Summary:The limb-girdle muscular dystrophies (LGMDs) are a group of genetically determined disorders of skeletal muscle, predominantly affecting the pelvic and shoulder-girdle musculature. The clinical course is variable but steadily progressive. Type 2ALGMD is the most frequent form, accounting for approximately 30% of identified cases. There are few reports of patients with Type 2A LGMD undergoing pregnancy and delivery. This case outlines a successful vaginal delivery in a woman with this condition.Keywords: high-risk pregnancy, maternal -fetal medicine, neurology, perinatal medicine
CASE REPORTThe patient, a 24-year-old primigravida, presented for antenatal care at The Royal Women's Hospital, Melbourne at 26 weeks gestation. Her neurological diagnosis was established at the age of 17 years on the basis of a muscle biopsy, which showed diagnostic features of myopathy. Further immunohistochemical studies using Western immunoblotting were arranged and proved consistent with Type 2A limb-girdle muscular dystrophy (LGMD). Her parents were consanguinous and her sister, aged 15 years, was experiencing similar symptoms at that time but had not undergone formal investigation.At the time of diagnosis the patient underwent calf tendon releases, with no subsequent neurological review. Prior to pregnancy she was unable to walk without assistance and relied on family members to support her while she walked. This included assistance to rise from the seated or lying position. She was unable to run or climb stairs. Her routine booking blood tests were essentially normal except for an elevated glucose tolerance test, consistent with gestational diabetes, which responded to dietary measures. Her body mass index at booking was 26 kg/m 2 . She underwent neurological review at 32 weeks gestation. Examination revealed shoulder-girdle weakness with inability to lift her arms above her head, symmetrical lower limb weakness, calf hypertrophy and wasted quadriceps and hamstring muscles, with power 2/5 in the limb girdles. Echocardiogram, electrocardiograph and pulmonary function tests were performed and were essentially normal. A caesarean section for delivery was initially recommended by the neurology team on the basis of her poor motor function and concerns that this may preclude a vaginal delivery. However, in conjunction with the patient's wishes, a vaginal delivery was proposed, with assistance in the second stage of labour if required.Serial ultrasounds in the third trimester showed appropriate fetal growth. Her antenatal course was complicated by a fall at 34 weeks gestation resulting in a right medial malleolar fracture. This necessitated the use of a wheelchair for mobility, and subcutaneous heparin was commenced for deep venous thrombosis prophylaxis.At 39 weeks gestation, induction of labour was recommended due to unstable blood sugars and numerous social and logistical issues, including difficulty for carers to arrange transport to the hospital for appointments. Artificial rupture of membranes was performed and an oxytocin...