|Year : 2013 | Volume
| Issue : 2 | Page : 97-100
Anesthetic implications in systemic lupus erythematosus patients posted for cesarean section: A series of five cases
Parul Jindal1, Ruchi Kapoor1, Gurjeet Khurana1, Jaya Chaturvedi2
1 Department of Anesthesiology, Himalayan Institute of Medical Sciences, Himalayan Institute Hospital Trust University, Dehradun, Uttarakhand, India
2 Department of Gynaecology and Obstetric, Himalayan Institute of Medical Sciences, Himalayan Institute Hospital Trust University, Dehradun, Uttarakhand, India
|Date of Web Publication||19-Dec-2013|
Department of Anesthesiology, Pain Management and ICU, Himalayan Institute of Medical Sciences, Jolly Grant, Dehradun, Uttarakhand
Source of Support: None, Conflict of Interest: None
Management of a parturient with systemic lupus erythematosus (SLE) requires a multidisciplinary approach. Although the ideal treatment strategy has not been formulated, certain management principles are recommended. We discuss the perioperative course and anesthetic management of five parturient with history of SLE who underwent cesarean section.
Keywords: Anesthetic implications, pregnant, systemic lupus erythematosus
|How to cite this article:|
Jindal P, Kapoor R, Khurana G, Chaturvedi J. Anesthetic implications in systemic lupus erythematosus patients posted for cesarean section: A series of five cases. J Obstet Anaesth Crit Care 2013;3:97-100
|How to cite this URL:|
Jindal P, Kapoor R, Khurana G, Chaturvedi J. Anesthetic implications in systemic lupus erythematosus patients posted for cesarean section: A series of five cases. J Obstet Anaesth Crit Care [serial online] 2013 [cited 2019 Jun 16];3:97-100. Available from: http://www.joacc.com/text.asp?2013/3/2/97/123306
| Introduction|| |
Systemic lupus erythematosus (SLE) is an autoimmune disease with heterogeneous presentation. It is is characterized by the presence of autoantibodies directed against nuclear antigens. The prevalence of SLE varies with ethnicity, but is estimated to be about 1 per 1,000 overall; with female to male ratio of 10:1, peak age of onset being between 15 and 40 years. ,, Therefore, it may coexist in pregnancy leading to complications in the parturient and adverse fetal outcome. Since it is a multisystem disorder, a thorough preanesthetic evaluation is mandatory for safe anesthesia. Anesthetic plan must be individualized based on the degree of the involvement of the various systems, current medications the patient is taking, and on the laboratory investigations.  We present the perioperative management of a series of five parturient with history of SLE posted for emergency or elective cesarean section.
| Case Report|| |
We present a series of five parturient who were booked cases with confirmed diagnosis of SLE undergoing regular antenatal check-up [Table 1].
|Table 1: Depicts the profile of the patients with SLE who underwent emergency/elective cesarean section|
Click here to view
In the present series, the parturient had been managed successfully in the antenatal period and had been able to continue their pregnancy up to third trimester. All patients underwent clinical evaluation, including history and review of historical data from case records, examination, and investigations. The risks and benefits of general and regional anesthesia were discussed with the subjects and informed consent was taken from them. Appropriate antibiotic prophylaxis was administered in all the parturient. Intraoperative monitoring included electrocardiogram, pulse oximeter, noninvasive blood pressure in all the cases, and end tidal carbon dioxide monitoring in general anesthesia (GA) case. Normothermia was maintained in all the patients. There was no significant blood loss in any case. All the patients had uneventful recovery and were discharged in satisfactory condition.
| Discussion|| |
Our own experience, as well as systematic review of the literature , suggests that perioperative management must be tailored to the individual patient. In our series, choice of anesthetic technique was left to the discretion of the consultant anesthetist involved. Decision was made after taking into account severity of the disease, the potential drug interactions with immunosuppressants, an unexpected difficult airway with subglottic stenosis or laryngeal edema, and coagulation profile of the patients.
Patients with SLE have a variety of abnormalities of varying intensity. Therefore, there are a host of presentations and the course is highly variable, ranging from relatively mild and uncomplicated to major life-threatening disease. Cardiovascular involvement could be in the form of pericarditis, myocarditis, arthrosclerosis, and myocardial ischemia.  Valvular involvement are seen in form of verrucous noninfective vegetations known as Libman-Sachs being the characteristic lesion and endocarditis.  Rhythm and conduction abnormalities are seen; common ones being sinus tachycardia, conduction abnormalities, and atrioventricular blocks.  Pulmonary involvement could vary from pleuritis, pleural effusion, alveolar hemorrhage, and interstitial lung disease. 
