Myasthenia Gravis in Pregnancy: A Case Report

Abstract

Objective. To present a case of maternal myasthenia gravis in pregnancy and give a systematic review of the literature. Case. We report the case of a 38-year-old parturient with a life-threatening complication of immune-mediated myasthenia gravis shortly after an elective cesarean section on patient's request under spinal anesthesia at 35 + 3 weeks of gestation. The newborn was transferred to the pediatric unit for surveillance and did not show any signs of muscular weakness in the course of time. The mother developed a respiratory insufficiency on the second day postpartum. The myasthenic crisis led to a progressive dyspnoea within minutes, which exacerbated in a secondary generalized seizure with cardiac-circulatory arrest. After successful cardiopulmonary resuscitation, the patient was transferred to intensive care. The interdisciplinary therapeutic approach included ventilatory assistance via endotracheal intubation, parenteral pyridostigmine, azathioprine, and steroids. By interdisciplinary measures, a stable state was regained. Conclusion. Myasthenia gravis especially when associated with pregnancy is a high-risk disease. As this disease predominantly occurs in women of reproductive age, it is important to be aware of this condition in obstetrics and its interdisciplinary diagnostic and therapeutic management.

Anti-MuSK-positive myasthenia gravis diagnosed during pregnancy: new challenges for an old disease?

“…Although both plasmapheresis and IvIG seem to be effective in the treatment of myasthenic exacerbations in anti-MuSK-positive MG, plasmapheresis seems to be associated with an increased risk for prematurity. Moreover, due to the physiological changes of coagulation factors that occur during pregnancy, plasmapheresis should be considered a second choice in the treatment of these patients 5 7 12 24…”

“…Although azathioprine has been considered safe, an increased risk of gestational complications such as prematurity, fetal growth restriction, low birth weight and increased risk of fetal myelosuppression have been described 24 26. Given the patient's moderate symptoms, we decided not to introduce this agent during pregnancy.…”

Myasthaenia Gravis: Clinical management issues before, during and after pregnancy

“…33,34 Symptoms of TNMG appear within the first few days of life, most commonly 12-48 hours after delivery and characteristically resolve within four weeks (18-21 days); occasionally, symptoms persist for as long as four months. 9,34,35 Symptoms of TNMG include a weak cry, ptosis, facial weakness, poor sucking, generalised hypotonia and respiratory distress; however, the severity of these symptoms differs from newborn to newborn, with some showing only mild hypotonia and others requiring mechanical ventilation due to significant breathing problems. 24,32,34 Thus, neonatal ICU facilities should be available at the time of delivery and infants born to myasthaenic mothers should be carefully monitored during their first 48-72 hours for signs of respiratory difficulty and muscle weakness.…”

Management of myasthenia gravis in pregnancy

“…Thymectomy is a standard treatment for MG patients with thymoma, but not for those with ocular type or muscle‐specific kinase (MuSK) antibody‐positive MG . During pregnancy, patients with thymoma who have not undergone thymectomy present with a higher incidence of exacerbation than those who have undergone thymectomy . Infants born to MG patients who have undergone thymectomy have less risk of developing neonatal MG .…”