Myasthenia gravis and pregnancy: anaesthetic management--a series of cases. Eur J Anaesthesiol. 2010;27:985-990. [PMID: 20733499 DOI: 10.1097/eja.0b013e32833e263f]

Maternal posture-physiology interactions in human pregnancy: a narrative review

There are several well-known medical conditions in which posture and gravity interact with natural history, including pregnancy. In this review, we provide a comprehensive overview of interactions between maternal posture and maternal physiology and pathophysiology at rest during pregnancy. We conducted a systematic literature search of the MEDLINE database and identified 644 studies from 1991 through 2021, inclusive, that met our inclusion criteria. We present a narrative review of the resulting literature and highlight discrepancies, research gaps, and potential clinical implications. We organize the results by organ system and, commencing with the neurological system, proceed in our synthesis generally in the craniocaudal direction, concluding with the skin. The circulatory system warranted our greatest and closest consideration-literature concerning the dynamic interplay between physiology (heart rate, stroke volume, cardiac output, blood pressure, and systemic vascular resistance), pathophysiology (e.g., hypertension in pregnancy), and postural changes provide an intricate and fascinating example of the importance of the subject of this review. Other organ systems discussed include respiratory, renal, genitourinary, gastrointestinal, abdominal, and endocrine. In addition to summarizing the existing literature on maternal posture-physiology interactions, we also point out gaps and opportunities for further research and clinical developments in this area. Overall, our review provides both insight into and relevance of maternal posture-physiology interactions vis à vis healthcare's mission to improve health and wellness during pregnancy and beyond.

Myasthenia gravis and pregnancy: Lessons learned from a complex a case report

Myasthenia gravis primarily affects young adults, with a higher incidence in women, particularly between the ages of 20 and 30. When a young woman with myasthenia gravis contemplates pregnancy, healthcare providers must consider the potential implications. The interplay between hormonal factors and changes in the immune system establishes a complex relationship between myasthenia gravis and pregnancy. On one hand, pregnancy can alter the course of the disease, while on the other hand, the disease can impact the progression of the pregnancy and the well-being of the fetus. In this case report, we present the case of a 28-year-old woman suffering from myasthenia gravis who had undergone a thymectomy 5 years ago and was being treated with an acetylcholinesterase inhibitor. After a planned conception, the patient presented a relapse of her disease during the third trimester of pregnancy, with the onset of severe hydramnios. This observation highlights a specific case of decompensation of myasthenia gravis during pregnancy, associated with the presence of severe hydramnios. Subsequently, we delve into the existing literature to examine the reciprocal influence between myasthenia gravis and pregnancy, as well as the effects of anti-myasthenic treatments on pregnancy outcomes.

Choices and Challenges With Treatment of Myasthenia Gravis in Pregnancy: A Systematic Review

Myasthenia gravis (MG) is an autoimmune disease affecting young women in their second and third decades, coinciding with their reproductive years. We aim to explore the choices and challenges in the treatment of MG in pregnancy. Cochrane, PubMed, Google Scholar, and Embase were the four databases systematically searched for studies with patients reporting pregnancy outcomes for women with MG during pregnancy using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) technique. Quality assessment was done using the Joanna Briggs Institute critical tool (JBI, Adelaide, Australia) for methodological quality. From 2000 to 2023, 40 studies from database search results were considered. There is a substantial risk of complications with MG, especially if it appears during pregnancy. In particular, widespread weakness is a cause of severe, life-threatening disorders, but several treatment options are available.

Risk factors for pregnancy-related clinical outcome in myasthenia gravis: a systemic review and meta-analysis

OBJECTIVE

Myasthenia gravis (MG) is an autoimmune disorder that frequently affects females at reproductive age. Herein, we aimed to assess the associations of clinical factors with pregnancy-related outcome in MG.

METHODS

We searched PubMed and EMBASE for case-control and cohort studies that reported the MG status during or after pregnancy and relevant clinical variables. The data was extracted in proportions and odds ratios (ORs) with 95% confidence intervals (CIs) in subsequent meta-analysis.

