Anaesthetic management of a woman with autosomal recessive limb-girdle muscular dystrophy for emergency caesarean section

Maternal health and obstetric complications of genetic neuromuscular disorders in pregnancy: A systematic review

BACKGROUND

Genetic neuromuscular disorders affect muscle function and control by the nervous system, presenting significant clinical challenges, particularly during pregnancy.

OBJECTIVES

To systematically review the literature on the obstetric outcomes and complications in women with genetic neuromuscular disorders.

SEARCH STRATEGY

We searched PubMed/Medline, Scopus, and CINAHL Ultimate from inception till June 2024 using terms like "pregnancy", "genetic neuromuscular disorder", "myotonic dystrophy", "maternal health" etc. SELECTION CRITERIA: Pregnant women with genetic neuromuscular disorders.

DATA COLLECTION AND ANALYSIS

Screening, selection, and data extraction were performed independently by two reviewers.

MAIN RESULTS

A total of 28 studies from 1978 to 2023 examined pregnancy outcomes in women with genetic neuromuscular disorders. The disorders included myotonic dystrophy, spinal muscular atrophy (SMA), Charcot-Marie-Tooth disease (CMT), and others. Common complications were polyhydramnios, preterm labor, miscarriages, and cesarean sections. Myotonic dystrophy type 1 (DM1) showed higher neonatal risks than type 2 (DM2). Women with SMA faced exacerbated muscle weakness, while CMT and limb-girdle muscular dystrophy were associated with preterm labor and cesarean deliveries. Pompe disease exacerbated symptoms, and GNE myopathy showed similar pregnancy outcomes to the general population. Non-dystrophic myotonias had higher fetal distress and postpartum complications.

CONCLUSIONS

Women with genetic neuromuscular disorders face increased pregnancy complications, including preterm labor, cesarean sections, and disease symptom exacerbation. Multidisciplinary care between neurologists and obstetricians is essential in managing these high-risk pregnancies effectively, ensuring better maternal and neonatal outcomes. Further research is needed to develop standardized care protocols and improve clinical management.

Limb-girdle muscular dystrophy in pregnancy: a narrative review

Limb-girdle muscular dystrophy (LGMD) poses unique challenges for women during pregnancy, necessitating comprehensive care and tailored management strategies. The present narrative review aims to examine the unique challenges and management strategies required for women with LGMD during pregnancy. With over 30 genetic subtypes identified and the potential for additional discoveries through advanced diagnostic techniques, preconception counseling plays a crucial role in informing prospective parents about reproductive risks and available options. Baseline assessments, including cardiac and pulmonary evaluations, are essential to guide antenatal care, alongside genetic testing for precise diagnosis and counseling. Optimizing maternal health through respiratory exercises, cardiac monitoring, and individualized exercise and nutrition plans is paramount to avoid potential complications. During pregnancy, close monitoring of maternal and fetal well-being is important, with collaborative care between obstetricians and specialists. An individualized approach to delivery mode considering factors such as muscle strength, pelvic size, and fetal presentation is crucial. While vaginal delivery has been proven to be possible, the need for an emergency cesarean delivery should always be kept in mind. Regional anesthesia is preferred, with proactive planning for potential respiratory support. Bupivacaine has been shown to be effective with epidural catheters that may be used for prolonged relief with opioids like morphine and fentanyl, while also evaluating the patients' respiratory function. Postpartum considerations include pain management, mobility support, breastfeeding assistance, and emotional support. Early mobilization and tailored physiotherapy regimens may promote optimal recovery, while comprehensive breastfeeding guidance is needed to address challenges related to muscle weakness. Access to mental health resources and support networks is essential to helping individuals cope with the emotional demands of parenthood alongside managing LGMD. By addressing the unique needs of pregnant individuals with LGMD, healthcare providers can optimize maternal and fetal outcomes while supporting individuals in their journey to parenthood.

