Case series: Combined spinal epidural anesthesia for Cesarean delivery andex utero intrapartum treatment procedure

  • Ronald B. George
  • Abigail H. Melnick
  • Erin C. Rose
  • Ashraf S. Habib
Case Reports/Case Series

Abstract

Purpose

To report the use of regional anesthesia andiv nitroglycerin to provide anesthesia and uterine relaxation for three Cesarean deliveries (CD) involvingex utero intrapartum treatment (EXIT) of potentially life-threatening airway obstruction in the newborn.

Clinical features

Case 1 - a 36-yr-old woman at 38 weeks’ gestation was scheduled for an elective CD for fetal skeletal dysplasia and micrognathia.Case 2 - a 34-yr-old woman at 35 weeks gestation had a fetal ultrasound revealing fixed neck flexion and micrognathia consistent with fetal arthrogryposis.Case 3 -a 27-yr-old woman presented at 38 weeks gestation for CD for severe fetal micrognathia, with mandibular growth below the fifth percentile. For each case, a combined spinal epidural anesthetic was performed with 0.75% bupivacaine, fentanyl and morphine intrathecally followed by placement of a multiorifice epidural catheter. Prior to uterine incision patients received a loading dose followed by aniv infusion of nitroglycerin. Uterine relaxation was sufficient in all cases for delivery of the fetus, and allowed for evaluation by direct laryngoscopy and intubation while maintaining fetal-placental circulation. The surgical procedures were completed without incident.

Conclusions

Anesthesia and uterine relaxation for CD and EXIT procedures can be safely provided with regional anesthesia andiv nitroglycerin.

Série de cas: L’anesthésie rachidienne et péridurale combinée pour les interventions de césarienne et de traitement ex utero intrapartum

Résumé

Objectif

Rendre compte du recours à l’anesthésie régionale et à la nitroglycérine iv pour la relaxation utérine dans trois cas d’accouchement par césarienne (AC) ayant nécessité le traitement ex utero intrapartum (EXIT — ex utero intrapartum treatment) d’obstruction potentiellement dangereuse des voies respiratoires du nouveau-né.

Éléments cliniques

Cas 1 — une femme de 36 ans á 38 semaines de gestation devait subir une césarienne élective en raison d’une dysplasie squelettique et de micrognathie chez le fœtus. Cas 2 — une femme de 34 ans à 35 semaines de gestation dont l’échographie fœtale a révélé une flexion fixe du cou et une micrognathie associées à une myodystrophie fœtale. Cas 3 — une femme de 27 ans, à 38 semaines de gestation, est venue pour une césarienne en raison d’une micrognathie fœtale grave, avec croissance mandibulaire en dessous du cinquième centile. Dans les trois cas, une anesthésie rachidienne et péridurale combinée a été effectuée avec de la bupivacaïne 0,75 % intrathécale, du fentanyl et de la morphine, suivie par l’insertion d’un cathéter péridural à orifices multiples. Avant l’incision utérine, les patientes ont reçu une dose de charge suivie d’une perfusion iv de nitroglycérine. La relaxation utérine a suffi dans tous les cas pour l’accouchement du fœtus, et a permis l’évaluation par laryngoscopie directe ainsi que l’intubation tout en maintenant la circulation fœtale et placentaire. Les chirurgies ont été effectuées sans incident.

Conclusion

L’anesthésie et la relaxation utérine pour césarienne et EXIT peuvent être fournies en toute sécurité par une anesthésie régionale et une perfusion de nitroglycérine.

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Copyright information

© Canadian Anesthesiologists 2007

Authors and Affiliations

  • Ronald B. George
    • 1
  • Abigail H. Melnick
    • 1
  • Erin C. Rose
    • 1
  • Ashraf S. Habib
    • 1
  1. 1.Department of Anesthesiology, Women’s Anesthesia and Critical CareDuke University Medical CenterDurhamUSA

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