RESULTS

Fifteen eligible articles reporting on 734 pregnancies with 193 worsening and 51 improved episodes were included out of 1765 records. The estimated worsening proportions in total, antepartum and postpartum periods were 0.36 (95% CI 0.25-0.40), 0.23 (95% CI 0.14-0.34) and 0.11 (95% CI 0.04-0.22) respectively. The proportion of pregnancy-related improvement in enrolled patients was 0.28 (95% CI 0.17-0.40), with 0.07 (95% CI 0.00-0.28) during pregnancy and 0.14 (95% CI 0.02-0.34) after pregnancy. No significant associations were disclosed between the clinical factors and MG worsening. Thymectomy before delivery is a strong predictor for MG improvement in postpartum period (OR 4.85, 95% CI 1.88-12.50, p = 0.001).

CONCLUSION

The total proportion of pregnancy-related MG worsening and improvement in MG was 0.36 (95% CI 0.25-0.40) and 0.28 (95% CI 0.17-0.40), respectively. Thymectomy before the delivery may aid in clinical improvements associated with pregnancy. Future prospective cohort studies are required to determine more relevant factors.

Myasthenia Gravis in pregnancy: Systematic review and case series

Background

Myasthenia gravis is an autoimmune disease which can impact pregnancy.

Methods

Six databases were systematically searched for studies with at least five subjects reporting pregnancy outcomes for women with myasthenia gravis in pregnancy. Assessment of bias was performed for all included studies. Forty-eight cases from our own centre were also included in the analysis.

Results

In total, 32 publications met inclusion criteria for systematic review, for a total of 33 unique data sets including 48 cases from our institution. Outcome data was available for 824 pregnancies. Spontaneous vaginal delivery occurred in 56.3% of pregnancies. Overall risk of myasthenia gravis exacerbation was 33.8% with a 6.4% risk of myasthenic crisis in pregnancy and 8.2% postpartum. The incidence risk of transient neonatal myasthenia gravis was 13.0%.

Conclusions

The current systematic review provides the best estimates of risk currently available to aid in counselling women with myasthenia gravis in pregnancy.

Fetal Surveillance in Pregnancies with Myasthenia Gravis

Myasthenia gravis (MG) is an autoimmune condition, that commonly impacts adult women of reproductive age. Myasthenia gravis in pregnancy is rare, but the incidence is higher in different geographical areas. Pregnancies in mothers with MG can have an unfortunate outcome. Acetylcholine receptor antibodies may pass into the fetal circulation and can affect the fetal neuromuscular junction, generating transient MG or even fetal arthrogryposis. The 2016 and 2021 International Consensus Guidance for Management of Myasthenia Gravis issued by Myasthenia Gravis Foundation of America is lacking in recommendation for fetal surveillance for pregnancies in women with MG. The aim of this paper is to highlight fetal and neonatal complications in mothers with MG and to offer antenatal care insights. Close maternal and pregnancy monitoring can improve pregnancy outcome. Patients with MG should be encouraged to conceive, to avoid triggers for exacerbations of the disease during pregnancy and a multidisciplinary team should be established to ensure the optimal support and therapy.

Myasthenia gravis and covid-19 in pregnancy: a review of the literature and case series report

OBJECTIVES

The aim of our study was to investigate the interrelations of symptoms, clinical outcomes and treatment regimens in pregnant women, diagnosed with myasthenia gravis and superimposed COVID-19 infection.

METHODS

We conducted an observational retrospective study between August, 2020 and July, 2021. Five patients with preexisting MG and superimposed COVID- infection were included in our study. We investigated the duration of MG, the antibody patient status, any present comorbidities, MG baseline treatment and MG severity class prior to the COVID-19 infection, MG severity class and treatment during the COVID-infection, and last but not least, the maternal and fetal clinical outcome.

RESULTS

None of the participants were hospitalized as they were treated under quarantine at their homes. The most frequently reported complaints were anosmia, headache and fever, which were observed in 3 out of 5 patients. The MG severity was evaluated twice - before and after the quarantine period. Progression to a more advanced stage was found in 2 of our 5 patients. Three of the patients did not require any changes in the prescribed baseline MG treatment. In 2 patients the pyridostigmine dosage had to be increased. One patient received azithromycin and 4 patients were given LMWH (nadroparin) as specific anti-COVID measures. All patients fully recovered and gave birth to healthy newborns.

