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Facioscapulo- Adolescence Very slow, arrest Face first, then neck, Atrophy of accessory Labile hypertension Hyperkalemia with “ 15,81,82 Yes
humeral or early of progression shoulder, and pelvic muscles of respiration common. Conduction succinylcholine.
Dominant adulthood. is common. girdle. 10% become predispose to infection. anomalies (5%), Exaggerated lordosis.
wheelchair-bound. Respiratory failure is dysrhythmia, and Postoperative
rare. cardiomyopathy. respiratory problems.
Limb-girdle 10 to 30 years Progressive. Pelvic first, then shoulder Respiratory failure after Occasional conduction Hyperkalemia with Wheelchair during 83,84,85,86,87,88 Yes
Recessive old. girdle. 30 years or more of anomalies, succinylcholine. pregnancy,
(five subtypes) disease. dysrhythmia, and Lumbar lordosis. prolonged
cardiomyopathy. second stage,
increased C/S
rate.
Scapuloperoneal Late childhood Very slow, arrest Shoulder girdle, legs, then Uncommon. Hyperkalemia with “ 81 Yes
Dominant or early of progession pelvic girdle. succinylcholine.
adulthood. is common.
Congenital Birth. Nonprogressive, Generalized, proximal Respiratory failure may Hyperkalemia with “ 89
(includes more or very slowly more than distal. occur much later. succinylcholine.
than one progressive, or Swallowing difficulties, Kyphoscoliosis.
disorder) improve. diaphragmatic
Recessive involvement.

C/S = cesarean section
, ,
Table 5.8 Congenital myopathies1 90 91

Disease Respiratory Cardiovascular
Inheritance Clinical course Muscular involvement involvement involvement Anesthesia problems Obstetrical problems Specific references

Central core Nonprogressive. Mild, symmetrical, Some Cardiomyopathy Airway (mandibular Decreased muscle 15,88,92,93,94,95,96
Dominant proximal, face and hypoplasia, short neck), strength.
with variable legs. kyphoscoliosis,
expression malignant
hyperthermia, lumbar
lordosis.
Minicore (Multicore) Slowly progressive or Proximal, mild, trunk, Recurrent chest Cardiomyopathy Kyphoscoliosis 97
Recessive nonprogressive. face and infections (rare).
extremities, secondary to
swallowing kyphoscoliosis,
difficulties. diaphragmatic
weakness and
chronic
aspiration.
Nocturnal
hypoventilation.
Nemaline (rod body) Slowly progressive or Mild, generalized, Chronic Cardiomyopathy, Airway (high-arched Dystocia 98,99,100,101,102
Four forms, most nonprogressive. symmetrical, aspiration, congenital heart palate, micrognathia),
common form is proximal, microatelectasis disease (rare). kyphoscoliosis, lumbar
Recessive swallowing secondary to lordosis, and other
difficulties. diaphragmatic dysmorphic features,
involvement. aspiration.
Nocturnal
hypoventilation.
Centronuclear May or may not be Generalized Cardiomyopathy Airway (high-arched 103
(myotubular) progressive. (rare). palate), kyphoscoliosis.
Dominant or sex-
linked
, , , ,
Table 5.9 Disorders of muscle energy metabolism 1 22 108 109 110

Disease Respiratory Cardiovascular Anesthesia Obstetrical
Inheritance Onset Clinical course Muscular involvement involvement involvement problems problems Specific references

Carnitine deficiency, Childhood Progressive weakness, Proximal, improved Possible Rare Avoid fasting, Postpartum rapid 111,112,113,114
systemic form death secondary to with carnitine cardiomyopathy. sux, shivering, progression of
Recessive irreversible coma. supplement in hypoglycemia, weakness if
Treatment: carnitine some cases. metabolic no treatment,
supplement and acidosis. death.
carbohydrate. Recurrent
hepatic
encephalopathy.
Carnitine deficiency, Childhood Slowly progressive. Proximal, can affect Progress to Cardiomyopathy Rhabdomyolysis “ 115
myopathic form Treatment: carnitine pharyngeal muscles. respiratory
Recessive supplement and diet. failure.
Carnitine-palmitoyl- Childhood Normal strength Weakness is induced by May require Rhabdomyolysis Rhabdomyolysis 116,117,118,119,120,121
transferase between attacks. fasting and exercise, respiratory precipitated in labor, normal
deficiency Treatment: high and may be severe assistance by fasting, uterine muscle
Recessive carbohydrate and low and generalized. during exercise, sux, tone despite
fat diet. Muscle cramps. episode of NSAID. Avoid abnormal muscle
weakness. shivering, biopsy.
give glucose.
WPW in one case Severe lactic Preterm labor, avoid
Complex III Childhood Slowly progressive. Mild generalized Decreased O2
consumption, report. acidosis, labor, elective
deficiency weakness, muscle
prevent shivering. cesarean section.
cramps, exercise increased CO2
production.
intolerance.

