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Anesthetic Management of Pregnant Patient with Neurological and Neuromuscular Disorders

  • Dominika Dabrowska
Chapter

Abstract

Neurological and neuromuscular diseases in obstetric patients are significant causes of maternal morbidity and mortality and have many obstetric and anesthetic implications. Specific areas of concerns include:
  1. 1.

    The effect of these disorders on pregnancy and maternal and fetal outcomes

     
  2. 2.

    Effects of pregnancy on the course of the disease

     
  3. 3.

    Safety of the medications and anesthetic interventions

     

The choice of the ideal analgesic and anesthetic technique in patients with neurological and neuromuscular disease should be based on thorough antenatal assessment, severity of the disease, and individual risk-to-benefit ratio. Regional techniques are widely used and provide significant advantages in obstetric patients with pre-existing neurological or neuromuscular disorders, but occasionally they may be contraindicated or technically difficult. Whether regional or general anesthesia is offered, it is imperative that the anesthetic management involves a cautious approach and avoidance of the drugs and factors with negative effect on the mother and the fetus.

The objective of this chapter is to review the most common neurological and neuromuscular conditions affecting obstetric patients with a special emphasis on their anesthetic implications.

Keywords

Pregnancy Anesthetic management Neurological diseases Neuromuscular diseases 

References

  1. 1.
    Knight M, Nair M, Tuffnell D, Kenyon S, Shakespeare J, Brocklehurst P, et al., editors. On behalf of MBRRACE-UK. Saving lives, improving mothers’ care—surveillance of maternal deaths in the UK 2012–14 and lessons learned to inform maternity care from the UK and Ireland confidential enquiries into maternal deaths and morbidity 2009–14. Oxford: National Perinatal Epidemiology Unit, University of Oxford; 2016.Google Scholar
  2. 2.
    Confavreux C, Hutchinson M, Hours MM, Cortinovis-Tourniaire P, Moreau T. Rate of pregnancy-related relapse in multiple sclerosis. Pregnancy in Multiple Sclerosis Group. N Engl J Med. 1998;339:285–91.CrossRefGoogle Scholar
  3. 3.
    Bamford C, Sibley W, Laguna J. Anesthesia in multiple sclerosis. Can J Neurol Sci. 1978;5:41–4.PubMedGoogle Scholar
  4. 4.
    Bader AM, Hunt CO, Datta S, Naulty JS, Ostheimer GW. Anesthesia for the obstetric patient with multiple sclerosis. J Clin Anesth. 1988;1:21–4.CrossRefGoogle Scholar
  5. 5.
    Drake E, Drake M, Bird J, Russell R. Obstetric regional blocks for women with multiple sclerosis: a survey of UK experience. Int J Obstet Anesth. 2006;15:115–23.CrossRefGoogle Scholar
  6. 6.
    Pastó P, Portaccio E, Ghezzi A, Hakiki B, Giannini M, Razzolini M, et al. Epidural analgesia and cesarean delivery in multiple sclerosis post-partum relapses: the Italian cohort study. BMC Neurol. 2012;12:165.  https://doi.org/10.1186/1471-2377-12-165.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Brett RS, Schmidt JH, Gage JS, Schartel SA, Poppers PJ. Measurement of acetylcholine receptor concentration in skeletal muscle from a patient with multiple sclerosis and resistance to atracurium. Anesthesiology. 1987;66:837–9.CrossRefGoogle Scholar
  8. 8.
    RCOG. Epilepsy in pregnancy. Green-top Guideline No. 68, June 2016. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg68/.
  9. 9.
    Hvas CL, Henriksen TB, Ostergaard JR, Dam M. Epilepsy and pregnancy: effect of antiepileptic drugs and lifestyle on birthweight. BJOG. 2000;107:896–902.CrossRefGoogle Scholar
  10. 10.
    Griffiths S, Durbridge JA. Anaesthetic implications of neurological disease in pregnancy. Continuing education in anaesthesia. Crit Care Pain. 2011;11(5):157–61.  https://doi.org/10.1093/bjaceaccp/mkr023.CrossRefGoogle Scholar
  11. 11.
    Perks A, Cheema S, Mohanraj R. Anaesthesia and epilepsy. Br J Anaesth. 2012;108:562–71.  https://doi.org/10.1093/bja/aes027.CrossRefPubMedGoogle Scholar
  12. 12.
