In Practice
Myasthenia Gravis in Pregnancy persistent nonproductive cough. Her lungs are clear to auscultation bilaterally. Regional spinal anesthesia is performed without incident. She is in the obstetric postanesthesia care unit (PACU) post cesarean surgical birth. Her first hour in the PACU is uneventful and she and her baby are showing no signs of muscle weakness. Maternal vital signs are 122/78, 78, 18 with oxygen saturation 99 percent on room air. During the second hour of recovery, her
Abstract Myasthenia gravis (MG) is a chronic autoimmune neuromuscular disease and is the most common disorder of neuromuscular transmission. MG is caused by a defect in the transmission of nerve impulses to muscles in which communication from nerves to muscles is interrupted at the neuromuscular junction. This interruption can cause significant impact to muscle functions, which can have serious consequences for a pregnant woman, especially during labor. This brief article, which is meant to be used as an easy-reference tool in the clinical setting, examines the disease process and its eff ect on the antepartum, intrapartum and postpartum periods. DOI: 10.1111/1751-486X.12206 Keywords autoimmune disorder | myasthenia gravis | neuromuscular | pregnancy
248
© 2015, AWHONN
http://nwh.awhonn.org
Photo © iStock Collection / thinkstockphotos.com
I
Imagine that you’re caring for a 34-year-old primigravida at 36 4/7 weeks gestation for preterm premature rupture of membranes (PPROM) and breech presentation. She was diagnosed with myasthenia gravis (MG) 3 years prior to her pregnancy. She is medicated with pyridostigmine, prednisone and azathioprine to treat her disease at this time. Symptoms initially progressed in her pregnancy, but disappeared completely in the second trimester after adjusting her medications. She reports an upper respiratory infection over the past 3 to 4 days with a
CHERYL K. ROTH SARAH DENT KYLE MCDEVITT
What Is MG? MG is a chronic autoimmune neuromuscular disease, and is the most common disorder of neuromuscular transmission. Two-thirds of affected individuals are female, with common onset in the second and third decade of life (Bird, Stafford, & Dildy, 2014). It’s reported to have an incidence from one in 10,000 to one in 50,000 among women of reproductive age (Varner, 2013). MG is caused by a defect to the transmission of nerve impulses to muscles. The communication from the nerve to the muscle is interrupted at the neuromuscular junction. Normally, when impulses travel down a nerve, acetylcholine is released; it binds with acetylcholine receptors, generating muscle contraction. In MG, antibodies that are produced by the body’s immune system block, alter or destroy the receptors for acetylcholine at the neuromuscular junction (National Institute of Neurological Disorders and Stroke [NINDS], 2014). This prevents muscle contraction from occurring. Some people with MG develop thymomas (tumors of the thymus gland). These thymomas are generally benign, but they can become malignant (Wheatley-Price, Jonker, Jonker, Shamji, & Gomes, 2014). The relationship between the thymus gland and MG isn’t yet fully understood. It’s believed that the thymus gland may give incorrect instructions to developing immune cells, resulting in autoimmunity and the production of the acetylcholine receptor antibodies (NINDS, 2014). The production of these antibodies sets the stage for the attack on neuromuscular transmission seen in MG.
Symptoms MG is characterized by varying degrees of weakness to the muscles of the body, and most commonly affects the muscles that control the eyes, facial expressions, chewing, talking and swallowing. The disease can also affect muscles associated with breathing and neck and limb movement (Téllez-Zenteno, HernándezRonquillo, Salinas, Estanol, & da Silva, 2004). Approximately 50 percent of people with MG present with ocular symptoms of ptosis and/or diplopia. About 15 percent present with bulbar
June | July 2015
symptoms, which include dysarthria, dysphagia and fatigable chewing. Fewer than 5 percent present with proximal limb weakness alone (Bird et al., 2014). A myasthenic crisis occurs when muscles that control breathing weaken to the point that ventilation is inadequate, creating a medical emergency and requiring assisted ventilation. In individuals whose respiratory muscles are affected by their disease, a crisis may be triggered by infection, fever, surgery, emotional stress or an adverse reaction to medication.
In Practice
oxygen saturation levels suddenly drop into the 70s and 80s. She is reporting marked shortness of breath, stating, “I can’t breathe!”
