Anesthetic Management of a Parturient With Neuromyelitis Optica

Abstract

Topics: Nonobstetric Maternal DiseaseN euromyelitis optica (NMO) is a severe inflammatory demyelinating disorder of the spinal cord and optic nerves that can cause paraplegia and blindness. Information about the anesthetic management of NMO in pregnancy is limited. This case report presents the management of a woman with NMO for a cesarean delivery (CD) and discusses the anesthetic considerations.The 40-year-old G2P1 woman with NMO was to have a repeat elective CD at 38 weeks' gestation. She had an urgent CD for fetal distress 18 months previously with an existing labor epidural catheter used for surgical anesthesia. No adverse effects were reported. Two months postpartum, the patient had new-onset paresthesias in both feet; within 48 hours she was unable to walk and also had changes in visual acuity. A spinal MRI showed a hyperintense lesion of the spinal cord from T2-T5, and serologic testing was positive for the NMO-specific autoantibody to the aquaporin-4 water channel (AQP4 Ab). Remission occurred after treatment with intravenous (IV) methylprednisolone for 5 days. The second pregnancy began 7 months after diagnosis. IV steroids and monthly immunoglobulin infusions prevented relapse during pregnancy. On the day of surgery, the patient reported no changes in her symptoms, which included scapular pain and lower extremity numbness and weakness, that had occurred during pregnancy. Her medications included oxycodone, lamotrigine, valacyclovir, prenatal vitamins, and monthly IV immunoglobulin therapy. Vital signs were within normal limits, as was mental status and visual acuity. Muscle strength, tone, and bulk were also normal.The patient preferred general anesthesia for delivery. Rapid sequence induction was performed with propofol, fentanyl, and rocuronium. Tracheal intubation using a video laryngoscope was successful, and anesthesia was maintained with sevoflurane in oxygen and nitrous oxide. A healthy boy was delivered, with Apgar scores of 7 and 8 at 1 and 5 minutes. The patient received IV oxytocin and hydromorphone after delivery of the infant. Neuromuscular blockade was reversed with neostigmine and glycopyrrolate although an additional dose of neostigmine was administered due to an inadequate train-of-four response after the initial dose. Extubation was complicated by mild respiratory fatigue, which responded to bimodal positive airway pressure in the PACU. IV hydromorphone was provided for pain control for 2 days. The patient had no evidence of NMO relapse in the immediate postpartum period. An MRI 3 days postoperatively was unchanged from the baseline MRI performed 1 month before admission. Rituximab therapy was started 3 weeks postpartum. At 6-and 18-month follow-up, she was doing well without worsening of the NMO.NMO is a unique entity separate from multiple sclerosis (MS), with a complex and multifactorial pathogenesis. Recurrent NMO is 3 to 9 times more prevalent in women; the median age of onset is 35 to 45 years, with a higher prevalence in black, Asian, and Indian populations compared to whites. ...