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Anesthetic management of Guillain-Barré syndrome in pregnancy
Abstract Number: F-79
Abstract Type: Case Report/Case Series
Introduction: Guillain-Barre syndrome (GBS) is an immune mediated progressive demyelinating disorder characterised by acute or sub-acute proximal skeletal muscle paralysis. Reported incidence in general population is between 0.75 to 2 in 100,000 per year (1) . It is less common during pregnancy. We report the management of patient with GBS for emergency caesarean delivery.
Case Report: 24 year old primigravida presented at 20 weeks of gestation following chest infection with significant sensory symptoms and weakness, primarily affecting lower limbs. Following neurological assessment she was areflexic with reduced amplitude in motor studies of the both upper and lower limbs with sub-normal conduction velocity. Sensory responses were absent for median and ulnar nerves but no involvement of bulbar or the muscles of respiration occured at any point
GBS was diagnosed. Her condition improved significantly with immunoglobulin treatment though residual left sided weakness remained throughout her otherwise uncomplicated pregnancy.
Management plan was to provide epidural analgesia in labour but she was admitted with significant antepartum haemorrhage requiring delivery by emergency caesarean section which was carried out under spinal anaesthetic at the level of L3/L4 with 2.4ml 0.5% hyperbaric bupivacaine and 300μg diamorphine. Boluses of sympathomimetic agents were administered and titrated to effect. Post natal review next day showed a full return to her previous function. Continued follow up into post partum period did not show any evidence of worsening neurology.
Discussion: Anaesthetic management of delivery and caesarean with active or resolving GBS is not well defined. Management is focused on maintenance of normal homeostatic mechanisms and avoidance of agents that possess the potential to exacerbate the condition. Regional anaesthesia is not contraindicated but sensitivity to local anaesthetics has been reported causing profound hypotension. Autonomic instability is possible during acute phase but rarely persists longer than two weeks. We planned epidural in labour to avoid the occurrence of this. Also epidural can be used to extend the block cautiously to attain surgical anaesthesia. But the urgency of this case did not give us sufficient time for epidural block.
Spinal anaesthesia has been used successfully in pregnant patients with GBS. Benefit of regional anaesthesia in pregnancy with GBS may outweigh the theoretical risk of further neurological damage. Medicolegal aspects of regional anaesthesia with pre-existing neurological condition should be taken into account and informed consent and documenting baseline neurological status is advisable.
If general anaesthesia required, avoid suxamethonium because of the risk of hyperkalaemia. They are sensitive to non-depolarizing relaxants and post-operative ventilatory support may be required.
Ref: 1. Kocabas S Anesthetic Management of GBS in pregnancy J Clin Anesth. 2007 Jun; 19(4):299-302