eMedicine Specialties > Obstetrics and Gynecology > Medical Problems in Pregnancy

Myasthenia Gravis and Pregnancy: Follow-up

Author: Idan Sharon, MD, Consulting Staff, Departments of Neurology and Psychiatry, Cornell New York Methodist Hospital; Private Practice
Contributor Information and Disclosures

Updated: Dec 13, 2007

Follow-up

Further Inpatient Care

  • Follow-up consists of evaluating patients for adverse effects of pharmaceuticals and preventing infection. Observing the patient for signs of respiratory deterioration is necessary. The postanesthetic period is very important because postpartum exacerbation is common. Arterial blood gases should be checked often; thus, a surgical ICU is the best place for postoperative myasthenic patients.
  • Rest periods should be emphasized in the months after delivery. Caring for a newborn is difficult, and maternal exhaustion may occur. The disease course is variable and unpredictable during pregnancy and after delivery. One pregnancy without exacerbations does not necessarily mean that future pregnancies carry no risk. Pregnancy can lead to many complications; therefore, the physician must be vigilant.

Complications

  • Some rare problems may occur during pregnancy. Maternal complications are discussed as follows:
    • In 2000, Ellison and colleagues reported a rare case of bone marrow suppression in a patient who experienced leukopenia and thrombocytopenia during all 3 of her pregnancies.10 Her third pregnancy was the most serious. Her platelet count was 48 X 109/L, and her WBC count dropped to 1.5 X 109/L at 35 weeks' gestation. She improved after receiving 65 mg of human immunoglobulin (1 mg/kg for 2 d). Labor was induced, and she delivered a boy. Interestingly, 1 day after each delivery, her platelet and WBC counts increased. On the third postnatal day, her platelet count increased to 128 X 109/L from 82 X 109/L after immunoglobulin transfusion, and her WBC count increased to 2.5 X 109/L from 2.2 X 109/L. Bone marrow suppression has been observed in other pregnant MG patients. In 1992, Igarashi et al reported that suppression could be due to megakaryocyte colony-forming unit suppressive factor produced by autoimmune mechanisms.15
    • Some exacerbations can be linked to the anxiety and physiological stress of pregnancy. Hypoventilation is a risk during pregnancy because respiratory muscles are weakened from MG. Also, the lungs do not become fully inflated because the diaphragm is elevated during pregnancy. Approximately 20% of patients experience respiratory crises that require mechanical ventilation. This is one of most severe complications.
    • Infections due to decreased immunity play a very important role in the exacerbation of MG during pregnancy.
    • Labor also may be complicated. Although smooth muscle is not affected by autoantibodies and the uterus is not compromised, the second stage of labor involves striated muscle. The patient may become exhausted during labor and may require assistance. Forceps delivery has been recommended.
    • In 1979, Duff and colleagues described an association between MG and preeclampsia.9 They observed preeclampsia in 3 patients and reasoned that altered immune status could be an etiologic factor in preeclampsia. Preeclampsia also may be problematic from a pharmacological standpoint because magnesium sulfate is contraindicated in myasthenic patients.
  • Not only is the mother at risk, her baby also faces significant risks, including neonatal MG, prematurity, severe malformation, and death.
    • Rates of neonatal MG are as high as 10-20%. Affected babies show respiratory distress and inadequate suck. Babies are affected by transient myasthenia, which is self-limited and lasts approximately 3 weeks. This is due to the transplacental transfer of antibodies. This is puzzling because no close correlation exists between maternal disease severity and neonatal myasthenia, nor is there a correlation between the occurrence of neonatal MG and maternal anti-AChR antibody titers. These unpredictable results could be due to the protective role of alpha-fetoprotein in neonatal MG. Alpha-fetoprotein has been shown to inhibit the binding of MG antibody to its receptor.
    • More severe neonatal problems have been reported, including death from malformations attributable to MG. In 1991, Carr and colleagues reported that the most common fetal abnormalities are pulmonary hypoplasia and arthrogryposis.8 They reported the case of a patient whose 2 previous births were followed by neonatal death due to malformation. During the patient's third pregnancy, they decided to decrease her antibody titer, which was very high (400 nmol/L), by using plasmapheresis and prednisone. They found that fetal breathing increased when antibody levels were low and it decreased with increasing antibody titers. The presence of abnormalities in this case coincided with the presence of AChR antibodies of high avidity. The hypothesis was that these antibodies inhibited fetal diaphragmatic motion, which resulted in a lack of stimulation of normal fetal lung development.
    • Prematurity is also a concern. In 1991, Plauche compiled the results from various studies and found that premature delivery occurs in approximately 36.5% of cases.2