CONCLUSION

To our knowledge, this is the first study on pregnant MG patients with superimposed COVID-19 infection. Based on our observations in this study it would seem that the coexistence of MG and COVID-19 infection in pregnancy does not elicit exacerbation in neither of those conditions. Further research is needed to confirm or challenge these findings, especially with the prospects of new virus variants emerging in the future.

Myasthenia Gravis and Pregnancy: Toronto Specialty Center Experience

BACKGROUND

Myasthenia gravis (MG) is an autoimmune disorder that frequently affects young women of reproductive age. The multidirectional interplay between MG, pregnancy, and fetal health poses a complex scenario for pregnant women with MG and the healthcare team. Here, we reviewed our local experience with MG, pregnancy, and outcomes.

METHODS

We performed a retrospective chart review of patients with MG attending the Prosserman Family Neuromuscular Clinic from 2001 to 2019 and who were referred to a high-risk pregnancy clinic. MG status was defined as stable, better, or worse. Information was collected on the delivery route, pregnancy, and neonatal complications.

RESULTS

We identified 20 women with MG for a total of 28 pregnancies. Worsening was observed in 50% of pregnancies: 18% during pregnancy, 25% following delivery, and 7% during both. 66.7% of patients with MG duration of 2 years or less had worsening during pregnancy. Three patients who stopped immunosuppressive treatment during pregnancy worsened and one had a crisis. C-section was done in 29% of pregnancies. The rate of delivery complications was 7% and of neonatal MG was 7%.

CONCLUSION

A high proportion of MG patients worsened during pregnancy, particularly those with disease duration less than 2 years, and those who discontinued immunosuppression during pregnancy. However, pregnancy was largely unaffected, rate of neonatal MG was low, frequencies of C-section, delivery complications, and premature births were similar to the general population. While the study has limitations due to the retrospective nature, these insights provide some guidance when counseling young myasthenic women about family planning.

Steroid-induced rapid recovery from respiratory dysfunction in a patient with myasthenia gravis after spinal anesthesia

We report an 83-year-old man with myasthenia gravis (MG) who developed respiratory depression after spinal anesthesia for transurethral laser enucleation of the prostate. He became less responsive after complained of dyspnea, with a decrease of SpO₂ to 83% approximately 13 min after intrathecal administration of 0.5% isobaric bupivacaine 3 ml. With a diagnosis of exacerbation of MG, hydrocortisone 100 mg was administered, following which both consciousness and spontaneous respiration rapidly improved. Cold sense was observed below the C4 dermatome. We provided general anesthesia without using muscle relaxants until disappearance of the effect of spinal anesthesia. Surgery completed uneventfully and confirmed wearing off the local anesthetics effect. He was discharged without respiratory problems on postoperative 3 day.

Myasthenia gravis and pregnancy

Myasthenia gravis (MG) is an autoimmune disorder of neuromuscular junction that has higher incidence in younger women than men, which could be related to differences in sex hormones physiology and immune system functioning between males and females. MG can first present during pregnancy and variably affect pregnancy, labor, and postpartum period. In this paper, we had an updated overview on our understanding about MG presentation and its effect on pregnancy and vice versa, therapeutic options for MG pregnant women, management of pregnancy or labor complications in MG patients, and finally fetal and neonatal considerations in MG pregnant women. A multidisciplinary approach, involving obstetricians/gynecologists, neurologists, and anes-thesiologists, plays a pivotal role in improving the clinical outcomes in both MG mothers and their infants during pregnancy, delivery and postpartum.

