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Excerpt
Case: A 31 year old primip underwent cesarean delivery for worsening myasthenia. She had multiple previous ICU admissions for respiratory compromise although PFTs in pregnancy were normal. Symptoms included dysphonia, dysphagia and severe gastroesophageal reflux.
Body mass index was normal. Mallampati score was 1 with excellent mouth opening and jaw protrusion. Following aspiration prophylaxis an epidural was sited L3/4. 20mls 2% Lidocaine with 1 in 200,000 epinephrine and 100micrograms of fentanyl was incrementally administered achieving a T6 pinprick block bilaterally. Surgery proceeded uneventfully, she experienced no dyspnea and saturations were maintained at 96 - 99% on air. 3mg of epidural morphine provided good postoperative analgesia. Following 48 hours of intense monitoring she was discharged to a postnatal ward.
On postoperative day 3 she suffered an acute myasthenic exacerbation with excessive drooling and deterioration in pulmonary function (peak flow rate reduced from 400l/min to 130l/min). She underwent plasmapheresis and was discharged two weeks later.
Discussion: Epidural anesthesia provided sufficient anesthesia for cesarean section without compromising respiratory function in a patient with severe myasthenia gravis. This avoided using muscle relaxants, narcotics, barbiturates and inhalational anesthetics all of which can exacerbate myasthenia and result in postoperative ventilation. This case also highlights the unpredictable nature of myasthenia gravis in pregnancy and the need for careful monitoring particularly postpartum (4).
