• Pregnancy;
  • Anaesthesia;
  • Syndrome: Guillain Barré


  1. Top of page
  2. Abstract
  3. Case history 1
  4. Case history 2
  5. Discussion
  6. Bibliography

Two case histories of pregnant women with Guillain Barré syndrome (acute demyelinating polyradiculoneuritis) are reported. The first required anaesthesia during the second trimester for a minor surgical procedure. The second woman was admitted to the Intensive Care Unit in the first trimester and was ventilated for 18 weeks. Both babies were carried to term and delivered by Caesarean section. A review of the management of Guillain Barré syndrome in pregnancy discusses anaesthetic management, intensive care and the use of plasmapheresis and γ-globulins. The care of pregnant women recovered from Guillain Barré syndrome is also discussed.

Guillain Barré syndrome (GBS) is an acute or subacute demyelinating polyradiculoneuritis and is the most common cause of acute generalised paralysis. It typically begins with fine distal paraesthesia followed by leg weakness. The weakness then extends proximally and is commonly accompanied by pain in the large muscles of the legs or back. In severe cases the disease then affects respiration, eye movements, swallowing or autonomic function. It has an annual incidence of 0.75–2% per 100 000 [ 1] but is possibly less common in pregnancy [ 2]. We present two cases of GBS in pregnancy. In the first, involvement of the anaesthetic team was required for surgery in the second trimester and also on the delivery suite. The second case is a severe case presenting in the first trimester requiring ventilation on the Intensive Care Unit.

Case history 1

  1. Top of page
  2. Abstract
  3. Case history 1
  4. Case history 2
  5. Discussion
  6. Bibliography

The patient was a 36-year-old woman who was 24 weeks pregnant having had an uncomplicated pregnancy and vaginal delivery 16 months previously. She had experienced flu-like symptoms and an upper respiratory tract infection 3 weeks earlier and 4 days after that began experiencing paraesthesia and back pain.

She was admitted to the medical unit with paraesthesia in the hands and feet and an unsteady gait. This progressed after admission to paralysis of the lower limbs although she retained some use of her arms.

Neurological examination on admission revealed absent knee and ankle reflexes, reduced power in the arms and legs, and reduced sensation in a glove and stocking distribution. There was no disturbance of cranial nerve function. Her FEV1 was 1.36 l and her forced vital capacity (FVC) was 1.5 l. Her full blood count, urea, creatinine, electrolytes and glucose were normal but she had a raised plasma viscosity of 1.9. Lumbar puncture revealed a raised cerebrospinal fluid (CSF) protein of 1.0 g.l−1 with no abnormality of IgG pattern. The results of virology received later provided evidence of a recent infection with the Epstein–Barr virus.

A diagnosis of GBS was made and she was managed conservatively with regular monitoring of her FEV1 and FVC. Respiratory support was never required.

A few weeks after admission, at 27 weeks' gestation, she developed intractable constipation owing to a combination of immobility and autonomic nervous system dysfunction. This caused distressing colicky abdominal pain. After discussion between the neurologists, surgeons and obstetricians, it was decided that she should have a manual evacuation of her rectum with an intravenous infusion of ritodrine as a tocolytic agent over the peri-operative period. At this point she was scheduled on the emergency evening list and presented to the on-call anaesthetic registrar without prior consultation.

It was decided that the procedure should be carried out under spinal anaesthesia. A 25G spinal needle was inserted at the L2–3 interspace with the patient supported in the left lateral position and 1.9 ml of 0.5% hyperbaric bupivacaine was injected. This provided good anaesthesia without haemodynamic instability. No further operative procedures were required.

Apart from mild hypertension, her pregnancy otherwise continued normally, and labour was induced for postmaturity. At this point, she was able to walk without crutches although she was still having problems with steps and stairs. Neurological examination was still abnormal with reduced power and altered sensation in both limbs and the absence of all but one tendon reflex. However, she had not suffered any further bladder or bowel disturbance.

