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Anti-NMDA receptor antibody encephalitis in a pregnant woman: Anesthetic and pain management considerations for a combined C-section and oophorectomy
Abstract Number: F-74
Abstract Type: Case Report/Case Series
Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is caused by production of antibodies to the NMDA receptor and is characterized by psychiatric and neurologic symptoms. Ovarian teratomas are found in the majority of female patients. To date, there have been no reports of pregnant patients with anti-NMDAR encephalitis undergoing neuraxial anesthesia for C-section. Symptoms of this disease such as psychosis, paroxysmal sympathetic hyperactivity, and central hypoventilation pose risks during anesthesia. We provide the first report of neuraxial anesthetic management of a patient with severe, treatment refractory anti-NMDAR encephalitis undergoing C-section.
A 28-yo G1P0 with an intrauterine pregnancy of 16wks estimated gestational age (EGA) was transferred from an outside hospital in status epilepticus where she originally presented with complaints of increasing anxiety, insomnia, and inability to follow commands. She was admitted to our ICU where she was intubated and sedated. Keppra and lacosamide were given to control her seizures. CSF samples obtained at the outside hospital were positive for NMDAR antibody. An abdominopelvic MRI was negative for teratoma, but was notably obscured by the gravid uterus. The patient required initiation of clonidine, bromocriptine, methadone, and propanolol for severe autonomic dysfunction, and also needed prolonged ventilator support and tracheostomy. She completed a total of eleven plasma exchanges and two doses of rituximab with minimal symptom relief.
The patient was discharged to a rehabilitation facility at 21wks EGA, but continued to worsen, experiencing periodic catatonia, anorexia, and intrauterine growth restriction, and was readmitted to our hospital. At 24wks EGA, she received one dose of cyclophosphamide for refractory symptoms. Because of lack of improvement, a C-section was scheduled for 28wks EGA, prior to the next planned dose of cyclophosphamide. This timing would allow for increased fetal maturity without further exposure to chemotherapy. In addition, if a tumor was found, an oophorectomy could be performed to prevent continued secretion of antibodies. We planned a combined spinal-epidural for optimal anesthetic density and duration. Intravenous methadone was given perioperatively to avoid withdrawal and minimize autonomic dysfunction. Anesthesia and delivery occurred without incident, and she underwent a right oophorectomy for a grossly visible lesion which pathology confirmed as a mature cystic teratoma. Satisfactory post-operative analgesia was provided with a combination of neuraxial morphine and subfascial wound infusion of 0.5% bupivacaine at 5ml/hr.
The patient was discharged 2wks after delivery, but returned the next day in status epilpeticus. After another prolonged hospitalization requiring intubation, her seizures were ultimately controlled with high dose keppra, lacosamide, and fosphenytoin. She was discharged 10d later to home health with neurologic follow up.