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ORIGINAL ARTICLE
Year : 2019  |  Volume : 10  |  Issue : 2  |  Page : 58-61

Guillain–Barre syndrome in pregnancy and its association with maternal and perinatal outcome


Department of Obstetrics and Gynecology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Mangalore, Karnataka, India

Date of Web Publication24-Jan-2020

Correspondence Address:
Dr. Shraddha K Shetty
Department of Obstetrics and Gynecology, Kasturba Medical College, Light House Hill Road, Mangalore - 575 001, Karnataka
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjmsr.mjmsr_32_19

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  Abstract 


Background: Guillain–Barre syndrome or acute inflammatory demyelinating proliferative syndrome is rare in pregnancy. It affects the nervous system, presenting as an acute onset of symmetric ascending weakness resulting in respiratory failure and autonomic dysfunction. Aims: This study aims to study the incidence of GBS in pregnant women and its association with maternal and perinatal outcome. Settings and Design: Retrospective observational study conducted at a tertiary care hospital. Materials and Methods: Records of all women diagnosed as GBS in pregnancy and postpartum period were analyzed. Maternal and perinatal outcomes were studied based on the pattern of involvement of limbs, need for ventilator support, treatment with plasmapheresis and intravenous immunoglobulin (IVIG), intrauterine fetal demise (IUFD), and neonatal deaths. Results: During the study of 3 years, there were 11,484 deliveries, of which 8 women had GBS. The incidence of GBS was 0.06%. Lower limb weakness developed in 6 (75%) of women, bifacial weakness in 2 (25%), IVIG received by 3 (37.5%), and (62.5%) underwent plasmapheresis. Four (50%) required ventilator support and maternal mortality was recorded in 2 (25%) due to respiratory failure and IUFD in 2 (25%) of women. Conclusions: GBS is associated with high maternal and perinatal morbidity. Timely diagnosis by obstetricians and management in women complaining of muscular weakness and respiratory difficulty in pregnancy and early postpartum period will help in improving the maternal and perinatal outcome.

Keywords: Immunoglobulins, neuropathy, paraesthesia, plasmapheresis, syndrome


How to cite this article:
Rupalakshmi V, Shetty SK. Guillain–Barre syndrome in pregnancy and its association with maternal and perinatal outcome. Muller J Med Sci Res 2019;10:58-61

How to cite this URL:
Rupalakshmi V, Shetty SK. Guillain–Barre syndrome in pregnancy and its association with maternal and perinatal outcome. Muller J Med Sci Res [serial online] 2019 [cited 2020 Feb 26];10:58-61. Available from: http://www.mjmsr.net/text.asp?2019/10/2/58/276687




  Introduction Top


Guillain–Barre syndrome (GBS) includes a group of immune-mediated neuropathy involving peripheral nerves.[1] Patients usually have flu-like symptoms or gastroenteritis prior to the development of GBS, as infection is the predisposing factor. GBS has features of pain, paraesthesia, numbness, or limb weakness. Many studies have observed that autoimmune mechanisms play an important role in etiopathogenesis of GBS.[2] Most commonly present in the third trimester and first 2 weeks' postpartum.[3] The incidence is more in the postpartum period due to delayed hypersensitivity. Diagnosis is often missed in pregnancy and puerperium due to delay in diagnosis of the condition as clinical features mimics pregnancy symptoms.

The aim of the study was to study the incidence of GBS in pregnant women and its association with maternal and perinatal outcomes.


  Materials and Methods Top


A 3-year retrospective observational study was conducted at a tertiary care hospital from January 2015 to December 2017. Records of all women admitted to the hospital and diagnosed as GBS based on clinical, laboratory, and electrodiagnostic criteria in pregnancy and postpartum period were analyzed. Demographic details such as age, parity, time of presentation of symptoms, and mode of delivery were recorded. The maternal outcome was studied based on the predisposing factors, time of presentation of symptoms, type of symptoms, stage of presentation, type of GBS, need for ventilator support, treatment with plasmapheresis and intravenous immunoglobulin (IVIG). Perinatal outcomes analyzed were fetal growth restriction, intrauterine fetal demise (IUFD), and neonatal deaths.


  Results Top


During the study, there were 11,484 deliveries, eight women developed GBS. The incidence of GBS was 0.06%. The mean age of women in the study group was 20–35 years. The duration of symptoms at the admission was 1–15 days and the duration of admission to the hospital was 3–24 days. Six (75%) of the women had vaginal delivery and the remaining 2 (25%) underwent cesarean delivery [Table 1]. Indications for cesarean delivery were premature rupture of membranes with nonreassuring fetal status (NRFHS) and abruptio placenta with NRFHS.
Table 1: Demographic characteristics

