Journal of Clinical Anesthesia (2007) 19, 299–302

Case report

Anesthetic management of Guillain-Barré syndrome

in pregnancy
Seden Kocabas MD (Specialist)a,*, Semra Karaman MD (Associate Professor)a ,
Vicdan Firat MD (Professor)a , Fikret Bademkiran MD (Specialist)b
a
Department of Anesthesiology and Reanimation, Ege University Faculty of Medicine, azmir, Turkey
b
Department of Neurology, Ege University Faculty of Medicine, azmir, Turkey

Received 3 May 2006; revised 5 September 2006; accepted 16 September 2006

Keywords: Abstract We report the case of a 23-year-old woman who was diagnosed with an axonal type of
Guillain-Barré syndrome; Guillain-Barré syndrome at 16 weeks' gestation. The patient had severe motor loss but she was treated
Immunoglobulin; effectively with intravenous immunoglobulin, and she underwent cesarean delivery with epidural
Pregnancy; anesthesia at full term.
Radiculoneuropathy © 2007 Elsevier Inc. All rights reserved.

1. Introduction Guillain-Barré syndrome complicating pregnancy is a rare

Guillain-Barré syndrome is an acute inflammatory,
demyelinating polyradiculoneuropathy characterized by
progressive motor weakness, areflexia, and ascending
paralysis. Patients usually have a history of upper respiratory
tract infection or gastroenteritis within one to three weeks
before the onset of disease [1]. Guillain-Barré syndrome
presents with weakness that first involves the extremities,
followed by involvement of the trunk, neck, and facial mus-
cles. In severe cases, loss of reflexes, motor paralysis, and
respiratory failure can occur. Other clinical features, such as
sensory symptoms, cranial nerve involvement, and auto-
nomic dysfunction, may be present. The reported incidence
of this syndrome in the general population is approximately
0.75 to two in 100,000 per year [1].
neurologic event that has been associated with an increased
incidence of respiratory failure (35%) and an increase in
maternal mortality (10%-13%) [2,3]. There are no specific
guidelines for the anesthetic management of labor or vaginalor
cesarean delivery in patients with Guillain-Barré syndrome.
Although regional anesthesia has been used successfully in
several cases [1,4-7], some investigators have expressed
concerns about the use of epidural anesthesia in patients with
this syndrome [8-10]. We report the case of a 23-year-old
patient who was diagnosed with Guillain-Barré syndrome at
16 weeks of gestation and who underwent cesarean delivery
with epidural anesthesia at full-term pregnancy.
2. Case report

* Corresponding author. Tel.: +90 232 3695394. A 23-year-old, gravida 1, para 0 woman developed an
E-mail address: nskocabas@hotmail.com (S. Kocabas). upper respiratory tract infection at 14 weeks' gestation. She

