Hindawi Publishing Corporation
Case Reports in Obstetrics and Gynecology
Volume 2012, Article ID 736024, 4 pages
Myasthenia GravisinPregnancy:A Case Report
SebastianBerlit,Benjamin Tuschy,SaskiaSpaich,Marc S¨ utterlin,
Department of Obstetrics and Gynecology, University Medical Center Mannheim, 68167 Mannheim, Germany
Correspondence should be addressed to Sebastian Berlit, firstname.lastname@example.org
Received 22 October 2011; Accepted 6 December 2011
Academic Editors: E. Bujold and Y. Purwosunu
Copyright © 2012 Sebastian Berlit et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
Objective. To present a case of maternal myasthenia gravis in pregnancy and give a systematic review of the literature. Case.
We report the case of a 38-year-old parturient with a life-threatening complication of immune-mediated myasthenia gravis
shortly after an elective cesarean section on patient’s request under spinal anesthesia at 35 + 3 weeks of gestation. The newborn
was transferred to the pediatric unit for surveillance and did not show any signs of muscular weakness in the course of time.
The mother developed a respiratory insufficiency on the second day postpartum. The myasthenic crisis led to a progressive
dyspnoea within minutes, which exacerbated in a secondary generalized seizure with cardiac-circulatory arrest. After successful
cardiopulmonary resuscitation, the patient was transferred to intensive care. The interdisciplinary therapeutic approach included
ventilatory assistance via endotracheal intubation, parenteral pyridostigmine, azathioprine, and steroids. By interdisciplinary
measures, a stable state was regained. Conclusion. Myasthenia gravis especially when associated with pregnancy is a high-risk
disease. As this disease predominantly occurs in women of reproductive age, it is important to be aware of this condition in
obstetrics and its interdisciplinary diagnostic and therapeutic management.
The heterogeneous group of congenital and acquired myas-
thenia gravis (MG) syndromes is clinically characterized
by an insufficient neuromuscular transmission leading to
progressive paresis. Myasthenia gravis is an autoimmune
disorder of the neuromuscular transmission, caused by
autoantibodies against the nicotinic acetylcholine receptor,
hence leading to an insufficient nerve impulse transmission
to striated muscle fibers . These antibodies of the IgG
isotype are detected in 80–90% of generalized MG and in
50–70% of ocular MG . Seronegative MG is caused by
humoral factors. In 40% of patients with seronegative MG
IgG antibodies against the muscle specific kinase (MuSK) are
found and do not occur in patients with seropositive MG
Prevalence of MG lays between 1 in 10.000 and 1 in
50.000, with 2/3 of affected individuals being female. Com-
their reproductive years, are affected [5, 6].
In the case of maternal myasthenia gravis, both the
mother and the child may develop myasthenia symptoms
with varying degrees of weakness and progressive fatigability
of the skeletal muscles. Therefore, in this paper, we attempt
to summarize inevitable interdisciplinary diagnostic and
therapeutic strategies considering the medical management
in pregnancy as well as the puerperal and neonate period by
a systematic literature review.
Data for the case report were generated by reviewing
labour, delivery, and postpartal records.
The database of the US National Library of Medicine
(PUBMED) was used to identify publications being pub-
lished from 1966 to June 2011.
We report the case of a 38-year-old, previously thymec-
tomized patient with immune-mediated MG, who under-
went an elective cesarean operation under spinal anesthesia
at 35 + 3 weeks of pregnancy, after having had a premature
2Case Reports in Obstetrics and Gynecology
rupture of membranes. Upon admission, the patient had
no contractions and showed no signs of muscular weakness
perceiving a sufficient medication (pyridostigmine bromide,
prednisone, azathioprine). In the course of pregnancy, there
was an initial progress of myasthenic symptoms, which
disappeared completely after adjusting medication as stated
above. Elective cesarean section was performed on patient’s
request. The surgery was implemented without complica-
tions. A lively male infant (weight: 3120g, length: 51cm,
and did not show any signs of muscular weakness.
The newborn was transferred to the pediatric unit for
surveillance and did not show any signs of neonatal MG
initially as well as in the course of time.
The mother developed a respiratory insufficiency on
the second postpartal day. The myasthenic crisis led to
progressive dyspnoea which exacerbated in a secondary
generalized seizure with cardiac-circulatory arrest. After
successful cardiopulmonary resuscitation, the patient was
transferred for intensive care treatment.
Blood values showed an elevated antibody titer (Ach-
R-Ak 54.5nmol/L, normal range <0.4nmol/L) as well as
slightly elevated inflammation values (CRP 15mg/dL, nor-
mal range <5mg/dL; leucocytes 12.000/µL, normal range
4.000–9.400/µL), a computed tomography did not show any
cerebral pathologies, but a lobar pneumonia was detected.
tilatory assistance via endotracheal intubation, parenteral
antibiotics (piperacillin and tazobactam), pyridostigmine,
azathioprine, and corticosteroids. By these contemplated
measures, a stable state was regained, so that after five days
of intensive care treatment the patient was transferred to
normal ward. On the eleventh postpartal day, the patient
could be dismissed in good clinical condition.
The course of MG in pregnancy as well as its influence
on pregnancy outcome is unpredictable. It has been shown
that in 31% of patients the disease remained stable during
pregnancy, whereas in 29% an improvement and in 40% an
exacerbation of myasthenia symptoms were observed .