sux = succinylcholine; NSAID = nonsteroidal anti-inflammatory drug; WPW = Wolff-Parkinson-White
2 Musculoskeletal disorders


ensure temperature monitoring. In addition, propofol may be con- The main complaint is one of stiffness and the affected individual
may not be aware of the diagnosis.146 Stiffness on initiating
traindicated because of the propofol infusion syndrome (PRIS).
Propofol infusion syndrome, manifested by life-threatening voluntary movement is relieved by exercise (˜˜warm-up™™ phe-
myocardial failure and metabolic acidosis, was reported first in a nomenon). There is no muscular weakness or involvement of
pediatric intensive care unit patient, but more recently in patients other organs. Smooth muscle is never affected, thus uterine con-
affected with disorders of lipid metabolism. The long-chain tri- tractions are normal. Temporary worsening of myotonia can
occur in the second half of pregnancy.147 Treatment is with an
glycerides present in the lipid vehicle of propofol may play a role
in the development of PRIS.122,123 oral lidocaine-like antidysrhythmic agent. Therapy is used fre-
quently because the myotonia is more incapacitating and drug
use is safer in these patients. This is in contrast to myotonic
Mitochondrial myopathy
dystrophy where cardiac involvement limits drug therapy.
Several variants of this condition have been described,148 includ-
Mitochondrial myopathies are rare diseases caused by genetic
defects in the morphology of mitochondria. A maternal mode of ing the more severe autosomal-recessive form (Becker myotonia).
inheritance is characteristic of many mitochondrial diseases, Epidural, spinal, or general anesthesia can be used safely as
because mitochondrial DNA is transmitted by the oocyte. Some long as precipitation of a myotonic crisis is prevented as
forms are very severe and patients are extremely handicapped. described previously (see Table 5.5) and treatment is readily
Mitochondrial myopathy is characterized by fixed proximal available (see Table 5.6) Response to nondepolarizing muscle
relaxants is normal.68
weakness with marked exercise intolerance. Rhabdomyolysis is
rare. Skeletal-muscle biopsy is characteristic (ragged red fibers).
Reports of pregnancies with normal progression of labor, epidural
Sodium channel disorders of muscle (hyperkalemic
analgesia, and assisted delivery have been described.124,125,126
periodic paralysis, paramyotonia congenita, and
Epidural analgesia prevents lactic acidosis during labor and
potassium aggravated myotonia = sodium channel
enables the use of outlet forceps or vacuum for delivery.
myotonia)
Paramyotonia congenita is the rarest of the myotonic syndromes.
Disorders of muscle membrane excitability
It is transmitted as an autosomal-dominant characteristic. The
These diseases are characterized by myotonia and, as opposed to myotonia is termed paradoxical because the muscular stiffness is
exacerbated by exercise.127 Paramyotonia congenita is a nonpro-
myotonic dystrophy, they do not present with significant perma-
nent muscle weakness until late in their course. Myotonia is a gressive illness and, for most patients, the symptoms are more of
persistent contraction of a muscle observed after cessation of a nuisance than a handicap. As in myotonia congenita, there is a
voluntary contraction.127 These disorders are amenable to treat- tendency to muscle hypertrophy. It affects mostly the face, ton-
ment, and with effective preventative measures progressive gue, neck, and hand muscles, and occasionally leg muscles.
weakness can be avoided. Diagnosis is based on clinical history Paramyotonia congenita is commonly induced or aggravated by
and confirmed by measuring serum electrolytes during attacks, exposure to cold, or after exercise. Usually, symptoms respond
by provocative tests or by DNA analysis. Although it is difficult to rapidly to warming but episodes of flaccid paralysis lasting sev-
interpret caffeine-halothane contracture tests in myotonic eral hours after the muscles have rewarmed may occur.
patients, most authors believe that they are not MH suscepti- Pretreatment with tocainide prevents or improves the symptoms
ble.128,129,130,131,132,133 Clinical features, prevention, treatment, in all patients.149 There appears to be no other organ system
anesthetic, and obstetrical problems are summarized in involved. Doubt has arisen as to whether paramyotonia congenita
Table 5.10.134,135,136,137,138,139,140,141,142,143,144,145 and hyperkalemic periodic paralysis are separate entities.127,150
There is increasing evidence to suggest that they are allelic dis-
orders, the locus having been traced to chromosome 17.151 The
Calcium channel disorders of muscle (hypokalemic
predominant feature of paramyotonia congenita is myotonia,
periodic paralysis)
whereas in hyperkalemic periodic paralysis the main clinical
symptom is muscle weakness.134 In severely affected women,
Previously known as dyskalemic periodic paralysis, hypokalemic
symptoms may be worse during pregnancy.134,149 A case report
periodic paralysis is now classified as a calcium channel disorder
of muscle. suggested that a cold-induced abdominal wall contraction led to
premature labor and delivery.152 Subsequently, the same patient
had another pregnancy with a normal delivery and an epidural
Chloride channel disorders of muscle (= myotonia
without any problem.153 Anesthetic considerations are the same
congenita = Thomsen disease)
as for myotonia congenita (see Table 5.10).154
Myotonia congenita is a rare inherited autosomal-dominant dis-
ease. Symptoms may be present from birth, but usually appear
Inflammatory myopathies
later. This mild, nonprogressive disease is characterized by gen-
eralized, cold-aggravated, painless myotonia, and muscular Inflammatory myopathies have an autoimmune origin and
hypertrophy. Males are more severely affected than females. can be classified into three groups: dermatomyositis (DM),



