Pregnancy in myasthenia gravis: a retrospective analysis of maternal and neonatal outcome from a large tertiary care centre in Germany.

PURPOSE: Myasthenia gravis (MG) is a rare, potentially life-threatening autoimmune disease with fluctuating muscle weakness frequently affecting women of childbearing age. MG can affect maternal as well as neonatal outcome with risk of worsening of myasthenic symptoms in the mothers and risk of transient neonatal myasthenia gravis (TNMG) and arthrogryposis multiplex congenita (AMC) or foetal acetylcholine receptor antibody-associated disorders (FARAD) in the neonates. METHODS: Retrospective analysis of maternal and neonatal outcome in a cohort of pregnant MG patients treated at a tertiary care centre in Germany. RESULTS: Overall, 66 pregnancies were analysed. During 40 (63%) pregnancies, women experienced a worsening of myasthenic symptoms, of whom 10 patients (15.7%) needed acute therapy with IVIg or plasma exchange. There was no case of myasthenic crisis. Rate of caesarean section was comparable to the overall C-section rate at our centre (38% vs. 40%). However, there was a slightly higher rate for operative vaginal delivery (15% vs. 10%) as potential indicator for fatiguing striated musculature in MG patients during the expulsion stage. Rate of TNMG as well as AMC was 3% (two cases each). CONCLUSIONS: Maternal and neonatal outcome in our cohort was favourable with a low rate of myasthenic exacerbations requiring acute therapies and a low rate of TNMG and AMC/FARAD. Our data might help neurologists and obstetricians to advice MG patients with desire to have children.

Management of Myasthenia Gravis in Pregnancy.

Myasthenia gravis is an autoimmune disorder characterized by fluctuating weakness of extraocular and proximal limb muscles. It occurs in 1 in 5000 in the overall population and is 2 times more common in women than men. The onset in women is most common in the third decade, and risk of severe exacerbation occurs most frequently in the year after presentation. The disease does not have an impact on fertility and overlap with pregnancy is expected. This article provides a description of the disease process and its impact on the expecting mother, fetus, and newborn. Management options in pregnancy and lactation are discussed.

Myasthenia gravis in pregnancy and birth: identifying risk factors, optimising care.

Women with myasthenia gravis (MG) have increased risk of pregnancy complications and an adverse pregnancy outcome. This study examined risk factors for such complications in order to improve the care for pregnant MG women. Through the Medical Birth Registry of Norway, 73 MG mothers with 135 births were identified. Their obstetrical and clinical records were examined. Data on pregnancy, delivery and the newborn were combined with information on mother's disease. The risk for neonatal MG was halved if the mother was thymectomized (P = 0.03). Children with neonatal MG were more likely to display signs of foetal distress during delivery (P = 0.05). Only in one-third of the pregnancies did the patient see a neurologist during pregnancy. These patients used MG medication more often during pregnancy (P = 0.001), and were more likely to be thymectomized (P = 0.007). They also had a higher rate of elective sections (P = 0.009). Thymectomy may have a protective effect against neonatal MG. Neonatal MG can cause foetal distress during delivery. Most MG women benefit from being examined by a neurologist during pregnancy, to minimize risks and select the best delivery mode in collaboration with obstetricians.

[Myasthenia gravis and pregnancy: clinical course and management of delivery and the postpartum phase]. / Myasthénie auto-immune et grossesse: évolution clinique, accouchement et post-partum.