Pragmatic approach to neuraxial anesthesia in obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system

Neuraxial anesthesia provides optimal labor analgesia and cesarean delivery anesthesia. Obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system present unique challenges to the anesthesiologist. Potential concerns include mechanical interference, patient injury and the need for imaging. Unfortunately, the existing literature regarding neuraxial anesthesia in these patients is largely limited to case series and rare retrospective studies. The lack of practice guidance may lead to unwarranted fear of patient harm and subsequent avoidance of neuraxial anesthesia for cesarean delivery or neuraxial analgesia for labor, with additional risks of exposure to general anesthesia. In this narrative review, we use available evidence to recommend a framework when considering neuraxial anesthesia for an obstetrical patient with neuraxial pathology.

A challenging case of hypercapnic respiratory failure during pregnancy

We describe a 40-year-old female who presented with progressive breathlessness and hypercapnic respiratory failure during pregnancy secondary to undiagnosed muscle-specific kinase myasthenia gravis. Her presentation was progressive and protracted, having over five contacts with healthcare professionals over nine months, many of these predating her pregnancy. Her atypical presentation for myasthenia with minimal limb weakness led to consideration of other causes of hypercapnic respiratory failure. Once diagnosed, she was treated with intravenous immunoglobulin and non-invasive ventilation. She gave birth to a pre-term infant by planned caesarean section. Her insidious presentation and the progressive nature of her breathlessness were unusual and our report highlights the predominant involvement of respiratory muscles in muscle-specific kinase myasthenia. Her pregnancy may have further delayed her diagnosis due the attribution of some symptoms to normal pregnancy. Early recognition and treatment of myasthenia gravis are important to prevent life-threatening complications.

Myasthenia gravis and pregnancy

Myasthenia gravis (MG) is an autoimmune disorder with bimodal age of presentation, occurring in young women of reproductive age and at an older age in men. Occasionally, MG is diagnosed during pregnancy. Management of MG includes symptomatic treatment with cholinesterase inhibitors and immunosuppressive therapy for controlling the disease activity. Treatment of MG in women of reproductive age, who may be contemplating pregnancy, requires discussion regarding the choice of medication as well as the understanding of risks/adverse effects involved with various treatments. During the peripartum period, it is essential to ensure careful monitoring of the disease state along with the well-being of the mother and fetus and to coordinate neonatal monitoring overseen by a multidisciplinary team comprising a high-risk maternal fetal medicine specialist, a neurologist familiar with these complex issues, and a neonatologist.

Management of labor and delivery in myasthenia gravis: A new protocol

AIM

Pregnancy with myasthenia gravis (MG) is known to be associated with an increased cesarean section rate, presumably due to maternal fatigue during labor. Although epidural labor analgesia (ELA) appears to be a good option for circumventing maternal fatigue, a protocol for managing MG deliveries has not been established. This study, based on a review of our case series, aimed to evaluate the validity of our management protocol for maternal MG, in which ELA is used depending on MG severity.

METHODS

Parturients with systemic muscle weakness or worsening symptoms were classified as Category A (A), and those without symptoms were classified as Category B (B). In A, ELA was given at the onset of labor. Immediate vacuum delivery was done once the fetal head descended to station +2. For B, spontaneous vaginal delivery was chosen. The duration, blood loss, fetal weight, Apgar score and MG symptoms on post-partum day (PPD) 1, 14 and 30 were recorded.

RESULTS

Six patients were enrolled. Four were classified in A, and two were classified in B. No adverse events occurred during labor. Transvaginal delivery was successfully achieved in all the patients. Symptoms of MG were well-controlled. MG symptoms were stable on PPD 1 in all the patients although two patients complained of worsening symptoms after PPD 14.

CONCLUSION

Women with MG can safely undergo spontaneous or operative vaginal delivery. ELA is a good option for circumventing the effects of maternal fatigue on delivery. Our protocol may lower the cesarean section rate in maternal MG.

