Neurologic and neuromuscular disorders can significantly complicate the clinical management of the obstetric patient. These disorders may have an impact on the course of pregnancy and/or lead to substantial challenges in the delivery of the parturient. A thorough assessment of the patient in collaboration with the neurology and obstetric services is necessary to provide optimum care. This chapter outlines the anesthetic considerations in women with common neurologic and neuromuscular disorders. Although the discussion is by no means exhaustive, the selected disorders may have significant impact on the anesthetic and obstetric management of parturients.
Multiple sclerosis (MS) belongs to a group of disorders characterized by abnormalities in the myelin sheath from either defective synthesis or loss of myelin postneuronal development. MS is the most common demyelinating disorder, with a prevalence of greater than 1 million individuals affected worldwide. Of these, 400,000 reside in the United States. Women are more commonly affected than men, with a mean onset age of 30 years. As a result, MS may occur during reproductive age. MS does not affect the peripheral nervous system and usually does not have a negative impact on fertility or pregnancy outcome. Indeed, most MS patients can maintain a high level of function for many years after initial diagnosis.
The clinical course of MS is highly variable and is characterized by either exacerbating-remitting or chronic progressive patterns of disability. Clinical symptoms depend on the location of the demyelinating lesions and may include muscle weakness, visual disturbances, paresthesia, loss of balance, fatigue, bowel or bladder dysfunction, cognitive impairment, and cerebellar manifestations (such as ataxia, slurred speech, and intention tremors). Severe respiratory complications can also occur from respiratory and bulbar muscle weakness.1
Diagnosis is based on the clinical presentation as well as diagnostic testing, such as magnetic resonance imaging (MRI) (Figure 25-1), computed tomography (CT), visual evoked potentials, and lumbar puncture for cerebrospinal fluid (CSF) testing for elevated immunoglobulin levels and specific oligoclonal bands of immunoglobulin G (IgG). The detection of plaques on MRI due to focal loss of myelin in white matter can confirm the diagnosis but may not always correlate with the severity of the disease (Figure 25-1).2
Magnetic resonance imaging scans include white matter plaques in multiple sclerosis. (Permission granted for Lövblad KO, Anzalone N, Dörfler A, et al. MR imaging in multiple sclerosis: review and recommendations for current practice. AJNR Am J Neuroradiol. 2010;31(6):983–989 © by American Society of Neuroradiology.)
Although the cause of MS is still not known, several genetic factors, environmental factors, viral or infectious exposure, and autoimmune etiologies have been proposed. The disease is thought to develop from a complex interplay ...