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Laura MRCOG Part 2 > 9) Maternal Medicine: Neurology > Flashcards

9) Maternal Medicine: Neurology Flashcards

1
Q

Prevalence of epilepsy in pregnancy

A

0.5-1%

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2
Q

Percentage of WWE in reproductive age group

A

2/3

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3
Q

When can women be considered “no longer epileptic”?

A

If 10 years seizure free (5 of those off medication) or if childhood seizures but have reached adulthood without seizures or treatment.

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4
Q

Women with which type of seizures are highest risk for SUDEP

A

Tonic-clinic seizures

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5
Q

Rate of congenital malformations in WWE (including on AED)

A 
Unmediated: 2.8% (comparable to background risk)
Medicated: 4-10% risk
   - Levetiracetam 1-2%
   - Lamotrigine 2-5% (Dose dependent)
   - Carbemazepine 3.4%
   - Valproate 10%
   - Polypharmacy 17%
17% risk if previous child affected by AED congenital malformation.
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6
Q

Types of congenital malformations

A

Valproate - NTD, orofacial cleft, hypospadias, poor cognition and neurodevelopment (learning difficulties and autism)

Lamotrigine: Cardiac defects + clefts.
Levetiracetam: Cardiac defects + NTD
These have a lower risk of cognitive problems than SV.

Carbamazepine & Phenytoin - Cardiac/Cleft
Phenobarbital - Cardiac

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7
Q

When should folic acid be used?

A

5mg 3/12 pre-conception and at least until end of first trimester

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8
Q

What proportion of patients will remain seizure free throughout pregnancy?

A

67% seizure free.
As high as 74-92% if seizure free for 9-12m pre-conception.
Generalised seizures 74%, focal seizures 60%.

(17% will have improved control, 17% worsened control)

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9
Q

Risk of child having epilepsy

A

4-5% if one parent affected.
15-20% if both parents affected.
10% if previous child affected.

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10
Q

Advice re: AED dosing

A

Drug levels likely to fall in pregnancy (lamotrigine can fall by up to 70%). No role for routine level checking but need to consider clinical symptoms and likely increase dose in pregnancy.

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11
Q

Which infants should receive vitamin K?

A

Mothers on anti-epileptic drugs - 1mg vitamin K IM.

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12
Q

When should WWE be delivered?

A

No indication for early delivery.

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13
Q

Risk of seizure intrapartum

A

1-2% risk in labour
1-2% risk in first 24 hours postpartum
(Overall risk 3.5%)

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14
Q

What can be used prophylactically for women at high risk of seizures in labour?

A

Clobazam orally.

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15
Q

What percentage of pregnancies are complicated by status epileptics?

A

1%

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16
Q

Management of seizures in pregnancy/labour

A

If IV access: 4mg lorazepam or 5-10mg diazepam.
If no IV access: 10-20mg rectal diazepam, 10mg buccal midazolam.
If not resolving: 10-15mg/kg phenytoin.

If persistent uterine hypertonic - tocolytic.
If not resolved after 5 minutes then expedite delivery.

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17
Q

Risk of PND in WWE

A

29%

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18
Q

Contraception in WWE

A

If enzyme inducing drug (carbamazepine, phenytoin, topimarate, phenobarbitals, primidone) - either depot or coil (Mirena or copper).

If non-enzyme inducing drug then any method.

Lamotrigine levels are reduced by oestrogen containing contraceptives therefore avoid those or increase dose.

Emergency contraception - if enzyme inducer then copper coil or double dose LNG.

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19
Q

In what percentage of pregnancies are AEDs used?

A

1 in 200

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20
Q

What percentage of WWE will deliver a healthy baby?

A

96%

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21
Q

Risk of mortality in WWE compared to general population

A

10 x higher

60 per 100,000

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22
Q

When is fetal harm from AEDs highest?

A

1st trimester for congenital malformations. 3rd trimester for cognitive impairment.

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23
Q

Risk of SGA in WWE taking AEDs

A

2 x higher

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24
Q

Other risks of epilepsy in pregnancy

A 
Miscarriage
APH
Hypertension
IOL
CS
PTB
PPH
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25
Q

Which are the first line AEDs in people with generalised epilepsy syndromes?

A

Lamotrigine and Levetiracetam

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26
Q

Breastfeeding in epilepsy

A

Yes!