Generally worsening of clinical symptoms occurs in about
one-third of MG patients. Although possible at any state
during pregnancy, it is more likely during the first trimester
and the first month postpartum [7–9]. An improvement of
symptoms has been observed in 20–40% of patients in the
second and third trimesters of pregnancy . The clinical
course of MG throughout the first pregnancy does not
predict the clinical course of subsequent pregnancies .
Reviewing the literature, there is no great influence of
MG on pregnancy.
The incidence of spontaneous abortion and growth
restriction is not increased [9, 10]. MG does not increase
the incidence of prematurity, but frequency of premature
rupture of membranes, as stated in the case above, is
increased . Preterm delivery rate in patients with MG is
There is no increase of incidence of preeclampsia in
pregnant women with MG, although some cases have been
described [12, 13]. Noteworthy is the fact that the use of
magnesium sulfate is contraindicated in patients with MG
Generally patients with MG should be observed closely
throughout pregnancy by a neurologist and an obstetrician.
checkups in order to detect fetal akinesia, manifesting itself
by a reduction of fetal movements and breathing motion, as
well as hydramnios .
Generally hypoventilation in MG patients is a risk. Preg-
nancy leads to an aggravation of respiratory complications,
as movement of the diaphragm is limited due to an enlarge-
ment of the uterus. A respiratory crisis as described in our
case is one of the most severe complications. An immediate
interdisciplinary therapeutic approach is necessary.
MG maternal mortality risk is inversely correlated to the
duration of the disease, the highest in the first year and the
lowest risk 7 years after the beginning of the disease .
Pregnancy does not worsen the long-term outcome of MG
Several therapeutic strategies and approaches have to be
taken into account in patients with MG. Generally patients
with MG should be educated to avoid unnecessary physical
activities to diminish fatigue. Before planning pregnancy,
there should be an informed decision regarding the medical
management of MG throughout pregnancy explaining fetal
and maternal risks. Medical advice should be based upon
severity of MG [16, 17].
Thymectomy has been recommended for the treatment
of MG and is a primary disease controlling modality.
The incidence of clinical exacerbations seems to be higher
in nonthymectomized than thymectomized patients, while
there is no difference in the development of neonatal MG
between the two groups . Still, complete remission of
the disease has been described in approximately 45% of
thymectomized patients and clinical improvement is not
noted until years after surgery [18, 19]. Therefore, the
authors state that an operative therapy can be postponed
until after delivery, since a delay does not adversely affect
Medical treatment should not be altered in pregnancy.
Anticholinesterase inhibitors have been safely used in preg-
nant patients with MG, and in 50% of patients monotherapy
severe neonatal MG with microcephaly have been described
Corticosteroid therapy appears to be safe during preg-
nancy with little teratogenic risk [21–23]. Only a slight
increase in incidence of cleft palate has been described
. High-dose corticosteroid therapy increases the risk of
premature rupture of membranes .
Azathioprine is not recommended in pregnancy as
fetuses exposed have an increased risk of myelosuppression
As some previous publications show, cyclosporine A is
not necessarily associated with severe effects to the fetus,
although an increase of risk for fetuses small for gestational
Case Reports in Obstetrics and Gynecology3
age, fetal myelosuppression, prematurity, and spontaneous
abortion have been observed [28, 29]. Mycophenolate
mofetil , methotrexate , and cyclophosphamide [32,
33] are contraindicated in pregnancy. Plasmapheresis on
the other hand has been safely accomplished throughout
pregnancy especially when a short-time benefit is needed [7,
9]. Due to the removal of hormones via plasmapheresis, the
risk for prematurity is increased . The use of intravenous
immunoglobulins in pregnancy is still experimental but
seems to be an effective and safe therapeutic approach .
Regarding the mode of delivery, a vaginal birth should be
preferred as the uterus is not affected by autoantibodies as it
does not consist of striated muscle [7, 17]. As striated muscle
is required. Cesarean section should only be performed
if there is an obstetric indication . Generally epidural
anesthesia should be preferred and narcotic analgesia and
muscle relaxants avoided .
Neonatal MG has been observed in 10–20% of newborns
of parturients with MG [37, 38]. Neuromuscular symptoms
in newborns manifest clinically within the first 12–48 hours
postpartum, so that a rigorous monitoring is inevitable .
In general there is no correlation between the severty of
maternal MG and the occurrence of a neonatal MG [9, 37,
40]. Furthermore cases of pulmonary hypoplasia, arthrogry-
posis congenital, and nonspecific hyperbilirubinemia have
been reported [7, 41, 42]. These fetal complications rarely
occur. MG patients should still be informed that, although
the clinical state throughout pregnancy concerning MG is
stable, fetal complications might occur.
Breastfeeding is not contraindicated in parturients with
MG, although serum antibodies versus acetylcholine recep-
tors might reach the newborn via breast milk, so that neona-
tal MG might be enhanced . A nonsignificant transfer of
pyridostigmine bromide and corticosteroids has been shown
in various publications [43, 44]. Authors suggest to defer
breastfeeding until 4 hours after having taken the above-
mentioned medication . Breastfeeding is contraindi-
cated in mothers taking mycophenolate mofetil, cyclophos-
phamide, methotrexate, azathioprine, cyclosporine A .
is a high-risk disease, and its course is unpredictable. Severe
up to life-threatening conditions might occur especially due
to generalized weakness, in particular respiratory insuffi-
ciency endangering the parturient as well as the newborn. As
this disease predominantly occurs in women of reproductive
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