Management of myasthenia gravis in pregnancy

Abstract

To a neurologist, pregnancy and delivery are major issues for patients with neuroimmunological diseases, including myasthenia gravis (MG). MG is an autoimmune disease caused by antibodies against the nicotinic acetylcholine receptor or other postsynaptic antigens, such as muscle‐specific kinase or low‐density lipoprotein receptor‐related protein 4. In Japan, a nationwide survey in 2006 showed that 15 100 people, or 11.8 per 100 000 persons, had been diagnosed with MG. In women with MG who became pregnant, the disease symptoms worsened for 41%, whereas 30% showed no change, and 29% had remission of symptoms. Exacerbations occur in the first trimester and in the first 3 months postpartum. It is also important to watch for transient neonatal MG, which occurs in 10–30% of infants delivered by mothers with MG. It is critical to carefully monitor antimuscle‐specific kinase antibody‐positive patients with MG because of their greater risk for bulbar palsy. The present review discusses the effects of pregnancy on MG and the management of MG in pregnancy.

Management of labor and delivery in myasthenia gravis: A new protocol

“…Although the patient might have had fewer stressors if she had undergone ELA, the condition was treatable by simply resting or increasing medication. Nonetheless, one might consider performing an ELA for all patients with a generalized MG‐complicated pregnancy because the disease course is unpredictable, and relapses frequently occur in the post‐partum period even if the patients show no muscular weakness . From this point of view, Category B patients could also benefit from ELA if the first or second stage of labor is prolonged.…”

“…Surgical vaginal delivery plus epidural analgesia may also apply to all patients in whom MG is diagnosed less than 2 years prior to conception for two reasons: first, because disease exacerbation and mortality increase within 1 year after MG diagnosis, and second, because most systemic symptoms occur within 2 years after the disease onset; hence, one can diagnose ocular MG only after this period . Patients tend initially to present ptosis as the sole symptom although muscle weakness in the limb, bulbar, neck or shoulder girdle muscles and respiratory weakness appears to emerge afterward.…”

“…It mainly affects the neuromuscular junction, causing neuromuscular fatigue, especially during repetitive muscle contractions. Although the uterine muscles, which consist of smooth muscles, are rarely affected in MG‐complicated pregnancies, voluntary muscle weakness can be exacerbated due to the expulsive efforts during the second stage of labor, and fatigability can contribute to respiratory distress . Thus, easing the stress and controlling pain are crucial to managing labor in cases of maternal MG, especially for those with systemic symptoms .…”

“…1 Thus, easing the stress and controlling pain are crucial to managing labor in cases of maternal MG, especially for those with systemic symptoms. 1,2 The cesarean section rate tends to be higher among mothers with MG, [3][4][5] presumably because of prolonged labor due to maternal fatigue. Although epidural labor analgesia (ELA) appears to be a good option for circumventing these problems, optimal obstetrical management has not been established.…”

Myasthenia Gravis as a Risk Factor During Pregnancy

“…Данное заболевание встречается в два раза чаще среди женщин репродуктивного возраста. Частота встречаемости беременных женщин, болеющих миастенией, определяется как один случай на 20000 беременных [3,4,7]. В связи с этим очень важным является вопрос о рациональном ведении беременности и родов у этой категории женщин.…”