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Correspondence |
Toronto, Ontario
To the Editor:
Monochorionic twin gestations may be complicated by twin to twin transfusion syndrome (TTTS). In addition to the fetal complications, parturients with severe TTTS are at risk of developing mirror syndrome,1 characterized by pulmonary edema (PEd), anasarca, albuminuria and possibly hypertension. As well, hemodilution may decrease hemoglobin levels. Although the maternal manifestations generally reflect the severity of the fetal placental pathology, the etiology of these changes remains unknown.1
Recently, laparoscopic laser ablation has emerged as a promising approach to this condition.2 However, since there is limited literature with regards to the anesthetic management of these patients,3,4 we retrospectively reviewed the evolution of the anesthetic techniques used for this procedure in our institution, along with their associated complications.
Thirty charts of parturients with severe TTTS who underwent laser photocoagulation were reviewed. Initially, due to a lack of expertise and practice guidelines, 18 of these procedures were conducted under general anesthesia (GA) while four had epidurals, one of which required conversion to GA. Postoperatively, four patients receiving GA developed PEd. Three of these responded to furosemide, the fourth required intensive care unit admission. All patients, including those who did not develop PEd, required approximately 1 L·hr–1 of crystalloid to maintain their blood pressures. Although the development of PEd was not necessarily related to the anesthetic technique, following discussions with the attending obstetrician, we elected to attempt these procedures under local infiltration plus conscious sedation. The speculation was that, by avoiding general or regional anesthesia, we could potentially decrease fluid administration in patients who are at risk of developing PEd. Two patients were managed using midazolam and fentanyl boluses, the remaining six received a remifentanil infusion. Following completion of the data collection, an additional eight cases were performed using remifentanil. None of the conscious sedation patients developed PEd.
The etiology of the PEd in this population remains unknown. Compounding factors may include the use of tocolytic agents, particularly iv nitroglycerin,3 physiological changes of pregnancy3 and fetal surgery.5 Some authors have speculated that hysterotomy and uterine manipulation may stimulate the release of prostaglandins or thromboplastins that, in turn, alter maternal lung vascular permeability.5
Although further experience is needed, we have found that this technique (Table
) is reliable, provides satisfactory surgical conditions and a comfortable, relaxed patient. Moreover, the hemodynamic stability offered by a remifentanil infusion may potentially decrease the amount of iv fluids required and, in turn, the risk of precipitating PEd in these patients.
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References
1 Carbillon L, Oury JF, Guerin JM, Azancot A, Blot P. Clinical biological features of Ballantyne syndrome and the role of placental hydrops. Obstet Gynecol Surv 1997; 52: 310–4.[Medline]
2 Milner R, Crombleholme TM. Troubles with twins: fetoscopic therapy. Sem Perinatol 1999; 23: 474–83.
3 Gaiser RR, Kurth CD. Anesthetic considerations for fetal surgery. Sem Perinatol 1999; 23: 507–14.
4 Galinkin JL, Gaiser RR, Cohen DE, Crombleholme TM, Johnson M, Kurth CD. Anesthesia for fetoscopic fetal surgery: twin reverse arterial perfusion sequence and twin-twin transfusions syndrome. Anesth Analg 2000; 91: 1394–7.
5 DiFederico EM, Burlingame JM, Kilpatrick SJ, Harrison M, Matthay MA. Pulmonary edema in obstetric patients is rapidly resolved except in the presence of infection or of nitroglycerin tocolysis after open fetal surgery. Am J Obstet Gynecol 1998; 179: 925–33.[Medline]
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