Corea gravidum: How can we offer patients adequate analgesia for delivery?

López Pérez, V.

doi:10.1016/j.redare.2022.09.005

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"apellidos" => "López Pérez" "email" => array:1 [ 0 => "Ver_nica@icloud.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Universitario 12 de Octubre, Madrid, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Corea gravídico: ¿cómo podemos ofrecer a las pacientes una analgesia adecuada para el parto?" ] ] "textoCompleto" => "Chorea gravidarum, the development of chorea during pregnancy, is a rare entity that is diagnosed by exclusion.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Chorea gravidarum has important implications for the mother and the foetus, and deciding on the best approach to labour pain management can be difficult.We describe the case of a 20-year-old patient undergoing psychiatric follow-up for unspecified psychosis, an eating disorder, and probable personality disorder. Prior to pregnancy, she had been under treatment with sertraline 100 mg (2–0–0), ziprasidone 80 mg (1–0–1), lorazepam 1 mg (1–0–1), asenapine 5 mg sublingually before bedtime, and topiramate 50 mg. Her medication was adjusted to sertraline 100 mg (1–1/2–0), ziprasidone 60 mg (1–0–1), topiramate was discontinued, and lorazepam and asenapine remained unchanged. By the time she was first seen by her gynaecologist, at 7 weeks of pregnancy, her psychiatrist had already adjusted her treatment to 2 mg clonazepam at breakfast and lunch and 0.5 mg at night, 150 mg sertraline at breakfast, haloperidol drops (5–5–15), and pregnancy food supplements.Involuntary movements had started 1 month prior to pregnancy, although the patient did not seek treatment for this until she was 5 month pregnant. Onset consisted of occasional mild dyskinesia in the left upper limb that gradually intensified and spread to the rest of her body, accompanied by blurred vision in the left eye, loss of strength, tingling in the left side of the body, and holocranial headache. The physical examination revealed abnormal movements that mimicked chorea in the right upper limb and to a lesser extent in the left limb. The movements changed when she was distracted, disappeared with sleep, and worsened with pregnancy.The patient’s pregnancy was otherwise uneventful, and she continued with the same treatment regimen throughout. She was admitted to our hospital due to preterm rupture of membranes at 33 + 5 weeks of gestation, and corticosteroids every 12 hours were started for foetal maturation. Due to the mother’s status, the case was discussed with her gynaecologists and it was decided to induce labour and ultimately deliver the infant by caesarean section under general anaesthesia, because her continual choreic movements made it impossible to administer neuraxial analgesia. In the initial stages of dilation she was given 0.1 mcg/kg/min remifentanil for analgesia. The patient remained stable with good pain control. The choreic movements disappeared due to the sedative effect of remifentanil, so we decided to administer an epidural. The patient was placed in right lateral decubitus and single-shot epidural was performed without complications, which allowed us to administer an infusion of levobupivacaine 0.125% + 2 mcg/ml fentanyl for pain management, and withdraw remifentanil. A healthy boy was delivered vaginally at 34 + 6 days of gestation.The patient showed no sign of chorea for around 12 hours after delivery, although they progressively reappeared over the following days, and 5 months later, at the time of writing, they are still present.Chorea gravidarum is usually associated with pathologies such as lupus, antiphospholipid antibodies, rheumatic fever, and Wilson’s or Huntington’s disease. It is rare in developed countries, but incidence is increasing in developing countries.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> There is scant mention of chorea gravidarum in the literature, and it is all but silent on labour pain management in these patients. Diagnosis must include laboratory studies to rule out systemic inflammatory processes, streptococcal infection, thyrotoxicosis, diabetes, and other potential causes, along with imaging studies of the head and brain, electroencephalogram, electrocardiogram, and cardiac ultrasound to rule out the presence of rheumatic pathology,<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a> and finally, vaginal or abdominal ultrasound for the foetal study. In this patient, we were unable to determine the cause of chorea gravidarum. We were able to rule out Wilson’s disease, and the antistreptolysin (ASLO) and lupus anticoagulant tests were normal. The brain MRI was unremarkable, and the other studies were also negative.In most patients, abnormal movements appear after the first trimester and subside after delivery. Treatment is currently reserved for cases in which chorea gravidarum-induced rhabdomyolysis can be life-threatening for the mother or foetus. During pregnancy, treatment is limited to haloperidol and chlorpromazine, which have been shown to be safe at low doses.No studies have so far been published on labour pain management in these patients. The involuntary abnormal movements make it extremely difficult to perform an epidural, and in many cases the only option is caesarean section under general anaesthesia.In our patient, the movements subsided under remifentanil sedation, and allowed us to offer the mother a normal, pain-free delivery.Conflict of interestNone.FundingNone." 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Toral" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "BMJ Case Rep" "fecha" => "2018" "volumen" => "11" "paginaInicial" => "e227112" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Movement disorders and pregnancy: a review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S.M. Kranick" 1 => "E.M. Mowry" 2 => "A. Colcher" 3 => "S. Horn" 4 => "L.I. 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ISSN: 2341-1929

Revista Española de Anestesiología y Reanimación (REDAR) -the Spanish Journal of Anesthesiology and Resuscitation- is the scientific body of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy. This is a monthly journal (10 issues) that publishes scientific articles of all areas within its specialty: clinical anesthesia, resuscitation-intensive medicine and critical care, diagnosis and treatment of acute and chronic pain, urgent care and emergencies and studies on basic science and related fields. The journal accepts work in both Spanish and English.

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