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Himmelwright RS, Dominguez JE. Postpartum Respiratory Depression. Anesthesiol Clin 2021; 39:687-709. [PMID: 34776104 DOI: 10.1016/j.anclin.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Postpartum respiratory depression is a complex, multifactorial issue that encompasses a patient's baseline preexisting conditions, certain pregnancy-specific conditions or complications, as well as the iatrogenic element of various medications given in the peripartum period. In this review, we discuss many of these factors including obesity, sleep-disordered breathing, chronic lung disease, neuromuscular disorders, opioids, preeclampsia, peripartum cardiomyopathy, postpartum hemorrhage, amniotic fluid embolism, sepsis, acute respiratory distress syndrome (ARDS), and medications such as analgesics, sedatives, anesthetics, and magnesium. Current recommendations for screening, treatment, and prevention are also discussed.
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Affiliation(s)
| | - Jennifer E Dominguez
- Duke University Medical Center, DUMC 3094, MS#9, 2301 Erwin Road, Durham, NC 27710, USA.
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Santos E, Braga A, Gabriel D, Duarte S, Martins da Silva A, Matos I, Freijo M, Martins J, Silveira F, Nadais G, Sousa F, Fraga C, Santos Silva R, Lopes C, Gonçalves G, Pinto C, Sousa Braga J, Leite MI. MuSK myasthenia gravis and pregnancy. Neuromuscul Disord 2017; 28:150-153. [PMID: 29305138 DOI: 10.1016/j.nmd.2017.11.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 10/19/2017] [Accepted: 11/21/2017] [Indexed: 01/15/2023]
Abstract
Muscle specific kinase (MuSK) myasthenia gravis (MG, MuSK-MG) is a rare subgroup of MG affecting mainly women during childbearing years. We investigated the influence of pregnancy in the course of MuSK-MG and pregnancy outcomes in females with MuSK-MG. A multicentre cohort of 17 women with MuSK-MG was studied retrospectively; 13 of them with ≥1 pregnancy. MuSK-MG onset age was 35,4 years; 23,0% had other autoimmune disorder; 46,2% were treatment refractory. Thirteen women experienced 27 pregnancies, either after MG onset (group I) (n = 4; maternal age at conception = 29.8 years) or before MG onset (group II) (n = 23; maternal age at conception = 26.2 years). In group I pregnancy occurred in average 9.8 years after the MG onset; it occurred in average 17.0 years before MG in group II. In group I, all were on steroids at time of conception, one on azathioprine and another receiving IVIG regularly. There were mild exacerbations that responded to treatment adjustments. There were no relapses in the 12 months following the delivery. There was no pre-eclampsia, birth defects or stillbirths in either group; 3 miscarriages in group II. One case of neonatal MG was recorded. In this small series, pregnancy did not seem to precipitate MuSK-MG or to have a major influence in the MuSK-MG course, and there was no apparent negative impact in pregnancy outcomes in those where pregnancy followed the MG onset. The weight was lower in the newborn of the group I mothers, although none had low birth weight.
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Affiliation(s)
- Ernestina Santos
- Neurology Department, Hospital Santo Antonio, Centro Hospitalar Porto, Porto, Portugal; Unit for Multidisciplinary Research in Biomedicine, Instituto de Ciencias Biomedicas de Abel Salazar, Universidade do Porto, Porto, Portugal.