Treatment There are several therapies used to reduce and improve the muscle weakness associated with MG. Medications used to treat the disease include acetylcholinesterase inhibitors, such as neostigmine (Prostigmin, Vagostigmin) and
MG is characterized by varying degrees of weakness to the muscles of the body, and most commonly affects the muscles that control the eyes, facial expressions, chewing, talking and swallowing pyridostigmine (generic only). These drugs help improve muscle weakness and strength and are the first-line treatment for MG. Immunosuppressive glucocorticoid drugs, such as prednisone, azathioprine and cyclosporine (all generic only), may also be used, which improve strength by suppressing the production of antibodies. Thymectomy, the surgical removal of the thymus gland, can reduce symptoms and may cure up to 50 percent of people with the condition. Thymectomy is recommended for patients with thymoma. Other therapies used to treat MG include plasmapheresis, a procedure in which the abnormal antibodies are removed from the blood, and high-dose intravenous immune globulin, which temporarily modifies the immune system. This therapy may be used to help individuals during especially difficult periods of weakness (NINDS, 2014).
Antepartum Considerations Antepartum considerations include the following:
Nursing for Women’s Health
249
In Practice postpartum period are the most common times for MG symptom exacerbation
• Preconception planning is important. Pregnancy is not recommended in the first 2 years following diagnosis, as maternal morbidity is higher during this period (Kalidindi et al., 2007). Cheryl K. Roth, PhD, WHNP-BC, RNC-OB, RNFA, is a nurse practitioner at Honor Health Scottsdale Shea Medical Center in Scottsdale, AZ. Sarah Dent, MSN, RNCOB, is a clinical director at Honor Health Scottsdale Shea Medical Center in Scottsdale, AZ. Kyle McDevitt, MSN, RN, is a student at Arizona State University in Phoenix, AZ. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: cheryl.roth@ honorhealth.com.
250
Nursing for Women’s Health
• Women with MG should have an informed discussion with their health care provider regarding the medical management of their disease throughout their pregnancy and should understand the fetal and maternal risks. • During pregnancy, two-thirds of women with MG experience no changes to the clinical course of their disease, while one-third have an exacerbation of their disease. The first trimester and the immediate postpartum period are the most common times for MG symptom exacerbation. Symptoms improve in the second and third trimester in 20 percent to 40 percent of patients. Complete remission can occur in some people. • Acetylcholinesterase inhibitor dose adjustment may be required in pregnancy as a
result of increased renal clearance, expanded maternal blood volume and delayed gastric emptying. Glucocorticoids may be used if anticholinesterases don’t control symptoms. Glucocorticoid medications have been wellstudied in pregnancy, and have been found to be relatively safe. However, high doses of cyclosporine and azathioprine have been linked to spontaneous abortion, preterm labor, low birth weight, chromosomal damage and hematologic suppression. The risk of using these medications in pregnancy should be weighed against the benefit of controlling myasthenic symptoms (Bird et al., 2014). • The benefit versus risk of intravenous immunoglobulins in pregnancy must be considered. These interventions should be reserved for cases in which other therapies have failed and respiratory failure or profound dysphagia and weakness threatens a mother and fetus (Ellison, Thomson, Walker, & Greer, 2000). • Diligent assessment and prompt treatment of infections in pregnant women with MG is indicated, as infection may precipitate a flare. In one study of 65 pregnant women with MG, four women had infection (pyelonephritis, endometritis or mastitis) and all developed exacerbations (Djelmis, Sostarko,
Volume 19
Issue 3
Photos © iStock Collection / thinkstockphotos.com
The first trimester and the immediate
• An anesthesia consult is recommended before labor and birth as the plan of care must be individualized. Care will need to be individualized based on a woman’s disease history. Regional anesthesia is recommended for mild to moderate disease when vaginal birth is anticipated. General anesthesia is recommended for women with severe disease (Bird et al., 2014).
