[Anesthetic management for EXIT (ex-utero intrapartum treatment) of a twin gestation: one normal and one with a large epignathus].

: We experienced cesarean section of a twin gestation of which one was normal and the other had a large epignathus. Anesthesia was induced with rapid administration of propofol and suxamethonium, then her trachea was intubated and operation was started. Anesthesia was maintained with 3% sevoflurane in 100% oxygen. Five minutes from the start of the surgery, the first baby was born with Apgar score of 3/7. One minute later, the head of the second with large epignathus was out of the uterus. But we judged that her trachea was difficult to intubate, but she showed spontaneous respiration. Then we inserted a tracheal tube (ID 2 mm) to her nose for the airway, and she was carried into the infant warmer after amputating the umbilical cord. After the delivery, sevoflurane was discontinued, and propofol, fentanyl and ketamine were started. Cesarean section was finished with total blood loss of 1,900 g including amniotic fluid. In the infant warmer, tracheostomy was performed on the second baby, and the baby was carried to NICU. Thirteen days later, the epignathus was extracted without complication. General anesthesia with inhalational agent is usually chosen for cesarean section with EXIT. For EXIT, uterine relaxation and fetal akinesia are necessary, but deep inhalational anesthesia causes massive bleeding, hypotension and loss of spontaneous respiration of the fetus. Twin gestation with one normal and the other with airway trouble has many problems. We have to consider mother, normal baby and troubled baby during EXIT. We should treat them appropriately with prudence.