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BRIEF COMMUNICATION
Year : 2012  |  Volume : 56  |  Issue : 4  |  Page : 409-411  

Perioperative management of term pregnant patient with Guillian Barre syndrome


1 Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
2 Department of Critical Care, Medanta, Gurgaon, India
3 Department of Anaesthesia, Consultant Anaesthesiologist and Intensivist, Cauvery Hospital, Mysore, Karnataka, India

Date of Web Publication8-Sep-2012

Correspondence Address:
B Jyothi
Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli - 580 022, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.100848

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How to cite this article:
Jyothi B, Verma H, Vaidyanathan, Shaikh SS. Perioperative management of term pregnant patient with Guillian Barre syndrome. Indian J Anaesth 2012;56:409-11

How to cite this URL:
Jyothi B, Verma H, Vaidyanathan, Shaikh SS. Perioperative management of term pregnant patient with Guillian Barre syndrome. Indian J Anaesth [serial online] 2012 [cited 2020 May 28];56:409-11. Available from: http://www.ijaweb.org/text.asp?2012/56/4/409/100848


   Introduction Top


Guillian Barre syndrome (GBS) is rare occurrence in medicine, and possibly even rarer in pregnancies, with an incidence of 1.7/lakh pregnancies. GBS occurrence in pregnancy is associated with an increased need for ventilatory support and increased maternal mortality. There are no established guidelines for the anaesthetic management of a pregnant GBS patient. We describe herein how a case of a 25-year-old primipara at term gestation with GBS was managed in the perioperative period.


   Case Report Top


A 25-year-old primipara with bilateral lower limb (LL) weakness progressing to involve both upper limbs (UL) was admitted to the hospital at 36 weeks of gestation with complaints of dizziness and headache. She had an uneventful obstetric history till then. At admission, her higher mental functions were normal, she had bilateral facial nerve palsy, motor power of 1/5 in all limbs and bilateral plantar flexor response. There were no sensory abnormalities or signs of respiratory distress. Cerebrospinal fluid analysis showed increased protein with no leucocytosis and the characteristic albumino-cytological dissociation, consistent with a diagnosis of GBS. Supportive care like incentive spirometry and chest physiotherapy was given from Day 1 in the Intensive Care Unit (ICU). Plasmapheresis and intravenous (iv) IgG was advised to the patient, but she could not afford the same. Dexamethasone 8 mg iv bid and thromboprophylaxis in the form of subcutaneous (s/c) low molecular weight heparin (LMWH) 5000 IU 8 th hourly was started.

On the 2 nd day, the patient complained of headache, dizziness, episodic bradycardia that responded to atropine 10 μg/kg and fluctuations in blood pressure (BP) that did not need any intervention. On the 10 th day, obstetricians decided to deliver the baby by caesarean section. On the day before surgery, the bulbar weakness had improved and the patient could chew, swallow, vocalise and cough out effectively. Motor power in LL was 1/5 and UL was 2/5, with flaccid paralysis. Baseline Arterial blood gas showed no hypoxia, CO 2 retention or acidosis (pH 7.36, PaO 2 78.5, PaCO 2 33.5). Airway, neck and spine were unremarkable. LMWH was stopped the previous night. Heart rate (HR) response during deep breathing was performed to assess autonomic neuropathy, and was found to be borderline (11-15 beats/min). Coagulation profile was within normal limits. Risk consent and consent for the need of post-operative ventilator support were taken.

General anaesthesia (GA) was administered using a modified rapid sequence induction. The patient was given acid aspiration prophylaxis in the morning. Routine monitors electrocardiogram (ECG), pulse oximetry (SPO 2 ), end tidal carbon dioxide (ETCO 2 ) and non-invasive blood pressure (NIBP) were attached. On the table, glycopyrrolate iv 0.2 mg was given and pre-oxygenated for 3 min, and anaesthesia was induced with vecuronium 0.1 mg/kg followed by lignocaine iv 1 mg/kg and propofol iv 2 mg/kg and intubated with a 7 mm cuffed tracheal tube. She was maintained on nitrous oxide:oxygen 50:50, with intermittent halothane

0.4-0.6% and top up with vecuronium iv 1 mg twice. A male baby weighing 3 kg with APGAR score of 8 at the 1 st minute and 10 at the 5 th minute was delivered. Then, Injection fentanyl iv 1.5 μg/kg and oxytocin 10 units iv infusion was started. A total of 1500 mL of iv fluids was given and the urine output was 120 mL. At the end of surgery, the patient reversed with neostigmine iv 0.05 mg/kg + glycopyrrolate 0.01 mg/kg. As the patient regained consciousness, was obeying commands and had a sustained head lift more than 5 s, the trachea was extubated after thorough throat suction. The patient was monitored in the ICU with supplemental oxygen face mask. On the 14 th day, power in the UL was 3/5 and in the LL was 2/5. She had good respiratory effort and cough reflex and episodes of autonomic instability were not seen. She was discharged from the ICU after an uneventful post-operative course.


