Purpose: We report the use of Patient-Controlled Intravenous Analgesia (PCIA) with remifentanil in two parturients with twin pregnancies in whom epidural analgesia was contraindicated.
Clinical features: Two patients with a twin pregnancy were admitted to the labor ward at 36 weeks of gestation. Epidural analgesia was contraindicated because of anticoagulation therapy or because of severe thrombocytopenia. PCIA remifentanil was offered to these patients. In the first case, pain from contractions was well controlled during labor, and the first twin was easily delivered. On the other hand, the second twin was in the breech position and an internal version was required rapidly because of fetal bradycardia to deliver the baby as soon as possible. Pain increased in intensity during this maneuver and PCIA remifentanil was insufficient. In the second case, the course of labor was uneventful and the patient easily delivered twins.
Conclusion: In the case of twin pregnancy, we recommend remifentanil PCIA only if epidural analgesia is contraindicated (and not as a routine) because of the high risk of obstetrical maneuvers or potential cesarean delivery for the second twin, and the lack of efficacy of remifentanil, at the dose used in this report.