singleton cesarean delivery, in part because of the improved quality of surgical anesthesia compared with epidural block (7). The introduction of pencil-point spinal needles has reduced the incidence of postdural puncture headache to 1%–2%, thus eliminating a main disadvantage over epidural anesthesia for surgery (1,8). However, the rapid onset of block with spinal anesthesia may be associated with a more intense initial hypotensive effect than that observed after epidural anesthesia (1,7,8). The exaggerated aortocaval compression associated with multifetal pregnancy has been considered by some to be a contraindication to spinal anesthesia. It is thought that excessive hypotension in these cases might result in fetal hypoxemia at delivery (8). This hypothesis has not been confirmed, primarily because triplet delivery has been too infrequent in the past to allow a comparison of maternal and neonatal outcomes after spinal 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.
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Methods
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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.
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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.
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Results
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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).
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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).
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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).
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.
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Discussion
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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 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 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.
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Acknowledgments
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Supported in part by the Richard Saltonstall Charitable Foundation (to LCG).
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Footnotes
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Presented in part at the 21st annual meeting of the Society for Maternal-Fetal Medicine, Reno, NV, February 5–10, 2001. Published in abstract form in the American Journal of Obstetrics and Gynecology 184:S169,2001.
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Accepted for publication June 11, 2001.
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Abstract
Introduction