Renal involvement is seen in form of lupus nephritis characterized by proteinuria, hematuria, abnormal urinary segments.  Parturient with SLE are at high risk of developing pregnancy induced hypertension (PIH) irrespective of their pre-pregnant renal status. The risk may increase in case the patient requires more than 30 mg of prednisolone daily.  In our series, one patient who was on high dose of steroids had developed PIH in third trimester, but was managed successfully with regional anesthesia.
A 37-95% of SLE patients may manifest central and peripheral nervous system complications. American College of Rheumatology (ACR) recommends the term neuropsychiatric systemic lupus erythromatosus (NPSLE) to encompass all possible manifestations which may vary from headaches, seizures, cerebrovascular disease, psychosis, acute confusional states to even demyelinating disease states. 
Hematological manifestations commonly seen in SLE include anemia, thrombocytopenia, and leucopenia. Anemia is found in about half of SLE patients with the most common cause being anemia of chronic disease; however, other causes include autoimmune hemolytic anemia, iron deficiency anemia, anemia of chronic renal failure, and cyclophosphamide myelotoxicity. This anemia may be worsened by the dilutional anemia of pregnancy. , Nonerosive arthritis is seen in patients with SLE. Prolonged glucocorticoid use for immunosuppression could cause osteoporosis. Incidence of atlantoaxial subluxation has been reported. 
Antiphospholipid syndrome may occur secondary to SLE and is characterized clinically by recurrent pregnancy loss and by presence of lupus anticoagulant antibodies which may falsely prolong activated partial thromboplastin time in such individuals.  Pregnancy complicated with antiphospholipid syndrome warrants use of aspirin and heparin to prevent thrombosis.  SLE being an autoimmune disorder, patient is often on immunosuppressant drugs like corticosteroids which are continued in the pregnancy.
The prepregnancy visit aims at the activity of the lupus, organ damage, medication exposure, thorough preanesthetic assessment, and laboratory test. Care of this high risk group requires a multidisciplinary approach. In SLE patients with bad obstetric history, regular assessment of maternal disease activity and regular intrauterine growth assessment are recommended.
As SLE symptom are nonspecific and overlap with the physiological changes during pregnancy the investigations become mainstay in monitoring pregnancy.  Complete blood count has to be done in all patients alongside coagulation profile. Platelet count should be repeated every month because of high risk of thrombocytopenia in lupus pregnancies.  Electrocardiography may be done when suspecting pericarditis, myocarditis, and chest X-ray may be reserved for extreme cases where pleural effusion or interstitial pneumonitis is seen clinically.  For patients with renal involvement, every month creatinine clearance and 24 h urine protein should be checked. If the patient is on steroids then a close watch on blood glucose levels is advocated. Anticardiolipin antibody, lupus anticoagulant, anti β2 glycoprotien should be done to rule out any secondary involvement in preceding months.
Monitoring during anesthesia includes five lead electrocardiogram (ECG), noninvasive blood pressure, pulse oximetery, and invasive monitoring should be used in patients with myocarditis, valvular involvement, or conduction abnormalities. Renal protective strategies and maintenance of urine output, avoidance of nephrotoxic drugs are the goals during anesthesia. Adequate pain management and corticosteroid cover should be given intraoperatively to prevent adrenal suppression. Antibiotics are to be given to prevent infection. Patient should be positioned with care to avoid joint stress.
Regional anesthesia should be preferred over GA in parturients with history of SLE presenting for cesarean section. Difficult airway should be anticipated in all the patients, smaller sized tubes, and laryngeal mask airway must be available considering potential laryngeal and subglottic involvement. Laryngeal involvement could vary from mild inflammation to laryngeal edema, epiglottis, and vocal cord paralysis  to acute airway obstruction. The pathophysiology of laryngeal inflammation of SLE is not well-understood although the tissue deposition of immune complexes with activation of complements is less likely the cause. Compression of recurrent laryngeal nerve by dilated pulmonary artery has been reported as cause of left palsy in patients with SLE. Secondary nerve vasculitis is believed to be a cause especially in vocal cord palsy involving right side.  All these symptoms could worsen in a pregnant SLE patient presenting for cesarean section as during pregnancy extracellular fluid and vascular engorgement may lead to edema and compromise upper airway.  There is a significant risk of failed intubation and airway trauma during instrumentation.
