Case report Open Access Anesthetic management of an undiagnosed advanced extrauterine pregnancy under combined spinal-epidural anesthesia Arun Kalava 1 *, Simon Mardakh 1 , Jonathan Weinberg 1 , Joel Yarmush 1 , Joseph Schianodicola 1 , Khaja Ahmed 1 Correspondence: arunkalava@yahoo.com 1 Department of Anesthesiology, New York Methodist Hospital, Brooklyn, New York, USA. Abstract Advanced extrauterine (abdominal) pregnancy is extremely rare. Management of such a pregnancy invariably involves a laparotomy under general anesthesia and has never been reported to have been performed in its entirety under neuraxial anesthesia. We report a case of a 26- year-old multigravida who presented with severe abdominal pain at 32 weeks and 1 day gestational age and on laparotomy was found to have an undiagnosed extrauterine pregnancy. We believe this is the very irst reported case of advanced extrauterine pregnancy, diagnosed at laparotomy, performed under combined spinal-epidural anesthesia and successfully managed in its entirety, without conversion to general anesthesia. he postoperative period was uneventful, with both mother and neonate being discharged 3 days ater surgery. hrough this case we discuss the management and outcome of this rare presentation performed successfully under neuraxial anesthesia. Keywords: Extrauterine pregnancy, combined spinal epidural anesthesia, anesthetic management © 2012 Kalava et al; licensee Herbert Publications Ltd. his is an Open Access article distributed under the terms of Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0). his permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction The reported incidence of abdominal pregnancy is 10.9 per 100,000 live births and 9.2 per 1000 ectopic pregnancies in the United States [ 1 ], with higher incidence seen in developing nations [ 2]. Management of such a pregnancy depends on the gestational age and invariably involves surgical intervention i.e., laparoscopy or laparotomy. General anesthesia with tracheal intubation is preferred for a surgery involving an extrauterine pregnancy, as it is frequently complicated by extensive hemorrhage. In the recent decades maternal mortality and morbidity from pulmonary aspiration (incidence 1: 500 to 1: 400 for obstetric patients versus 1:2000 for all patients) and failed endotracheal intubation (incidence of 1: 300 to 1:250 [3- 5] versus 1:2000 for all patients) have been the primary motivators for transition towards greater use of neuraxial anesthesia instead of general anesthesia in cesarean delivery. Further, difficult intubation is relatively common (65% of total difficult intubations) in patients undergoing emergency cesarean section [6]. Rice T and Bowser C reported a case of advanced extrauterine pregnancy at 34 weeks that was diagnosed at laparotomy under spinal anesthesia, with the patient having to be immediately anesthetized and intubated for the duration of the surgery [ 7]. To our knowledge, it has never been reported of having been performed in its entirety under combined spinal-epidural (CSE) anesthesia. Case report A 26-year-old, American Society of Anesthesiologists (ASA) physical status II E, Gravida 7, Para 2, with 2 prior Cesarean sections, history of placenta previa, and who had prenatal care elsewhere, presented to the emergency department at a 32 week and 1 day gestational age with severe abdominal pain. She was on prenatal vitamins and had no known drug allergies. She denied smoking cigarettes and consuming alcohol. A bedside ultrasound done by the obstetrician showed a fetus in transverse lie, with a heart rate of 150/minute and placenta lying below the fetus. A diagnosis of acute abdomen was made and the patient was scheduled for an emergency exploratory laparotomy to rule out placental abruption vs. uterine rupture with possible placenta accreta. On pre-anesthetic evaluation, we found a young anxious woman, who was 64 inches tall and weighed 192 pounds with a BMI of 33 kg/m 2 . Her blood pressure was 93/63 mm Hg (mean arterial pressure of 73), and heart rate was 97/ minute. On airway assessment, the patient had adequate mouth opening, no loose teeth, caps or crowns and the Mallampati grade was III. There were no masses palpable in the neck, she had good flexion/extension of the neck and the temporo-mandibular distance was 3 fingers breadth. She was afebrile, heart and lungs were clear to auscultation. There was severe generalized tenderness of the abdomen with no signs of peritonitis. Bilateral Journal of Anesthesiology & Clinical Science ISSN 2049-9752