Intrapartum Considerations Intrapartum considerations include the following: • Magnesium sulfate is contraindicated for women with MG since it can precipitate a severe crisis (Bird et al., 2014). Severe hypertension can be treated with methyldopa or hydralazine, while calcium channel blockers and beta blockers, such as labetalol, should be avoided if possible. Seizure prophylaxis may need to be managed in coordination with neurology providers. • Continuous fetal monitoring is indicated during a myasthenic crisis if the fetus is at a viable gestational age. Birth during a myasthenic crisis is not optimal, as it’s an additional stressor for the woman. The decision to initiate birth must be based on the total obstetric picture. • The first stage of labor is not affected because the uterus is made of smooth muscle, which doesn’t have the acetylcholine receptors affected by MG. The second stage of labor may be affected because the muscles used during pushing may easily weaken (Chaudhry, Vignarajah, & Koren, 2012). An instrument-assisted birth should be considered to reduce the effects of maternal fatigue on birth. Stress and exertion can precipitate a myasthenic crisis. Because the uterus is made of smooth muscle and not affected by the presence of acetylcholine receptor antibodies, there’s not a higher risk of uterine atony during crisis, but surgery can worsen a myasthenic crisis (Chaudhry et al., 2012). Decisions regarding cesarean surgical birth
June | July 2015
The first stage of labor is not affected because the uterus is made of smooth muscle, which doesn’t have the acetylcholine receptors affected by MG during a crisis must be individualized based on benefit versus risk. • Sedatives, opioids and tranquilizers can exacerbate respiratory depression and should be used with caution (Berlit, Tuschy, Spaich, Suttenlin, & Schaffelder, 2012). These might include morphine and other anesthetic agents (Hopkins, Alshaeri, Akst, & Berger, 2014).
In Practice
Mayer, &Ivanisevic, 2002). Complaints of dyspnea or cough call for prompt evaluation for possible myasthenic flare with diaphragm and respiratory muscle weakness (Stafford & Dildy, 2005).
• Mortality risk is highest risk in the first year, with risk decreasing after 7 years (Chaudhry et al., 2012).
Fetal Considerations Fetal considerations include the following: • Fetal risks include neonatal MG, prematurity, severe malformation and death (Bird et al., 2014). • The development of fetal abnormalities related to transplacental passage of antiacetylcholine antibodies is a major concern during pregnancy. This can occur in 10 percent to 20 percent of pregnancies (Varner, 2013). Abnormal sonographic findings in affected pregnancies may include polyhydramnios due to impaired fetal swallowing. • Symptoms of respiratory distress, poor feeding and flaccid tone usually appear within 48 hours of birth and may be ongoing for up to 3 months. All infants born to women with MG should be observed in a special care nursery for the first 48 to 72 hours of life. • In subsequent pregnancies the risk of recurrence of neonatal MG is approximately 75 percent (Bird et al., 2014).
Postpartum Considerations Postpartum considerations include the following: • Breastfeeding isn’t contraindicated in women with MG. Glucocorticoids can be used safely in lactation, but breastfeeding isn’t
Nursing for Women’s Health
251
Djelmis, J., Sostarko, M., Mayer, D., & Ivanisevic, M. (2002). Myasthenia gravis in pregnancy: Report on 69 cases. European Journal of Obstetrics Gynecology and Reproductive Biology, 104(1), 21–25. Ellison, J., Thomson, A. J., Walker, I. D., & Greer, I. A. (2000), Thrombocytopenia and leucopenia precipitated by pregnancy in a woman with myasthenia gravis. BJOG: An International Journal of Obstetrics & Gynaecology, 107, 1052– 1054. doi:10.1111/j.1471-0528.2000. tb10414.x Hopkins, A. N., Alshaeri, T., Akst, S. A., & Berger, J. S. (2014). Neurologic disease with pregnancy and considerations for the obstetric anesthesiologist. Seminars in Perinatology, 38(6), 359–369. Kalidindi, M., Ganpot, S., Tahmesebi, F., Govind, A., Okolo, S., & Yoong, W. (2007). Myasthenia gravis and pregnancy. Journal of Obstetrics and Gynaecology, 27(1), 30–32. National Institute of Neurological Disorders and Stroke (NINDS). (2014). Myasthenia gravis fact sheet. Retrieved from www.ninds.nih.gov/disorders/ myasthenia_gravis/detail_ myasthenia_gravis.htm Stafford, I. P., & Dildy, G. A. (2005). Myasthenia gravis and pregnancy. Clinics in Obstetrics & Gynecology, 48, 48.
severe malformation and death recommended for women taking azathioprine, cyclosporine and methotrexate.
