Suman Arora*,NeeruSahni**, Latha Y***
*Additional Professor; **Assistant Professor; ***Senior Resident
Department of Anesthesiology& Intensive Care, Postgraduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh, 160012, (India)
Key words: Anesthesia, Epidural; Cesarean Section; Guillain-Barre Syndrome/complications; Guillain-Barre Syndrome/physiopathology; Pregnancy; Pregnancy Complications
Citation: Arora S, Sahni N, LathaY.The choice of anesthesia for cesarean section in patients with Guillain Barre Syndrome – The dilemma continues. Anaesth Pain & Intensive Care 2015;19(2):209-210
Guillain Barre syndrome (GBS) in pregnancy is associated with increased maternal mortality due to respiratory failure.1 Though the incidence of GBS is low(0.75-2 in 100,000 per year)2there are case reports describing anesthesia for a patient with GBS. The review of literature does not show any consensus or guideline for choice of anesthesia and/or safe management of these patients for emergency surgery like cesarean section (CS).
A patient with GBS suffers from ascending paralysis, progressive motor weakness and areflexia. The exact etiology of this syndrome is not known but it usually follows episodes of gastroenteritis or upper respiratory infection, as also in our patient.3 The characteristic ascending paralysis raises the doubt of this syndrome as it is the most common cause of acute generalized paralysis.4 Though the uterine tone is maintained and there is no contraindication for normal vaginal delivery in a pregnant patient with GBS,4the presence of IUGR and oligohydramnios may lead to the decision for cesarean delivery.
The extent of disease helps guide the decision for general anesthesia or neuraxial block. In all cases postoperative care in intensive care unit is needed. Arterial blood pressure monitoring may be done in anticipation of any fluctuations due to autonomic dysfunction. It is prudent to avoid succinyl choline in these patients due to risk of severe hyperkalemia. Feldman reported sudden cardiac arrest after administration of succinyl choline to a patient with GBS.5
Many authors have reported successful neuraxial block in pregnant patients with GBS. Brooks et al have reported uneventful subarachnoid block in a pregnant patient with GBS who had autonomic dysfunction as well.4 Alici et al reported uneventful epidural anesthesia for the same patient with GBS twice for two consecutive cesareans.6Kocabas et al also optedfor epidural anesthesia for pregnant patient with recovering GBS presenting for elective CS.3
Wipfli and colleagues have described uneventful subarachnoid block in a tetraparetic elderly patient with decreased respiratory reserve presenting for transurethral resection of prostate.7They also reviewed eighteen cases of GBS who received neuraxial block for various surgeries and concluded that there is no causal relationship between neuraxial block and GBS.
On the other hand, Kim et al gave general anesthesia to GBS patient for emergency CS. The patient had worsening respiratory distress and had to be put on mechanical ventilation prior to delivery of foetus.8
Patient with GBS when diagnosed early in pregnancy should receive thromboprophylaxis as the incidence of thromboembolism is 1-13% which can cause significant mortality.9
Anesthesia for a pregnant patient with GBS is solely the discretion of anesthetist who decides the management depending upon the patient’s clinical condition. As the incidence of GBS is very low, there is no prospective randomized trial available and there is paucity of evidence based literature regarding management of such patients.
May SE, Caudle MR, Kleinman GE. Landry-Guillain-Barre-Strohl syndrome in pregnancy: a report of two cases. J Reprod Med 1989;34:550-2
Chan LY, Tsui MH, Leung TN. Guillain-Barre Syndrome in pregnancy. ActaObstetGynecolScand 2004;83(4):319-25.
Kocabas S, Karaman S, Firat V, Bademkiran F. Anesthetic management of Guillain-Barre syndrome in pregnancy. J ClinAnesth 2007;19:299-302.
Brooks H, Christian AS, May AE. Pregnancy, anaesthesia and Guillain Barre syndrome. Anaesthesia 2000;55(9):894-98.
Feldman JM. Cardiac arrest after succinylcholine administration in a pregnant patient recovered from Guillain-Barre syndrome. Anesthesiology 1990;72:942-4.
Alici H A, Cesur M, Erdem AF, Gursac M. Repeated use of epidural anaesthesia for caesarean delivery in a patient with Guillain Barre syndrome. Int J ObsAnesth 2005;14:269-73.
Wipfli M, Arnold M, Luginbuhl M. Repeated spinal anesthesia in a tetraparetic with Guillain Barre syndrome. J ClinAnesth 2013;25:409-412.
Kim H, Ryu J, Hwong JW, Do SW. Anesthetic management for cesarean delivery in a Guillain-Barré syndrome patient -A case report-.
Korean J Anesthesiol 2013;64(3):268-71.
Ferner R, Barnett M, Hughes RA. Management of Guillain-Barre syndrome. Br J Hosp Med 1987;38(6):525-8, 530.