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All patients presented at progressive stage. Sensory symptoms were seen in 6 (75%) of the patients. The sensory loss was found in 1 patient (12.5%). Lower limb weakness developed in 6 (75%) of women, bifacial weakness in 2 (25%) [Table 2]. One (12.5%) of the women presented in 2nd trimester, 3 (37.5%) of them in 3rd trimester, while 50% of them presented in the postnatal period. Only 1 (12.5%) woman had a history of loose stools and fever 5 days back as a precedent factor. Two (25%) had associated risk factors of anemia.
Table 2: Characteristics of Guillain-Barre syndrome

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Based on the electrophysiological study, 7 (87.5%) patients had acute inflammatory demyelinating polyneuropathy (AIDP) and 1 (12.5%) had acute motor axonal neuropathy (AMAN). Two (25%) needed treatment for autonomic dysfunction. IVIG was received by 3 (37.5%) and 5 (62.5%) underwent plasmapheresis [Table 2]. Four (50%) required ventilator support and maternal mortality was recorded in 2 (25%) due to respiratory failure. Fetal growth restriction in 3 (37.5%) and IUFD was observed in 2 (25%) of the patients [Table 3].
Table 3: Maternal and perinatal outcome of Guillain-Barre syndrome in pregnancy

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  Discussion Top


GBS is rare in pregnancy with incidences of 1.2–1.9 cases/100,000 annually.[4] In the study, the incidence of GBS was 0.06%. GBS usually worsens in postpartum period due to the rapid increase in delayed-type hypersensitivity which was noted in 50% of the study population.[5] In the study, 50% of the women presented in the postnatal period. According to a study done by Hughes and Cornblath, on-third of GBS patients usually have a flu-like illness or gastroenteritis.[1] In the present study, only 1 (12.5%) woman had a history of loose stools and fever 5 days back as a precedent factor and 2 (25%) had associated risk factors of anemia. Hadden and Gregson observed that influenza or diarrhea are the common preceding infections but found only in about 50% of the patients, and the organisms resulting in the infection usually disappear from the body when the neuropathy has developed.[6]

Mycoplasma pneumoniae, Campylobacter jejuni, Cytomegalovirus, and Epstin–Barr virus are the organisms commonly responsible for GBS. According to literature, etiopathogenesis is preceding infection triggering the autoimmune response by the activated T lymphocytes and antibodies on the peripheral nerve myelin and axon resulting in temporary paralysis.[6]

The most common features are pain, numbness, paraesthesia, or weakness of the limbs usually misdiagnosed resulting in delay in diagnosis and treatment.[2] 7 (87.5%) patients had AIDP and 1 (12.5%) had AMAN. Kalita et al. observed that AIDP is the most common variant of GBS with a good prognosis compared to AMAN.[7] The diagnosis was done by various electrophysiological and nerve conduction studies. Serological and neurophysiological investigations help in making the diagnosis.[8]

In the present study, IVIG was received by 3 (37.5%) and 5 (62.5%) underwent plasmapheresis. Yamada et al. studied the effect of IVIG and plasma exchange in the treatment of GBS in pregnancy. They concluded that IVIG and plasma exchange were effective in the treatment of GBS.[9] Studies have shown that the management in pregnancy is similar to nonpregnant state and women during pregnancy and puerperium recover after IVIG and plasmapheresis, and the temporary paralysis subsides after the treatment.[10]

In the study, all 8 patients with GBS needed intensive care unit (ICU) care. Four (50%) required ventilator support in the study population. GBS can be managed in ICU involving ventilator support, plasma exchange or IVIG and psychological support.

About 75% of the women recovered well and 50% needed no mechanical support. Areeyapinan and Phanthumchinda observed that the patients had a better outcome if associated with less disability at the time of diagnosis.[11]

Meenakshi-Sundaram et al. studied GBS in pregnancy and postpartum period; they concluded that obstetricians should keep in mind the possibility of GBS if a pregnant woman complains of lower limb weakness or difficulty in breathing with preceding viral infection or diarrhea.[12]

About 75% of the patients delivered vaginally and 2 (25%) underwent cesarean section for obstetric indications. Labor induction or cesarean section may trigger worsening of the maternal condition during the acute phase of GBS.[13] Various studies have shown that there is no clinical evidence that terminating the pregnancy in view of worsening GBS may improve the maternal outcome, and vaginal delivery is not a contraindication in these women.[14] There are not many studies in the literature to prove the efficacy of cesarean delivery over vaginal delivery and the type of anesthesia during cesarean delivery. Many reported studies have used general or epidural anesthetic techniques.[15]

In the present study, 12.5% of women had preterm delivery. Various studies have found that in conditions where ventilator support is needed in pregnancy, the incidence of premature delivery is also increased.[16]

In a study by Kim et al., one patient had developed pulmonary embolism following GBS after delivery.[17] According to the literature, the incidence of pulmonary embolism is 1%–13% in nonpregnant women, and prophylactic anticoagulants can be started in immobilized GBS patients.[18] Physiotherapy, compressive stockings, and early ambulation should be encouraged in women following delivery.[14]

