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Delivery of Craniopagus Conjoined Twins- The Anesthetic Management and Successful Implementation of Simulation and the Multidisciplinary Approach
Abstract Number: SU-14
Abstract Type: Case Report/Case Series
We present a case of a successful delivery of a 30 year old female with craniopagus twins at 32 weeks gestation with premature rupture of membranes. Discovery of the patient’s twin gestation occurred at 21 week appointment. At this point the patient was referred to our high risk perinatal center for maternal fetal medicine obstetrical management. We present the anesthetic considerations during this case for both mother and twins during delivery, and use of a multidisciplinary approach to ensure safety for the patients. The teams involved in the planning for the delivery included: high risk obstetricians, anesthesiology, neonatology, respiratory therapy, nursing staff, and neurosurgery. A simulation session was performed and involved the different staff anticipated to be present during delivery. During this session particular consideration was given towards gentle delivery of the neonates (given concern for dural traction), hand off of the neonates, potential for airway compromise, and having adequate resources in the event of severe blood loss with uterine atony.
After careful planning the twins were delivered via cesarean section utilizing neuroaxial technique with a combined spinal epidural. Venous access included two peripheral 18g intravenous lines with a central line kit available if needed. The spinal consisted of morphine, fentanyl and hyperbaric bupivacaine. Her blood pressure was maintained between 120/70 and 140/90, requiring minimal pressor support with phenylephrine. Oxytocin was given after delivery, per protocol, with adequate uterine contraction. Packed red blood cells, fresh frozen plasma, and platelets were readily available if rapid transfusion was required, however the estimated blood loss was 1000cc and no transfusion took place. Total crystalloid given was 2000cc. The procedure lasted one and half hours. No intra-operative complications occurred and the twins were transported to the neonatal ICU for further monitoring. Both infants breathed spontaneously, and airway support was not initially required.
Conjoined twinning is a rare embryological phenomenon reported to occur once in 50,000 to 100,000 live births (1). There are limited numbers of case reports on delivery of conjoined twins, which identify concerns and suggested anesthetic management (3). We present the utility of simulation with members of the care team, to identify possible safety concerns, and the need for a multidisciplinary approach to reduce morbidity and mortality for both mother and children.
• Martinez-Frias, et.al. (2009) Journal of Pediatric Surgery. Apr;44(4):811-20
• Athanasiadis, et.al. (2007) Donald School Journal of Ultrasound in Obstetrics and Gynecology Apr; 44(4):811-20
• Drake, et.al (2008) International Journal of Obstetric Anesthesia 17, 174-176