Peri-operative management of newly diagnosed rheumatoid arthritis for cesarean section: A case report

ABSTRACT We present a 28-year-old booked G1P0 at 35 weeks scheduled for cesarean section to highlight the challenges with the anesthetic management of rheumatoid arthritis (RA) in a recently diagnosed parturient. She presented with a 4-day history of insidious multiple joint pains with high-grade fever. The joint pain started from the shoulder and affected mouth opening and neck movement. Her past medical history revealed that she had been on fertility treatment for reproductive difficulties. An assessment of early-onset RA in a booked nulliparous was made by the rheumatologist. On preoperative assessment for elective cesarean section, she reported a low-pitch hoarseness of voice following the onset of the flitting joint pains. The physical examination revealed a young woman, distressed and febrile to touch (38.6°C). There was mild tachycardia (heart rate = 102), regular, and good volume. The systolic blood pressure was 139/82 mmHg with first and second heart sounds only. The abdomen was at a fundal height of about 38 weeks. The fetal heart sounds were heard and regular. The airway examination indicated adequate mouth opening (4 cm), limited neck movement, and Class 3 Mallampati view. Prehydration was done with 0.9% saline 1000 mL, and spinal anesthesia was induced through the L3/4 interspace with a 25G pencil-point spinal needle The spinal medications, hyperbaric bupivacaine 9 mg + fentanyl 15 μg, were instilled. The sensory level was determined to be at T4. A set of twins was delivered with Apgar scores as follows, twin 1 (8/1, 9/5) and twin 2 (8/1, 9/5) by the attending neonatologist. The third stage was managed with oxytocin 5 i.u. bolus and 35 units in 500 mL of 0.9% to run at 100 mL/h. She was discharged on the 4 th day postpartum having made remarkable improvement with the joint pain and movement. The postnatal clinic visit revealed a healthy mother and babies.