Combined spinal epidural anaesthesia for caesarean delivery of quadruplets: a case report

High-order multiple gestation pregnancy is rare, and patients will usually deliver by caesarean delivery (CD), due to the higher incidence of maternal and perinatal morbidity. Anaesthesia for cases involving quadruplets or higher order pregnancy is poorly described: literature review identified only nine cases detailing the conduct of anaesthesia. We present a case of spontaneous quad-chorionic quad-amniotic pregnancy in a 34-year-old patient with two prior CDs, who underwent elective CD at 30 + 5 weeks' gestation under combined spinal epidural (CSE) anaesthesia with a reduced-dose intrathecal hyperbaric bupivacaine 0.5% 2.0 mL and diamorphine 300 μg. Key clinical considerations include aortocaval compression and spinal hypotension, heightened risks of haemorrhage, hypertensive disorders, eclampsia, preterm delivery and perinatal morbidity. Despite pregnancy induced hypertension, surgery proceeded uneventfully, with an operating time of 46 minutes and 350 mL blood loss. Four live neonates (weighing 1300-1345 g) were delivered and admitted to the neonatal unit without major morbidity. No additional intraoperative analgesia or epidural anaesthesia top-up was required, and the patient reported high satisfaction with anaesthetic management. Postoperative recovery was complicated by maternal hypertension, managed with oral therapy, with hospital discharge on the 4^th postoperative day. At 10 months post-delivery, the quadruplets continue to meet age-adjusted developmental milestones. To our knowledge, this is the first reported case in which low dose CSE anaesthesia was provided for a quadruplet or higher-order CD. The case description highlights the challenges associated with high-order multiple gestation pregnancy, and considerations for the anaesthetist in such cases.