Anesthetic management of a parturient with neuromyelitis optica

Pregnancy and neuromyelitis optica spectrum disorders: 2022 recommendations from the French Multiple Sclerosis Society

BACKGROUND

In 2020, the French Multiple Sclerosis (MS) Society (SFSEP) decided to develop a national evidence-based consensus on pregnancy in MS. As neuromyelitis optica spectrum disorders (NMOSD) shares a series of commonalities with MS, but also some significant differences, specific recommendations had to be developed.

OBJECTIVES

To establish recommendations on pregnancy in women with NMOSD.

METHODS

The French Group for Recommendations in Multiple Sclerosis (France4MS) reviewed PubMed and universities databases (January 1975 through June 2021). The RAND/UCLA appropriateness method, which was developed to synthesise the scientific literature and expert opinions on health care topics, was used to reach a formal agreement. Fifty-six MS experts worked on the full-text review and initial wording of recommendations. A sub-group of nine NMOSD experts was dedicated to analysing available data on NMOSD. A group of 62 multidisciplinary healthcare specialists validated the final proposal of summarised evidence.

RESULTS

A strong agreement was reached for all 66 proposed recommendations. They cover diverse topics, such as pregnancy planning, follow-up during pregnancy and postpartum, delivery routes, loco-regional analgesia or anaesthesia, prevention of postpartum relapses, breastfeeding, vaccinations, reproductive assistance, management of relapses, and disease-modifying treatments.

CONCLUSION

Physicians and patients should be aware of the new and specific evidence-based recommendations of the French MS Society for pregnancy in women with NMOSD. They should help harmonise counselling and treatment practise, allowing for better individualised choices.

General anesthesia, using remimazolam, for the patient with myelin oligodendrocyte glycoprotein antibody associated disease (MOGAD): A case report

RATIONALE

Myelin oligodendrocyte glycoprotein antibody associated disease (MOGAD) is one of auto-immune demyelinating diseases of nervous system. Although both regional anesthesia and general anesthesia has been successfully performed in the patient with demyelinating diseases of nervous system, it has been controversial which one is better.

PATIENT CONCERNS

Forty-four male patient was admitted for arthroscopic elbow surgery due to limitation of range of motion. The patient was diagnosed as MOGAD with anti-N-methyl-D-aspartate (NMDA) receptor encephalitis, and steroid was used to prevent and treat symptoms and signs.

DIAGNOSIS

He was diagnosed as MOGAD with anti-NMDA receptor encephalitis, 1 year ago. The patient complaint of dizziness, diplopia, nausea, vomiting, seizure, general weakness and so on when he was confirmed as MOGAD with anti-NMDA receptor encephalitis. The diagnosis of MOGAD was confirmed with positive anti-myelin oligodendrocyte glycoprotein (MOG) Immunoglobulin (Ig)G and negative anti-aquaporin 4 (AQP4) IgG in the blood.

INTERVENTIONS AND OUTCOMES

After steroid cover, total intravenous anesthesia (TIVA) with remimazolam and remifentanil was established for the patients. Rocuronium was administered under monitoring of neuromuscular blockade, using train of 4 (TOF). The operation was performed without any event under right lateral decubitus position. The patient was uneventfully recovered from anesthesia.

LESSONS

The case report showed total intravenous anesthesia with remimazolam and remifentanil under proper monitoring was successfully performed in the patient with MOGAD.

Pregnancy and Neuromyelitis Optica Spectrum Disorder - Reciprocal Effects and Practical Recommendations: A Systematic Review

Introduction: Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory disorder of the central nervous system characterized by severe, antibody-mediated astrocyte loss with secondary demyelination and axonal damage, predominantly targeting optic nerves and the spinal cord. Recent publications have alluded to increased disease activity during pregnancy, and adverse maternal and fetal outcomes in patients with NMOSD. Our objective was to systematically review published literature to help counsel and manage women with NMOSD contemplating pregnancy. Methods: We searched five databases including MEDLINE and EMBASE, for English-language publications describing pregnancies in women with NMOSD. Article selection, data extraction, and risk-of-bias assessment using Joanna Briggs' critical appraisal tool for case reports and case series, were performed in duplicate. Pooled incidences were calculated where possible, and a narrative summary was provided. Results: Of 2,118 identified titles, 22 case reports and seven case series, representing 595 pregnancies in 389 women, were included. The mean maternal age was 28.12 ± 5.19 years. At least 20% of cases were first diagnosed during pregnancy. There were no maternal deaths. Pooled estimates for clinical outcomes could not be obtained due to inadequate reporting. NMOSD-related disability and relapses increased considerably during pregnancy and especially in the immediate postpartum period. Although a high proportion of early pregnancy losses were reported, an association with disease activity or therapeutic interventions could not be established. Apart from one publication which reported an increased risk of preeclampsia, there was no increase in adverse obstetric outcomes including preterm birth, fetal growth restriction or congenital malformations. Initial attacks and relapses were successfully managed with oral or intravenous corticosteroids and immunosuppressants, and refractory cases with immunoglobulin, plasma exchange and immunoadsorption. Conclusion: Increased NMOSD-related disability and relapses during pregnancy the postpartum period may respond to aggressive management with corticosteroids and immunosuppressants such as azathioprine, which are safely administered during pregnancy and lactation. Emerging safety data on monoclonal antibodies during pregnancy, make these attractive options, while intravenous immunoglobulin, plasma exchange and immunoadsorption can be safely used to treat severe relapses. The complex interplay between NMOSD and pregnancy outcomes would be best understood through prospective analysis of data collected through an international registry. Disclosure: Dalia Rotstein has served as a consultant or speaker for Alexion and Roche. She has received research support from Roche Canada. Rohan D'Souza has served as a consultant and speaker for Ferring Canada Inc and Ferring Global Inc, on topics unrelated to this manuscript. The other authors have no relevant relationships to disclose.

