Multiple Gestation 

 

 

Considerations 

 

  • Considerations of pregnancy, full stomach, 3 patients 

  • ↑ Maternal complications:

    • ↑ aorto-caval compression 

    • ↑ desaturation 

    • PPROM 

    • Preterm labor 

    • Prolonged labor 

    • Pre-eclampsia/eclampsia

    • Placental abruption 

    • DIC 

    • Operative delivery 

    • Uterine atony

    • Antepartum & PPH 

  • ↑ Fetal complications: 

    • Preterm delivery 

    • Congenital anomalies 

    • Polyhydramnios

    • Cord entanglement 

    • Umbilical cord prolapse

    • IUGR 

    • Twin-to-twin transfusion 

    • Malpresentation 

    • ↑ mortality 

 

 

Anesthetic Management

 

  • If trial of labor & vaginal delivery as per obstetrics (most obstetricians allow a trial of labor if both twins have vertex presentation):

    • Ensure very good epidural & 2 large bore IV's

    • Ensure OR & personnel ready for stat GA at any time especially for delivery of twin B 

    • Have nitroglycerine available: uterine relaxation may be required to facilitate internal version & breech extraction of twin B

  • If cesarean section (more common scenario): 

    • Ensure 2 large bore IV's & active cross match 

    • Epidural, spinal, & GA all safe for cesarean section 

    • Aortocaval compression & rapid desaturation are exaggerated in this population

    • Have nitroglycerine ready for uterine relaxation  

    • Be prepared for post partum hemorrhage, need for resuscitation & uterotonics 

    • Neonatal resuscitation team must be present