   Discussion Top


GBS is an acute post-infectious polyneuropathy of autoimmune nature, characterised by demyelination of the peripheral nervous system and rapidly progressive paralysis. [1],[2] GBS rarely complicates pregnancies, and there are few case reports. [3],[4]

Effects of pregnancy on GBS include the pressure of the gravid uterus on the diaphragm and its subsequent cephalad shift, decreasing functional residual capacity. Bulbar palsy manifests as difficulty in expelling secretions and dysphasia, and inability to maintain a patent airway increases the risk of aspiration. [5] Intubation may be required to secure the airway and, if intercostals/diaphragmatic involvement occurs, ventilatory support may be necessary.

Hypotension can occur due to hypovolaemia, autonomic dysfunction, supine hypotension syndrome, positive pressure ventilation and more than anticipated blood loss during delivery or foetal extraction. This can be managed with proper positioning (wedge below right hip), adequate volume expansion and use of directly acting vasopressors. [6]

In our case, regional anaesthesia was avoided as there are reports of worsening of neurological status of the pregnant GBS patient after delivery under epidural anaesthesia, and those authors believed that the anaesthetic technique played a major role in progression of disease. [7] With existing autonomic dysfunction, we were concerned about exaggerated haemodynamic alterations that can result following central neuraxial block; hence, general anaesthesia was chosen.

The risk of post-operative respiratory dysfunction lead us to use propofol for induction and fentanyl for analgesia. [8] Propofol was given preferably over thiopentone as an induction agent in view of the clear headed recovery and possible additive antiemetic effect. Inhalational induction can increase the risk of atonic uterus and subsequent post-partum haemorrhage. Intermediate-acting non-depolarising muscle relaxants were used instead of succinyl choline as it can cause severe hyperkalaemia due to the release of excessive potassium from the damaged muscles. [9] However, non-depolarising muscle relaxants (NDMRs) are known to produce variable responses. [10] Early in the disease, resistance to NDMR may be due to a denervation effect with an increased number of acetylcholine receptors, which is gradually replaced by re-innervation-induced hypersensitivity. [10] Whenever available, neuromuscular monitoring should be considered as a standard practice. Fortunately, no intraoperative fluctuations in vital signs were observed in this case. Intramuscular diclofenac 75 mg was found to be sufficient for post-operative analgesia.

In conclusion, GBS is rare in pregnancy but can be managed with good maternal and foetal outcome. Careful evaluation and documentation of then patient's baseline neurological status, thorough drug history and timely discussion with the patient regarding the risks and benefits of various techniques will help in achieving safe perioperative patient outcome.

 
   References Top

1.Kocabas S, Karaman S, Firat V, Bademkiran F. Anaesthetic management of Guillian-Barre syndrome in pregnancy. J Clin Anesth 2007;19:299-302.  Back to cited text no. 1
[PUBMED]    
2.Connelly M, Shagrin J, Warfield C. Epidural opioids for management of pain in a patient with GBS. Anaesthesiology 1990;72:381-3.  Back to cited text no. 2
[PUBMED]    
3.Gupta R, Chhabra B, Senthilnathan TA, Bharadwaj M, Ghei A, Thakur A. Critical care of pregnant patient with GBS. Indian J Anaesth 2003;47:50-2.  Back to cited text no. 3
    
4.Brooks H, Christian AS, May AE. Pregnancy, Anaesthesia and GBS. Anaesthesia 2000;55:894-8.  Back to cited text no. 4
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5.Newsanger DL, Warren CR. Guillian Barre Syndrome. Am Fam Phy 2004;69:2405-10.  Back to cited text no. 5
    
6.Zochodne DW. Autonomic involvement in GBS- a review. Muscle Nerve 1994;17:1145-55.  Back to cited text no. 6
[PUBMED]    
7.Wiertlewski S, Magot A, Drapier S, Malinovsky JM, Pereon Y. Worsening of neurological symptoms after epidural anaesthesia for labor in GB patient. Anaesth Analg 2004;98:825-7.  Back to cited text no. 7
    
8.Gipson C, Tobias JD. Perioperative care of child with GBS. Saudi J Anaesth 2008;2:67-73.   Back to cited text no. 8
    
9.Feldman JM. Cardiac arrest after succinylcholine in a pregnant patient recovered from GBS. Anaesthesiology 1990;72:942-4.  Back to cited text no. 9
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10.Fiacchino F, Gemma M, Bricchi M, Giudici D, Ciano C . Hypo and Hypersensitivity to vecuronium in a patient with GBS. Anaesth Analg 1994;78:187-9.  Back to cited text no. 10
    




 

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