General anaesthesia for caesarean section in a patient with neuromyelitis optica spectrum disorder (NMOSD)

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We report the anaesthetic management of a patient with pre-existing NMOSD undergoing a caesarean delivery.

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Multidisciplinary collaboration and careful patient counselling were essential to optimize maternal and foetal outcomes.

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The use of neuromuscular monitoring and sugammadex reversal might play an important role in anesthetic management of patients with NMOSD.

Introduction

Neuromyelitis optica spectrum disorder (NMOSD) is a rare demyelinating disorder affecting the spinal cord and optic nerves. The anesthetic management in parturient women with NMOSD are controversial and remains challenging.

Presentation of case

A 35-year-old G2P1 woman at 36 weeks of gestation with NMOSD presented for pre-anesthesia assessment prior to caesarean section. Her NMOSD had been diagnosed four years previously and was treated with intravenous methylprednisolone (IVMP) and plasma exchange (PLEX). She underwent general anesthesia without developing adverse respiratory events or signs and symptoms of muscle weakness.

Discussion

Both neuraxial and general anaesthesia for NMOSD have been described in previous case reports. Risk factors of general anesthesia in pregnancy with NMOSD must be weighed against the likely risk of NMOSD relapse and the potential deteriorating neurological symptoms after neuraxial anesthesia.

Conclusion

A multidisciplinary collaboration together with careful anesthetic consideration is required for the anesthetic and perioperative management of these patients.

Epidural Labor Analgesia for a Patient with Neuromyelitis Optica: A Case Report and Review of the Literature

Neuromyelitis optica (NMO) is a rare demyelinating disorder affecting the spinal cord and optic nerves. Like multiple sclerosis (MS), it predominantly affects women during childbearing years. The impact of neuraxial anesthesia on the course of NMO is uncertain. There are no large studies available to draw definitive conclusions regarding the safety of neuraxial anesthesia in this population. A review of the current literature suggests that neuraxial anesthesia is unlikely to exacerbate neurologic symptoms in pregnant patients with NMO. However, given the rarity of this disease entity among patients requesting epidural labor analgesia, we recommend taking a cautious approach.

Neuromyelitis optica and pregnancy

Neuromyelitis optica (NMO) and the associated NMO spectrum disorders are demyelinating disorders affecting the spinal cord and optic nerves. It has prominent female predominance and many of these patients are in their childbearing years. As pregnancy seems to have a major impact on this disease course, in this review, recent studies with a focus on this disease and pregnancy and safety of available treatment options during this period are discussed.

[A treatment of neuromyelitis optica (Devic's disease) during pregnancy]

Neuromyelitis optica (Devic's disease) is an inflammatory demyelinating disease of the central nervous system that mainly affects spinal cord, optic nerve and brain regions with high aquaporin 4 antigen expression. This is a severe autoimmune disease caused by autoantibodies directed against aquaporin 4 and associated with high morbidity and mortality. Unlike other inflammatory conditions such as multiple sclerosis or rheumatoid polyarthritis, pregnancy does not seem to influence the activity of neuromyelitis optica, hence the need for a thorough treatment during pregnancy. Corticosteroid therapy is the treatment of choice for neuromyelitis optica during pregnancy. Other treatments may also be used including rituximab, some immunosuppressive agents and immunoglobulins. Immunosuppressive treatment or rituximab is recommended when the long-term corticosteroid treatment is contraindicated, in case of inefficiency or if side effects are intolerable. Immunoglobulins are administered to patients with serious outbreaks of neuromyelitis optica which do not respond to bolus methylprednisolone. Immunoglobulins alone can also be continued at a dose of 0.4 g/kg/day for 6-8 weeks until delivery. Plasmapheresis is also a good alternative to bolus methylprednisolone when outbreaks are extremely severe.

Spinal anesthesia for cesarean delivery in a woman with neuromyelitis optica

Neuromyelitis optica (NMO), or Devic's disease, is an idiopathic severe demyelinating disease that preferentially affects the optic nerve and spinal cord. Neuraxial anesthesia in women with multiple sclerosis is widely accepted, but reports of the use of neuraxial anesthesia in patients with NMO are scarce. We report the case of a morbidly obese primigravida undergoing a planned cesarean delivery at 32 weeks' gestation due to an acute exacerbation of NMO, managed with spinal anesthesia. Other than increased intraoperative hyperalgesia requiring inhaled nitrous oxide/oxygen, the mother experienced no apparent anesthetic-related complications.