Myasthenia Gravis in Pregnancy: Achieving Optimal Outcomes Through Precision Care – A Case Series From South India & Review of Literature

Introduction: Myasthenia Gravis (MG) is an autoimmune neuromuscular disorder affecting skeletal muscles, particularly in women of reproductive age. Though uncommon with a prevalence of only 0.3 to 2.8 per 100,000, the incidence peaks during 2nd and 3rd decades of life, and can have signicant impact in pregnancy. The course of the disease in pregnancy is not entirely understood. Methodology: A retrospective case series analysis of 4 cases were carried out for a period of 5 years from 2018 in a tertiary care centre in South India to identify and describe the disease course in pregnancy and effect of disease in the pregnant women and their fetuses. From this study, we aimed to describe the disease course of MG in pregnancy and formulate an optimal management plan, learning from our experience. Results: All patients included in the study were in a state of remission prior to conception. With vigilant monitoring and collaborative multidisciplinary approach, two patients successfully carried their pregnancies to term without encountering any complications, maintaining a stable course throughout the antenatal, intrapartum, and postpartum periods. However, one patient experienced an acute exacerbation upon contracting COVID-19 category C. Subsequently, her pregnancy was complicated by late-onset fetal growth restriction, preterm premature rupture of membranes (PPROM), preterm birth and postpartum exacerbation. Despite these challenges, both maternal and fetal outcomes were favorable, attributed to meticulous surveillance and critical care interventions. Another patient experienced an exacerbation at 10 weeks of gestation but otherwise had an uneventful pregnancy, labour, and postpartum recovery. Conclusion: One third of Myasthenia gravis patients can have exacerbations in pregnancy with a small but signicant subset experiencing potentially life threatening Myasthenic crisis. All necessary precautions should be pro-actively taken to prevent factors that could trigger a myasthenic crisis, including cautious drug selection during anaesthesia and the avoidance of medications that may exacerbate MG during acute infections. Caesarean section should be for obstetric indications only. Managing myasthenia gravis in pregnancy is quite challenging and requires multidisciplinary input with close monitoring and follow up.