The Rest of the Story … You quickly called for help, anesthesia arrived to the room immediately and intubated the woman, performing bag and mask ventilation until she was transferred to the intensive care unit for mechanical ventilation. She was treated with pyridostigmine, azathioprine and corticosteroids and received intravenous immunoglobulin and five treatments of plasmapheresis. After 2 days she was extubated and transferred to
252
Nursing for Women’s Health
postpartum, and was discharged home in good clinical condition on the fifth postpartum day. NWH
References Berlit, B., Tuschy, B., Spaich, S., Suttenlin, M., & Schaffelder, R. (2012). Myasthenia gravis in pregnancy: A case report. Obstetrics & Gynecology, 73(60), 24 .
Varner, M.(2013). Myasthenia gravis and pregnancy. Clinics in Obstetrics & Gynecology, 56(2), 372–381. Wheatley-Price, P., Jonker, H., Jonker, D., Shamji, F., & Gomes, M. M. (2014). Thymic epithelial neoplasms: A 12-year Canadian regional cancer program experience. Clinical Lung Cancer, 15(3), 231–236. doi:10.1016/j.cllc.2013.12.003
Bird, J., Stafford, I., & Dildy, G. (2014). Myasthenia gravis. Up to Date. Retrieved from www.uptodate.com/ contents/management-of-myastheniagravis-in-pregnancy Chaudhry, S. A., Vignarajah, B., & Koren, G. (2012) Myasthenia gravis during pregnancy. Canadian Family Physician, 58(12),1346–1349.
Volume 19
Issue 3
Photos © iStock Collection / thinkstockphotos.com
Fetal risks include neonatal MG, prematurity,
Téllez-Zenteno, J. F., Hernández-Ronquillo, L., Salinas, V., Estanol, B., & da Silva, O. (2004). Myasthenia gravis and pregnancy: Clinical implications and neonatal outcome. BMC Musculoskeletal Disorders, 5, 42.
Myasthenia Gravis in Pregnancy persistent nonproductive cough. Her lungs are clear to auscultation bilaterally. Regional spinal anesthesia is performed without incident. She is in the obstetric postanesthesia care unit (PACU) post cesarean surgical birth. Her first hour in the PACU is uneventful and she and her baby are showing no signs of muscle weakness. Maternal vital signs are 122/78, 78, 18 with oxygen saturation 99 percent on room air. During the second hour of recovery, her
Abstract Myasthenia gravis (MG) is a chronic autoimmune neuromuscular disease and is the most common disorder of neuromuscular transmission. MG is caused by a defect in the transmission of nerve impulses to muscles in which communication from nerves to muscles is interrupted at the neuromuscular junction. This interruption can cause significant impact to muscle functions, which can have serious consequences for a pregnant woman, especially during labor. This brief article, which is meant to be used as an easy-reference tool in the clinical setting, examines the disease process and its eff ect on the antepartum, intrapartum and postpartum periods. DOI: 10.1111/1751-486X.12206 Keywords autoimmune disorder | myasthenia gravis | neuromuscular | pregnancy
248
© 2015, AWHONN
http://nwh.awhonn.org
Photo © iStock Collection / thinkstockphotos.com
I
Imagine that you’re caring for a 34-year-old primigravida at 36 4/7 weeks gestation for preterm premature rupture of membranes (PPROM) and breech presentation. She was diagnosed with myasthenia gravis (MG) 3 years prior to her pregnancy. She is medicated with pyridostigmine, prednisone and azathioprine to treat her disease at this time. Symptoms initially progressed in her pregnancy, but disappeared completely in the second trimester after adjusting her medications. She reports an upper respiratory infection over the past 3 to 4 days with a
CHERYL K. ROTH SARAH DENT KYLE MCDEVITT
What Is MG? MG is a chronic autoimmune neuromuscular disease, and is the most common disorder of neuromuscular transmission. Two-thirds of affected individuals are female, with common onset in the second and third decade of life (Bird, Stafford, & Dildy, 2014). It’s reported to have an incidence from one in 10,000 to one in 50,000 among women of reproductive age (Varner, 2013). MG is caused by a defect to the transmission of nerve impulses to muscles. The communication from the nerve to the muscle is interrupted at the neuromuscular junction. Normally, when impulses travel down a nerve, acetylcholine is released; it binds with acetylcholine receptors, generating muscle contraction. In MG, antibodies that are produced by the body’s immune system block, alter or destroy the receptors for acetylcholine at the neuromuscular junction (National Institute of Neurological Disorders and Stroke [NINDS], 2014). This prevents muscle contraction from occurring. Some people with MG develop thymomas (tumors of the thymus gland). These thymomas are generally benign, but they can become malignant (Wheatley-Price, Jonker, Jonker, Shamji, & Gomes, 2014). The relationship between the thymus gland and MG isn’t yet fully understood. It’s believed that the thymus gland may give incorrect instructions to developing immune cells, resulting in autoimmunity and the production of the acetylcholine receptor antibodies (NINDS, 2014). The production of these antibodies sets the stage for the attack on neuromuscular transmission seen in MG.