108
,
Table 5.10 Disorders of muscle membrane excitability134 135

Disease Muscular Provocation of Duration of Respiratory Cardiac Anesthesia Obstetrical Prenatal
Inheritance Onset involvement attacks attacks involvement involvement Treatment problems problems Case reports diagnosis

Hypokalemic Late first or Proximal limbs Rest after exercise, high 2 to 4 hours to Rarely Fluid retention, Acute: KCL; Avoid: PIH. More 136,137,138,139
Dominant second progressing to sodium or carbohydrate days. respiratory bradycardia, Prevention: hypokalemia, frequent 140,141,142
calcium decade. trunk and neck, meal, bicarbonate, distress can dysrhythmia, acetazolamide sux, glucose and
channel Male more rarely bulbar or glucose, insulin, be fatal. cardiac failure. load, alkalosis. worse
þ KCL, early
disorder severely respiratory adrenalin, epidural monitor EKG, crises.
affected. muscles. corticosteroid, cold, analgesia for Kþ and glucose.
stress, infection, vaginal delivery Keep warm.
trauma, menstruation. with a passive NDMR safe.
second stage.
Hyperkalemic Infancy and Proximal limbs Fasting, cold, rest after 2 to 3 hours. Mild Dysrhythmia. Acute: glucose Avoid: fasting, sux, PIH. More 143,144,145 Possible
Dominant childhood. progressing to exercise, KCL, weakness. and insulin or KCL. Monitor frequent
sodium trunk and face. corticosteroid. calcium EKG, Kþ, and
channel gluconate; glucose. Give worse
disorder Prevention: glucose. Keep crises.
acetazolamide, warm. NDMR
frequent meals. safe.

KCl = potassium chloride; sux = succinylcholine; EKG = electrocardiogram; NDMR = nondepolarizing muscle relaxant; PIH = pregnancy-induced hypertension
2 Musculoskeletal disorders


