///2009 Abstract Details
2009 Abstract Details2018-05-01T17:45:11+00:00

Idiopathic Dermatomyositis: Implications for Cesarean Section Anesthesia

Abstract Number: 232
Abstract Type: Case Report/Case Series

Christine Bezouska M.D.1

Introduction: Idiopathic dermatomyositis, an inflammatory myopathy, usually presents in childhood or middle age, and is uncommon in the childbearing years.1 We describe a young adult with dermatomyositis who needed emergency Cesarean section, and identify some anesthetic concerns raised by this disorder.

Case: A 24-year-old woman had developed rash, myalgias, and proximal muscle weakness after the Cesarean birth of her first child at age 20. Appropriate workup, including skin and muscle biopsies, led to the diagnosis of dermatomyositis.2 She responded well to methotrexate, but stopped it before attempting this pregnancy. Symptoms were controlled with prednisone.

A contraction stress test at 33 weeks produced repeated late decelerations. With a closed cervix, high fetal station, and prior hysterotomy, immediate Cesarean delivery was recommended.

PT, PTT, INR, and platelet count were normal, as were recent PFTs and echocardiogram. CPK was elevated at 427, consistent with her dermatomyositis. The patient reported no recent weakness or sensory changes, and physical examination was normal but for obesity (155 cm, 90 kg) and the expected skin changes over her knuckles.

12 mg of hyperbaric spinal bupivacaine with 20 mcg of fentanyl produced a T4 level within 12 minutes. A vigorous male infant had three loops of nuchal cord. Blood loss was average and hemodynamics stable. Hydrocortisone 100 mg IV was given at the surgeons request.

The patient recovered sensory and motor function normally. The next day, she was tachycardic (120 bpm) with palpitations and shortness of breath. CPK and troponin levels did not rise. EKG showed no acute changes. Her symptoms resolved, and she went home on the third postoperative day.

Discussion: A multisystemic disease, dermatomyositis can produce dysphonia, dysphagia, and respiratory muscle weakness in addition to proximal limb weakness.3 Interstitial lung disease can occur.3 Cardiac involvement can include cardiomyopathy and conduction abnormalities.4 Sensory neuropathy has also been described.5

We observed normal onset, offset, and spread of spinal anesthesia, with no intraoperative dyspnea, dysphagia, or dysphonia. We avoided general anesthesia since little is known about the interactions of muscle relaxants and halogenated agents with the cardiac, pulmonary, and skeletal muscle abnormalities in this disease.

Previously associated with poor reproductive outcomes, response of dermatomyositis to new therapies such as intravenous immunoglobulin1,6 suggests that more affected patients may present for obstetric anesthesia in future. Additional reports of anesthetic experience in this population will be welcome.

REFERENCES:

1. Obstet Gynecol 2007;109:561-3

2. Semin Neurol 2008;28:241-9

3. Am Fam Physician 2001;64:1565-72

4. Rheumatology (Oxford) 2006;45 Suppl 4:18-21

5. Muscle Nerve 2007;36:721-5

6. Arthritis Rheum 2005;53:119-21

SOAP 2009