A lumbar epidural was inserted in early labour at 5 cm of cervical dilatation. A low-dose mixture of bupivacaine 0.1% and fentanyl 2 μ−1 was used to maintain mobility. A total of 30 ml was given over 2.5 h. She later required an emergency Caesarean section for failure to progress and fetal distress which was carried out under extension of the existing epidural block using 20 ml of a 50 : 50 mixture of lidocaine 2% and bupivacaine 0.5%. There was no haemodynamic instability. She was reviewed and assessed postpartum once the epidural block had worn off and her neurological function was unchanged from the antepartum period.

Four months postpartum she had still not made a full recovery. On neurological examination, her reflexes were still depressed with reduced altered sensation on her lower limbs. It was felt that it may take a further 12 months before she was fully recovered.

Case history 2

  1. Top of page
  2. Abstract
  3. Case history 1
  4. Case history 2
  5. Discussion
  6. Bibliography

A 28-year-old primigravida was admitted to the maternity unit with a 7-week history of amenorrhea, nausea, vomiting and weakness. She gave a history of glandular fever 4 months previously but had otherwise been fit and well. She was presumed to be dehydrated owing to hyperemesis and was rehydrated. However, over the next 24 h she became progressively weaker and complained of difficulty in breathing.

At this point she was admitted to the Intensive Care Unit (ICU) with a presumed diagnosis of GBS. She had marked lower limb weakness and was unable to lift her knees from the bed or abduct her hips. There was relative sparing of the upper limbs but she spoke in a whisper and had a vital capacity of only 0.8 l. She was therefore anaesthetised using fentanyl, thiopental and atracurium. Her trachea was intubated and her lungs were ventilated using synchronised intermittent mandatory ventilation (SIMV). A nasogastric tube, arterial line and internal jugular line were established. All blood parameters were within normal limits. Sedation was maintained with infusions of alfentanil and proprofol with boluses of midazolam as necessary. Early tracheostomy was planned and was performed 5 days later.

Her neurological condition deteriorated over the next 2 days to the extent that the only movement she had was blinking and this was used as a means of communication. At this point, treatment with immunoglobulins was started.

Seven days after her admission to ICU, she developed a sinus tachycardia and labile hypertension which responded to labetalol. She still only had minimal eyelid movement and plasmapheresis was performed. Three exchanges of 4 l each were performed over the next 4 days.

After 3 weeks of ventilation she was able to move her jaw but had no limb movement. A percutaneous endoscopic gastrostomy was performed to allow adequate nutrition. Abdominal ultrasound showed a viable fetus of 10 weeks' gestation.

After 4 weeks on the ICU she developed a chest infection which responded to treatment with ceftazidime. After 6 weeks on ICU her neurological function began to improve and she had some movement of fingers and toes. She continued to make slow steady progress. An ultrasound scan at 17 weeks' gestation showed a normal fetus of a size compatible with gestational age.

She was successfully weaned from ventilation after a period of 18 weeks and was discharged to a medical ward 2 weeks later for rehabilitation. At this point she was 27 weeks pregnant. She made good progress with rehabilitation and was transferred to the antenatal ward at 36 weeks' gestation, at which time she was mobilising using elbow crutches. A vaginal delivery was anticipated but vaginal examination revealed multiple warts and therefore an elective Caesarean section was planned for 38 weeks' gestation. She was given cimetidine 400 mg orally the night before the Caesarean section and again the next morning.

Following administration of sodium citrate an epidural catheter was sited at L2–3. A total of 15 ml of bupivacaine 0.5% was given in divided doses to achieve a bilateral block to T4. After delivery of a live male child, 3 mg of diamorphine was administered epidurally. The baby weighed 3050 g and was healthy.

The mother made an uneventful recovery and was discharged after 28 days. Mother and baby remain well and she now has normal power and sensation in all limbs.


  1. Top of page
  2. Abstract
  3. Case history 1
  4. Case history 2
  5. Discussion
  6. Bibliography

The management of GBS in pregnancy is similar to that in the nonpregnant population. This comprises mainly symptomatic care and includes thrombo-embolic prophylaxis, adequate nutrition and physiotherapy. Pulse rate and rhythm, blood pressure, respiratory frequency, and fluid and electrolyte balance require monitoring [ 3]. The FVC should exceed 1.5 l; this should be measured three times a day and the ability to cough and protect the airway assessed. If the FVC is less than 1.5 l or the patient is at risk of aspiration, she should be transferred to an ICU [ 3].