Peri-partum respiratory management of pregnant women with neuro-muscular disorders: a prospective observational study (IT-NEUMA-Pregn study)

BACKGROUND

Pregnant women with neuromuscular diseases (NMDs) often display respiratory muscle impairment which increases the risk for pulmonary complications (PCs). The aim of this study was to identify pregnant NMDs patients with pulmonary risk factors and to apply in these women non-invasive ventilation (NIV) combined with mechanical insufflation-exsufflation (MI-E) in the peri-partum period.

METHODS

We conducted a multicenter observational study on women with NMDs undergoing cesarean section or spontaneous labor in a network of 7 national hospitals. In these subjects we applied a protocol for screening and preventing PCs, and we evaluated PCs rate, maternal and neonatal outcome.

RESULTS

Twenty-four patients out of the 94 enrolled pregnant women were at risk for PCs and were trained or retrained to use NIV and/or MI-E before delivery. After delivery, 17 patients required NIV with or without MI-E. Despite nine out of the 24 women at pulmonary risk developed postpartum PCs, none of them needed reintubation nor tracheostomy. In addition, the average birth weight and Apgar score were normal. Only one patient without pulmonary risk factors developed postpartum PCs.

CONCLUSION

This study showed the feasibility of applying a protocol for screening and treating pregnant NMDs women with pulmonary risk. Despite a PCs rate of 37% was observed in these patients, maternal and neonatal outcome were favorable.

Pregnancy and myopathies: Reciprocal impacts between pregnancy, delivery, and myopathies and their treatments. A clinical review

During pregnancy, women undergo physical and physiological changes, which can impact the neuromuscular disease course, but also delivery and fetus health. Generally, there is little impact on the disease course, but sometimes an impairment is noticed, which could be attributed to pregnancy and not to disease progression. Cardiac and respiratory functions have to be assessed at the beginning of pregnancy and a close follow-up is mandatory in case of disorder. Labour and delivery are often impacted. Labour is prolonged because of muscle weakness that is an increased risk of instrumental delivery or Cesarean sections. Patients with myotonic dystrophy are at risk of postpartum hemorrhage. Fetal loss can be associated with fetal disease in myotonic dystrophy, and is at high risk for patients with active inflammatory myopathy only.

Obstetric management of a woman with limb-girdle muscular dystrophy type 2i and dilated cardiomyopathy

Limb-girdle muscular dystrophy describes a clinical phenotype with progressive weakness and atrophy of the muscles of the shoulders and hips. One of the more common types, limb-girdle muscular dystrophy type 2i, is associated with impaired cardiac function and restrictive lung disease, typically disproportionate to muscular disease. This condition presents a number of complex challenges in pregnancy and there are few case reports of its successful management. Here we discuss the course of the first pregnancy of a 20-year-old woman with limb-girdle muscular dystrophy type 2i.

Anesthetic management of a patient with limb-girdle muscular dystrophy 2B:CARE-compliant case report and literature review

Background

Limb-girdle muscular dystrophies (LGMDs) belong to few neuromuscular disorders mainly involving pelvic and shoulder girdle muscles. Also, cardiac or pulmonary complications, increased rhabdomyolysis risk when exposed to volatile anesthetics and succinylcholine may increase anesthesia related risks. However, current reports about the anesthesia management of these patients are limited.

Case presentation

We described our anesthetic management of a 36 years old woman with LGMD 2B receiving arthroscopic knee surgery. In consideration of the high risk of rhabdomyolysis, total intravenous anesthesia (TIVA) was selected for her surgery. Considering the unpredictable respiratory depression, opioid based patient-controlled intravenous analgesia was replaced with an intra-articular cocktail therapy consisting of 20 ml of 0.2% ropivacaine. Also, we reviewed the literatures on anesthetic management of LGMD through searching PubMed, in order to provide a comprehensive and safe guidance for the surgery.