MuSK myasthenia gravis and pregnancy

Muscle specific kinase (MuSK) myasthenia gravis (MG, MuSK-MG) is a rare subgroup of MG affecting mainly women during childbearing years. We investigated the influence of pregnancy in the course of MuSK-MG and pregnancy outcomes in females with MuSK-MG. A multicentre cohort of 17 women with MuSK-MG was studied retrospectively; 13 of them with ≥1 pregnancy. MuSK-MG onset age was 35,4 years; 23,0% had other autoimmune disorder; 46,2% were treatment refractory. Thirteen women experienced 27 pregnancies, either after MG onset (group I) (n = 4; maternal age at conception = 29.8 years) or before MG onset (group II) (n = 23; maternal age at conception = 26.2 years). In group I pregnancy occurred in average 9.8 years after the MG onset; it occurred in average 17.0 years before MG in group II. In group I, all were on steroids at time of conception, one on azathioprine and another receiving IVIG regularly. There were mild exacerbations that responded to treatment adjustments. There were no relapses in the 12 months following the delivery. There was no pre-eclampsia, birth defects or stillbirths in either group; 3 miscarriages in group II. One case of neonatal MG was recorded. In this small series, pregnancy did not seem to precipitate MuSK-MG or to have a major influence in the MuSK-MG course, and there was no apparent negative impact in pregnancy outcomes in those where pregnancy followed the MG onset. The weight was lower in the newborn of the group I mothers, although none had low birth weight.

Neuromuscular Disease in the Neurointensive Care Unit

Neuromuscular diseases are syndromic disorders that affect nerve, muscle, and/or neuromuscular junction. Knowledge about the management of these diseases is required for anesthesiologists, because these may frequently be encountered in the intensive care unit, operating room, and other settings. The challenges and advances in management for some of the neuromuscular diseases most commonly encountered in the operating room and neurointensive care unit are reviewed.

Clinical follow-up of pregnancy in myasthenia gravis patients

This study aimed to analyze the outcome and impact of pregnancy in women with myasthenia gravis (MG). Obstetric and clinical data were retrospectively analyzed before, during and after pregnancy. Predictors of outcome were studied. We included 35 pregnancies from 21 MG patients. In the course of MG symptoms in 30 pregnancies with live births, 50% deteriorated (mainly during the second trimester, p = 0.028), 30% improved, and 20% remained unchanged. The deterioration group had more frequent abnormal repetitive nerve stimulation (RNS) (p = 0.028) and lower myasthenia gravis composite (MGC) scores (p = 0.045) before pregnancy. The improvement group was associated with higher MGC scores (p = 0.012) before pregnancy. The no-change group was associated with longer duration of MG (p = 0.026) and normal RNS (p = 0.008) before pregnancy. The course of MG in the second pregnancy was different from that in the previous pregnancy in 65.3% of cases. Obstetric complications were reported in 20 pregnancies; the most common was preterm premature rupture of membranes (PPROM) (25.8%), and the most severe were abortion (11.4%) and fetal death (2.9%). Most of the patients delivered via caesarean section (66.7%). Spinal anesthesia was performed in 73.3%. Transient neonatal myasthenia gravis occurred in 12.9% of live-born infants, and no predictors were found. In conclusion, severity and duration of MG, RNS and treatment influence MG and pregnancy. Pregnant MG patients have greater rates of PPROM and caesarean delivery. Our data suggest that duration of MG, MGC and RNS before pregnancy may be useful in helping to predict the course of MG during pregnancy.

Pregnancy with co-morbidities: Anesthetic aspects during operative intervention

The presence of co-morbidities during pregnancy can pose numerous challenges to the attending anesthesiologists during operative deliveries or during the provision of labor analgesia services. The presence of cardiac diseases, endocrinological disorders, respiratory diseases, renal pathologies, hepatic dysfunction, anemia, neurological and musculoskeletal disorders, connective tissue diseases and many others not only influence the obstetric outcome, but can significantly impact the anesthetic technique. The choice of anesthesia during the pregnancy depends upon the type of surgery, the period of gestation, the site of surgery, general condition of patient and so on. Whatever, the anesthetic technique is chosen the methodology should be based on evidentially supported literature and the clinical judgment of the attending anesthesiologist. The list of co-morbid diseases is unending. However, the present review describes the common co-morbidities encountered during pregnancy and their anesthetic management during operative deliveries.