Apart from conservative management, plasmapheresis and γ-globulins are used in GBS to modify disease progression. The use of plasmapheresis in GBS is debatable but is probably of benefit [ 4]. In this technique, 200–250−1 of plasma is removed over 4–6 sessions and replaced with albumin or saline [ 1].

Plasmapheresis is generally used if the patient presents less than 7 days from the onset of symptoms or requires respiratory support [ 5]. However, anaphylaxis, pulmonary oedema, haemorrhage, hypocalcaemia, fluid imbalance and haemolysis are all complications of plasmapheresis [ 6]. It requires the availability of specialised equipment and staff trained in the technique. In pregnancy, it should be reserved for severe cases but has been used [ 3, 5, 7]. Plasmapheresis has no effect on fetal development.

Treatment with high-dose intravenous pooled γ-globulin is an alternative which has been used with success in the nonpregnant population [ 6]. It has also been used previously in a severe case during pregnancy [ 8].

Recent evidence in the literature would suggest that immunoglobulin therapy is probably the treatment of choice [ 9]. Our first patient did not require respiratory support so, apart from the treatment of her constipation, was managed conservatively. The second woman had more severe disease and was treated with both plasmapheresis and γ-globulins.

Anaesthesia and Guillain Barré syndrome

When our first patient presented for surgery we considered general anaesthesia. As she was 27 weeks pregnant this would have necessitated a rapid sequence induction. However, succinylcholine should be avoided in GBS owing to the risk of hyperkalaemia. This is due to proliferation of postsynaptic receptors. Succinylcholine-induced hyperkalaemia leading to cardiac arrest has also been reported in a patient after recovery from GBS [ 10].

Our patient had had a previous anaesthetic and tracheal intubation had been easy, so we could have considered using a nondepolarising muscle relaxant. However, as the pathophysiology of GBS is of a demyelinating polyradiculoneuritis, these patients are sensitive to competitive nondepolarising muscle relaxants. If they are used, postoperative ventilation may be required. Our patient was frightened of the possibility of ventilation and we were also concerned about cardiovascular stability; GBS causes autonomic nervous system instability [ 1] and she had been prescribed a ritodrine infusion over the peri-operative period.

Regional anaesthesia

Patients with GBS are also sensitive to local anaesthetics. Profound hypotension and bradycardia may occur with cardiovascular collapse [ 11]. In our first patient, we used spinal anaesthesia as we only required a low block. However, in the second woman, when regional anaesthesia was used for Caesarean section, it was felt safer to use an epidural and extend the block cautiously. This was because she had some residual weakness of upper and lower limbs and there was concern about respiratory reserve if the block was too high. Epidural anaesthesia for pain relief in labour is useful as it prevents autonomic instability secondary to pain. Practitioners who have used epidural anaesthesia successfully have reported that patients require only small doses of local anaesthetic drugs [ 12]. Indirect sympathomimetic agents may also be unpredictable and therefore direct acting adrenergic agents are indicated.

For patients with respiratory compromise, the risk-to-benefit ratio of regional vs. general anaesthesia has to be carefully considered [ 13].

Intensive care of the pregnant patient with GBS

One-third of patients with GBS will require assisted ventilation in the ICU [ 14]. Management of the pregnant patient with GBS is similar to the nonpregnant population. Uteroplacental oxygen delivery must be maximised. The fetus operates on the steep portion of the oxygen dissociation curve so only a small change in oxygen partial pressure may result in a large change in fetal saturation [ 15]. Higher airway pressures in pregnant compared with nonpregnant women may be acceptable owing to the decrease in lung compliance in pregnancy [ 15].

There is concern about drug usage during the first trimester of pregnancy and the effect on fetal development. The drugs used for sedation in our second patient are not known to be teratogenic and the need for sedation outweighed any potential risk.

As well as the normal routine intensive care management, great care must be taken to avoid aortocaval compression, maintain adequate nutrition and to ensure thromboprophylaxis.