Symptoms MG is characterized by varying degrees of weakness to the muscles of the body, and most commonly affects the muscles that control the eyes, facial expressions, chewing, talking and swallowing. The disease can also affect muscles associated with breathing and neck and limb movement (Téllez-Zenteno, HernándezRonquillo, Salinas, Estanol, & da Silva, 2004). Approximately 50 percent of people with MG present with ocular symptoms of ptosis and/or diplopia. About 15 percent present with bulbar
June | July 2015
symptoms, which include dysarthria, dysphagia and fatigable chewing. Fewer than 5 percent present with proximal limb weakness alone (Bird et al., 2014). A myasthenic crisis occurs when muscles that control breathing weaken to the point that ventilation is inadequate, creating a medical emergency and requiring assisted ventilation. In individuals whose respiratory muscles are affected by their disease, a crisis may be triggered by infection, fever, surgery, emotional stress or an adverse reaction to medication.
In Practice
oxygen saturation levels suddenly drop into the 70s and 80s. She is reporting marked shortness of breath, stating, “I can’t breathe!”
Treatment There are several therapies used to reduce and improve the muscle weakness associated with MG. Medications used to treat the disease include acetylcholinesterase inhibitors, such as neostigmine (Prostigmin, Vagostigmin) and
MG is characterized by varying degrees of weakness to the muscles of the body, and most commonly affects the muscles that control the eyes, facial expressions, chewing, talking and swallowing pyridostigmine (generic only). These drugs help improve muscle weakness and strength and are the first-line treatment for MG. Immunosuppressive glucocorticoid drugs, such as prednisone, azathioprine and cyclosporine (all generic only), may also be used, which improve strength by suppressing the production of antibodies. Thymectomy, the surgical removal of the thymus gland, can reduce symptoms and may cure up to 50 percent of people with the condition. Thymectomy is recommended for patients with thymoma. Other therapies used to treat MG include plasmapheresis, a procedure in which the abnormal antibodies are removed from the blood, and high-dose intravenous immune globulin, which temporarily modifies the immune system. This therapy may be used to help individuals during especially difficult periods of weakness (NINDS, 2014).
Antepartum Considerations Antepartum considerations include the following:
Nursing for Women’s Health
249
In Practice postpartum period are the most common times for MG symptom exacerbation
• Preconception planning is important. Pregnancy is not recommended in the first 2 years following diagnosis, as maternal morbidity is higher during this period (Kalidindi et al., 2007). Cheryl K. Roth, PhD, WHNP-BC, RNC-OB, RNFA, is a nurse practitioner at Honor Health Scottsdale Shea Medical Center in Scottsdale, AZ. Sarah Dent, MSN, RNCOB, is a clinical director at Honor Health Scottsdale Shea Medical Center in Scottsdale, AZ. Kyle McDevitt, MSN, RN, is a student at Arizona State University in Phoenix, AZ. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: cheryl.roth@ honorhealth.com.
