Download Neurologic Disorders in Pregnancy

Neurologic Disorders in Pregnancy
Raymond Powrie MD FRCP(C) FACP
Professor of Medicine, Obstetrics & Gynecology
Alpert School of Medicine at Brown University
Interim Chief of Medicine
Women & Infants Hospital of Rhode Island
Chief Medical Quality Officer
Care New England
Condition
Prevalence in Pregnancy
Headaches
Tension 86%
Migraine 2% in pregnancy (0.2 % hospitalized) – 17% of all
women
Cluster 0.01% all women in a lifetime
Secondary causes
Mononeuropathies
Carpal Tunnel 5-10%
Bell’s 0.057%
Obturator Nerve
Femoral Neuropathy
Peroneal Nerve Compression
Meralgia paresthetica
Epilepsy
1-2%
Multiple Sclerosis
0.15
Myasthenia gravis
0.02%
Stroke
0.01% Intracerebral bleeds, subarachnoid hemorrhage,
ischemic stroke, Cerebral venous thrombosis
Headaches
Type
Location
Pain
characteris
tics
Tension
Occipital or
band like
around head
Pressure
Frontotemporal,
unilateral
Throbbin
g/pulsatin
g
Migraine
Other
characteristics
Duration
Treatment
Prophylaxis for
HA>2/week or 2
debilitating/month
End of day
30 min to
7 days
Paracetamol 1 gm every 6 hours
ASA<100 mg /daily
Nortriptuline 10-50
mg PO QHS
Headaches
NSAIDS 1st and 2nd trimester
Associated
nausea,
photophobia.
Aura in up to
10-30%.
4-72 hours
Paracetamol 1 gm every 6 hours
Nortriptyline 10-50
mg PO QHS
NSAIDS 1st and 2nd trimester
Beta Blockers
Codeine, pethidine
Metroclopramide/caffeine/parace
tamol cocktail
prochlorperazine
Rebound HA
Bilateral
Throbbin
g or
pressure
Caffeine
withdrawal
Bilateral
Pulsating
Occurs with
use of
analgesia
more than 23 times/week
Variable
Stop analgesia and consider
prophylaxis
Avoid analgesia, avoid
triggers and consider
prophylaxis with
nortriptyline or beta
blockers
1 hour if
caffeine
ingested, 7
days if not
Resolves with time
Maintain consistent
caffeine uptake
Type
Location
Pain characteristics
Preeclampsia
Bilateral
Pulsating
Hypertensive crisis
bilateral
Subarachnoid
Hemorrhage
Other characteristics
Duration
Treatment
Scotomata
Epigastric pain
Hypertesion
Proteinuria
Intermittent
Delivery
Throbbing/pulsating
BP usually >160/120
Resolves within 1
hour of
normalization of
BP
Gradual lowering
of PB
Unilateral
Abrupt in onset,
severe and ‘worst
ever’ ,
incapacitating.
Worse with exertion
N/V
Altered consciousness
Days
Intervention to
treat underlying
vascular lesion
Cerebral venous
thrombosis
Diffuse
severe
Progressive
Often neuro deficits
Constant
Cluster
Unilateral
periorbital
Severe lancinating
short lived
Tearing, sweating,
congestion, edema,
miosis, agitation
15-180 minutes
Headaches
Prednisone
High Flow oxygen
Headaches
Type
Location
Pain characteristics
Other characteristics
Duration
Treatment
Post-dural
puncture HA
Diffuse
Constant but worse
with upright
position
Neck stiffness,
Hyper-aucusis
nausea
photophobia
1 week
Epidural blood
patch or
IV caffeine
Brain tumor
Localized
Constant
Focal neurologic
signs
Constant
Resection
Papilledema
Visual field defects
Intracranial
pressure on LP is
>200 mm H2O
Constant but
resolves within
72 hours of
normalization of
intracranial
pressure
Lumbar
puncture
Worse in morning
Worse with cough
or bending forward
Idiopathic
intracranial
hypertension
(‘pseudotumor
cerebri’)
Diffuse
Constant
Worse with
coughing or
val salva
Acetozolamide
CVT
Cerebral Venous Thrombosis
• Pregnancy carries an increased risk of cerebral
venous thrombosis (CVT)
• Symptoms (headache and neurological complaints)
classically develop within three weeks after delivery
• Causes ~2% of strokes seen in pregnancy
– incidence is higher in under-developed countries.
