Acute post-infective peripheral neuropathy (Guillain-Barre syndrome; Landry’s paralysis) is a rare condition that usually follows an acute respiratory infection, although it may follow clostridial diarrhoea or surgery, and more recently has been linked to infection with the Zika virus. In pregnant women, the disease may have a rapid course and an increased risk of maternal mortality. There may be a slight increase in incidence in the early postpartum period. The symptoms usually commence some days after the infection, which triggers an autoimmune acute demyelinating neuropathy. The first symptoms are peripheral sensory paraesthesiae followed by a loss of motor power. The neuropathy ascends and may affect respiratory muscles. Generally, the disease is short-lived, and full recovery is usual over a period of weeks or months.
Problems and special considerations
Respiratory reserve in pregnant women is reduced, making these patients especially prone to respiratory impairment.
Autonomic dysfunction may be present and may cause significant haemodynamic fluctuations in response to regional anaesthesia, blood loss or tracheal intubation.
Women with a past history of Guillain-Barre syndrome who present for obstetric analgesia and anaesthesia may have concerns about whether regional techniques will cause a recurrence of the disease. Some may be anxious about having a needle in their back if they have had a bad experience with a lumbar puncture during investigation of the acute episode, or they may be worried about a significant motor block (e.g. when a caesarean section is performed).
Residual neurological impairment is rare after an acute episode.
Management options
Management of the acute illness should take into account the physiological changes of pregnancy and the wellbeing of the growing fetus. Careful monitoring of respiratory function is required, with ventilatory support when necessary. Particular attention must be paid to the avoidance of aortocaval compression and thromboprophylaxis in the immobilised parturient.
General and regional anaesthetic techniques have both been employed for the delivery of women with Guillain-Barre syndrome. If general anaesthesia is required, suxamethonium should be avoided because of the risk of hyperkalaemia, and neuromuscular function should be monitored. The mother should be closely observed for features of respiratory compromise in the immediate postpartum period.
There is no contraindication to regional analgesia or anaesthesia, when there is a past history of Guillain-Barre syndrome, and the woman can be reassured that it will not cause a recurrence of the acute episode. The risks and benefits of regional blocks should be discussed before the woman is in pain, preferably at an antenatal consultation. The woman’s fears of a motor block need to be considered by the anaesthetist, particularly if she has required ventilation for her acute illness. If there is any neurological deficit, this should be assessed and documented before a regional block is performed.
Key points
• Acute Guillain-Barre syndrome is rare in pregnancy but carries an increased risk of maternal morbidity and mortality.
• Antenatal assessment of women with a previous history of Guillain-Barre syndrome is advisable, since they may be very worried about regional analgesia and anaesthesia.
• Regional analgesia and anaesthesia are not contraindicated.
Further reading
Pacheco LD, Saad AF, Hankins GDV, Chiosi G, Saade G. Guillain-Barre syndrome in pregnancy.
Obstet Gynecol 2016; 128: 1105-10.
Willison HJ, Jacobs BC, van Doom PA. Guillain-Barre syndrome. Lancet 2016; 388: 717-27.