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27
Q

What is SUDEP?

A

Death unrelated to trauma/drowning/status epileptics.

Main cause of death in WWE.

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28
Q

Incidence of SUDEP

A

On Lamotrigine: 2.5 per 1000 pt years

On other AEDs: 0.5-1 per 1000 pt years

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29
Q

In SCI, percentage of worsening spasticity?

A

12%

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30
Q

In SCI, treatment of spasticity

A

Intrathecal baclofen

Oral oxybutynin can be used for bladder spasms

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31
Q

What percentage of women with SCI conceive post injury?

A

14%

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32
Q

At what level of SCI is a ventilation assessment in pregnancy advised?

A 
Above T4
(Vital capacity <12-15ml/kg requires mechanical ventilation)
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33
Q

At what level of SCI is there a risk of autonomic dysreflexia?

A

Above T6

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34
Q

At what level of SCI is there a risk of late PTL, altered perception of FM and inability to feel labour pains?

A

Above T10

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35
Q

What percentage of patients with SCI have PTL?

A

15%

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36
Q

At what level of SCI is there an increased risk of malpresentation?

A

Above T12

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37
Q

Above what level of SCI is there a risk of scarring in epidural space affecting analgesia?

A

Above L2-L4

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38
Q

What percentage of patients with SCI have their mobility limited further by pregnancy?

A

4.5%

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39
Q

What is the effect of SCI on congenital malformations and stillbirths?

A

Not increased

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40
Q

What is the recommended mode of delivery for patients with SCI?

A

Vaginal delivery unless concerns re: cephalopelvic disproportion.
- If SCI at young age or pelvic trauma then clinical pelvimetry recommended and likely CS.

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41
Q

Is admission recommended in patients with SCI?

A

Recommended late in 3rd trimester to avoid unattended delivery

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42
Q

What is the effect of SCI on VTE risk?

A
  • First 6 months are SCI risk is increased, after this it reverts to normal.
  • Score “1” on VTE for immobility in chronic SCI.
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43
Q

What happens in autonomic dysreflexia?

A

Any noxious stimuli below level of lesion isn’t modulated by the brain and so sympathetic system goes crazy!

Hypertension –> Vagal stimulation –> Bradycardia

Life threatening.

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44
Q

Symptoms of autonomic dysreflexia

A

Nausea, anxiety, malaise, prickling sensation in skull, ringing in head, throbbing headache.

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45
Q

Treatment of autonomic dysreflexia

A

Removal of noxious stimuli.

Medical treatment: SL nifedipine, GTN patch/spray, Nitroglycerine ointment, Labetalol/Hydralazine.

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46
Q

Who needs an epidural in SCI?

A

Should be recommended early in labour for people with lesion above T6 to prevent AD.
Can be used as an option for analgesia for others.

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47
Q

What level is sensory supply from uterus?

A

L1-T11

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48
Q

What level is cervical dilatation perceived at?

A

T11/T12

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49
Q

Rules for suprapubic catheter and CS

A

Change catheter in 24 hours prior to surgery
Incision 2cm above suprapubic catheter
Use non-absorbable sutures

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50
Q

Breastfeeding in SCI

A

Yes! Initiation may be delayed if SCI above T4 (may require visual stimulation or oxytocin nasal spray)

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51
Q

Risks of spinal cord injury occurring during pregnancy

A

Increased rates of miscarriage and congenital anomalies (secondary to hypoxia from spinal shock).
Direct trauma to uterus from compression can cause injury.

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52
Q

MS is more common in men or women?

A

2-3 x more common in women

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53
Q

Mean age of onset of MS

A

30 years

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54
Q

What proportion of women with MS will develop during their reproductive years?

55
Q

Incidence of MS

56
Q

What percentage of people with MS have an affected family member?

57
Q

Risk of MS based on family history

A 
1 in 67 if one affected parent
20% if both parents affected or monozygotic twin
10% if one parent and one sibling
5% if dizygotic twin
2.7% if one affected sibling
58
Q

What are the types of MS and which are most common?

A

85% is relapsing and remitting
10-15% primary progressive
Secondary progressive

59
Q

Effect of pregnancy on MS relapses

A
  • Less likely to relapse during pregnancy
  • 20-30% relapse rate in 3-4m postpartum
  • Relapses occur less often in parous women
  • Pregnancy after MS onset associated with lower risk of progression

Overall pregnancy does not alter risk of MS or long term progression.