– dehydration is an important and preventable additional
risk
• Fatality rate ranging from 4 to 36%
Sidebar
CVT
Red Flags
•
•
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•
•
•
•
Sudden onset
New-onset
Severe (‘the worst headache of my life’)
Increasing in severity and frequency
Concomitant HIV/ Cancer
Head trauma
Associated neurologic findings including
sleepiness or change in mental status
• Fever
• Seizures
Mono-Neuropathies
Mononeuropathies
Neuropathy
Features
Etiology
Treatment
Meralgia paresthetica
(lateral femoral cutaneous
nerve)
Numbness over upper
outer thigh
Compression of groin by
gravid abdomen
Resolves in weeks after
delivery
Obturator nerve
Medial thigh pain &
abductor weakness –
circumducting wide
based gait
Compression of nerve with
vaginal delivery
Resolves in months after
delivery
Femoral neuropathy
‘knee buckling’ but
normal thigh adduction
AND sensory loss over
the anterior and medial
thigh
Lithotomy positioning with
sharp flexion of the hip
compresses nerve
Recovery over months
with physical therapy +/kneed brace
Peroneal nerve
compression
Foot drop with pain and
tingling on dorsum of
foot and anterolateral
leg
Prolonged squatting,
sustained knee flexion of
pressure on fibular head
from stirrups or labor
coaches
Recovery over 8 weeks =/leg brace
Meralgia Paresthetica
Obturator Neuropathy
Femoral Neuropathy
Peroneal Neuropathy
Mononeuropathies
Neuropathy
Features
Etiology
Treatment
Bell’s Palsy
(C.N. VII)
Assymmetric facial
droop
0.057% of
pregnancies
Edema of facial
nerve
Esp. third trimester
and with
preeclampsia
Prednisone 1mg/kg
daily for 7 days
No antivirals
Carpal tunnel
syndrome
(median nerve)
Numbness/pain
thumb, index and
middle finger
5-10% of
pregnancies
Edema in carpal
tunnel compresses
median nerve
Splints
Carpal Tunnel Syndrome
Multiple Sclerosis
Multiple Sclerosis
3.6 per 100 000
• Neuroinflammation and neurodegeneration in
brain and spinal cord
– Sensory loss in limbs, visual loss, sub-acute motor
loss, double vision and gait disturbance most
common
– Variable pace of progression
•
•
•
•
Relapsing remitting
Secondary progressive
Primary progressive
Progressive relapsing
Pregnancy Effects
• Inheritance poorly understood
– 2-3% prevalence in offspring versus 0.1% in general population
• No difference in long- term outcome
– Less relapses in pregnancy
– Increased relapse in first three months after delivery (double
the rate)
• Treatment of relapse
– High dose steroids 3g methylprednisolone IV daily for 3-5 days
– Cannot use mitoxantrone or natalizumab
– Might use IV immunoglobulin or plasmapheresis but long term
benefits unclear
MS
Disease Modifying Agents (DMD)
• Disease modifying agents
– best for relapsing remitting type
– glatiramer OK but little studied
• Interferon-beta an abortifacient
– Recommended to stop preconception
• Extra relapse of 0.2/year off medication
• Pregnancy may also help ameliorate disease
course
Symptom Management
Symptoms
Pregnancy Effects
Treatment in Pregnancy
Fatigue
Worsened by fatigue of
normal pregnancy
Sleep hygiene
Avoid stimulants
Avoid amantadine
Limb spasticity
Worsened in some in
pregnancy
Physical therapy and
benzodiazepines
?Tizanidine
Urinary symptoms
UTI more likely
Baclofen
Oxybutinin
? tolteridine
Postpartum
• Probably no role for IV gammaglobulin
prophylaxis
• DMD medications likely compatible with
breastfeeding but often deferred
– Not restarted in the context of a relapse
Myasthenia Gravis
1 in 20000 deliveries
• Chronic autoimmune disorder in which
autoantibodies block/destroy acetylcholine
receptors (AchR antibodies) causing impaired
transmission at neuromuscular junction
Myasthenia Gravis
• Early fatigue in affected SKELETAL muscle
– Ocular and extraocular muscles causing diploplia
and ptosis
– Can affect muscles of speech, swallowing and
breathing
• Does not affect cardiac or smooth (uterine)
muscle
MG
Treatment
• Pyridostigmine (an oral cholinesterase
inhibitor)
– Dose may need to be increased
• Plasmapheresis or IV immunoglobulin
• Particularly for “myasthenic crisis”
• Steroids/azathioprine/cyclosporine
• Thymectomy
• ideally before a pregnancy to decrease the risk of
