Guillain-Barre disease in pregnancy treated with intravenous immunoglobulin

Case report A 17-year-old primigravida, 25 weeks pregnant, was admitted to the hospital with a 4-day history of bilateral muscular weakness in the lower extremities with bilateral numbness and tingling in the hands and feet. She denied any history of upper respiratory tract infection. On examination her blood pressure was 120/50 mmHg. Chest examination was normal. On abdominal examination she had a fundal height consistent with 25 weeks’ gestation, and the fetal heart was heard. On neurological examination she was found to have an unsteady gait, had proximal weakness of all extremities, absent deep tendon and Babinski re ̄ exes, and diminished pinprick sensation in all extremities. Cranial nerves were intact. Investigations carried out on admission showed that she had normal liver function tests, and her vital capacity was 1 ́8 litres. Lumbar puncture showed normal protein and glucose levels. The preliminary diagnosis was Guillain-BarreÂ syndrome. Motor nerve conduction tests carried out 2 days after admission showed ® ndings consistent with an acute in ̄ ammatory polyneuropathy. The day after admission she was started on intravenous immunoglobins 24 g daily for 4 days. Over the next 5 days she developed progressive motor weakness that included difficulty in swallowing, slurred speech, and had to be admitted to the intensive care unit. During the same period her vital capacity reduced to 0 ́8 litres and the AST rose to 105 IU/l. As a result of her decreased ability to maintain spontaneous ventilation and deteriorating respiratory function an elective intubation was done 6 days after admission. Two days later she had a tracheostomy because of continued muscular paralysis and inability to clear her secretions. The patient remained on the intensive care unit for the next 53 days. During this time she had serial 2-weekly ultrasound scans to assess the growth of the fetus which showed normal growth velocities. The patient was prescribed prophylactic heparin and 2-weekly steroid injections. She was fed through a nasogastric tube with total parentral nutrition. By the end of the 4 week of her stay on intensive care a gradual improvement was noticed in the patient’s tone and strength in the lower limbs and hands. By the end of the 6th week her need for ventilatory support was minimal. At 33 weeks’ gestation the patient began contracting every 3 minutes. On abdominal examination the presentation was cephalic and on vaginal examination the cervix was 3 cm dilated and fully effaced. Because of her trachestomy and the need for intensive monitoring postdelivery a joint decision between the anaesthetists and the obstetricians was reached to deliver her by elective caesarean section. This was done and a live male infant was delivered, birth weight 1 ́87 kg with Apgar scores of 7 at 1 minute and 10 at 5 minutes, with no evidence of respiratory or neurological abnormalities. In the postpartum period the patient’s neurological status continued to improve. She was discharged from the intensive care unit at the end of the 1st week to the neurological ward and she had her tracheostomy site closed at the end of the 2nd week. At the time of discharge from hospital, 4 weeks postpartum the patient was able to lift her legs off the bed but was still unable to walk independently, requiring outpatient rehabilitation.