Dyspepsia is a common symptom in pregnant women and can be worsened by aspirin, non-steroidal anti-inflammatory drugs, and corticosteroids therefore, increasing the risk of aspiration if GA is administered. Fetal outcome is superior in cases where regional anesthesia is administered.  GA should be reserved for indications such as fetal distress or placenta previa or if the patient is anticoagulated. In the series, the Apgar score of the neonates was above 7 both at birth and at 3 min when spinal anesthesia was administered. While that of parturient given GA was 6 at 1 min and 7 at 3 min. Isolated case report in literature have mentioned good fetal outcome irrespective of the anesthesia technique used. Cuenco et al., administered GA in a parturient with pulmonary hypertension complicated by SLE pneumonitis and vasculitis, pulmonary edema, and severe orthopnea. The patient's infant daughter showed no signs of respiratory depression, required no ventilatory support, and received routine care in the normal newborn nursery.  In yet another case report, Streit et al., reported a successful maternal-fetal outcome in a pregnant patient with SLE with associated pulmonary arterial hypertension. A healthy female infant weighing 2,760 g with Apgar scores of 8, 9, and 10 at 1, 5 and 10 minutes, respectively, were delivered via cesarean section under epidural anesthesia. 
Isolated elevation of partial thromboplastin time secondary to lupus anticoagulant is not contraindication to regional anesthesia.  Among the five patients we managed, four had normal platelet counts and coagulation parameters hence subarachnoid block was administered safely. One patient had thrombocytopenia so GA was administered to the patient.
We did not administer epidural in any patient because three patients were posted for emergency cesarean section and one patient was morbidly obese making it technically difficult.
Thus, we conclude that in absence of contraindication regional anesthesia is the preferred choice for pregnant patient with SLE who presents for cesarean section.
| Acknowledgement|| |
We would like to express our gratitude and appreciation to our colleagues in gynecology and obstetrics department who are doing incredible work.
| References|| |
|1.||Davies SR. Systemic Lupus erythematosus and the obstetrical patient-implications for the anesthetist. Can J Anaesth 1991;38:790-5. |
|2.||Pandey DP, Pai MV, Kumar P. Systemic Lupus erythematosus and pregnancy: Today′s scenario. Internet J Gynaecol Obstet 2009;11:2. |
|3.||Mintz G, Rodriguez-Alvarez E. Systemic lupus erythematosus. Rheum Dis Clin North Am 1989;15:255-74. |
|4.||Ben-Menachem E. Review article: Systemic lupus erythematosus: A review for anaesthesiologists. Anesth Analg 2010;111:665-76. |
|5.||Yeh TT, Yang YH, Lin YT, Lu CS, Chiang BL. Cardiopulmonary involvement in pediatric systemic lupus erythematosus: A twenty-year retrospective analysis. J Microbiol Immunol Infect 2007;40:525-31. |
|6.||Knockeart DC. Cardiac involvement in systemic inflammatory diseases. Eur Heart J 2007;28,1797-804. |
|7.||Kaman DL, Strange C. Pulmonary manifestations of systemic lupus erythematosus. Clin Chest Med 2010;31:479-88. |
|8.||Mok CC. Understanding lupus nephritis: Diagnosis, management, and treatment options. Int J Womens Health 2012;4:213-22. |
|9.||Manson JJ, Rahman A. Systemic lupus erythematosus. Orphanet J Rare Dis 2006;1:6. |
|10.||Klemp P, Meyers OL, Keyzer C. Atlanto-axial subluxation in systemic lupus erythematosus: A case report. S Afr Med J 1977;52:331-2. |
|11.||Garg P, Gaba P, Saxena KN, Taneja B. Anesthetic implication of antiphospholipid antibody syndrome in pregnancy. J Obstetric Anaesth Critical Care 2011;1:35-7. |
|12.||Rai R, Cohen H, Dave M, Regan L. Randomized controlled trial of aspirin and aspirin plus heparin in pregnant women with recurrent miscarriage associated with phospholipids antibodies (or antiphospholipid antibodies). BMJ 1997;314:253-7. |
|13.||Lee JH, Sung IY, Park JH, Roh JL. Recurrent laryngeal neuropathy in a systemic lupus erythematosus (SLE) patient. Am J Phys Med Rehabil 2008;87:68-70. |
|14.||Narsimulu G. Bilateral vocal cord palsy as a manifestation of systemic lupus eryhtematosus. Lupus 2009;1:1-2. |
|15.||Ni Mhuireachtaigh R, O′Gorman DA. Anesthesia in pregnant patients for nonobstetric surgery. J Clin Anesth 2006;18:60-6. |
|16.||Afolabi BB, Lesi FE, Merah NA. Regional versus general anesthesia for cesarean section. Cochrane Database of systematic reviews 2006;4:CD004350. |
|17.||Cuenco J, Tzeng G, Wittels B. Anesthetic management of the parturient with systemic lupus erythematosus, pulmonary hypertension, and pulmonary edema. Anesthesiology 1999,91:568-70. |
|18.||Streit M, Speich R, Fischler M, Ulrich S. Successful pregnancy in pulmonary arterial hypertension associated with systemic lupus erythematosus: A case report. J Med Case Rep 2009;3:7255. |