title: Case series: Combined spinal epidural anesthesia for Cesarean delivery and ex utero intrapartum treatment procedure.
abstract: OBJECTIVE
  To report the use of regional anesthesia and iv nitroglycerin to provide anesthesia and uterine relaxation for three Cesarean deliveries (CD) involving ex utero intrapartum treatment (EXIT) of potentially life-threatening airway obstruction in the newborn.
  
  
  METHODS
  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 an iv 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 and iv nitroglycerin.
authors.affiliation: Department of Anesthesiology, Women's Anesthesia and Critical Care, Box 3094, Duke University Medical Center, Durham, NC 27710, USA. ronald.george@duke.edu
authors.forename: Ronald B
authors.initials: RB
authors.lastname: George
authors.forename: Abigail H
authors.initials: AH
authors.lastname: Melnick
authors.forename: Erin C
authors.initials: EC
authors.lastname: Rose
authors.forename: Ashraf S
authors.initials: AS
authors.lastname: Habib
mesh_terms: D000328:Adult; D000402:Airway Obstruction / Q000151:congenital / Q000601:surgery*; D000767:Anesthesia, Epidural; D000773:Anesthesia, Obstetrical; D000775:Anesthesia, Spinal; D002045:Bupivacaine; D002585:Cesarean Section / Q000295:instrumentation / Q000379:methods*; D005260:Female; D005283:Fentanyl; D005315:Fetal Diseases / Q000601:surgery*; D005333:Fetus / Q000002:abnormalities / Q000601:surgery; D006801:Humans; D007231:Infant, Newborn; D009020:Morphine; D009126:Muscle Relaxation / Q000502:physiology; D005996:Nitroglycerin / Q000008:administration & dosage; D011247:Pregnancy; D015149:Tocolytic Agents / Q000008:administration & dosage; D014599:Uterus / Q000187:drug effects / Q000502:physiology
chemical_list: D015149:Tocolytic Agents; D009020:Morphine; D005996:Nitroglycerin; D005283:Fentanyl; D002045:Bupivacaine