Australian and New Zealand Journal of Obstetrics and Gynaecology 2005; 45: 331–332 331 Blackwell Publishing, Ltd. Case Series Myasthenic crisis during pregnancy Successful management of pregnancy-aggravated myasthenic crisis after complete remission of the disease Mohan GURJAR and Manish JAGIA All India Institute of Medical Sciences, New Delhi, India Introduction Myasthenia gravis (MG), a well known neuromuscular disorder, affects women approximately twice as often as it affects men. The highest incidence is seen in women during their reproductive years. During pregnancy, myasthenia results in an increase in maternal mortality, morbidity, pregnancy wastage, and premature labour. 1 Uncommonly, pregnancy can exacerbate this disease to a life-threatening condition called a myasthenic crisis. This case highlights that early recognition of the condition and intensive care of the patient can improve the outcome in these patients. Case report A 31-year-old woman was admitted to the neurology ward with complaints of her eyelids drooping for 1 month, diffi- culty swallowing and an altered voice for 20 days, fatigue while walking and climbing stairs for 2 weeks and shortness of breath for 1 week (Osserman classification of MG, stage 3). She was known to have had myasthenia gravis diagnosed 12 years previously and underwent thymectomy for a thy- moma during the first trimester of her second pregnancy 2.5 years ago. After delivery of the second baby, she received radiotherapy for 5 weeks. This resulted in complete remission of her myasthenic symptoms and anticholinesterase drugs were stopped within 2 months. At the time of admission, she was not on any treatment for myasthenia gravis. Oral pyridostigmine 60 mg, 8 hourly, was started. From the history, examination and ultrasonog- raphy, a diagnosis of missed abortion was made, and retained product of conception were removed on the fifth day of her admission under anaesthesia using low dose fentanyl (0.5 μg/kg) and propofol (2 mg / kg), and a laryngeal mask airway (LMA). Postoperatively, the LMA was removed as the patient was awake and following commands. The patient was admitted to intensive care on the 6th day of her admission with complaints of bulbar weakness and dyspnea at rest. Endotracheal intubation was undertaken after administration of propofol and ventilatory support was provided. A nasogastric tube was placed into her stomach for enteral nutrition and oral medication. This myasthenic crisis was controlled by anticholinesterase medication (oral Neostig- mine 30 mg, 4 hourly) and plasmapheresis (five cycles). Over a period of 2 weeks she was gradually weaned off the venti- latory support and extubated. She was discharged after 3 weeks of intensive care with- out any further complication. At follow up, she remained stable on anticholinesterase medication. Discussion Women with known diagnosis of myasthenia gravis show an unpredictable course of disease during pregnancy. Complete remission, clinical improvement, acute exacerbations or no change in myasthenic symptoms during pregnancy, have all been reported. Plauche’s literature review 1 of 322 pregnan- cies occurring in 225 myasthenic women found exacerbation during pregnancy in 132 (41%) and post partum exacerbations in 96 (30.6%). Only five patients had exacerbations in early pregnancy in this series. In another series of 69 cases of myasthenia gravis in pregnancy reported by Djelmis et al., 2 10 patients (14.5%) developed deterioration during preg- nancy (in the last 4 weeks of pregnancy) and 11 (15.9%) during the puerperium; a total of 21 (30.4%) exacerbations occurred. Other patients’ status remained unchanged or even improved. In myasthenia gravis mothers, pregnancy-associated changes can affect the course of the disease. Worsening of the symptoms in these patients is usually observed more in the first trimester. 3 One of the reason can be early pregnancy- induced nausea or vomiting, resulting in an inability to adhere to the required regular dosages schedule. 1 Increased renal clearance, expanded blood volume, and unpredictable gastrointestinal absorption of oral drugs often alter the pat- tern of medication dosing necessary to maintain myasthenia gravis control. 1 The lower incidence of exacerbation in second and third trimester is likely to be secondary to the immunosuppression that takes place in those phases of ges- tation. 3 A study performed on rats showed that sex hormones do not appear to have an influence on severity of the Correspondence: Dr Manish Jagia, C1A-12C, Janak Puri, New Delhi – 110058, India. Email: address: jagiamanish@yahoo.com Received 05 January 2005; accepted 07 April 2005.