NEUROLOGIC and
PSYCHIATRIC Disorders
Encountered in
PREGNANCYHEADACHE
* Most common neurologic complaint in preg.
Tension-type headaches are common;
these present as mild to moderate pain in the
head & back of the neck, w/muscle tightness;
no associated nausea or neuro. disturbances.
* 39% postpartum headaches are tension-type.Diagnosis During Pregnancy-
some general statements
Some_ have Chronic disease — diagnosis known
before pregnancy; some have successful preg.
S/S appearing for 1% time in pregnancy must be
distinguished from preg. complications.
Pregnant patients at risk should receive same
evaluation & screening, like non-pregnant.
CTS & MRI can be used safely in preg.
Note that neuro-psychiatric diseases have been
found to contribute to maternal mortality rates.Migraine in Pregnancy
* Severe incapacitating periodic headache, w/
neuro- dysfunction/disturbance
* I.H.S. classification (2004) : migraine w/o aura
(unilat.throbbing + n/v or photophobia);
migraine w/ aura (premonitory neuro. signs);
chronic migraine (occurs at least 15 days/mo.
for more than 3 months, cause unknown)
* Pathophysiology still uncertain50-70% of migraineurs
experience a dramatic
improvement during
pregnancy.* 15% of migraines appear for the 1% time
during pregnancy, usually preceded by aura,
and occurring most often in 1° trimester.
* Some women may have a relapse postpartum.
* The onset of new neurologic symptoms
warrants a complete evaluation.Prophylaxis vs. freq. Migraines
Propranolol 20-80mg TID
Atenolol 50-100mg/day
Amitriptyline 10-150mg/day
Labetolol 50-150mg BIDManagement of Migraine in Pregnancy
* Analgesics — acetaminophen/paracetamol,
NSAIDs like ibuprofen, ASA
* For severe episodes, treat aggressively w/ IVF
hydration & parenteral anti-emetics.
Meperidine may be given with the antiemetic
metoclopramide or promethazine.
* Avoid ergotamine derivatives in pregnancy.Seizure Disorders in Pregnancy
EPILEPSYSEIZURES
* 2°¢ most prevalent neurologic condition in
pregnancy, next to headaches.
* Epilepsy can somehow affect prenatal course,
and labor and delivery.
* Several anticonvulsants are teratogenic.Causes of Convulsive Disorders
Trauma
Tumor/s
AV malformations
Alcohol withdrawal
Drug-induced withdrawals
Infections/abscessEpilepsy during Pregnancy
* Recent evidence suggests that untreated
epilepsy is not associated with increased
incidence of fetal malformations.
* Women with epilepsy have a small risk
increase of other pregnancy complications —
increased CS delivery rate, labor induction,
gestational HPN/preeclampsia.Epilepsy & Pregnancy
* Due to present-day good prenatal
management, epilepsy is better controlled in
at approx. 80% of pregnant women.
The risk of seizures in preg. is decreased by as
much as 50% if patient is seizure-free the year
before pregnancy.
Increased seizure freq. in pregnancy is
associated w/ lowered anti-convulsant levels
and/or lower seizure threshold.* Subtherapeutic anticonvulsant levels are caused
by nausea & vomiting in 1°t trim. , by decreased
gastrointestinal motility
use of antacids w/c lower anticonv. absorption
pregnancy hypervolemia & altered CHON bind
increased drug metab due to enzymes
increased GFR enhancing drug clearance.
* Many women discontinue their anticonv. meds
for fear of teratogenicity.“The fetus of an epileptic who takes
anticonvulsants has an indisputably
increased risk of congenital
malformations!”
Monotherapy is associated w/ lower
birth defect rate, compared w/ multi-
agent therapy.What then can be done?
Folic acid supplementation should be done,
since it has been shown to likely decrease
malformation rates associated with
anticonvulsant therapy.
Pre-conceptional counselling may help.Management in Pregnancy
Main Tx goal remains to be seizure prevention
or seizure control.
Seizure-provoking stimuli should be avoided.
Emphasize medication compliance.
Maintain anti-convulsant at lowest effective
dose.
Do CAS.Cerebrovascular Dses in Pregnancy -
STROKE
* STROKE IS RELATIVELY UNCOMMON IN
PREGNANT WOMEN.
If, however, stroke in pregnancy is diagnosed,
it significantly contributes to mat. mortality.
Recurrence risk for ischemic stroke associated
w/ pregnancy is low. There are no current
guidelines re. prophylaxis in preg. patients
with stroke history.Pregnancy-related Risk Factors
Hypertension (any type), most common factor
Eclampsia (assoc. cerebral/cortical infarction)
Cesarean delivery (1.5-fold more than NSD)
Hemorrhage
Blood transfusion
Puerperal sepsisHemorrhagic Stroke
* Intracerebral bleed during pregnancy is often
associated with chronic hypertension with
superimposed preeclampsia.
