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Unique Maternal Anesthetic Management for Twin Gestation Exit Procedure
Abstract Number: F-36
Abstract Type: Case Report/Case Series
Background: Ex utero intrapartum surgery (EXIT) is performed when there is suspected fetal airway pathology requiring management of the airway while fetoplacental circulation is intact. Neonatal airway obstruction is associated with significant morbidity and mortality.1 Maintenance of placental support while the airway is secured requires multidisciplinary expertise to provide simultaneous surgical care to both mother and fetus. We present anesthetic management for an EXIT procedure with twin gestation. To our knowledge this is only the second report of EXIT procedure for twin gestation and the only report involving airway pathology in both twins.2 It is also the first successfully documented use of desflurane for uterine relaxation during an EXIT procedure.
Case: The patient was a 28 year old G5P3 at 30 3/7 wks gestation with monochorionic-diamniotic twins complicated by severe micrognathia in both twins. The patient was in preterm labor and scheduled for an EXIT procedure. Large bore intravenous access was obtained and an intra-arterial line placed. We performed a rapid sequence induction with propofol and succinylcholine and secured the maternal airway. Anesthesia was maintained using 100% oxygen at 10 L flow and 2.0 MAC desflurane to achieve uterine relaxation. A prophylactic phenylephrine infusion was administered to maintain MAP within 20% of baseline. A MAP > 60 mmHg was maintained throughout the procedure.
After uterine incision, Twin A was partially delivered and the airway was secured by the ENT surgeon; ETCO2 was confirmed, umbilical vessels were clamped and Twin A was fully delivered. The same sequence of events occurred for Twin B. Total time from uterine incision to delivery of Twin B was 30 minutes. Following delivery of Twin B, desflurane was discontinued. An oxytocin infusion was started and 250 mcg IM methylergonovine empirically given to prevent uterine atony. Two additional 200 mcg doses of carboprost tromethamine were administered. Total EBL was 2L. The patient recovered uneventfully and both neonates did well.
Discussion: This is the first report of an EXIT procedure for twin gestation involving airway pathology of both twins and the first report of successful use of desflurane for uterine relaxation during EXIT. We chose desflurane for uterine relaxation because it’s low solubility and fast titratability. Twin B did well despite two required EXIT time periods and the need for phenylephrine infusion, as evidenced by the umbilical artery pH of 7.20. Communication and preparation are key components to a successful EXIT procedure to optimize maternal and fetal outcomes.
1.Zadra N, et al. Ex utero intrapartum surgery (EXIT): indications and anaesthetic management. Best Pract and Res Clin Anaesth 2004; 18:259-71.
2.Gaiser RR, et al. The cesarean delivery of a twin gestation under 2 minimum alveolar anesthetic concentration isoflurane: one normal and one with a large neck mass. Anesth Anal 1999; 88:584-6.