Guillain-Barré syndrome (GBS) is a rare, acute, auto-immune-mediated polyradiculoneuropathy that can start a few days or weeks following a viral infection [1]. A few cases of COVID-19-associated GBS in the general population [1] and during pregnancy [2] have been reported. Its co-occurrence during a full-term pregnancy is uncommon and can result in significant maternal and perinatal morbidity [2]. The obstetrical and anaesthesia management of this risky situation is not yet well known, so there are no guidelines available [3]. In this case report, we describe our experience of successful and original preoperative management allowing for the improvement of GBS clinical features before a non-complicated caesarean delivery under spinal anesthesia.
Guillain-Barré syndrome, an inflammatory auto-immune polyradiculoneuropathy associated with numerous viral infections, may occur after the SARS-CoV2 viral process [4]. Some cases were reported after COVID-19 vaccination [5], while other studies showed that the prevalence of SARS-CoV2-associated GBS has declined since the introduction of vaccines [6]. In pregnant women, COVID-19-associated Guillain-Barré syndrome can occur at any time during gestation with atypical clinical features and difficult diagnosis [7] and can lead to adverse maternal and perinatal outcomes [8]. Even if the severity of COVID-19 in the Omicron wave was reduced [9], we think that the risk of serious complications like GBS is always present, especially in unvaccinated patients [10].
The choice of an anaesthesia technique was difficult given the conditions of our patient. Spinal anaesthesia may have some limits in patients with motor weakness in the lower extremities. Nevertheless, general anaesthesia for a full-stomach pregnant patient with pneumonia and dysphagia seems to be associated with a high risk of difficult intubation, aspiration, and cardiac arrest caused by GBS-related dysautonomia or the use of succinylcholine, which was implicated in a cardiac arrest with severe hyperkalemia after a crush induction in a pregnant woman recovering from GBS [11]. As a result, opting for the treatment of GBS and its complications, like pneumonia, before delivery was beneficial. On the other hand, general anaesthesia may worsen foetal outcomes, particularly in cases of acute foetal distress and foetalbradycardia. Previous studies showed poor outcomes in neonates whose mothers suffered from GBS [8]. There were high rates of pre-term birth (35.7%) and stillbirth (8.33%) with a 66.7% rate of spontaneous vaginal delivery [8].
In our case, plasmapheresis was safe and effective during pregnancy, but it required continuous maternal and foetal monitoring. We should mention that special hygiene measures are mandatory to prevent nosocomial infections for pregnant women with GBS, who are vulnerable to viral and bacterial infections, and this risk may increase with plasmapheresis. Daily blood samples to control the hemostatic status and plasmatic protein concentrations like albumin, prothrombin, and particularly fibrinogen are needed. These blood samples are mandatory because these factors can decrease after plasmapheresis. Finally, we recommend an enhanced recovery strategy after cesarean section delivery for these patients, in order to reduce postpartum complications [12].
COVID-19-associated GBS in pregnancy is a rare co-occurrence.
GBS in pregnancy can cause adverse maternal and perinatal outcomes.
Anaesthesia for pregnant women with GBS is a risky situation.
Clinical features of GBS may be improved by plasmapheresis which may reduce the risks related to anesthesia.
Plasmaphereis for pregnant women with GBS requires special hygiene measures and continuous monitoring.