Miscellaneous

Medicolegal Pitfalls

  • Because many medications can adversely affect patients with myasthenia gravis (MG), the following drugs should be avoided:
    • Narcotics
    • Tranquilizers
    • Barbiturates
    • Inhalation anesthetics (ie, halothane, trichloroethylene, ether)
    • Magnesium and lithium salts
    • Penicillamine
    • Beta-adrenergic agents
    • Quinidine
    • Aminoglycoside antibiotics
    • Colistin
    • Neomycin
    • Tetracycline drugs
    • Lincomycin
    • Polymyxin
    • Quinacrine
    • Chloroquine
 


More on Myasthenia Gravis and Pregnancy

Overview: Myasthenia Gravis and Pregnancy
Differential Diagnoses & Workup: Myasthenia Gravis and Pregnancy
Treatment & Medication: Myasthenia Gravis and Pregnancy
Follow-up: Myasthenia Gravis and Pregnancy
References
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References

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Further Reading

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Keywords

MG, autoimmune neuromuscular disease, human acetylcholine receptors, AChRs, pregnancy complications, pregnancy comorbidity, autoimmune neuromuscular disease, rheumatoid arthritis, systemic lupus erythematosus, SLE, pemphigus, Hashimoto thyroiditis, Hashimoto's thyroiditis, thymic abnormality, scleroderma, dermatitis herpetiformis, autoimmune hemolytic anemia, polymyositis, sarcoidosis, MG and pregnancy

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Contributor Information and Disclosures

Author

Idan Sharon, MD, Consulting Staff, Departments of Neurology and Psychiatry, Cornell New York Methodist Hospital; Private Practice
Idan Sharon, MD is a member of the following medical societies: American Academy of Neurology, American Medical Association, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

Medical Editor

Bryan D Cowan, MD, Professor and Chairman, Department of Obstetrics and Gynecology, University of Mississippi College of Medicine; Consulting Staff, Department of Obstetrics and Gynecology, Veterans Affairs Medical Center; Medical Director, Wiser Hospital for Women, University of Mississippi Medical Center
Bryan D Cowan, MD is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Gynecological and Obstetrical Society, American Medical Association, American Society for Reproductive Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Endocrine Society, Sigma Xi, Society for Assisted Reproductive Technologies, Society for Gynecologic Investigation, Society for the Study of Reproduction, and Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Gail F Whitman-Elia, MD, Professor, Department of Obstetrics and Gynecology, University of South Carolina School of Medicine
Gail F Whitman-Elia, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Clinical Endocrinologists, American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, American Medical Women's Association, American Public Health Association, American Society for Reproductive Medicine, Endocrine Society, and South Carolina Medical Association
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Assumption Community Hospital
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

David Chelmow, MD, Professor of Obstetrics and Gynecology, Tufts University School of Medicine; Program Director, Tufts University Affiliated Hospitals OB/GYN Residency Program; Chair, Tufts University Health Sciences Campus Institutional Review Board
David Chelmow, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, Phi Beta Kappa, Sigma Xi, Society for Gynecologic Investigation, and Society for Medical Decision Making
Disclosure: Nothing to disclose.

 
 
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