OBJECTIVES: To study influences of pregnancy on the time-course of myasthenia gravis (MG) and of MG on pregnancy, delivery, postpartum and newborn. METHODS: We retrospectively collected data from 100 women affected with MG, hospitalized between 1994 and 2003 in departments of Neurology of Lille University Hospital. RESULTS: Eighteen patients had a total of 36 pregnancies, occurring 7.2 years on average after MG onset. MG exacerbation occurred in 7 patients (26 percent) during pregnancy and in 4 (14.8 percent) during postpartum. One patient died of acute respiratory failure during postpartum. Delay between the onset of MG and pregnancy was the only variable significantly associated with MG exacerbation: 5.8 years when exacerbation and 9.5 years when no exacerbation (p=0.03). Seven miscarriages, two therapeutic abortions and no death at birth were reported. Levels of anti-acetylcholine receptor antibodies were abnormal in 3 of 27 newborns (11 percent), but only one (3.7 percent) developed seronegative transient neonatal myasthenia gravis. DISCUSSION: During pregnancy, the clinical course of MG is variable but exacerbations were associated with a shorter delay between MG diagnosis and pregnancy. The risk of transient neonatal myasthenia gravis is relatively small but exists even when the parturient has stable MG without elevated levels of anti-acetylcholine receptor antibodies. CONCLUSION: Our study confirms pregnancy is more difficult to manage at the beginning of MG. Given the unpredictable course of MG during pregnancy, we recommend women affected with MG to begin a pregnancy when the disease is stable.

[Myasthenia gravis and pregnancy]. / Macierzynstwo chorych na miastenie.

We retrospectively analyzed the course and outcome of pregnancy in a group of 26 women with myasthenia gravis. Premature births were noted in 7.9% of pregnancies, the rate of cesarean section was 15.8%. Neonatal myasthenia was observed in 10 children born by 5 women (16% of the mothers). There were three neonatal deaths: two due to neonatal myasthenia, one in a child born with multiple congenital anomalies. Transient exacerbation of MG symptoms was observed during four pregnancies (10.5%). MG is not associated with increased risk for MG patient and the newborn. Giving birth to one child with transient MG increases the risk of transient MG in consecutive pregnancies.

[Myasthenia gravis and pregnancy. Report on 13 cases]. / Myasthénie et grossesse: à propos de 13 grossesses.

OBJECTIVES: To evaluate our experience of myasthenia during pregnancy. MATERIALS AND METHODS: Retrospective study in a tertiary care university hospital including pregnant women affected by myasthenia gravis and who delivered in the obstetrical tertiary center. Medical and delivery reports were analyzed. RESULTS: Between 1994 and 2002, 12 women, age 31 (25-36), delivered 14 children. One women delivered twice, and there was one twin pregnancy. Clinical symptoms of myasthenia worsened in five. One was admitted twice to the intensive care unit during her pregnancy. Two were admitted to intensive care unit during the first month of post-partum. Gestational age at birth was 39.3 weeks (38-40.6), all birth weights were normal: 3329 g (2660-4520). Six women delivered vaginally, two by instrumental extraction and five by cesarean section. Apgar score was normal for all infants: 9/10. The level of anti-acetylcholine receptor antibodies (anti AchR) was high: 36.4 nM/L (0-46.8) (normal below 0.6 nM/L), but was not related to neonatal outcome. Three children presented neonatal myasthenia. CONCLUSION: We recommend obstetrical monitoring in tertiary centers for pregnant women with myasthenia gravis because of the risk of neonatal myasthenia. Measurement of anti-acetylcholine receptor antibodies may be useful. Pediatric and maternal observation is necessary in the first days of post partum.

Myasthenia gravis in pregnancy: report on 69 cases.

OBJECTIVE: To review our experience with pregnancies in women with myasthenia gravis (MG). STUDY DESIGN: Sixty nine pregnancies among 65 women with MG patients managed by our department over 28 years were included. The course of the disease in pregnancy, mode of delivery and postpartal period were evaluated. RESULTS: One pregnancy miscarried. In 15% of patients the MG deteriorated in pregnancy a further 16% in the puerperium. 17% of pregnancies were delivered by cesarean section, one due to myasthenia exacerbation. All women with puerperal infections developed exacerbations. One neonatal death, not attributable to myasthenia, was recorded. Transitory neonatal myasthenia gravis (TNMG) was diagnosed in 30% infants. Its incidence was inversely associated with maternal disease duration (P < 0.05). Newborns of thymectomized mothers showed lower rate of neonatal myasthenia compared to those of non-thymectomized women (P < 0.05). CONCLUSIONS: MG patients can have normal pregnancy and delivery but the course is unpredictable. Shorter disease history and infection predispose to puerperal exacerbation. Maternal thymectomy lessens the likelihood of neonatal myasthenia. An interdisciplinary approach is required for managing the pregnant women with MG.