Epidural anesthesia for cesarean section in a pregnant woman with myasthenia gravis – A case report

Authors

Abstract

IntroductionMyasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction characterized by fluctuating muscle weakness. Pregnancy poses anesthetic challenges due to increased sensitivity to neuromuscular blocking agents and the risk of postoperative respiratory compromise.
Case PresentationA 20-year-old woman at 38 weeks’ gestation with a history of MG treated with pyridostigmine was scheduled for elective cesarean section. General anesthesia was avoided because of the potential for exaggerated response to nondepolarizing muscle relaxants and difficult extubation. Epidural anesthesia was preferred to provide a controlled and titratable block. Hemodynamic parameters remained stable intraoperatively. Postoperative analgesia was maintained via the epidural catheter. The patient had an uneventful recovery and was discharged on postoperative day three.
ConclusionEpidural anesthesia may be a safe and effective alternative to general anesthesia in parturients with MG, minimizing respiratory complications while ensuring adequate surgical anesthesia and postoperative analgesia.

Keywords

Introduction

Myasthenia gravis (MG) is an autoimmune disease that develops through autoantibodies targeting the neuromuscular junction and is characterized by weakness and fatigue in voluntary muscles.¹ In the pathogenesis, autoantibodies developed against nicotinic acetylcholine receptors (AChR), which facilitate nerve-muscle transmission, play a key role, and these antibodies disrupt neuromuscular transmission by reducing the number and function of receptors on the postsynaptic membrane.² Treatment of the disease includes symptomatic pharmacological agents, immunomodulatory drugs, plasmapheresis, thymectomy, and supportive approaches.1 The clinical course of MG is characterized by unpredictable remissions and flare-ups. Its prevalence is reported to be between 1 in 10,000 and 1 in 50,000, with women accounting for 65–70% of cases.³
Clinically, MG is characterized by fluctuating muscle weakness without reflex, sensory, or coordination disorders. In most cases, initial findings are limited to the ocular muscles and manifest as diplopia or ptosis; while symptoms remain limited to the ocular muscles in 20% of patients, they may progress to the extremities and bulbar muscles in 80%.2 Symptoms are generally mild in the morning, worsening as the day progresses and with repeated muscle activity, but partial improvement is observed with rest. Infection, stress, surgical procedures, and pregnancy can trigger exacerbations.
Recent literature indicates that the management of myasthenia gravis during pregnancy requires a multidisciplinary approach due to potential maternal respiratory complications and the increased sensitivity to neuromuscular blocking agents. Current evidence suggests that regional anesthesia techniques, including epidural anesthesia, are often preferred for cesarean delivery in patients with myasthenia gravis, as they allow controlled titration of the anesthetic level and avoid the risks associated with general anesthesia and neuromuscular blockade .^4,5 Furthermore, recent reviews emphasize that individualized anesthetic planning and careful perioperative monitoring are essential to minimize maternal and neonatal complications in obstetric patients with neuromuscular disorders.⁶ This case report aims to present the management of epidural anesthesia in a cesarean section in a pregnant woman diagnosed with MG.

Case Presentation

A 20-year-old patient weighing 64 kg, 38 weeks pregnant, gravida 1 para 0, who had been diagnosed with MG at age 15, was scheduled for an elective cesarean section. The patient was taking 3 x 60 mg of pyridostigmine daily and had not been regularly attending neurology follow-ups for a long time. A neurology consultation was requested due to the development of marked ptosis and restricted eye movements in all directions at the end of the day. Neurological examination revealed restricted eye movements in all directions, normal cranial nerve examination, normoactive deep tendon reflexes, motor strength of 5/5 in all four extremities, and normal speech function. There was difficulty in heel walking and intentional tremor. Although swallowing difficulty was described from time to time, the acetylcholine receptor antibody was negative. There was no history of respiratory distress, and the one-breath count test was normal. Electromyography revealed motor end-plate dysfunction, showing severe postsynaptic type involvement. Neurology recommended continuing the current treatment; avoiding nondepolarizing muscle relaxants, neuromuscular junction blocking agents, and antiarrhythmics if possible; and using opioids with caution. No additional pathology was observed in laboratory tests.
General anesthesia was avoided due to increased sensitivity to muscle relaxants and the risk of possible extubation difficulties. Epidural anesthesia was preferred because it provides a more controlled level of block and offers effective postoperative analgesia. Standard monitoring (3-lead electrocardiography [ECG], peripheral oxygen saturation [SpO₂], noninvasive arterial blood pressure, and capnography) was performed. Hydration was provided with Ringer's lactate via a second intravenous line using a 20-G branule. An epidural catheter was placed at the L3–L4 level in the sitting position, and a test dose of 1.5% lidocaine (3 mL) was administered. Upon the absence of hemodynamic instability or motor block, the patient was placed in the supine position. A total of 20 mL of 0.25% bupivacaine was administered in 5 mL fractions at 5-minute intervals. The level of sensory block was assessed using the pinprick and hot-cold tests. Adequate anesthesia was achieved at the T6 level at the 20th minute, and the surgery was started. At the 5th minute of the operation, 5 mg of ephedrine was administered due to a 25% hypotension compared to the baseline value, and hemodynamics remained stable. An additional 10 mL of 0.25% bupivacaine was administered at the 30th minute. The surgical duration was recorded as 75 minutes, and the anesthesia duration as 100 minutes.
The newborn's APGAR scores at 1 and 5 minutes were 7 and 8, respectively. No myasthenic crisis was observed during the intraoperative and early postoperative periods. Starting from the first postoperative hour, analgesia was provided with a 3 mL/hour infusion of 0.125% bupivacaine through the epidural catheter. The patient was discharged without complications on the third postoperative day.
Ethical Approval
Written informed consent was obtained from the patient for publication. Formal ethics committee approval was not required.
Reporting Guidelines
This case is reported in accordance with the CARE guidelines.