In a study done by Furara et al., they observed 7% of maternal mortality and 20% with disability after 1 year.[19] Hadden and Gregson observed that the recovery time of GBS may be 2 weeks–6 months. Regardless of treatments, there is a chance of poor outcome due to axonal degeneration, psychosocial factors, and chronic inflammatory demyelinating polyradiculoneuropathy.[6] Maternal mortality depends on variants of GBS and associated respiratory muscle involvement and autonomic dysfunction. In the present study, maternal mortality was recorded in 2 (25%) due to respiratory failure. Many studies have shown that the cardiovascular complications, ventilator-associated pneumonia, and pulmonary thromboembolism are responsible for the mortality.[6]


  Conclusions Top


GBS is rare in pregnancy, but if present, is associated with very high maternal and perinatal morbidity and mortality. Obstetricians should be aware of the presenting symptoms of GBS. Timely diagnosis and management of women complaining of muscular weakness and respiratory difficulty in pregnancy and early postpartum period will help in improving the maternal and perinatal outcome. Treatment with IVIG and plasmapheresis in pregnancy reduces the neurological symptoms and benefit the patients for complete recovery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hughes RA, Cornblath DR. Guillain-Barre syndrome. Lancet 2005;366:1653-66.  Back to cited text no. 1
    
2.
Vijayaraghavan J, Vasudevan D, Sadique N, Rajeswari KS, Pondurangi M, Jayashree. Arare case of Guillain-Barre syndrome with pregnancy. J Indian Med Assoc 2006;104:269-70.  Back to cited text no. 2
    
3.
Zeeman GG. A case of acute inflammatory demyelinating polyradiculoneuropathy in early pregnancy. Am J Perinatol 2001;18:213-5.  Back to cited text no. 3
    
4.
Sharma SR, Sharma N, Masaraf H, Singh SA. Guillain-Barre syndrome complicating pregnancy and correlation with maternal and fetal outcome in North Eastern India: A retrospective study. Ann Indian Acad Neurol 2015;18:215-8.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
D'ambrosio G, de Angelis G. Guillain-Barre syndrome in pregnancy. Rev Neurol (Paris) 1985;141:33-6.  Back to cited text no. 5
    
6.
Hadden RD, Gregson NA. Guillain-Barre syndrome and Campylobacter jejuni infection. J Appl Microbiol 2001;90:145-54.  Back to cited text no. 6
    
7.
Kalita J, Misra UK, Goyal G, Das M. Guillain-Barre syndrome: Subtypes and predictors of outcome from India. J Peripher Nerv Syst 2014;19:36-43.  Back to cited text no. 7
    
8.
Douglas MR, Winer JB. Guillain-Barre syndrome and its treatment. Expert Rev Neurother 2006;6:1569-74.  Back to cited text no. 8
    
9.
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 Reprod Biol 2001;97:101-4.  Back to cited text no. 9
    
10.
Brooks H, Christian AS, May AE. Pregnancy, anaesthesia and Guillain-Barre syndrome. Anaesthesia 2000;55:894-8.  Back to cited text no. 10
    
11.
Areeyapinan P, Phanthumchinda K. Guillain-Barre syndrome: A clinical study in king Chulalongkorn memorial hospital. J Med Assoc Thai 2010;93:1150-5.  Back to cited text no. 11
    
12.
Meenakshi-Sundaram S, Swaminathan K, Karthik SN, Bharathi S. Relapsing Guillain-Barre syndrome in pregnancy and postpartum. Ann Indian Acad Neurol 2014;17:352-4.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
Inamdar SA, Inamdar AH, Chaudhary R, Subhedar VS. Successful maternal and fetal outcome of Guillain-Barre syndrome complicating pregnancy: A case report. Int J Repro Contracep Obstet Gynecol 2013;2:478-9.  Back to cited text no. 13
    
14.
Chan LY, Tsui MH, Leung TN. Guillain-Barre syndrome in pregnancy. Acta Obstet Gynecol Scand 2004;83:319-25.  Back to cited text no. 14
    
15.
Karnad DR, Guntupalli KK. Neurologic disorders in pregnancy. Crit Care Med 2005;33:S362-71.  Back to cited text no. 15
    
16.
Bahadur A, Gupta N, Deka D, Mittal S. Successful maternal and fetal outcome of Guillain-Barre syndrome complicating pregnancy. Indian J Med Sci 2009;63:517-8.  Back to cited text no. 16
[PUBMED]  [Full text]  
17.
Kim H, Ryu J, Hwang JW, Do SH. Anesthetic management for cesarean delivery in a Guillain-Barre syndrome patient – A case report-. Korean J Anesthesiol 2013;64:268-71.  Back to cited text no. 17
    
18.
Gaber TA, Kirker SG, Jenner JR. Current practice of prophylactic anticoagulation in Guillain-Barre syndrome. Clin Rehabil 2002;16:190-3.  Back to cited text no. 18
    
19.
Furara S, Maw M, Khan F, Powell K. Weakness in pregnancy – Expect the unexpected. Obstet Med 2008;1:99-101.  Back to cited text no. 19
    



 
 
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