neonatal MG
MG
Medications to Avoid
• Magnesium sulfate
• Antibiotics
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Aminoglycosides (e.g. gentamicin)
Macrolides (e.g. ‘- mycin’)
Ampicillin
Fluoroquinilones (e.g. ‘-floxin’)
Calcium channel blockers (e.g. nifedipine)
Beta-blockers (e.g. labetalol)
Lithium
Iodine contrast
Statins
MG
• Myasthenic crisis
– Acute weakness of respiratory muscles requiring ventilation
– Don’t decrease steroid dosing precipitously
• Cholinergic crisis
– Small pupils, hyper-salivation and bradycardia
• Fetal/ Neonatal MG
– In utero: polyhydramnios, arthrogryposis multiplex congenita
– Neonatal: non-reassuring fetal heart tracing and neonatal weakness by
24 hours
– Breastfeeding on pyridostigmine is fine
• In labor:
– Skeletal muscle weakness may affect ability to push
– Consider switch of PO pyridostigmine to IM at a dose of 1/3 of the PO
dose
Stroke
Raymond Powrie
Professor Medicine and Obstetrics and Gynecology
Brown University
Stroke
• Ischemic 85%
– Thrombosis
– Embolism
– Systemic hypoperfusion
• Hemorrhagic 15%
– Intracerebral
• Usually hypertension related
– Subarachnoid Hemorrhage (SAH)
• Usually aneurysms and arteriovenous malformations (AVMs)
Stroke in Pregnancy
• Incidence
– 11-26 deliveries per 100,000 in pregnancy versus
10.7 per 100,000 in women of reproductive age
Stroke in Pregnancy
Timeframe
• Can occur at any time
• Greatest risk is probably in the day before and
the days following delivery
Stroke in Pregnancy
Risk Factors
• pre-eclampsia (25-40% of all pregnancy related strokes)
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cesarean delivery
OCP
hypertension
hypotension (typically from hemorrhage)
thrombophilia especially the lupus anticoagulant or anticardiolipin
alcohol and recreational drug abuse esp. cocaine
diabetes
sickle cell disease
smoking
heart disease including peripartum cardiomyopathy
hyperemesis and disturbances in electrolyte and fluid balance
Stroke in Preeclampsia
• Can be due to hemorrhage or ischemia
• Not always associated with severe
hypertension
– One study of 28 patients found a pre-stroke
systolic BP <150-160 was common
Blood Pressures in Pre-eclamptic
Patients Who Had a
Stroke in Pregnancy
SAH Aneurysms & AVM
Lesion
Diagnostic test
Treatment
SAH
CT/MRI =/- LP for xanthochromia
CT angiogram and coiling
(anueurysm) embolization
or sterotactic radiosurgery
(AVM)
Aneurysms
CT angiogram
Coiling if >7 mm even in
pregnancy
Limited second stage
AVM
CT angiogram
MRI/MRV
Pregnancy risk low
Embolization or
radiosurgery can be done
after pregnancy if
warranted
Limited second stage
Sidebar
PRES
• PRES Reversible posterior leucoencephalopathy syndrome can
occur as a consequence of eclampsia and pre-eclampsia
• Presents with altered alertness and behaviour, seizures and
visual loss, headaches and somnolence
• On neuro-imaging, the most common abnormality is white
matter oedema seen as hyperintensity on MRI FLAIR images
in the posterior cerebral hemispheres
– May be more likely to be asymmetric in eclamptic patients
Sidebar
PRES
• Comparing ‘TSE FLAIR’
imaging to ‘Diffusion
weighted’ MR imaging
is useful in patients with
eclampsia to
differentiate vasogenic
edema from edema
caused by ischemia
Acute Stroke
Timing
Seen by provider
10 minutes
Neurologic assessment
and head CT
CT head read
25 minutes
Fibrinolytics (if
indicated)
•since the time of arrival
in the ER
•Since the time of onset
of symptoms
45 minutes maximum
60 minutes
180 minutes
Thrombolysis in
Pregnancy
Case report: Thrombolytic therapy of a
26 year old pregnant patient
The 26 year old patient in her 23rd gestational week noticed
weakness of her right arm on awakening. She presented
with dense hemiparesis of the right side in the
emergency department. Speech was not affected (left
handedness). Diffusion weighted MR imaging showed
hyperintensity of the left basal ganglia and occlusion
of the medial cerebral artery M1 segment (see figure
1). Thrombolytic therapy with alteplase 0.9 mg/kg of
body weight for one hour was started. After two hours
re-opening of the vessel was seen on transcranial ultrasound.