polymyositis (PM) and inclusion-body myositis. Classic diagnostic for labor, especially if muscular weakness is important, and could
criteria are: proximal muscle weakness, elevated muscle enzymes be of use if a C/S is needed.
(50-fold above normal), abnormal EMG findings, muscle biopsy General anesthesia has been described in patients with DM or
PM.162,163 Succinylcholine should not be used for rapid sequence
and, more recently, autoantibody profile, and magnetic reso-
nance imaging.155 Myoglobinuria is rarely observed.156 Steroids induction, especially in patients with significant muscle necro-
sis.60 Dermatomyositis and polymyositis are rare diseases and
are considered the mainstay of treatment in most cases.
Treatment should be continued during pregnancy in accordance severe hyperkalemia, myoglobinuria, and MH have not been
described.7 Responses to nondepolarizing muscle relaxants
with disease activity. Immunosuppressive therapy should not be
seem to be normal.162 Any residual drug effect for neuromuscular
used unless the mother™s life is at risk. Patients with DM have skin
involvement early in the onset of the disease, but skin changes blockade or analgesia may lead to ventilatory insufficiency and
may precede or follow muscle involvement. The typical rash and pulmonary aspiration in severely affected women.
myositis allow a diagnosis of DM. A flare is an exacerbation or
crisis and is usually less of a problem for patients with DM. The
Tumors and masses
skin changes include various eruptions, erythema, and dermati-
tis. The classic lilac-colored (heliotrope) rash occurs on eyelids, Myositis ossificans progressiva
bridge of nose, and cheeks (butterfly distribution). Affected
Myositis ossificans progressiva is a rare, autosomal-dominant dis-
women respond well to therapy and generally recover their mus-
ease characterized by extraskeletal ossification involving muscle
cle strength completely after each relapse. Polymyositis is more
connective tissue.164 The disease usually starts in early childhood
prone to flares without complete recovery of muscle strength.
and is progressively debilitating. Patients develop diffuse lesions
Inclusion-body myositis responds poorly to treatment and is the
that may be exacerbated by attempts at excision. Disodium ethane
most frequent form of inflammatory myositis in patients over
1-hydroxy-1,1- disphosphate (EHDP) halts the progression of the
55 years of age, mainly in men.
disease, but well-formed ossifications do not regress.165 As the
Extramuscular manifestations may be present to a varying
disease progresses, patients develop severe limitation in chest
degree. Heart involvement is always present with EKG abnorm-
motion with the potential for secondary respiratory and cardiac
alities (atrial dysrhythmias or conduction abnormalities) and ele-
failure.80 Fertility is reduced and early pregnancy loss is common.
vated cardiac enzymes, and may lead to congestive heart failure.
The first reported case of pregnancy associated with myositis ossi-
Severe dysphagia requires aggressive treatment due to the risk of
ficans progressiva was an induced abortion at ten weeks™ gesta-
pulmonary aspiration. Cricopharyngeal myomectomy may be
tion.164 The only case report of a successful pregnancy described a
required. Neck flexors may be affected. Interstitial lung disease
C/S performed under local anesthesia and sedation for a 26-week
may be rapidly progressive in up to 10% of patients. Weakness
viable infant.166 Intubation of these patients may be impossible,
of the intercostal muscles and diaphragm can contribute to vent-
even with the use of a fiberoptic bronchoscope, because of a fixed
ilatory insufficiency. Malignancies are increased in patients
and flexed position of the neck. Tracheostomy may be difficult
with DM. The overlap syndrome describes the association
because of extensive calcification of the tracheal rings. Regional
of an inflammatory myopathy and a connective-tissue disease
anesthesia depends on the extent of existing kyphoscoliosis.
(such as scleroderma, rheumatoid arthritis, or systemic lupus
Anesthetic and obstetrical considerations are summarized in
erythematosis). The best described association is DM with
Table 5.11.
systemic sclerosis,157 which is associated with poor recovery of
function.
Since the peak incidence of DM occurs between 40 and 60 years
of age, there are only a few reported cases associated with preg-
nancy. Even in patients with controlled disease, fetal outcome
may be adversely affected,156 but many healthy infants have been
Table 5.11 Myositis ossificans progressiva
born to mothers with DM.158,159,160,161 Dermatomyositis and
polymyositis may be triggered by pregnancy, but only a small Anesthetic Considerations
proportion of patients with the disease show clinical exacerbation
 Airway:
during pregnancy. Pregnancy-induced hypertension and placen-
 difficult intubation (fixed neck and jaw)
tal abruption have been described with other connective-tissue
 calcification of tracheal rings preventing rapid tracheotomy
diseases, but not in DM or PM patients.
 Musculoskeletal:
Monitoring muscle strength during pregnancy is the best way
 kyphoscoliosis
to assess disease activity. Multidisciplinary consultations should
 Respiratory:
be obtained, especially to evaluate respiratory muscle involve-
 restrictive syndrome secondary to a fixed ribcage
ment, dysphagia, and cardiac abnormalities. Uterine muscle is
 Obstetrical:
unaffected. Extreme weakness could necessitate assisted labor
 fixed hip joints
and delivery, but is not reported.
 cesarean delivery
Anesthetic management for pregnant patients with DM or PM
 tissue calcification in the wound
has not been described. Regional anesthesia seems appropriate



110
Chapter 5


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muscular dystrophy. Am. J. Obstet. Gynecol. 1961; 82: 612“15.
innervation. Pregnant women with myopathies have specific
26. Bray, R. J. & Inkster, J. S. Anaesthesia in babies with congenital dystrophia
needs depending on the symptoms and severity of their disease.
myotonica. Anaesthesia 1984; 39: 1007“11.
The potential for anesthetic agents or techniques to induce MH, 27. Tsatsaris, V., Papatsonis, D., Goffinet, F., Dekker, G. & Carbonne, B.
hyperkalemia, or myotonic crisis must be assessed in the antena- Tocolysis with nifedipine or beta-adrenergic agonists: a meta-analysis.
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