CH 33 Nervous System and Autoimmune Disorders of Pregnancy Flashcards
CVA causes
insufficiency (arteriosclerosis, cerebral embolism, vasospasm from HTN), and bleeding into the cerebral cortex (arteriovenous malformarion, ruptured aneurysm)
What happens during CVA
brain becomes infarcted from lack of blood flow, or intracranial bleeding results in space occupying lesion. Severity affected by blood pressure, 02 sat, hypoglycemia, and adequacy of circulation Usually happens in last trimester or immediately postpartum
CVA causes exclusive to pregnancy
eclampsia, choriocarcinoma, and amniotic fluid embolism
Most common aneurysm
Saccular (berry) variety, which protrudes from the major arteries in the circle of Willis
Clinical findings of CVA
Headaches, visual disturbances, syncope, and hemiparesis
Use of CT and MRI for CVA
used to increase delineation of CVA involvement
Arteriography in CVA
definitive if surgical intervention is being considered because it can more precisely localize the involved area
Labs for CVA
coagulation profile, ANA, lupus anticoagulant, factor V Leiden, homocysteine, anticardiolipin, proteins C and S, antithrombin III, plasminogen levels
CVA treatment, what should be done
Manage supportively, and use surgery for some aneurysms. Anticoagulation with heparin. Tissue plasminogen activator is contraindicated in pregnancy. Normalize blood pressure, resp support, treat metabolic complications and coagulopathies or cardiac abnormalities
CVA meds for cerebral edema
Dexamethasone, hyperventilation, mannitol, phenobarbital to induce coma, and monitor ICP.
CVA surgical intervention for pregnancy
do surgery without disturbing fetus, unless fetal maturity allows for c section before intervention. If vaginal delivery must be done, use forceps and regional anesthesia to reduce cerebral pressure associated with Valsava maneuver
Migraines during pregnancy
decrease during pregnancy in 50-80% of patients
Migraine clinical findings
usually has a history, described as pounding and may settle in the eyes, temporal region or occiput; Associated with GI complaints (N/V/D), or systemic symptoms (vertigo, syncope), photophobia, sonophobia, aura. Sleep may abort attack.
Tension and caffeine withdrawal HA
associated with bandlike pressure pain
Migraine differentials
Rule out Meniere’s disease if there is vertigo; If there is vertigo associated with ataxia or gait r/o head trauma, brain tumors, seizure disorders and multiple sclerosis
Migraine treatment (environmental)
Identify triggers (missing meals, stress, aged cheese, sausage, chocolate, citrus fruits, wine, monosodium glutamate, strong odors or lights, inadequate sleep)
Migraine treatment, abortive meds
acetaminophen, acetaminophen with codeine, narcotics, magnesium. Not preferred during pregnancy: butalbital, isometheptene, caffeine, aspirin, naproxen, ibuprofen, and triptans. Don’t give NSAIDs in 3rd trimester..it’ll lead to oligohydramnios
Migraine treatment, prophylactic meds
beta mimetic blockers, low dose tricyclic antidepressants, CCBs, magnesium, riboflavin, and topiromate. DONT fgve valporic acid or divalproate during pregnancy.
MS pathogenesis
autoimmune demyelinating process in white matter of CNS. Affects women twice as much. Cause not known
MS clinical findings
weakness in extremities, sensory loss, difficulty with coordination, visual problems, increased reflexes, spasticity, bladder control problems
Differential diagnosis for MS
R/O myasthenia gravis by doing anticholinesterase (neostigmine) challenge and acetylcholine receptor antibody testing. R/o Guillian-Barre if there is hx of recent viral infection
Labs for MS
Check serum for Vitamin B 12, Lyme, human T cell lymphotrophic virus type 1, erythrocyte sedimentation rate, ANA, rheumatoid factor. Elevated IgG in cerebrospinal fluid is diagnostic
Imaging for MS
MRI would reveal lesions in white matter of the brain and spinal cord. Active plaques will enhance with contrast
MS treatment
Interferon beta 1a, interferon beta 1b, glatiramer. Give glatiramer if trying to conceive then discontinue when pregnancy is established. Treat exacerbations with IVIG and corticosteroids postpartum
Myasthenia Gravis, what is it
chronic disorder of the neuromuscular junction of striate muscles as result of acetylcholine receptor dysfunction. Antibodies to acetylcholine will be present. Occurs more commonly in females than males and in the 30s.
