Sarcoidosis is a systemic granulomatous reaction affecting many organs. The main effects of the disease are seen in the peripheral and central nervous systems and in the pulmonary and cardiac systems. An important aspect of the disease for the anaesthetist is pulmonary infiltration, which occurs in up to 80% of cases and produces a restrictive type of lung disease; there fore it is considered with the respiratory diseases.
The disease is treated with high doses of steroids and is not made worse by pregnancy.
Problems and special considerations
Sarcoidosis produces a restriction of the lungs, causing a reduction in the vital capacity and functional residual capacity. These changes, compounded by the physiological changes of pregnancy, mean that these patients may have little or no significant pulmonary reserve and may tolerate pregnancy (and especially labour) poorly. There is also an increased incidence of bronchospasm and airway hyperreactivity.
Cardiac impairment may be related to the primary disease (e.g. causing heart block or heart failure) or secondary to pulmonary involvement (causing pulmonary hypertension and right-sided failure). Patients with cardiac sarcoid may be sensitive to the negatively inotropic effects of anaesthetic agents.
There may also be renal impairment, central nervous system involvement, including isolated cranial nerve lesions, and haematological involvement. Anaemia affects 40% of cases, but thrombocytopenia is rare.
Mucosal infiltration of the upper airways occurs in about 5% of cases, and women may describe hoarseness, stridor, dysphagia or symptoms of obstructive sleep apnoea.
Sarcoidosis has been linked to adverse maternal and neonatal outcomes, including hypertensive disorders of pregnancy, thromboembolic disease, premature and caesarean delivery, and postpartum haemorrhage.
Management options
The main consideration is to assess the pulmonary and cardiac functions of the woman, and the effect of pregnancy and delivery on function. All these women should have pulmonary function tests performed in the first and third trimesters of their pregnancy unless mildly affected, and the management of the labour should be guided by the results. Electrocardiography should also be performed, with echocardiography if pulmonary hypertension or cardiomyopathy is suspected. Antenatal blood tests should include renal function and calcium levels.
In labour, the respiratory challenge of the work of labour and the ventilatory response to pain may be poorly tolerated; there fore epidural analgesia is recommended.
For caesarean section, general anaesthesia is best avoided, regional anaesthesia being the technique of choice. If general anaesthesia is necessary, the airway maybe more challenging if there is laryngeal involvement; a smaller-diameter tracheal tube or microlaryngoscopy tube may be necessary. Steroid replacement may need to be considered.
Respiratory, cardiac and renal deterioration may occur in the postpartum period, and a period of close monitoring is advisable.
Key points
• It is important to be aware of the generalised nature of sarcoidosis.
• Pulmonary involvement occurs in up to 80% of cases.
• Pulmonary and cardiac function should be assessed carefully in the antenatal period.
• Regional analgesia and anaesthesia are usually indicated in severe cases.
Further reading
Freymond N, Cottin V, Cordier JF. Infiltrative lung diseases in pregnancy. Clin Chest Med 2011; 32: 133-46.
Sanders D, Rowland R, Howell T. Sarcoidosis and anaesthesia. BJA Educ 2016; 16: 173-7.