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Anesthesia for Cesarean Section of Septuplet Gestation
Abstract Number: 247
Abstract Type: Case Report/Case Series
Introduction: Multiple gestations have become more frequent in the age of assisted reproductive technology and hormonal augmentation, but pregnancies of seven babies are still very rare. This case involves the anesthetic management of a 29 year old African American, G2 P 0010, obese class A2 diabetic with septuplet gestation conceived using follitropin and IUI. The patient was initially admitted at 17 weeks for advanced cervical effacement in spite of a cerclage being placed at 12 weeks. During the hospital course she was found to have an IUFD of fetus B at 23 weeks. She requested delivery and BPS at approx 27 4/7 weeks due to concern for further IUFD and was fully counseled by MFM and Pediatrics.
Methods: The patient was assessed several days prior to the procedure and a plan was discussed between the attending anesthesiologists. All methods of anesthesia were considered. It was decided to place an epidural prior to the OR and begin dosing it to ensure adequate function and level. In the patient’s L&D room she was placed in sitting position and prepped and draped. Bony landmarks were difficult to palpate, given the patients body habitus, but L3-4 in the midline was indentified and localized with 3mL of 1% lidocaine. An 18g, 4 inch tuohy needle was placed with loss of resistance to saline at 9cm. The catheter was threaded easily to approximately 6cm in the space. The epidural was then dosed with 10mL of 2% lidocaine with 1:200K epinephrine in divided doses, until a T10 level to sharp was achieved. The patient was then transported to the OR. Upon arrival to the OR, the level to sharp was reassessed. The epidural was dosed with an additional 8mL of 2% lido with epi. A T4 level was achieved and the patient was prepped and draped for surgery. At skin incision the patient was very comfortable. A classical vertical incision was made. Six live and one deceased baby were delivered over the course of four minutes with apgars ranging from 4-8 and weights of 615- 910g. Upon delivery of the final baby, IV oxytocin was started and allowed to drip freely. Good uterine tone was achieved with approximately 10 U oxytocin and no other uterotonics were necessary. The uterus was externalized with brief discomfort. The urine incision was closed and BPS was performed. Duramorph 2mg was given through the epidural after the BPS. The incision was closed and the patient taken to recovery and rated pain as 0/10.
Discussion: Multiple gestation pregnancies pose several problems to anesthesiologists. These include risk of high spinal, hypotension, bleeding due to uterine atony, difficult airway, and prolonged procedure time.
Anesthesia for breech presentation and multiple gestation. Pratt, S. Clinical Obstetrics and Gynecology. Sept 2003,(46)3: 711-29.
The anesthetic management of triplet cesarean delivery: a retrospective case series of maternal outcomes. Marino, T, et al. Anesth Analog. Oct 2001 (93)4: 991-5