60
Q

Epidural in MS?

A

Can do! No effect on risk of relapse.

61
Q

Breastfeeding in MS?

A

Yes! Beneficial - reduces risk of relapse 3 x

62
Q

Effect of MS on fertility/reproduction

A

No effect on fertility although lower AMH
Higher frequency of voluntary childlessness and TOP (20% v 12%)
ART (particularly unsuccessful attempts or agonist protocols) associated with increased relapse rate of 7 x in the 3/12 following.

63
Q

Percentage of women with MS with sexual dysfunction

64
Q

Effect of MS on miscarriage, stillbirth, congenital abnormality, perinatal mortality, antenatal hospital admissions, CS and instrumental delivery?

A

None of the fetal risks are increased.

Antenatal admission, CS and instrumental are increased.

65
Q

Effect of MS on PTB

66
Q

Effect of MS on FGR

A

1.7 x increased risk

67
Q

Which drugs can be continued until conception?

A

Interferon and glatiramer

68
Q

Which drugs can be used in pregnancy?

A

Steroids

Some women with severe disease may continue natalizumab which crosses placenta after 2nd trimester and can cause SGA/haematological abnormalities (but not miscarriage/congenital abnormalities).

69
Q

Growth scans in MS?

A

Yes please

70
Q

Mode of delivery in MS

A

Vaginal delivery safe

If severe neurological problems likely planned CS

71
Q

Lifetime risk of stroke

72
Q

Incidence of stroke in pregnancy (and compare rate to general population)

A

30 in 100,000 (3 x compared to normal population)

73
Q

When do the majority of strokes in pregnancy occur?

A

90% peripartum or in 6 weeks postpartum

74
Q

Mortality associated with stroke in pregnancy

A

10-20% (14% haemorrhage, 3% ischaemic)

75
Q

Residual disability associated with stroke in pregnancy

A

50% Haemorrhagic

33% Ischaemic

76
Q

What percentage of strokes are ischaemic/haemorrhagic/venous thrombus?

A

1/3 for each

77
Q

Which symptoms are more common with haemorrhage stroke?

A

Headache, reduced consciousness, nausea & vomiting

78
Q

Investigations for stroke in pregnancy

A

Imaging:

  • MRI first line in pregnancy if QUICK
  • If not quick, non-contrast CT scan (5% background radiation for fetus - not a concern)
  • CT angiogram for occlusions

Detecting cause:

  • ECG/24h tape
  • Echo
  • Doppler of carotid and vertebral artery
  • Consider thrombophilia screening
79
Q

Management of ischaemic stroke in pregnancy

A

Intravenous thrombolysis (recombinant tissue plasminogen activator)

  • pregnancy relative contraindication
  • major surgery in last 2/52 relative contraindication
80
Q

What is the risk of haemorrhage transformations after thrombolysis for ischaemic stroke?

81
Q

Treatment of haemorrhagic stroke

A

Haemostasis
Correction of coagulopathy
BP control
VTE prevention

82
Q

What proportion of strokes are recurrent strokes?

83
Q

Mode of delivery after stroke

A

No evidence that CS safer

84
Q

Risk of stroke recurrence

A

2% in future pregnancy
0.5% outside of pregnancy
In presence of thrombophilia 20%

85
Q

Incidence of cerebral venous thrombosis

86
Q

Greatest risk of CVT

A

3rd trimester to 4 weeks postpartum

87
Q

Presentation of CVT

A

Headache, papilloedema, focal neurological deficits, reduced consciousness, seizures

88
Q

Diagnosis of CVT

89
Q

Treatment of CVT

A

Anticoagulation 6 months

Follow up MRI after 6 months

90
Q

Most common site for CVT

A

Sagittal sinus with extension into cortical veins or primary thrombosis of cortical veins.

91
Q

Most common prodromal symptom prior to seizure in PET

92
Q

What percentage of headaches are migraine or tension?