0952-8180/$ – see front matter © 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.jclinane.2006.09.008
300
experienced arthralgia, myalgia, low-grade fever, and a
runny nose, which resolved over 5 days. Ten days later, she
presented with progressively ascending, bilaterally sym-
metric muscle weakness. The muscle weakness started with
the lower extremities and progressed to the upper extremi-
ties. Neurologic examination on admission showed that
muscle strength was 2 (on a 0-5 Medical Research Council
[MRC] scale) for the lower limb distal muscles and 3 for the
lower limb proximal, upper limb distal, and upper limb
proximal muscles. The patient also had weakness in neck
flexion and inability to walk. She had no knee or ankle
reflexes. There was also no sensory deficit or disturbance of
cranial nerve function. Ultrasound scan at 16 weeks'
gestation showed an appropriately sized fetus. Routine
laboratory screening tests and full blood count were all
within normal limits. The results of serologic tests were
negative. The patient was admitted to the intensive care unit
(ICU) of the Neurology Department with a presumed
diagnosis of Guillain-Barré syndrome.
The patient's neurologic condition deteriorated over the
next 24 hours, and she had progressively worsening muscle
strength (1 on a 0-5 MRC scale) in the upper and lower
limbs. The patient was started on intravenous immuno-
globulin (IVIG) treatment and was given a total of two g/kg
(140 g) of IVIG over a period of 5 days. She showed no signs
of respiratory failure requiring ventilatory support. She was
managed conservatively with regular monitoring of arterial
blood gases. Apart from the IVIG treatment, the patient was
given prophylactic anticoagulation to prevent venous
thromboembolism. She was mobilized and admitted into a
physical rehabilitation program. The patient developed left-
sided facial palsy on the sixth day of hospitalization. Nerve
conduction studies and cerebral spinal fluid (CSF) analysis
were planned as further workup. Electromyography, per-
formed on the 10th day of hospitalization, showed acute
motor axonal neuropathy, which is an axonal type of
Guillain-Barré syndrome characterized by severe motor
loss. We were unable to perform the CSF analysis, because
the patient refused lumbar puncture. The patient was
hemodynamically stable and showed no signs of autonomic
dysfunction throughout her stay in the ICU. Ultrasonography
scans performed by the obstetricians showed a viable fetus.
After 7 days of treatment in the ICU, the patient was
transferred to the physical therapy and rehabilitation ward.
After 30 days of rehabilitation she was discharged home,
because her disease showed no clinical progression. At the
time of discharge from the hospital, neurologic examination
showed muscle strength to be 1 (on a 0-5 MRC scale) for
lower limb distal muscles, 2 for lower limb proximal and
upper limb distal muscles, and 3 for upper limb proximal
muscles. The patient's facial asymmetry still existed at the
time of discharge. Arrangements for outpatient physical
therapy and outpatient follow-up with the neurologist were
also made.
The patient had an uneventful pregnancy course and
was admitted to the hospital for elective cesarean delivery
S. Kocabas et al.
at 38 weeks of gestation. Preoperative neurologic exam-
ination of the patient showed that she still had minimal
facial asymmetry, reduced muscle power of the upper
extremities (2 or 3 on a 0-5 MRC scale) and lower
extremities (1 or 2 on a 0-5 MRC scale), absent knee and
ankle reflexes, and no sensory deficit. The patient was
given ranitidine (150 mg) orally the night before surgery
and again the next morning.
In the operating room, an intravenous cannula was
inserted and balanced crystalloid solution infusion was
started at a rate of 15 to 20 mL/kg per hour. The patient
was given metoclopramide (10 mg, IV) to prevent nausea.
Electrocardiograph, pulse oximeter, and noninvasive blood
pressure were monitored (Datex-Ohmeda, Inc, Madison,
WI). An epidural catheter was inserted at the L3-L4
interspace through an 18-gauge Tuohy needle, with the
patient placed in the right lateral decubitus position. After
epidural catheter placement, the patient was placed supine
on the operating table, with left uterine displacement.
Supplemental oxygen (5 L/min) by facemask was given
until delivery. A test dose of 3 mL of 2% lidocaine with
1:200 000 epinephrine was given through the epidural
catheter. After verifying that there were no signs of
intravascular or intrathecal placement, epidural anesthesia
was induced with 18 mL of ropivacaine 0.5%, given in
incremental doses of 5 mL every two to three minutes.
Sensory block height was evaluated by bilateral pinprick
test at the midclavicular line every two minutes. The oper-
ation started when sensorial block level reached T4 at
12 minutes after anesthesia induction. The time from sur-
gical incision to delivery was 8 minutes, and the patient
delivered a full-term healthy baby (3600 g, 49 cm), with
5- and10-minute Apgar scores of 7 and 10, respectively. After
delivery, 100 μg fentanyl was administered through the
