A Rare case of Guillain-Barré syndrome in pregnancy treated with plasma exchange
A 28 years old female, Gravida 1 Para1was referred to Gynecology and Obstetrics Department of our hospital at 36 weeks of pregnancy with 4 days history of progressive weakness of limbs and difficulty in walking, which culminated in loss of ability to walk; the weakness progressed gradually to upper limbs, with a 1 day history of difficulty in swallowing and breathing.\nThe patient was in her usual state of health 4 days back when she noticed weakness in both lower limbs after she got up in the morning. The weakness worsened the following day and she was unable to walk. By the end of 3rd day, weakness was also noted in upper limbs and had difficulty in lifting her arms. On the 4th day of her illness, she had difficulty in swallowing and breathing and was referred to the hospital.\nOn examination, the patient was found acutely ill, pale, afebrile, acyanosed, anicteric, and hydration status was satisfactory. She was dyspneic with shallow breathing. Her breathing was vesicular with no added sounds. Cardiovascular examination showed no abnormality. On abdominal examination, she was almost in full — term pregnancy (36weeks) and was not in labor. On neurological examination, she was found to be conscious but restless, and apprehensive. She was aphonic and had weak cough reflex and gag reflex; all her cranial nerves were normal. She presented with all the features of flaccid quadriplegia with grade zero power in both lower limbs and grade three in upper limbs. Muscle tone was decreased and deep tendon reflexes were lost. There was no sensory impairment or bladder and bowel involvement. Nerve conduction tests and cerebrospinal fluid analysis suggested diagnosis of GBS.\nThe patient was taken up for Cesarean Section, surgery was conducted under general anesthesia, and a 2.5 kg healthy baby was delivered. The patient could not be extubated following surgery as she was not able to maintain spontaneous breathing. She was then shifted to ICU and kept on ventilator and the next day plasma exchange was started; this was the 5th day of illness. Therapeutic plasma exchange was performed as first line treatment and IVIG or steroids were not tried before, after, or simultaneously with plasma exchange. Plasma exchange was done on alternate days, with a total of five sessions and in each session; 2308.8 ± 182.73 ml (range: 2105-2562 ml) of plasma was removed. This was in accordance with the guidelines of removing 1-1.5 times plasma in each session. Five percent albumin was used as replacement fluid. No plasma was used as the patient's coagulation profile was within normal limits. Peripheral femoral access was used to carry out the procedure; proper catheter care was maintained and lines were flushed with heparin before and after the exchange. The patient had no complications during these sessions. Complete coagulation profile including: prothrombin time (PT), prothrombin index (PTI), activated partial thromboplastin time (APTT); complete blood count (CBC) including haemoglobin, platelet count; electrolytes (Na+, K+, Ca++); s. protein levels were checked before and after the procedure and remained within normal limits throughout the treatment period. After three sessions of plasma exchange, i.e., on the 9th day of illness, the patient was weaned off the ventilator and physiotherapy started. The patient was discharged on 14th day of illness. At the time of discharge, the power was 5/5 in upper limbs and 3/5 in the lower limbs. Follow-up of the patient after 2 months showed no residual weakness.