NEUROLOGIC and PSYCHIATRIC Disorders

Encountered in PREGNANCY

HEADACHE

• 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 1st 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 uncertain

50-70% of migraineurs experience a dramatic improvement during pregnancy.

• 15% of migraines appear for the 1st time during pregnancy, usually preceded by aura, and occurring most often in 1st 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 BID

Management 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

EPILEPSY

SEIZURES

• 2nd 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/abscess

Epilepsy 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 1st 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 sepsis

Hemorrhagic 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 palsy

Carpal Tunnel Syndrome

• Results from pressure of median nerve• Commonly associated with pregnancy• In some centers, its incidence in 3rd trimester

is noted to be more than 50%• Usually self-limited, and symptomatic relief is

sufficient in many of the cases

GBS

• 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 preferred

PSYCHIATRIC DISORDERS IN PREGNANCY

• PREGNANCY 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 disorders

• Level 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 1st week after delivery.

• Symptoms are mild and last for a few hours or a few days

• Supportive therapy • Monitoring for depression