epidural catheter. The patient was hemodynamically stable
and showed no signs of autonomic nervous system dysfunc-
tion throughout the operation. The last surgical suture was
placed at 50 minutes after surgical incision.
In the postpartum period, the patient underwent
neurologic assessment after the epidural block regressed
over a period of 120 minutes. It was observed that her
neurologic function showed no deterioration from the
antepartum period. The patient was given morphine (two mg)
through the epidural catheter for postoperative analgesia.
There was no indication of worsening clinical situation or
relapse of neurologic symptoms, and the patient was safely
discharged home on the fourth postoperative day. Six
months after the cesarean delivery, our patient was able to
walk without any aid, and she showed no motor weakness
of the upper or lower extremities.
3. Discussion
Management of Guillain-Barré syndrome consists of suppor-
tive care including respiratory assistance, hemodynamic and
Pregnancy and Guillain–Barré syndrome
nutritional support, and identification and treatment of
nosocomial infections. Because pregnancy itself is also a
strong risk factor for thromboembolism, early administration
of prophylactic anticoagulation and regular physiotherapy are
important [1,6]. Administration of plasmapheresis and IVIG
treatment is effective in preventing progression of neurologic
symptoms in Guillain-Barré syndrome [11]. Plasmapheresis
has potential risks such as hypotension, fluid overload,
pulmonary edema, septicemia, and abnormal clotting profile
[1]. Intravenous immunoglobulin treatment has the advantages
of a low risk of complications and ease of application [1].
The efficacy of a massive dose of IVIG (100 g/5 days) was
confirmed in pregnant patients who developed Guillain-Barré
syndrome [12,13]. Intravenous immunoglobulin treatment
seems to have prevented the progression of disease in our
patient, who reached 38 weeks of gestation without
deterioration in her neurologic status. There were no maternal
or fetal complications due to administration of IVIG at a dose
of two g/kg (140 g).
Normal uterine contractions are maintained and vaginal
delivery is possible in the parturient who presents with
Guillain-Barré syndrome. Therefore, the presence of this
syndrome in pregnancy is not an indication for cesarean
delivery [1,14]. Our patient required cesarean delivery at
38 weeks of gestation for cephalopelvic disproportion.
Anesthetic management of the parturient diagnosed with
Guillain-Barré syndrome depends on the patient's clinical
condition at the time of delivery. In patients with Guillain-
Barré syndrome, administration of regional or general
anesthesia has been associated with potential risks [1]. If
general anesthesia is necessary in a patient with Guillain-
Barré syndrome, succinylcholine should be avoided
because of the risk of hyperkalemia. Feldman [15] reported
a parturient who, within one month of recovering from
Guillain-Barré syndrome, had a cardiac arrest due to
hyperkalemia that occurred shortly after succinylcholine
administration for general anesthesia. Nondepolarizing
muscle relaxants should be used with caution in patients
diagnosed with Guillain-Barré syndrome, because they
may result in prolonged neuromuscular block and the need
for postoperative ventilation [6].
There are potential risks with regional anesthesia in
patients with neurologic disease. Steiner et al [9] reported
Guillain-Barré syndrome occurring one to two weeks after
epidural anesthesia administration in three patients under-
going general surgery, and one patient undergoing delivery.
Although they reported that epidural anesthesia might have
triggered Guillain-Barré syndrome in these patients, this
syndrome is also known to have an increased frequency
postpartum [16,17] and after surgery [18]. More recently,
Wiertlewski et al [8] reported a Guillain-Barré syndrome
case, with worsening of neurologic symptoms after delivery
during epidural anesthesia. In this case, labor analgesia was
induced by an initial injection of 10 mL 0.2% of ropivacaine
with 10 μg of sufentanil through the epidural catheter. The
patient was given additional doses of 15 mL of 0.2%
301
ropivacaine and 6 μg of sufentanil via a patient-controlled
epidural analgesia device over a three-hour period. An
uneventful delivery was accomplished 4 hours after initiation
of the epidural anesthesia, at which point the patient had both
a sensory and motor block. The patient did not fully recover
from the motor block induced by the epidural anesthetic, and
neurologic symptoms worsened immediately after delivery.
Intravenous immunoglobulin treatment during the postpar-
tum period was considerably less effective than IVIG
treatment during pregnancy. The authors suggested that the
anesthetic technique might have played a role in the disease
progression [8]. In our case, epidural anesthesia was induced
with 0.5% ropivacaine (18 mL), given in incremental doses
of 5 mL every two to three minutes. It must be remembered
that many patient-related, surgery-related, and anesthesia-
