Emergency Caesarean section in a patient with known sickle-cell disease and myasthenia gravis

Abstract

A 33-year-old patient with known sickle-cell disease (SS) booked for antenatal care at the Lagos University Teaching Hospital at six weeks gestational age. She had been diagnosed with myasthenia gravis three years prior to presentation and placed on oral anticholinesterase and steroid therapy, but her compliance was poor. She had had an operative delivery six years previously, under a general anaesthesia relaxant technique. It had been complicated by delayed emergence and residual muscle weakness, necessitating postoperative ICU admission for mechanical ventilation. In the index pregnancy, she had an emergency Caesarean section with bilateral tubal ligation under a combined spinal-epidural technique. A level of sensory block of T6 was achieved with 2.8 mL of 0.5% hyperbaric bupivacaine administered intrathecally. Towards the end of surgery, analgesia was supplemented through the epidural catheter with injection of 25 μg fentanyl in 6 mL of 0.25% plain bupivacaine. Supplemental oxygen was administered via a Hudson mask at 4 L/min. A live male baby with Apgar scores of 9 and 10 at one and five minutes, respectively, was delivered. The intraoperative period was uneventful. Postoperatively, she was managed in the high care unit. Postoperative analgesia was achieved via the epidural catheter with 6 mL of 0.125% bupivacaine and 2 μg/mL fentanyl four hourly for 48 hours. Subsequent recovery was uneventful. She was discharged to the postnatal ward on the fourth day postsurgery, and home with her baby 10 days later.

Keywords: Caesarean section, myasthenia gravis, epidural, sickle-cell disease