Discussion

MG is a fluctuating autoimmune disease resulting from autoantibodies developed against acetylcholine receptors or related molecules located on the postsynaptic membrane at the neuromuscular junction. The clinical picture is characterized by generalized or localized muscle weakness; proximal muscles are frequently affected, and ocular muscle involvement manifests as diplopia and ptosis. Ocular involvement is usually asymmetric and may involve multiple muscles.¹ While the vast majority of patients exhibit ocular symptoms during the course of the disease, a significant proportion of cases progress to generalized myasthenia gravis (GMG) despite predominant ocular findings at onset. An assisted second stage of labour should be considered in women who have experienced a recent disease exacerbation or a myasthenic crisis. The risk of disease exacerbation during pregnancy is approximately 34%. The incidence of myasthenic crisis is 6.4% during pregnancy and 8.2% in the postpartum period. This complication is serious and may be life-threatening.⁴
The antibody profile is important in terms of the clinical phenotype and prognosis of the disease. MuSK antibody positivity is generally not associated with the ocular form, while acetylcholine receptor and LRP4 antibodies can be detected in the ocular subgroup. The presence of antibodies increases the risk of generalization in the later period.¹ In the presented case, despite negative acetylcholine receptor antibody, post-synaptic type motor end-plate dysfunction was detected on electromyography. Despite the lack of long-term follow-up, the absence of clinical progression in this patient is noteworthy. Compared with the typical patterns of early disease progression, the patient reported only intermittent dysphagia accompanied by ptosis that increased toward the end of the day. However, the maintenance of clinical stability throughout pregnancy in our case supports the unpredictable course of MG during pregnancy.
One of the most critical points in anesthesia management is increased sensitivity to neuromuscular blockers. MG patients exhibit marked sensitivity to nondepolarizing agents, and even low-dose applications for priming or defasciculation can lead to loss of airway reflexes and respiratory complications. Combined spinal–epidural anesthesia has been reported to be safely performed even in newly diagnosed and clinically high-risk patients with MG.⁷ In our case, due to increasing fatigue and difficulty swallowing towards the end of the day, general anesthesia and curarization were avoided, and the epidural method was preferred for surgical anesthesia and postoperative analgesia.
In patients with MG, most intravenous anesthetic agents other than muscle relaxants can be used safely. The short duration of propofol action is advantageous. Opioids do not significantly impair neuromuscular transmission at therapeutic doses; however, the risk of central respiratory depression should be considered.
Epidural analgesia provides an important advantage in reducing the risk of respiratory depression by decreasing the need for systemic analgesics. The use of local anesthetics at low concentrations may limit motor block. Moreover, since anticholinesterase therapy may affect the hydrolysis of ester-type local anesthetics, amid-type agents should be preferred.⁸ In our case, adequate analgesia was achieved with the amid derivative bupivacaine, and no additional systemic analgesic was required.
A target block level above T4 for cesarean section may adversely affect respiratory function. Therefore, epidural anesthesia is advantageous over spinal anesthesia in terms of ensuring controlled spread. However, the need for higher doses should be considered. Although general anesthesia is recommended in patients with significant bulbar or respiratory involvement, no respiratory complications were observed during the intraoperative period in our case due to the absence of respiratory involvement and careful titration of the block level at T6. These findings support epidural anesthesia as a safe and effective option in pregnant women with MG, with appropriate patient selection and careful monitoring.

Limitations

The main limitation of our study is the limited number of patients. As it is a single case report, the findings cannot be generalized to larger patient populations or different clinical settings.

Conclusion

Anesthesia management in pregnant women with MG should be considered high-risk, and an individualized approach should be adopted. General anesthesia should be carefully planned due to increased sensitivity to neuromuscular blockers and the risk of respiratory depression from opioids. With appropriate patient selection, detailed preoperative evaluation, and meticulous intraoperative monitoring, epidural anesthesia offers a safe and effective option in cesarean section cases. This case demonstrates that regional anesthesia can be successfully applied in pregnant women with MG who have no respiratory involvement and are clinically stable, and that it can reduce the risk of perioperative complications.

Declarations

Abbreviations

AChR: Acetylcholine receptor
CARE: Case Report Guidelines
ECG: Electrocardiography
GMG: Generalized myasthenia gravis
MG: Myasthenia gravis
SpO₂: Peripheral oxygen saturation

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About This Article

Received:

March 12, 2026

Accepted:

April 24, 2026

Published Online:

May 1, 2026