93
Q

Effect of pregnancy on idiopathic intracranial hypertension

A

Worsens during pregnancy

94
Q

Describe the headache of IIH

A
  • Throbbing, retrobulbar
  • Worse with coughing/straining
  • Worse with eye movements
  • Associated visual disturbances, diplopia
  • Associated N/V
  • Papilloedema
  • Visual field defect with enlarged blind spot
  • 10% pseudo-localising sign of sixth nerve palsy (can’t look out)
95
Q

Diagnosis of IIH

A

Abnormally elevated CSF pressure (>25cmH20) with normal CSF constituents measured in lateral position.

96
Q

Treatment of idiopathic intracranial hypertension

A 
Monitor visual fields and acuity
Limit weight gain
Therapeutic LP
Acetazolamide
(Can use loop diuretics, avoid thiazide diuretics, can use steroids, can consider surgical/shunts)
97
Q

In what percentage of epidurals does a dural puncture occur?

98
Q

If dural puncture occurs, what is likelihood of headache?

99
Q

Describe the headache of dural puncture

A

Fronto-occipital into neck, worse on standing and occurring 24-48h postpartum.

100
Q

How long does dural puncture headache last if managed conservatively?

A

7-10d but can be up to 6 weeks

101
Q

Cure rate with epidural blood patch

102
Q

When does posterior reversible encephalopathy syndrome (PRES) occur?

A

In association with PET

103
Q

Headache of PRES

A

Headache, vomiting, visual disturbances, seizures and altered mental state.

104
Q

Radiological findings in PRES

A

Oedema posterior circulation of brain

105
Q

Management of PRES

A

As for severe PET

106
Q

Headache associated with reversible cerebral vasoconstriction syndrome

A

Recurrent severe sudden onset headaches over period of 1-3 weeks. Often with nausea/vomiting/photophobia/confusion/blurred vision.

107
Q

When does reversible cerebral vasoconstriction syndrome occur?

A

Postpartum period

108
Q

Imaging findings in reversible cerebral vasoconstriction syndrome

A

Diffuse arterial beading on angiography with resolution over 1-3 months

109
Q

Effect of pregnancy on migraines

A

Usually reduces frequency and severity

110
Q

Management of migraine

A

Analgesia, anti-emetics.
2nd line sumatriptan.
Prophylaxis: Propranolol or low dose amitryptiline.

111
Q

Increased risk of PET in patients with migraine

112
Q

Which women improve/worsen/stable with MG in pregnancy?

A

40% worsen, 30% stable, 30% improve.

113
Q

When are MG relapses most common?

A

First trimester or postpartum

114
Q

Effect of MG on obstetric outcomes

A

None! No increase in risk of miscarriage, PET, CS, FGR or PTB.

115
Q

Effect of MG on labour

A

Doesn’t affect first stage may affect 2nd stage.

116
Q

Mode of delivery for MG

A

Vaginal delivery recommended

117
Q

Epidural for MG

A

Yes, recommended (avoid GA and opiates)

118
Q

Risk of transient neonatal MG from antibodies

119
Q

What drug can’t you have with MG in PTL?

120
Q

Treatment for MG

A

Pyridostigmine (anti-cholinesterase inhibitor)
Steroids
Tacrolimus/ciclosporin
IVIG or plasmapheresis if acute crisis

121
Q

When does neonatal MG present and resolve?

A

Presents within 4d and resolved within 4 weeks

122
Q

What percentage of patients with MG have thymoma?

123
Q

Baseline investigations for patient with MG

A

Baseline motor strength
Pulmonary function
ECG
Thyroid function

124
Q

Proportion of patients with MG with thyroid dysfunction

125
Q

Incidence of Bells palsy

A

45 in 100000

126
Q

When does Bells palsy occur?

A

3rd trimester or immediate postpartum

127
Q

Increase in risk of Bells palsy with PIH/PET

A

4 x more likely

128
Q

Treatment of Bells palsy

A

Steroids if within 72h of onset

129
Q

How common is Carpal tunnel?

130
Q

What proportion of women with Carpal tunnel have bilateral symptoms?

131
Q

What percentage of women with Carpal tunnel have residual symptoms postnatally?

132
Q

Treatment of Carpal tunnel

A

Wrist splints

Local steroid injection

133
Q

What causes paraesthesia meralgia?

A

Stretching and compression lateral femoral cutaneous nerve under inguinal ligament.
Occurs third trimester but can be precipitated by protracted labour. Sx exaggerated by standing/walking.

Laura MRCOG Part 2 (56 decks)

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