Spinal Anesthesia With Staged Airway Contingency for Emergency Cesarean Delivery in a Parturient With Myasthenia Gravis, Ankylosing Spondylitis, and Multiple Sclerosis: An Observational Analytic Study

Abstract

Background. Emergency preterm cesarean delivery in a parturient with myasthenia gravis, ankylosing spondylitis, and multiple sclerosis combines neuromuscular weakness, a rigid spine with a possibly difficult airway, and demyelinating disease. Magnesium sulfate for fetal neuroprotection can worsen myasthenic weakness.

Objective. To describe the anesthetic plan and the outcome in one such patient.

Methods. A 34-year-old multiparous woman at 30 weeks + 2 days presented about 8 hours after premature rupture of membranes, with active ocular and bulbar symptoms. After a multidisciplinary consensus meeting she received single-shot spinal anesthesia (0.5% hyperbaric bupivacaine 10 mg with fentanyl 25 mcg, L4-L5, 27-gauge Quincke needle). A staged airway contingency plan with rocuronium and sugammadex was prepared and not used. Magnesium sulfate was given under neuromuscular surveillance.

Results. The sensory block reached T4. Mean arterial pressure stayed between 82.0 and 90.0 mmHg (largest fall, −8.9%), and no vasopressor was required. One transient rise in respiratory rate to 26 breaths/min occurred at delivery and resolved with face-mask oxygen. A preterm girl (1,415 g) had Apgar scores of 5, 7, and 8, and her Downes score fell from 5 to 1 within 24 hours on nasal continuous positive airway pressure. The mother had no myasthenic crisis during 24 hours of intensive care and moved to the ward on postoperative day 1.

Conclusion. In this patient, low-dose spinal anesthesia with a prepared airway contingency and monitored magnesium sulfate was followed by an uneventful maternal course. A single case cannot show efficacy, and follow-up was short.