| | - Antonio Braga
- Obstetrics Department, Centro Materno-Infantil do Norte, Centro Hospitalar Porto, Porto, Portugal
| | - Denis Gabriel
- Neurology Department, Hospital Santo Antonio, Centro Hospitalar Porto, Porto, Portugal
| | - Sara Duarte
- Neurology Department, Hospital Santo Antonio, Centro Hospitalar Porto, Porto, Portugal
| | - Ana Martins da Silva
- Neurology Department, Hospital Santo Antonio, Centro Hospitalar Porto, Porto, Portugal; Unit for Multidisciplinary Research in Biomedicine, Instituto de Ciencias Biomedicas de Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Ilda Matos
- Neurology Department, Centro Hospitalar do Nordeste, Mirandela, Portugal
| | - Marta Freijo
- Neurology Department, Centro Hospitalar do Nordeste, Mirandela, Portugal
| | - Joao Martins
- Neurology Department, Hospital de Pedro Hispano, Matosinhos, Portugal
| | | | - Goreti Nadais
- Neurology Department, Hospital Sao Joao, Porto, Portugal
| | - Filipa Sousa
- Neurology Department, Hospital de Braga, Braga, Portugal
| | - Carla Fraga
- Centro Hospitalar do Vale do Sousa, Penafiel, Portugal
| | - Rosa Santos Silva
- Neurology Department, Centro Hospitalar do Alto Minho, Viana do Castelo, Portugal
| | - Carlos Lopes
- Instituto de Ciencias Biomedicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Guilherme Gonçalves
- Unit for Multidisciplinary Research in Biomedicine, Instituto de Ciencias Biomedicas de Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Clara Pinto
- Obstetrics Department, Centro Materno-Infantil do Norte, Centro Hospitalar Porto, Porto, Portugal
| | - Jorge Sousa Braga
- Obstetrics Department, Centro Materno-Infantil do Norte, Centro Hospitalar Porto, Porto, Portugal
| | - Maria Isabel Leite
- Nuffield Department of Clinical Neurosciences, Oxford University Hospitals, University of Oxford, Oxford, United Kingdom
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Boldingh MI, Maniaol AH, Brunborg C, Weedon-Fekjær H, Verschuuren JJGM, Tallaksen CME. Increased risk for clinical onset of myasthenia gravis during the postpartum period. Neurology 2016; 87:2139-2145. [PMID: 27770065 DOI: 10.1212/wnl.0000000000003339] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 08/03/2016] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To study the risk of clinical onset of myasthenia gravis (MG) in pregnancy and during the first 6 months postpartum because an association between pregnancy or the postpartum period and the onset of autoimmune MG is widely assumed but not proven. METHODS The design was a cross-sectional population-based cohort study of 2 MG cohorts (Norway and the Netherlands) with 1,038 healthy controls from Norway. Data were obtained on 246 women with MG (age at onset 15-45 years). Data on pregnancy, hormonal factors, and clinical symptoms were collected by a previously validated environmental MG questionnaire. Relative risk of MG onset before, during, and after pregnancy was calculated by multinomial logistic regression for Norwegian women reaching 45 years of age, adjusted for the observed distribution of person-years in the corresponding control group. RESULTS Of the included women with MG, 13 (11.5%) of the Dutch and 24 (18.0%) of the Norwegian patients had their first myasthenia symptoms during the pregnancy or postpartum period. The postpartum period was confirmed to be significantly associated with the onset of symptoms of MG in Norwegian women with MG (relative risk 5.5, 95% confidence interval 2.6-11.6). The risk was highest after the first childbirth. CONCLUSIONS Women have a high-risk period for the onset of clinical symptoms of MG in the postpartum period, in particular after the first childbirth. Future studies should aim at elucidating the role of the hormonal-immunological-genetic interaction in the pathogenesis of MG.
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Affiliation(s)
- Marion I Boldingh
- From the Department of Neurology (M.I.B., A.H.M., C.M.E.T.) and Oslo Centre for Biostatistics and Epidemiology (C.B., H.W.-F.), Research Support Services, Oslo University Hospital, Norway; Department of Neurology (J.J.G.M.V.), Leiden University Medical Centre, the Netherlands; and Institute of Clinical Medicine (M.I.B., C.M.E.T.), University of Oslo, Norway.
| | - Angelina H Maniaol
- From the Department of Neurology (M.I.B., A.H.M., C.M.E.T.) and Oslo Centre for Biostatistics and Epidemiology (C.B., H.W.-F.), Research Support Services, Oslo University Hospital, Norway; Department of Neurology (J.J.G.M.V.), Leiden University Medical Centre, the Netherlands; and Institute of Clinical Medicine (M.I.B., C.M.E.T.), University of Oslo, Norway
| | - Cathrine Brunborg
- From the Department of Neurology (M.I.B., A.H.M., C.M.E.T.) and Oslo Centre for Biostatistics and Epidemiology (C.B., H.W.-F.), Research Support Services, Oslo University Hospital, Norway; Department of Neurology (J.J.G.M.V.), Leiden University Medical Centre, the Netherlands; and Institute of Clinical Medicine (M.I.B., C.M.E.T.), University of Oslo, Norway
| | - Harald Weedon-Fekjær