* It is thus important to properly manage
hypertension in pregnancy, especially systolic
HPN, to prevent cerebrovascular pathology.AVM
* Incidence of initial bleed from cerebral AVM is
not increased in and by pregnancy.
* Because of the possible higher risk of re-bleed
from an unresected AVM, cesarean delivery is
recommended (recom. vs bearing down).Degenerative Demyelinating Dses-
MS in Pregnancy
MS is an important cause of neurologic
disability in adulthood, and affects women
twice as often as men.
Incidence in the offspring is increased 15-fold.
Uncomplicated MS has no significant adverse
effects on pregnancy outcome.
No significant worsening of MS in pregnancy
Decreased relapse rate during pregnancy;
but significant relapse postpartally* Postpartum exacerbations of MS may prevent
women from exclusively breastfeeding their
newborn; the need for assistance during this
critical time should then be anticipated.Cesarean delivery in MS and MG patients is
reserved for obstetrical indications.
Ob plan is expectant vaginal delivery.
Epidural analgesia/anesthesia is recommended.Neuropathies - Bell Palsy
Acute idiopathic peripheral facial paralysis
Relatively common in women of reprod. age
Affects women 2-4x more than men of same
age; affects pregnant 3-4x more
Predisposing are pregnancy-related increase in
ECF & relative immunosuppression
Not clear if pregnancy alters outcome and
recovery from palsyCarpal Tunnel Syndrome
Results from pressure of median nerve
Commonly associated with pregnancy
In some centers, its incidence in 3™ trimester
is noted to be more than 50%
Usually self-limited, and symptomatic relief is
sufficient in many of the casesGBS
* Incidence is not increased antepartum
* When GBS develops during pregnancy, its
clinical course remains the same as in
nonpregnant. After an insidious onset,
paralysis and paresis continue to ascend, and
respiratory insufficiency becomes a serious
problem (need for ventilatory support in 1/3
of pregnant patients).Spinal Cord Injury & Pregnancy
Increased incidence of preterm birth
Low-birthweight infants (IUGR)
Majority with ASB of pregnancy & sympt.UTI
Significant bowel dysfunction & constipation
Autonomic dysreflexia associated w/ lesions
above T5-6 (stimuli from the bladder, bowel or
uterus lead to massive sympa. stimulation:
vasoconstriction & CAT release causing HPN,
tachycardia, respiratory distress)* Epidural analgesia extending to T10 prevents
autonomic dysreflexia and shld. be given at
the onset of true labor.
* Vaginal delivery is preferred; second-stage
labor may be expedited with forceps or
vacuum application.* Transection above T10 impairs the cough
reflex and may compromise respiratory
function. Thus, for some women with high
lesions, ventilatory support may be necessary
in late pregnancy and during labor.
Uterine contractions are not affected bt cord
lesions. If lesion is below T12, ut. contractions
are normally felt.Women w/ shunts for Hydrocephalus
* Usually have satisfactory pregnancy outcome
* Partial shunt obstruction is common, late in
pregnancy; most respond to conservative mx
* Vaginal delivery is preferredPSYCHIATRIC DISORDERS IN
PREGNANCYPREGNANCY AND PUERPERIUM ARE STRESSFUL
PERIODS.
Associated stress may provoke mental illness- an
exacerbation of preexisting disorder or a
recurrence or the onset of a new disorder.
Screening for mental illness done as early as 12
wks AOG can detect many disorders, a sig.# of
w/c precede pregnancy.
Psychia. dse is leading cause of late mat. deaths.
(suicide accounts for 65% of these deaths)Risk Factors
Prior personal history of depression
Family history of depression or psychia dse.
Hx of sexual or physical abuse
Substance abuse
Personality disorders
Smoking & nicotine dependence
Eating disordersLevel of perceived stress is higher for women
w/ fetus at risk for malformation, or ptt.w/
preterm labor, or medical complications.
To decrease psycho. stress after poor OB
outcome like stillbirth, some investigators
encourage parental contact w/ newborn and
provision of photos and other memorabilia of
the baby.Some reports of psychiatric disorders w/
pregnancy outcome, showing 3-fold increase
in delivery of LBW & preterm neonates.
Conversely, other studies conclude that
anxiety symptoms have no adverse on
pregnancy outcome.
Most common mood disorder even in
pregnancy is major depression (preg. as major
life stressor, effects of plac estrogen).Postpartum/Maternity Blues
Transient emotional hyperreactivity
experienced by 50% of women within the 1
week after delivery.
Symptoms are mild and last for a few hours or
a few days
Supportive therapy
Monitoring for depression