    Milhorat TH, Chow MW, Trinidad EM, Kula RW, Mandell M, Wolpert C, et al. Chiari I malformation redefined: clinical and radiographic findings for 364 symptomatic patients. Neurosurgery. 1999;44:1005–17.CrossRefGoogle Scholar
  13. 13.
    Mueller DM, Oro’ J. Chiari I malformation with or without syringomyelia and pregnancy: case studies and review of the literature. Am J Perinatol. 2005;22:67–70.CrossRefGoogle Scholar
  14. 14.
    Orth T, Babbar S, Porter B, Lu G, Gerkovich M. Maternal and pregnancy complications among women with Arnold-Chiari malformation: a national database review. Am J Obstet Gynecol. 2015;212  https://doi.org/10.1016/j.ajog.2014.10.922.CrossRefGoogle Scholar
  15. 15.
    Landau R, Giraud R, Delrue V, Kern C. Spinal anesthesia for cesarean delivery in a woman with a surgically corrected type I Arnold Chiari malformation. Anesth Analg. 2003;97:253–5.CrossRefGoogle Scholar
  16. 16.
    Kuczkowski KM. Spinal anesthesia for Cesarean delivery in a parturient with Arnold-Chiari type I malformation. Can J Anesth. 2004;51:639.CrossRefGoogle Scholar
  17. 17.
    Chantigan RC, Koehn MA, Ramin KD, Warner MA. Chiari I malformation in parturients. J Clin Anesth. 2002;14:201–5.CrossRefGoogle Scholar
  18. 18.
    Choi CK, Tyagaraj K. Combined spinal-epidural analgesia for labouring parturient with Arnold-Chiari type I malformation: a case report and a review of the literature. Case Rep Anesthesiol. 2013;2013:512915.  https://doi.org/10.1155/2013/512915.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Ghaly RF, Candido KD, Sauer R, Knezevic NN. Anesthetic management during cesarean section in woman with residual Arnold-Chiari malformation type I, cervical kyphosis and syringomyelia. Surg Neurol Int. 2012;3:26.CrossRefGoogle Scholar
  20. 20.
    Penney DJ, Smallman JM. Arnold Chiari malformation and pregnancy. Int J Obstet Anesth. 2001;10:139–41.CrossRefGoogle Scholar
  21. 21.
    Gambling D, Douglas M, McKay R. Obstetric anaesthesia and uncommon disorders. 2nd ed. Cambridge: Cambridge University Press; 2008. Section 3: Nervous system disorders. p. 167–89.CrossRefGoogle Scholar
  22. 22.
    Center for Disease Control and Prevention. Use of folic acid for prevention of spina bifida and other neural tube defects 1983-1991. MMWR Morb Mortal Wkly Rep. 1991;40:513–6.Google Scholar
  23. 23.
    Arata M, Grover S, Dunne K, Bryan D. Pregnancy outcome and complications in women with spina bifida. J Reprod Med. 2000;45:743–8.PubMedGoogle Scholar
  24. 24.
    McGrady EM, Davis AG. Spina bifida occulta and epidural anaesthesia. Anaesthesia. 1998;43:867–9.CrossRefGoogle Scholar
  25. 25.
    Vaagenes P, Fjaerestad I. Epidural block during labour in a patient with spina bifida cystica. Anaesthesia. 1981;36:299–301.CrossRefGoogle Scholar
  26. 26.
    Tidmarsh MD, May AE. Epidural anaesthesia and neural tube defects. Int J Obstet Anesth. 1998;7:111–4.CrossRefGoogle Scholar
  27. 27.
    Valente A, Frassanito L, Natale L, Draisci G. Occult spinal dysraphism in obstetrics: a case report of caesarean section with subarachnoid anaesthesia after remifentanil intravenous analgesia for labour. Case Rep Obstet Gynecol. 2012;2012:472482.  https://doi.org/10.1155/2012/472482.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Degler SM, Dowling RD, Sucherman DR, Leighton BL. Awake intubation using an intubating laryngeal mask airway in a parturient with spina bifida. Int J Obstet Anesth. 2005;14:77–8.CrossRefGoogle Scholar
  29. 29.
    Petsas A, Drake J. Perioperative management for patients with a chronic spinal cord injury. BJA Educ. 2015;15:123–30.CrossRefGoogle Scholar
  30. 30.
    Norwood F, Rudnik-Schöneborn S. 179th ENMC international workshop: pregnancy in women with neuromuscular disorders 5-7 November 2010, Naarden, The Netherlands. Neuromuscul Disord. 2012;22:183–90.CrossRefGoogle Scholar
  31. 31.
    Litman RS, Griggs SM, Dowling JJ, Riazi S. Malignant hyperthermia susceptibility and related diseases. Anesthesiology. 2018;128:159–67.  https://doi.org/10.1097/ALN0000000000001877.CrossRefPubMedGoogle Scholar
  32. 32.
    Ishikawa Y, Bach JR, Sarma RJ, Tamura T, Song J, Marra SW, et al. Cardiovascular considerations in the management of neuromuscular disease. Semin Neurol. 1995;15:93–108.CrossRefGoogle Scholar