Neurologic disease with pregnancy and considerations for the obstetric anesthesiologist

Women with neurologic conditions present a challenge during pregnancy and in the peripartum period. Given the low prevalence of these diseases during pregnancy, most management decisions are guided by retrospective reviews and case reports. This article reviews current literature for some of the more common or complex neurologic conditions affecting pregnancy with special consideration for anesthetic management. In particular, epilepsy; multiple sclerosis; primary intracranial hypertension; secondary intracranial hypertension-Arnold-Chiari malformations and intracranial neoplasms; spinal cord injury; neuromuscular junction disorders-myasthenia gravis; and hereditary neuromuscular disorders-myotonic dystrophy and spinal muscular atrophy will be discussed. By increasing understanding of anesthetic issues for parturients with neurologic disease, providers may more effectively anticipate anesthetic considerations, thereby optimizing care plans.

Myasthenia in pregnancy: best practice guidelines from a U.K. multispecialty working group

A national U.K. workshop to discuss practical clinical management issues related to pregnancy in women with myasthenia gravis was held in May 2011. The purpose was to develop recommendations to guide general neurologists and obstetricians and facilitate best practice before, during and after pregnancy. The main conclusions were (1) planning should be instituted well in advance of any potential pregnancy to allow time for myasthenic status and drug optimisation; (2) multidisciplinary liaison through the involvement of relevant specialists should occur throughout pregnancy, during delivery and in the neonatal period; (3) provided that their myasthenia is under good control before pregnancy, the majority of women can be reassured that it will remain stable throughout pregnancy and the postpartum months; (4) spontaneous vaginal delivery should be the aim and actively encouraged; (5) those with severe myasthenic weakness need careful, multidisciplinary management with prompt access to specialist advice and facilities; (6) newborn babies born to myasthenic mothers are at risk of transient myasthenic weakness, even if the mother's myasthenia is well-controlled, and should have rapid access to neonatal high-dependency support.

Neuromuscular disease and anesthesia

Patients with neuromuscular disease pose many anesthetic challenges and are at greater risk for perioperative complications, including respiratory or cardiovascular dysfunction and pulmonary aspiration. Therefore, these patients require special precautions, including interdisciplinary communication between primary care physicians, neurologists, physiatrists, surgeons, and anesthesiologists. Preoperative evaluation and optimization of comorbid conditions is critical. These patients may have adverse response to neuromuscular blocking drugs and the reversal drugs (e.g., neostigmine). They should be used with caution and titrated based on objective neuromuscular monitoring. Drugs that potentiate neuromuscular blocking drugs should also be avoided or their doses limited if possible. The risk of malignant hyperthermia in certain neuromuscular diseases mandates avoidance of triggering agents such as succinylcholine and inhaled anesthetics. Patients with neuromuscular disease may also be sensitive to sedative-hypnotics and opioids, which should be used judiciously. Finally, the postoperative period requires close monitoring due to increased risk of postoperative cardiorespiratory dysfunction.

Anesthesia and myasthenia gravis

Myasthenia gravis (MG) is a disease affecting the nicotinic acetylcholine receptor of the post-synaptic membrane of the neuromuscular junction, causing muscle fatigue and weakness. The myasthenic patient can be a challenge to anesthesiologists, and the post-surgical risk of respiratory failure has always been a matter of concern. The incidence and prevalence of MG have been increasing for decades and the disease is underdiagnosed. This makes it important for the anesthesiologist to be aware of possible signs of the disease and to be properly updated on the optimal perioperative anesthesiological management of the myasthenic patient. The review is based on electronic searches on PubMed and a review of the references of the articles. The following keywords were used: myasthenia gravis AND neuromuscular blocking agents, myasthenia gravis AND sevoflurane, myasthenia gravis AND epidural, myasthenia gravis AND neuromuscular blockade reversal and myasthenia gravis AND pyridostigmine. The articles included were from reviews and clinical trials written in English. MG patients can easily be anesthetized without need for post-surgery mechanical ventilation whether it is general anesthesia or peripheral nerve block. Volatile anesthesia or the use of an epidural for the patient makes it possible to avoid the use of neuromuscular blocking agents, and when used, it should be in smaller doses and the patient should be carefully monitored. This review shows that with thorough pre-operative evaluation, continuing the daily pyridostigmine and careful monitoring the MG patient can be managed safely.