Main Article Content

Sivalingam Nalliah
Sim Miao Ling
Chandramani Thuraisingham


Introduction: Myasthenia gravis (MG), an autoimmune disorder characterised by muscle weakness caused by impairment of the acetylcholine receptors at the neuromuscular junction as a result of autoantibodies acting against the ACh receptors, is twice as common in women, occurring in the second and third decades.  Successful pregnancy outcomes are possible with patient compliance to medication and care by a multidisciplinary team.Objective: The article demonstrates the ethical dilemma doctors face when dealing with termination of pregnancy in myasthenia gravis in pregnancy.Discussion: During pregnancy, MG exacerbates in one third of patients during the first trimester, and tends to improve during the second and third trimesters, with most women achieving normal delivery. The authors put up a case where decision for termination of pregnancy (TOP) could have been avoided through application of an ethical decision making framework.  The patient could have decided otherwise if a clear alternative line of management had been offered. Fully informed consent is essential preserving was not given and patient autonomy in such complex decisions. The emotive effects on the patient that biomedical imaging like showing a normal and active foetus through ultrasonography also needs to be considered.Analysis: A possible ethical framework using some of the principles of ethical decision-making, under the headings of i). Clear justification according to the norms and values of the individual, law and society for the intervention ii). Patient autonomy iii). Incongruence between parents in the abortion decision iv). The foetus as a person v). Directive counselling vi). Principle-based ethics, and, vii). Case-based ethics and case-based reasoning could be applied when confronted with the issue of termination of pregnancy in MG. While principle-based ethics is a useful starting point, care-based ethics also has a place in decisions on TOP.

Article Details

Regular Articles
Author Biographies

Sivalingam Nalliah, International Medical University

Professor , O&G

Chandramani Thuraisingham, International Medical University

Senior Lecture , Family Medicine


Eden RD, Gall SA. Myasthenia gravis and pregnancy: a reappraisal of thymectomy. Obstet Gynecol. 1983 Sep; 62(3):328-33.

Lo, Margaret C., et al. A Swollen Heart in Pregnancy. Journal of Medical Cases 2.6 (2011): 231-235.

Chaudhry SA, Vignarajah B, Koren G. Myasthenia gravis during pregnancy. Canadian Family Physician. 2012; 58(12):1346-1349.

Nervenarzt. 2010 Aug; 81(8):956-62. Doi: 10.1007/s00115-010-2995-7. Course and treatment of myasthenia gravis during pregnancy. Klehmet J, Dudenhausen J, Meisel A.

José F Téllez-Zenteno, Lizbeth Hernández-Ronquillo, Vicente Salinas, Bruno Estanol et al. Myasthenia gravis and pregnancy: clinical implications and neonatal outcome. BMC Musculoskelet Disord. 2004; 5: 42.

Almeida C, Coutinho E, Moreira D, Santos E, Aguiar J. Myasthenia gravis and pregnancy: anaesthetic management-a series of cases. Eur J Anaesthesiol. 2010 Nov; 27(11):985-90.

Ferrero S, Pretta S, Nicoletti A, Petrera P, Ragni N. Myasthenia gravis: management issues during pregnancy. Eur J Obstet Gynecol Reprod Biol. 2005 Aug 1; 121(2):129-38.

Berlit S, Tuschy B, Spaich S, Sütterlin M, Schaffelder R. Myasthenia gravis in pregnancy: a case report. Case Rep Obstet Gynecol. 2012; 2012:736024. Doi: 10.1155/2012/736024. Epub 2012 Jan 26.

Rahman R, Hoq MS, Arifuzzaman M, Kabir MA, Khanam NN. Pregnancy with myasthenia gravis. Mymensingh Med J. 2014 Apr; 23(2):395-400.

J. Djelmis, M. Sostarko, D. Mayer, and M. Ivanisevic, “Myasthenia gravis in pregnancy: report on 69 cases,” European Journal of Obstetrics Gynecology and Reproductive Biology, vol. 104, no. 1, pp. 21–25, 2002.

Picone O, Audibert F, Gajdos P, Fernandez H. Myasthenia gravis and pregnancy. Report on 13 cases. J Gynecol Obstet Biol Reprod (Paris). 2003 Nov; 32(7):654-9.

Podciechowski L, Brocka-Nitecka U, Dabrowska K, Bielak A, Hadacz B, Wilczynski J. Pregnancy complicated by Myasthenia gravis - twelve years’ experience. Neuro Endocrinol Lett. 2005 Oct; 26(5):603-8.

Quill TE, Brody H. Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Annals of Internal Medicine 1996, 125(9), 763-769.

Charles C, Gafni A, Whelan T. Decision-making in the physician–patient encounter: revisiting the shared treatment decision-making model. Social Science & Medicine 1999 Sept; 49(5); 651–661.

Appelbaum PS. Assessment of patient’s competence to consent to treatment. New England Journal of Medicine. 2007; 357: 1834-1840

English DC. Valid informed consent: a process, not a signature. Am Surg. 2002 Jan; 68(1):45-8.

Cook, Rebecca J. "Modern Day Inquisitions." University of Miami Law Review 65.3 (2011): 767-796.

Inadequate Preabortion Counselling and Decision Conflict as Predictors of Subsequent Relationship Difficulties and Psychological Stress in Men and Women Traumatology 1 March 2010: 16-30

Seminar in Ethics and Law the Ethox Centre, University Oxford. 2012-2013

Zechmeister, Ingrid. "Foetal images: the power of visual technology in antenatal care and the implications for women's reproductive freedom." Health care analysis 9.4 (2001): 387-400.

Nelson L J, Milliken N. Compelled Medical Treatment of Pregnant Women: Life, Liberty, and Law in Conflict .JAMA. 1988; 259(7):1060-1066

Maternal decision making, ethics, and the law. ACOG Committee Opinion No. 321. American College of Obstetricians and Gynecologists. Obstet Gynecol 2005; 106: 1127–37.

In re A.C., 573 A.2d 1235 (D.C. 1990).

Annas GJ. Foreclosing the use of force: A.C. reversed. Hastings Cent Rep 1990; 20(4):27-9.

Annas GJ. Protecting the liberty of pregnant patients [editorial]. N Engl J Med 1987;


Rhoden NK. The judge in the delivery room: the emergence of court-ordered caesareans. Calif Law Rev 1986; 74:1951–2030.

Dykes, K., and Karin Stjernqvist. "The importance of ultrasound to first-time mothers’ thoughts about their unborn child." Journal of Reproductive and Infant Psychology 19.2 (2001): 95-104.

Schenker, Joseph G., and Vered H. Eisenberg. "Ethical issues relating to reproduction control and women's health." International Journal of Gynecology & Obstetrics 58.1 (1997): 167-176.

Tomlinson, Tom. "Casuistry in medical ethics: Rehabilitated, or repeat offender?" Theoretical Medicine 15.1 (1994): 5-20.