Management of myasthenia gravis in pregnancy
- Shawn J Bird, MD
Shawn J Bird, MD
- Professor of Neurology
- University of Pennsylvania School of Medicine
- Irene P Stafford, MD
Irene P Stafford, MD
- Assistant Professor
- Department of Obstetrics and Gynecology
- Louisiana State University Health Science Center
- Gary A Dildy, III, MD
Gary A Dildy, III, MD
- Professor of Obstetrics and Gynecology
- Louisiana State University Health Sciences Center
- Section Editors
- Jeremy M Shefner, MD, PhD
Jeremy M Shefner, MD, PhD
- Section Editor — Neuromuscular Disease
- Professor and Chair of Neurology, Barrow Neurological Institute
- Professor of Neurology, University of Arizona, Phoenix
- Clinical Professor of Neurology, Creighton University
- Ira N Targoff, MD
Ira N Targoff, MD
- Section Editor — Muscle Disease
- Professor of Medicine, Section of Rheumatology
- University of Oklahoma Health Sciences Center
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
Myasthenia gravis (MG) is an autoimmune disorder characterized by a fluctuating degree and variable combination of weakness in ocular, bulbar, limb, and respiratory muscles. It results from abnormal T cell regulation and the production of autoantibodies directed against nicotinic acetylcholine receptors on the neuromuscular end plate of skeletal muscle. Affected patients (most often young women and older men) usually present with fatigable weakness after repetitive muscle use.
This topic will discuss the effect of pregnancy on MG and management of MG in pregnancy. It will also briefly review clinical and treatment issues related to MG that are discussed in greater detail separately. (See "Clinical manifestations of myasthenia gravis" and "Diagnosis of myasthenia gravis" and "Treatment of myasthenia gravis".)
There are two clinical forms of myasthenia: ocular and generalized. In ocular myasthenia gravis (OMG), the weakness is limited to the eyelids and extraocular muscles. In generalized disease, the weakness may also commonly affect ocular muscles, but it also involves a variable combination of bulbar, limb, and respiratory muscles.
Patients who have detectable antibodies to the acetylcholine receptor (AChR) are called seropositive (SPMG) and those without are called seronegative (SNMG). About half of patients with purely OMG are seropositive, compared with nearly four-fifths of those with generalized disease. An important consideration is that about 10 to 15 percent of those with MG have an underlying thymoma.
Epidemiology — MG is a relatively uncommon disorder. It occurs at any age, but there tends to be a bimodal distribution to the age of onset with an early peak in the second and third decades (female predominance) and a late peak in the sixth to eighth decade (male predominance). (See "Clinical manifestations of myasthenia gravis", section on 'Epidemiology'.)
- Plauché WC. Myasthenia gravis in mothers and their newborns. Clin Obstet Gynecol 1991; 34:82.
- Varner M. Myasthenia gravis and pregnancy. Clin Obstet Gynecol 2013; 56:372.
- Batocchi AP, Majolini L, Evoli A, et al. Course and treatment of myasthenia gravis during pregnancy. Neurology 1999; 52:447.
- Djelmis J, Sostarko M, Mayer D, Ivanisevic M. Myasthenia gravis in pregnancy: report on 69 cases. Eur J Obstet Gynecol Reprod Biol 2002; 104:21.
- Mitchell PJ, Bebbington M. Myasthenia gravis in pregnancy. Obstet Gynecol 1992; 80:178.
- Floyd RC, Roberts WE. Autoimmune diseases in pregnancy. Obstet Gynecol Clin North Am 1992; 19:719.
- Téllez-Zenteno JF, Hernández-Ronquillo L, Salinas V, et al. Myasthenia gravis and pregnancy: clinical implications and neonatal outcome. BMC Musculoskelet Disord 2004; 5:42.
- Ciafaloni E, Massey JM. The management of myasthenia gravis in pregnancy. Semin Neurol 2004; 24:95.
- Scott JS. Immunological diseases in pregnancy. Prog Allergy 1977; 23:321.