  33. 33.
    Pandey CK, Bose N, Garg G, Singh N, Baronia A, Agarwal A, et al. Gabapentin for the treatment of pain in Guillain-Barre syndrome: a double-blinded, placebo-controlled, crossover study. Anesth Analg. 2002;95:1719–23.CrossRefGoogle Scholar
  34. 34.
    Spillane J, Higham E, Kullman DM. Myasthenia gravis. BMJ. 2012;345:e8497.  https://doi.org/10.1136/bmj.e8497.CrossRefPubMedGoogle Scholar
  35. 35.
    Lucchi M, Ricciardi R, Melfi F, Duranti L, Basolo F, Palmiero G, et al. Association of thymoma and myasthenia gravis: oncological and neurological results of the surgical treatment. Eur J Cardiothorac Surg. 2009;35:812–6.CrossRefGoogle Scholar
  36. 36.
    Brenner T, Beyth Y, Abramsky O. Inhibitory effect of alpha-fetoprotein on the binding of myasthenia gravis antibody to acetylcholine receptor. Proc Natl Acad Sci U S A. 1980;77:3635–9.CrossRefGoogle Scholar
  37. 37.
    Roth TC, Raths J, Carboni G, Rosler K, Schmid RA. Effect of pregnancy and birth on the course of myasthenia gravis before or after transsternal radical thymectomy. Eur J Cardiothorac Surg. 2006;29:231–5.CrossRefGoogle Scholar
  38. 38.
    Hoff JM, Daltveit AK, Gilhus NE. Myasthenia gravis: consequences for pregnancy, delivery and the newborn. Neurology. 2003;61:1362–6.CrossRefGoogle Scholar
  39. 39.
    Hoff JM, Midelfart A. Maternal myasthenia gravis: a cause for arthrogryposis multiplex congenita. J Child Orthop. 2015;9:433–5.  https://doi.org/10.1007/s11832-015-0690-8.CrossRefGoogle Scholar
  40. 40.
    Leventhal SR, Orkin FK, Hirsh RA. Prediction of the need for postoperative mechanical ventilation in myasthenia gravis. Anesthesiology. 1980;53:26–30.CrossRefGoogle Scholar
  41. 41.
    Eisenkraft JB, Book WJ, Mann SM, Papatestas AE, Hubbard M. Resistance to succinylcholine in myasthenia gravis: a dose-response study. Anesthesiology. 1988;69:760–3.CrossRefGoogle Scholar
  42. 42.
    de Boer HD, van Egmond J, Driessen JJ, Booij LH. A new approach to anesthesia management in myasthenia gravis: reversal of neuromuscular blockade by sugammadex. Rev Esp Anestesiol Reanim. 2010;57:181–4.CrossRefGoogle Scholar
  43. 43.
    Norwood F, Dhanjal M, Hill M, James N, Jungbluth H, Kyle P, et al. Myasthenia in pregnancy: best practice guidelines from a U.K. multispecialty working group. J Neurol Neurosurg Psychiatry. 2014;85:538–43.  https://doi.org/10.1136/jnnp-2013-305572.CrossRefPubMedGoogle Scholar
  44. 44.
    Theadom A, Rodrigues M, Roxburgh R, Balalla S, Higgins C, Bhattacharjee R, et al. Prevalence of muscular dystrophies: a systematic literature review. Neuroepidemiology. 2014;43:259–68.CrossRefGoogle Scholar
  45. 45.
    Johnson NE, Hung M, Nasser E, Hagerman KA, Chen W, Ciafaloni E, et al. The impact of pregnancy on myotonic dystrophy: a registry-based study. J Neuromuscul Dis. 2015;2:447–52.CrossRefGoogle Scholar
  46. 46.
    Zaki M, Boyd PA, Impey L, Roberts A, Chamberlain P. Congenital myotonic dystrophy: prenatal ultrasound findings and pregnancy outcome. Ultrasound Obstet Gynecol. 2007;29:284–8.CrossRefGoogle Scholar
  47. 47.
    Kocabas S, Karaman S, Firat V, Bademkiran F. Anesthetic management of Guillain-Barré syndrome in pregnancy. J Clin Anesth. 2007;19:299–302.CrossRefGoogle Scholar
  48. 48.
    McGrady EM. Management of labour and delivery in a patient with Guillain-Barré syndrome. Anaesthesia. 1987;42:899–900.CrossRefGoogle Scholar
  49. 49.
    Chiriboga CA. Nusinersen for the treatment of spinal muscular atrophy. Expert Rev Neurother. 2017;17:955–62.CrossRefGoogle Scholar
  50. 50.
    Elsheik h BH, Zhang X, Swoboda KJ, Chelnick S, Reyna SP, Kolb SJ, et al. Pregnancy and delivery in women with spinal muscular atrophy. Int J Neurosci. 2017;127:953–7.CrossRefGoogle Scholar
  51. 51.
    Rudnik-Schöneborn S, Zerres K, Ignatius J, Rietschel M. Pregnancy and spinal muscular atrophy. J Neurol. 1992;239:26–30.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Dominika Dabrowska
    • 1
  1. 1.Chelsea and Westminster Hospital NHS Foundation TrustLondonUK

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