The physical and psychological comfort of the patient must be attended to. A previous case report describes how increasing uterine size necessitated frequent turning for patient comfort and the prevention of pressure sores. The patient in this report presented at 18 weeks' gestation and was ventilated for 61 days. Distress was caused by failure to appreciate that sensation was still intact and by the physical discomfort of the enlarged uterus in a paralysed patient [ 16]. Lumbar backache has been helped by the use of epidural morphine [ 5] but frequent turning is still required to prevent pressure sores and aortocaval compression.

In our second case, respiratory support on the ICU was instituted in the first trimester. Despite this and despite severe disease, a healthy fetus was carried to term. In other severe cases, fetal development has also been noted to be normal [ 3, 5]. Normal fetal activity has been noted even at times of maximum maternal paralysis [ 16]. In cases in which ventilatory support is required later on in pregnancy, the risk of premature birth has been noted to be greatly increased [ 3, 5].

In recent literature, the use of plasmapheresis and γ-globulins has been reported to prevent the need for admission to intensive care [ 17].

Effect of GBS on pregnancy

In the review of the literature by Nelson and Maclean, fetal survival was greater than 96% [ 16]. However, there has been one reported case of a newborn infant born to a mother with GBS who also had clinical features of the syndrome [ 8]. GBS has no effect on uterine contraction or cervical dilatation [ 3] and therefore these patients should be allowed to deliver vaginally. Indeed, in the acute phase, induction of labour or Caesarean section may provoke deterioration of the patient's condition. However as the ability to bear down will be weakened, vacuum extraction may be required [ 3, 18]; otherwise unnecessary obstetric intervention should be discouraged [ 19]. However, both our patients required Caesarean section for obstetric reasons, and this was carried out successfully using epidural anaesthesia.

Pregnancy and anaesthesia in patients recovered from GBS

The mortality from GBS is 3–8% owing to sepsis, pulmonary embolism, adult respiratory distress syndrome or unexplained cardiac arrest. Of the remainder, 5–10% will have some permanent residual disabling neurological deficit. A further 65% will have some persistent minor problem. Only around 15% recover completely [ 1].

The number of patients with GBS or who have recovered from GBS seen in any one obstetric unit will be small. It is hoped that the introduction of the Obstetric Anaesthetists Association UK Registry of High Risk Obstetric Anaesthesia will allow the experience of obstetric units to be pooled and shared. This has been initiated by a team of consultant obstetric anaesthetists, and is currently co-ordinated by Dr S. Yentis at

Regional anaesthesia is not contra-indicated in these patients. However, these women may have a fear of paralysis and of lumbar puncture and will benefit from sympathetic anaesthetic involvement and counselling during their pregnancy. The same may be true of other neurological conditions.

Antenatal anaesthetic assessment clinics are extremely useful in this situation. Five other patients recovered from either GBS or transverse myelitis have been seen in our clinic over the past 4 years (personal data). The first woman had had GBS more than 10 years previously and had no reservations or fears of regional anaesthesia. The second woman felt unable to accept regional anaesthesia for elective Caesarean section owing to her neurological history. The other three were also anxious and concerned about regional anaesthesia. This was due to fear about experiencing paralysis again and unpleasant memories of lumbar puncture. One woman reported having had a postdural puncture headache following lumbar puncture. Having been seen in the clinic, all three were happy to accept a ‘mobile’ epidural for labour if needed but still expressed reservations about having a spinal block for Caesarean section. It was also felt to be important that they should meet the on-duty anaesthetic team early in labour before any intervention was required. Subsequently, they all achieved spontaneous vaginal deliveries with two having low-dose epidurals.

Although rare, GBS does occur in pregnancy but can be managed successfully with a good outcome for mother and child. Both of the above patients delivered healthy, normal babies even though one of them presented in the first trimester with severe disease. Clinicians should be aware that mothers who have recovered from GBS often have fears and anxieties and require sympathetic management.


  1. Top of page
  2. Abstract
  3. Case history 1
  4. Case history 2
  5. Discussion
  6. Bibliography
  • 1
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  • 2
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  • 3
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  • 4
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