- From the Department of Neurology (M.I.B., A.H.M., C.M.E.T.) and Oslo Centre for Biostatistics and Epidemiology (C.B., H.W.-F.), Research Support Services, Oslo University Hospital, Norway; Department of Neurology (J.J.G.M.V.), Leiden University Medical Centre, the Netherlands; and Institute of Clinical Medicine (M.I.B., C.M.E.T.), University of Oslo, Norway
| | - Jan J G M Verschuuren
- From the Department of Neurology (M.I.B., A.H.M., C.M.E.T.) and Oslo Centre for Biostatistics and Epidemiology (C.B., H.W.-F.), Research Support Services, Oslo University Hospital, Norway; Department of Neurology (J.J.G.M.V.), Leiden University Medical Centre, the Netherlands; and Institute of Clinical Medicine (M.I.B., C.M.E.T.), University of Oslo, Norway
| | - Chantal M E Tallaksen
- From the Department of Neurology (M.I.B., A.H.M., C.M.E.T.) and Oslo Centre for Biostatistics and Epidemiology (C.B., H.W.-F.), Research Support Services, Oslo University Hospital, Norway; Department of Neurology (J.J.G.M.V.), Leiden University Medical Centre, the Netherlands; and Institute of Clinical Medicine (M.I.B., C.M.E.T.), University of Oslo, Norway
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Ferrero A, Suárez B, Fernández-Corona A, González García C. Miastenia gravis y gestación: caso clínico. Clínica e Investigación en Ginecología y Obstetricia 2008. [DOI: 10.1016/s0210-573x(08)73045-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Slama A, Toumi M, Tarmiz K, Letaifa Dhafer B, Jazia Khaled B. [Regional anaesthesia for labour and delivery in the myasthenic patient: report of five cases]. Ann Fr Anesth Reanim 2008; 27:180-181. [PMID: 18242043 DOI: 10.1016/j.annfar.2007.11.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Affiliation(s)
- Mohan Gurjar
- All India Institute of Medical Sciences, New Delhi, India.
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Abstract
Many neuromuscular conditions occur more frequently during pregnancy and include carpal tunnel syndrome, Bell's palsy, lumbosacral radiculopathy, meralgia paresthetica, intercostal neuralgia, and other compression neuropathies. Preexisting or coincident neuromuscular diseases, including demyelinating polyneuropathies, inflammatory muscle disease, myasthenia gravis, and inherited nerve and muscle disease present specific problems during pregnancy. We review management of neuromuscular disorders during pregnancy, labor, delivery, and the early postpartum period.
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Affiliation(s)
- Irene P Stafford
- Department of Obstetrics and Gynecology, Louisiana State University Health Sciences Center, New Orleans, Louisiana 70112, USA.
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Abstract
Henoch-Schönlein purpura (HSP) is an IgA-mediated small vessel vasculitis which commonly involves the skin, gastrointestinal system and kidneys. Numerous HSP triggers have been identified, and pregnancy has been reported as an exacerbating factor. After a pregnant woman had been diagnosed as having new-onset HSP, we reviewed all cases of immunofluorescence-proven HSP evaluated by the Department of Dermatology at the Johns Hopkins Hospital between 1990 and 2002, and report three cases of HSP occurring during pregnancy. Two patients developed new-onset HSP, one at 16 weeks gestation and one at 22 weeks, while the third developed a recurrence of HSP at 12 weeks gestation after 19 years of remission. We conclude that pregnancy may be a trigger for HSP onset or recurrence in susceptible individuals.
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Affiliation(s)
- D L Cummins
- Johns Hopkins Hospital, Baltimore, MD, U.S.A
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Abstract
OBJECTIVE To review our experience with pregnancies in women with myasthenia gravis (MG). STUDY DESIGN Sixty nine pregnancies among 65 women with MG patients managed by our department over 28 years were included. The course of the disease in pregnancy, mode of delivery and postpartal period were evaluated. RESULTS One pregnancy miscarried. In 15% of patients the MG deteriorated in pregnancy a further 16% in the puerperium. 17% of pregnancies were delivered by cesarean section, one due to myasthenia exacerbation. All women with puerperal infections developed exacerbations. One neonatal death, not attributable to myasthenia, was recorded. Transitory neonatal myasthenia gravis (TNMG) was diagnosed in 30% infants. Its incidence was inversely associated with maternal disease duration (P < 0.05). Newborns of thymectomized mothers showed lower rate of neonatal myasthenia compared to those of non-thymectomized women (P < 0.05). CONCLUSIONS MG patients can have normal pregnancy and delivery but the course is unpredictable. Shorter disease history and infection predispose to puerperal exacerbation. Maternal thymectomy lessens the likelihood of neonatal myasthenia. An interdisciplinary approach is required for managing the pregnant women with MG.
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Affiliation(s)
- Josip Djelmis
- Department of Obstetrics and Gynecology, Medical School University of Zagreb, Petrova 13, HR-10000 Zagreb, Croatia.
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