- Lu CH, Liou CM, Chen YS, et al. Anesthetic management in myasthenic parturient. Ma Zui Xue Za Zhi 1992; 30:193.
- Burke ME. Myasthenia gravis and pregnancy. J Perinat Neonatal Nurs 1993; 7:11.
- Uncu G, Küçükerdogan I, Ozan H, Cengiz C. Pregnancy and myasthenia gravis. A case report. Clin Exp Obstet Gynecol 1995; 22:145.
- Stafford IP, Dildy GA. Myasthenia gravis and pregnancy. Clin Obstet Gynecol 2005; 48:48.
- Ramsey-Goldman R, Schilling E. Immunosuppressive drug use during pregnancy. Rheum Dis Clin North Am 1997; 23:149.
- Haugen G, Fauchald P, Sødal G, et al. Pregnancy outcome in renal allograft recipients in Norway. The importance of immunosuppressive drug regimen and health status before pregnancy. Acta Obstet Gynecol Scand 1994; 73:541.
- Alstead EM, Ritchie JK, Lennard-Jones JE, et al. Safety of azathioprine in pregnancy in inflammatory bowel disease. Gastroenterology 1990; 99:443.
- Watson WJ, Katz VL, Bowes WA Jr. Plasmapheresis during pregnancy. Obstet Gynecol 1990; 76:451.
- Gracey DR, Howard FM Jr, Divertie MB. Plasmapheresis in the treatment of ventilator-dependent myasthenia gravis patients. Report of four cases. Chest 1984; 85:739.
- Benshushan A, Rojansky N, Weinstein D. Myasthenia gravis and preeclampsia. Isr J Med Sci 1994; 30:229.
- Piura B. The association of preeclampsia and myasthenia gravis: double trouble. Isr J Med Sci 1994; 30:243.
- Verspyck E, Mandelbrot L, Dommergues M, et al. Myasthenia gravis with polyhydramnios in the fetus of an asymptomatic mother. Prenat Diagn 1993; 13:539.
- Morel E, Bach JF, Briard ML, Aubry JP. Neonatal myasthenia gravis. Anti-acetylcholine receptor antibodies in the amniotic fluid. J Neuroimmunol 1984; 6:313.
- Carr SR, Gilchrist JM, Abuelo DN, Clark D. Treatment of antenatal myasthenia gravis. Obstet Gynecol 1991; 78:485.
- Leventhal SR, Orkin FK, Hirsh RA. Prediction of the need for postoperative mechanical ventilation in myasthenia gravis. Anesthesiology 1980; 53:26.
- Naguib M, el Dawlatly AA, Ashour M, Bamgboye EA. Multivariate determinants of the need for postoperative ventilation in myasthenia gravis. Can J Anaesth 1996; 43:1006.
- Hoff JM, Daltveit AK, Gilhus NE. Myasthenia gravis: consequences for pregnancy, delivery, and the newborn. Neurology 2003; 61:1362.
- Giwa-Osagie OF, Newton JR, Larcher V. Obstetric performance of patients with my asthenia gravis. Int J Gynaecol Obstet 1981; 19:267.
- Wen JC, Liu TC, Chen YH, et al. No increased risk of adverse pregnancy outcomes for women with myasthenia gravis: a nationwide population-based study. Eur J Neurol 2009; 16:889.
- Ciafaloni E, Massey JM. Myasthenia gravis and pregnancy. Neurol Clin 2004; 22:771.
- Cheng I, Lin CH, Lin MI, et al. Outcome of myasthenia gravis mothers and their infants. Acta Paediatr Taiwan 2007; 48:141.
- Gveric-Ahmetasevic S, Colić A, Elvedji-Gasparović V, et al. Can neonatal myasthenia gravis be predicted? J Perinat Med 2008; 36:503.
- Hoff JM, Daltveit AK, Gilhus NE. Myasthenia gravis in pregnancy and birth: identifying risk factors, optimising care. Eur J Neurol 2007; 14:38.