related risk factors may play a role in the etiology of
postoperative neurologic deficits [19]. Progressive central
nervous system (CNS) diseases may worsen perioperatively,
independent of anesthetic or surgical technique. Therefore, it
is very difficult to evaluate reliably the effect of anesthetic
technique on neurologic outcome [19].
Although there have been concerns regarding the
possibility of Guillain-Barré syndrome being triggered by
regional anesthesia, there is no evidence that epidural
anesthesia causes this syndrome. Several cases have been
reported in which epidural anesthesia was successfully used
for labor and cesarean delivery in patients with Guillain-
Barré syndrome [4-7]. In all the cases [4-7], the patients
tolerated the epidural and spinal anesthesia and recovered
satisfactorily.
Hebl et al [19] reviewed the medical records of all 139
patients treated at the Mayo Clinic between 1988 and
2000, who had a history of a CNS disorder and who
subsequently received neuraxial anesthesia or analgesia.
None of the 139 patients with a preexisting CNS disorder
undergoing neuraxial anesthesia or analgesia experienced
new or worsening neurologic deficits. The investigators
concluded that the risks commonly associated with
neuraxial anesthesia and analgesia in patients with
preexisting CNS disorders might not be as frequent as
once thought, and that neuraxial block should not be
considered an absolute contraindication within this patient
population [19].
Although rare, Guillain-Barré syndrome does occur in
pregnancy. It can be successfully managed when diag-
nosed early and treated effectively with IVIG or
plasmapheresis together with prevention of complications.
Our case shows that cesarean delivery can be successfully
carried out using epidural anesthesia in the pregnant
patient with Guillain-Barré syndrome. There was no
worsening of neurologic symptoms induced by epidural
anesthesia, and the parturient recovered fully from the
epidural-induced motor block. A thorough discussion of
risks of anesthesia with the patient is important so as to
minimize her psychological distress regarding the anes-
thetic procedure.
302
References
[1] Chan LY, Tsui MH, Leung TN. Guillain-Barre Syndrome in pregnancy.
Acta Obstet Gynecol Scand 2004;83:319-25.
[2] 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.
[3] Karnad DR, Kalpalatha KG. Neurologic disorders in pregnancy. Crit
Care Med 2005;33(10 Suppl):362-71.
[4] Vassiliev DV, Nystrom E, Leicht CH. Combined spinal and epidural
anesthesia for labor and cesarean delivery in a patient with Guillain-
Barre syndrome. Reg Anesth Pain Med 2001;26:174-6.
[5] McGrady EM. Management of labour and delivery in a patient with
Guillain-Barre syndrome. Anaesthesia 1987;42:899.
[6] Brooks H, Christian AS, May AE. Pregnancy, anaesthesia and
Guillain-Barre syndrome. Anaesthesia 2000;55:894-8.
[7] Alıcı HA, Cesur M, Erdem AF, Gürsaç M. Repeated use of epidural
anaesthesia for caesarean delivery in a patient with Guillain-Barre
syndrome. Int J Obstet Anesth 2005;14:269-73.
[8] Wiertlewski S, Magot A, Drapier S, Malinovsky JM, Pereon Y.
Worsening of neurologic symptoms after epidural anesthesia for labor
in a Guillain-Barré patient. Anesth Analg 2004;98:825-7.
[9] Steiner I, Argov Z, Cahan C, Abramsky O. Guillain-Barre syndrome
after epidural anesthesia: direct nerve root damage may trigger disease.
Neurology 1985;35:1473-5.
[10] Gautier PE, Pierre PA, Van Obbergh LJ. Guillain-Barre syndrome after
obstetrical epidural anesthesia. Reg Anesth 1989;14:251-2.
S. Kocabas et al.
[11] Randomised trial of plasma exchange, intravenous immunoglobulin,
and combined treatments in Guillain-Barre syndrome. Plasma
Exchange/Sandoglobulin Guillain-Barre Syndrome Trial Group.
Lancet 1997;349:225-30.
[12] Yamada H, Noro N, Kato EH, Ebina Y, Cho K, Fujimoto S. Massive
intravenous immunoglobulin treatment in pregnancy complicated by
Guillain-Barre Syndrome. Eur J Obstet Gynecol 2001;97:101-4.
[13] Seoud M, Naboulsı M, Khalıl A, Sarouphım P, Azar G, Khalıfeh R.
Landry Guillian-Barre Strohl syndrome in pregnancy: use of high-dose
intravenous immunoglobulin. Acta Obstet Gynecol Scand 1999;78:
912-8.
[14] Rockel A, Wissel J, Rolfs A. Guillain-Barre syndrome in pregnancy—
an indication for caesarian section? J Perinat Med 1994;22:393-8.
[15] Feldman JM. Cardiac arrest after succinylcholine administration in a
pregnant patient recovered from Guillain-Barre syndrome. Anesthe-
siology 1990;72:942-4.
[16] Cheng Q, Jiang GX, Fredrikson S, Link H, de Pedro-Cuestra J.
Increased incidence of Guillain-Barre syndrome postpartum. Epide-
miology 1998;9:601-4.
[17] Jiang GX, de Pedro-Cuestra J, Strigard K, Olsson T, Link H.
Pregnancy and Guillain-Barre syndrome: a nationwide register cohort
study. Neuroepidemiology 1996;15:192-200.
[18] Hogan JC, Briggs TP, Oldershaw PJ. Guillian-Barre Syndrome
following cardiopulmonary bypass. Int J Cardiol 1992;35:427-8.
[19] Hebl JR, Horlocker TT, Schroeder DD. Neuraxial anesthesia and
analgesia in patients with preexisting central nervous system disorders.
Anesth Analg 2006;103:223-8.