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Anesthetic management of a parturient with preterm labor and twins born seven days apart
Abstract Number: 242
Abstract Type: Case Report/Case Series
Introduction: Each year in the US approximately 12% of births are preterm. Despite advances in caring for parturients with preterm labor (PTL) the incidence has actually increased.1 When regional anesthesia (RA) is used during PTL, the perinatal mortality rate is lower compared to PTL without anesthesia. We present a case of the anesthetic management of a patient with PTL who delivered Twin B one week after a cervical cerclage which followed delivery of Twin A.
Case: A 34-year-old G3P0120 with a 23 5/7 week gestation twin pregnancy presented at 7cm cervical dilation with PTL and premature rupture of the amniotic membrane of Twin A following unsuccessful tocolysis. We were consulted for analgesia for the delivery of Twin A and cervical cerclage. The patient was positioned in the lateral decubitus position and a 17 gauge epidural catheter placed at L3-4. Following a negative test dose of 1.5% lidocaine 3mL with epinephrine 15mcg, the epidural was bolused with 100mcg fentanyl and 8mL 0.2% ropivacaine in divided doses. A continuous infusion of 0.2% ropivacaine was initiated at 8mL/hr. After 30 minutes the patient had a T6 sensory level deficit and was taken to the operating room (OR) for vaginal delivery of Twin A. A cervical cerclage was then performed. Twin B remained a stable intrauterine pregnancy. The ropivacaine infusion was discontinued; however, the catheter was left in place for 24 hours while the patient was closely monitored for signs of continued PTL. Tocolysis was achieved and the patient remained stable for 7 days until return of PTL secondary to chorioamnionitis. During an amniocentesis her contractions intensified and she became hypertensive and tachycardic with signs of fetal distress. The procedure was discontinued and the patient taken urgently to the OR. The anesthesiologist was notified and prepared for general anesthesia (GA) in the event an emergent cesarean section (C/S) was needed. The patient received analgesia with ketamine during the subsequent vaginal delivery, after which her vital signs stabilized.
Discussion: The anesthetic management of this patient in PTL was initially accomplished with RA. The precipitous delivery of Twin A was avoided by using epidural analgesia to decrease premature maternal expulsive efforts and provide pelvic floor relaxation needed for a controlled delivery. In addition, the epidural was available for use in the event that a C/S was required. It also provided analgesia during cervical cerclage placement. Unfortunately, RA was not able to be utilized the following week because of the urgency surrounding the delivery of Twin B. Although GA was not required, we were prepared for such in the event an emergency C/S was required. This case highlights several anesthetic challenges present when caring for the parturient with preterm twins.
Reference: 1) Iams, JD, et al. Primary, secondary and tertiary interventions to reduce the morbidity and mortality of preterm birth. Lancet 2008; 371:164.