Conclusions

Carefully conducted general anesthesia with TIVA technique is a good choice for LGMD patients. Neuraxial anesthesia may be used if general anesthesia needs to be avoided. To warrant safe anesthesia for surgery, any decision must be well thought out during perioperative period.

Limb-girdle muscular dystrophy with obesity for elective cesarean section: Anesthetic management and brief review of the literature

Limb-girdle muscular dystrophy (LGMD) is an autosomal recessive disorder in which the pelvic or shoulder girdle musculature is predominantly or primarily involved. We report the management of a 27-year-old primigravida with LGMD associated with obesity posted for elective cesarean section. She was successfully managed with epidural anesthesia assisted with noninvasive positive pressure ventilation. She had an uncomplicated intra- and post-operative course.

[Non-invasive mechanical ventilation in the pre- and intraoperative period and difficult airway]

Non-invasive mechanical ventilation is a method of ventilatory assistance aimed at increasing alveolar ventilation, thus achieving, in selected subjects, the avoidance of endotracheal intubation and invasive mechanical ventilation, with the consequent improvement in survival. There has been a systematic review and study of the technical, clinical experiences, and recommendations concerning the application of non-invasive mechanical ventilation in the pre- and intraoperative period. The use of prophylactic non-invasive mechanical ventilation before surgery that involves significant alterations in the ventilatory function may decrease the incidence of postoperative respiratory complications. Its intraoperative use will mainly depend on the type of surgery, type of anaesthetic technique, and the clinical status of the patient. Its use allows greater anaesthetic depth without deterioration of oxygenation and ventilation of patients.

Pregnancy course and outcome in women with hereditary neuromuscular disorders: comparison of obstetric risks in 178 patients

OBJECTIVE

Information about pregnancy and delivery in hereditary neuromuscular disorders (NMD) is limited and largely restricted to small case series and single case reports. Further data of obstetric histories in clinically and genetically defined subgroups are required.

STUDY DESIGN

We reviewed the obstetric histories of 178 patients with myotonic dystrophy type 1 (DM1) and 2 (DM2), Charcot-Marie-Tooth disease (CMT), spinal muscular atrophy (SMA), limb-girdle muscular dystrophy (LGMD), facioscapulohumeral muscular dystrophy (FSHD), and congenital myopathy (CM) by means of questionnaires and medical reports. Patients were recruited in the period 1992-2010 after they had at least completed one pregnancy. A total of 380 pregnancies resulting in 315 children were documented.

RESULTS

Compared to the normal German population, the number of miscarriages and hypertensive diseases in pregnancy was not increased in the cohort. Patients with NMD delivered more frequently by vaginal operations (8.9-18.2%) and by cesarean births with significantly high rates in DM1 (36.7%) and SMA (42.4%). Preterm deliveries were recorded in 30.7% of DM1, 12.6% of DM2, and 29.4% of SMA gestations. Abnormal fetal presentation occurred significantly more frequently in DM1 (34.6%) and LGMD (26.7%) deliveries and was a feature of chairbound patients. Considering a possible influence of pregnancy on the disease course, about half of LGMD, one-third of SMA, and one fifth of CMT patients reported a deterioration of symptoms in pregnancy. Neonatal outcome was favorable in all NMD but DM1, where infantile morbidity and mortality is often but not exclusively related to congenitally affected children.

CONCLUSION

Our data are important for obstetric care and genetic counseling of women with NMD who are contemplating pregnancy.

Normal vaginal delivery in a patient with autosomal recessive limb-girdle muscular dystrophy

The limb-girdle muscular dystrophies (LGMDs) are a group of genetically determined disorders of skeletal muscle, predominantly affecting the pelvic and shoulder-girdle musculature. The clinical course is variable but steadily progressive. Type 2A LGMD is the most frequent form, accounting for approximately 30% of identified cases. There are few reports of patients with Type 2A LGMD undergoing pregnancy and delivery. This case outlines a successful vaginal delivery in a woman with this condition.