Myasthenia gravis clinical findings
fatigued small muscles (especially ocular causing double vision), weakness increases, easily diagnosed later in the day. may have difficulty swallowing and with speech.
Myasthenia gravis diagnosis
administer edrophonium (tensilon) to assess improvement in muscular weakness. Perform radioimmunoassay for acetylcholine receptor antibody. Repetitive nerve stimulation would show decrement greater than 15%
Myasthenia gravis complications of pregnancy
exacerbation in 1/3 of pts. Doesn’t affect uterus since it is smooth muscle. Length of labor not affected but 2nd stage may be harder due to maternal fatigue. Exacerbations most common postpartum. Monitor fetal kicks with US, monitor for pulmonary issues and polyhydramnios. Neonate transient symptoms last around 3 weeks.
Myasthenia Gravis treatment
Anticholinesterases (neostigmine) must be given more frequently during pregnancy. May also use thymectomy, steroids, plasma exchange, and IVIG. Give anticholinesterase parenterally during labor. AVOID aminoglycoside antibiotics, mag sulfate, and chloroform
Rheumatoid arthritis parthenogenesis
chronic autoimmune disease characterized by symmetric inflammatory synovitis
Clinical findings of rheumatoid arthritis
insidious with prodrome of fatigue, weakness, generalized joint swelling and myalgias.
Diagnosis of Rheumatoid arthritis
made when patient is found to have inflammatory arthritis involving 3 or more joints. rheumatoid factor, elevated c reactive protein, elevated ESR, duration of symptoms for more than 6 weeks. Assess morning stiffness and number of joints involved
Abnormal labs in rheumatoid arthritis
mild leukocytes, elevated ESR, positive rheumatoid factor.
Treatment of rheumatoid arthritis
Rest, anti-inflammatory drugs, splints, PT, well balanced diet, joint movement. Low dose corticosteroids, hydroxychloroquine, sulfasalazine. Relapse may occur within 6 months postpartum. May need to terminate breastfeeding so that mother can take full range of pharmacologic therapy.
Meds to avoid for Rheumatoid arthritis in pregnancy
AVOID Cyclooxygenase inhibitors to avoid premature closure of ductus arteriosus and oligohydramnios. Avoid tumor necrosis factor inhibitors, penicillamine, gold, and methotrexate. Monitor Ro/SS-a and La/SS-b to determine feral risk of heart block
Systemic Lupus Erythematosus (SLE) pathogenesis
chronic inflammatory dz that affects many organs. cause is unknown.
SLE clinical findings
need to meet 4 of these criteria: malar rash, discoid rash, photosensitivity, oral ulcers, serositis, renal disorders, neuro disorders, hematologic disorders (anemia, leukopenia, thrombocytopenia), immunological disorders (anti DNA, anti Sm, false positive venereal dz research lab test), or abnormal ANA titer
Differential diagnosis SLE
rheumatoid arthritis, drug induced SLE symptoms, polyarteritis, chronic active hepatitis, and preeclampsia
Complications of SLE
preeclampsia, fetal growth restriction, risk of lupus flare, preterm delivery, may have deterioration of renal function
SLE treatment
Corticosteroids (may cause facial cleft, PROM, preterm delivery), hydroxychloroquine and azathioprine. Daily baby aspirin and heparin for those diagnosed with antiphospholipid antibody syndrome.
SLE monitoring during pregnancy
serial US for fetal growth, antenatal testing to ensure fetal well being. Deliver at 39 weeks. Uterine artery doppler at midgestation to predict fetal growth restriction
Drugs to avoid for SLE during pregnancy
Mycophenolate mofetil, cyclophosphamide, methotrexate, warfarin