Hemiparesiswas considerably improved. On
the following day the right arm paresis deteriorated
with leg strength being improved. The MR imaging
showed demarcation of an acute ischemic infarction
in the basal ganglia and partial re-occlusion of the
MCA (see figure 2). No hemorrhage was seen. Cardiotocogram
and ultrasound did not show abnormality
of the fetus. Further work-up revealed elevated IgG
and IgM anti-cardiolipin antibodies (46 GPL-U/m, 8.1
GPL-U/ml, respectively). Anticoagulation with subcutaneous
low molecular weight heparin was initiated.
The patient was transferred to the rehabilitation unit
on day 9. Premature vaginal delivery of a healthy boy
occurred in the 32nd + 6 gestational weekwith a birth
weight of 2100 grams, (length 43 cm, APGAR 3/7/8,
NA-pH 7.00). The boy is reported healthy at one year
follow-up.
• rt-TPA (tissue
plasminogen activator
e.g. alteplase®) can and
should be given in
pregnancy when
indicated
• 28 cases in the
literature… 10 for stroke
Cincinnati
Prehospital Stroke Scale
• Specificity 88%
• Sensitivity 66-100%
STROKE
• S *Ask her to SMILE.
• T *Ask her to TALK, to SPEAK A SIMPLE
SENTENCE.
(Coherently) (i.e. . . It is sunny out today?
• R *Ask her to RAISE BOTH ARMS
• TRANSFER/RAPID CT AND NEURO CONSULT
Facial Droop
• Have the patient smile or show teeth
– Normal: both sides of face move equally
– Abnormal: One side of face does not move as well as the other
Arm Drift
• Arm Drift: Patient closes eyes and extends both arms straight out with
palms for 10 seconds
– Normal: both arms move the same or both arms do not move at all
– Abnormal: one arm does not move or one arm drifts downward with the
other
Abnormal Speech
• Abnormal speech: have the
patient say ‘you can’t teach
an old dog new tricks’
– Normal: patient uses correct
words with no slurring
– Abnormal: patient slurs
words, uses the the wrong
words or is unable to speak
Differential Diagnosis
Acute Stroke
•
•
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•
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Migraine
TIA
Head trauma
Brain tumor
Todd's palsy (paresis, aphasia, neglect, etc. after a seizure
episode)
• Functional deficit (conversion reaction)
• Systemic infection
• Toxic-metabolic disturbances
–
–
–
–
hypoglycemia
acute renal failure
hepatic insufficiency
drug intoxication
Stroke versus Migraine Aura
• Can’t really diagnose a migraine the first or even the
second time it happens
• Auras are typically
– Brief
– More likely to be a positive than a negative symptoms
• Wavey lines inv vision versus no vision
• ‘Pins and needles’ versus numbness
– Visual>>Perioral sensory>>>Upper Limbs sensory
Stroke versus Migrainous Aura
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•
•
•
Symptoms must be visual, sensory, or speech related
Visual/sensory symptoms should be one sided
Symptoms gradually progress and last 5–60 minutes
Patients with migraine aura should almost always
have had a history of visual symptoms at some time
– the scotoma and the zig-zag lines (aka fortification lines)
are typical
Stroke versus Migrainous Aura
• If more than one aura symptom is present, symptoms should
occur in succession rather than simultaneously
• Sensory symptoms that progress as a slow march, and the
combination of positive ‘pins and needles’ sensation and
subsequent numbness, typically lasting 5 to 60 minutes
strongly suggest migraine aura
• Migraine aura speech symptoms are still being defined
– Comprehension is rarely if ever affected, whereas searching for words
or using wrong words is a typical feature
– Dysarticulation is always present