250
Nursing for Women’s Health
• Women with MG should have an informed discussion with their health care provider regarding the medical management of their disease throughout their pregnancy and should understand the fetal and maternal risks. • During pregnancy, two-thirds of women with MG experience no changes to the clinical course of their disease, while one-third have an exacerbation of their disease. The first trimester and the immediate postpartum period are the most common times for MG symptom exacerbation. Symptoms improve in the second and third trimester in 20 percent to 40 percent of patients. Complete remission can occur in some people. • Acetylcholinesterase inhibitor dose adjustment may be required in pregnancy as a
result of increased renal clearance, expanded maternal blood volume and delayed gastric emptying. Glucocorticoids may be used if anticholinesterases don’t control symptoms. Glucocorticoid medications have been wellstudied in pregnancy, and have been found to be relatively safe. However, high doses of cyclosporine and azathioprine have been linked to spontaneous abortion, preterm labor, low birth weight, chromosomal damage and hematologic suppression. The risk of using these medications in pregnancy should be weighed against the benefit of controlling myasthenic symptoms (Bird et al., 2014). • The benefit versus risk of intravenous immunoglobulins in pregnancy must be considered. These interventions should be reserved for cases in which other therapies have failed and respiratory failure or profound dysphagia and weakness threatens a mother and fetus (Ellison, Thomson, Walker, & Greer, 2000). • Diligent assessment and prompt treatment of infections in pregnant women with MG is indicated, as infection may precipitate a flare. In one study of 65 pregnant women with MG, four women had infection (pyelonephritis, endometritis or mastitis) and all developed exacerbations (Djelmis, Sostarko,
Volume 19
Issue 3
Photos © iStock Collection / thinkstockphotos.com
The first trimester and the immediate
• An anesthesia consult is recommended before labor and birth as the plan of care must be individualized. Care will need to be individualized based on a woman’s disease history. Regional anesthesia is recommended for mild to moderate disease when vaginal birth is anticipated. General anesthesia is recommended for women with severe disease (Bird et al., 2014).
Intrapartum Considerations Intrapartum considerations include the following: • Magnesium sulfate is contraindicated for women with MG since it can precipitate a severe crisis (Bird et al., 2014). Severe hypertension can be treated with methyldopa or hydralazine, while calcium channel blockers and beta blockers, such as labetalol, should be avoided if possible. Seizure prophylaxis may need to be managed in coordination with neurology providers. • Continuous fetal monitoring is indicated during a myasthenic crisis if the fetus is at a viable gestational age. Birth during a myasthenic crisis is not optimal, as it’s an additional stressor for the woman. The decision to initiate birth must be based on the total obstetric picture. • The first stage of labor is not affected because the uterus is made of smooth muscle, which doesn’t have the acetylcholine receptors affected by MG. The second stage of labor may be affected because the muscles used during pushing may easily weaken (Chaudhry, Vignarajah, & Koren, 2012). An instrument-assisted birth should be considered to reduce the effects of maternal fatigue on birth. Stress and exertion can precipitate a myasthenic crisis. Because the uterus is made of smooth muscle and not affected by the presence of acetylcholine receptor antibodies, there’s not a higher risk of uterine atony during crisis, but surgery can worsen a myasthenic crisis (Chaudhry et al., 2012). Decisions regarding cesarean surgical birth
June | July 2015
The first stage of labor is not affected because the uterus is made of smooth muscle, which doesn’t have the acetylcholine receptors affected by MG during a crisis must be individualized based on benefit versus risk. • Sedatives, opioids and tranquilizers can exacerbate respiratory depression and should be used with caution (Berlit, Tuschy, Spaich, Suttenlin, & Schaffelder, 2012). These might include morphine and other anesthetic agents (Hopkins, Alshaeri, Akst, & Berger, 2014).
In Practice
Mayer, &Ivanisevic, 2002). Complaints of dyspnea or cough call for prompt evaluation for possible myasthenic flare with diaphragm and respiratory muscle weakness (Stafford & Dildy, 2005).
• Mortality risk is highest risk in the first year, with risk decreasing after 7 years (Chaudhry et al., 2012).
Fetal Considerations Fetal considerations include the following: • Fetal risks include neonatal MG, prematurity, severe malformation and death (Bird et al., 2014). • The development of fetal abnormalities related to transplacental passage of antiacetylcholine antibodies is a major concern during pregnancy. This can occur in 10 percent to 20 percent of pregnancies (Varner, 2013). Abnormal sonographic findings in affected pregnancies may include polyhydramnios due to impaired fetal swallowing. • Symptoms of respiratory distress, poor feeding and flaccid tone usually appear within 48 hours of birth and may be ongoing for up to 3 months. All infants born to women with MG should be observed in a special care nursery for the first 48 to 72 hours of life. • In subsequent pregnancies the risk of recurrence of neonatal MG is approximately 75 percent (Bird et al., 2014).
Postpartum Considerations Postpartum considerations include the following: • Breastfeeding isn’t contraindicated in women with MG. Glucocorticoids can be used safely in lactation, but breastfeeding isn’t
Nursing for Women’s Health
251
Djelmis, J., Sostarko, M., Mayer, D., & Ivanisevic, M. (2002). Myasthenia gravis in pregnancy: Report on 69 cases. European Journal of Obstetrics Gynecology and Reproductive Biology, 104(1), 21–25. Ellison, J., Thomson, A. J., Walker, I. D., & Greer, I. A. (2000), Thrombocytopenia and leucopenia precipitated by pregnancy in a woman with myasthenia gravis. BJOG: An International Journal of Obstetrics & Gynaecology, 107, 1052– 1054. doi:10.1111/j.1471-0528.2000. tb10414.x Hopkins, A. N., Alshaeri, T., Akst, S. A., & Berger, J. S. (2014). Neurologic disease with pregnancy and considerations for the obstetric anesthesiologist. Seminars in Perinatology, 38(6), 359–369. Kalidindi, M., Ganpot, S., Tahmesebi, F., Govind, A., Okolo, S., & Yoong, W. (2007). Myasthenia gravis and pregnancy. Journal of Obstetrics and Gynaecology, 27(1), 30–32. National Institute of Neurological Disorders and Stroke (NINDS). (2014). Myasthenia gravis fact sheet. Retrieved from www.ninds.nih.gov/disorders/ myasthenia_gravis/detail_ myasthenia_gravis.htm Stafford, I. P., & Dildy, G. A. (2005). Myasthenia gravis and pregnancy. Clinics in Obstetrics & Gynecology, 48, 48.
severe malformation and death recommended for women taking azathioprine, cyclosporine and methotrexate.
The Rest of the Story … You quickly called for help, anesthesia arrived to the room immediately and intubated the woman, performing bag and mask ventilation until she was transferred to the intensive care unit for mechanical ventilation. She was treated with pyridostigmine, azathioprine and corticosteroids and received intravenous immunoglobulin and five treatments of plasmapheresis. After 2 days she was extubated and transferred to
252
Nursing for Women’s Health
postpartum, and was discharged home in good clinical condition on the fifth postpartum day. NWH
References Berlit, B., Tuschy, B., Spaich, S., Suttenlin, M., & Schaffelder, R. (2012). Myasthenia gravis in pregnancy: A case report. Obstetrics & Gynecology, 73(60), 24 .
Varner, M.(2013). Myasthenia gravis and pregnancy. Clinics in Obstetrics & Gynecology, 56(2), 372–381. Wheatley-Price, P., Jonker, H., Jonker, D., Shamji, F., & Gomes, M. M. (2014). Thymic epithelial neoplasms: A 12-year Canadian regional cancer program experience. Clinical Lung Cancer, 15(3), 231–236. doi:10.1016/j.cllc.2013.12.003
Bird, J., Stafford, I., & Dildy, G. (2014). Myasthenia gravis. Up to Date. Retrieved from www.uptodate.com/ contents/management-of-myastheniagravis-in-pregnancy Chaudhry, S. A., Vignarajah, B., & Koren, G. (2012) Myasthenia gravis during pregnancy. Canadian Family Physician, 58(12),1346–1349.
Volume 19
Issue 3
Photos © iStock Collection / thinkstockphotos.com
Fetal risks include neonatal MG, prematurity,
Téllez-Zenteno, J. F., Hernández-Ronquillo, L., Salinas, V., Estanol, B., & da Silva, O. (2004). Myasthenia gravis and pregnancy: Clinical implications and neonatal outcome. BMC Musculoskeletal Disorders, 5, 42.
