CH 33 Nervous System and Autoimmune Disorders of Pregnancy

Question 1

CVA causes

Answer 1

insufficiency (arteriosclerosis, cerebral embolism, vasospasm from HTN), and bleeding into the cerebral cortex (arteriovenous malformarion, ruptured aneurysm)

Question 2

What happens during CVA

Answer 2

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

Question 3

CVA causes exclusive to pregnancy

Answer 3

eclampsia, choriocarcinoma, and amniotic fluid embolism

Question 4

Most common aneurysm

Answer 4

Saccular (berry) variety, which protrudes from the major arteries in the circle of Willis

Question 5

Clinical findings of CVA

Answer 5

Headaches, visual disturbances, syncope, and hemiparesis

Question 6

Use of CT and MRI for CVA

Answer 6

used to increase delineation of CVA involvement

Question 7

Arteriography in CVA

Answer 7

definitive if surgical intervention is being considered because it can more precisely localize the involved area

Question 8

Labs for CVA

Answer 8

coagulation profile, ANA, lupus anticoagulant, factor V Leiden, homocysteine, anticardiolipin, proteins C and S, antithrombin III, plasminogen levels

Question 9

CVA treatment, what should be done

Answer 9

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

Question 10

CVA meds for cerebral edema

Answer 10

Dexamethasone, hyperventilation, mannitol, phenobarbital to induce coma, and monitor ICP.

Question 11

CVA surgical intervention for pregnancy

Answer 11

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

Question 12

Migraines during pregnancy

Answer 12

decrease during pregnancy in 50-80% of patients

Question 13

Migraine clinical findings

Answer 13

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.

Question 14

Tension and caffeine withdrawal HA

Answer 14

associated with bandlike pressure pain

Question 15

Migraine differentials

Answer 15

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

Question 16

Migraine treatment (environmental)

Answer 16

Identify triggers (missing meals, stress, aged cheese, sausage, chocolate, citrus fruits, wine, monosodium glutamate, strong odors or lights, inadequate sleep)

Question 17

Migraine treatment, abortive meds

Answer 17

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

Question 18

Migraine treatment, prophylactic meds

Answer 18

beta mimetic blockers, low dose tricyclic antidepressants, CCBs, magnesium, riboflavin, and topiromate. DONT fgve valporic acid or divalproate during pregnancy.

Question 19

MS pathogenesis

Answer 19

autoimmune demyelinating process in white matter of CNS. Affects women twice as much. Cause not known

Question 20

MS clinical findings

Answer 20

weakness in extremities, sensory loss, difficulty with coordination, visual problems, increased reflexes, spasticity, bladder control problems

Question 21

Differential diagnosis for MS

Answer 21

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

Question 22

Labs for MS

Answer 22

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

Question 23

Imaging for MS

Answer 23

MRI would reveal lesions in white matter of the brain and spinal cord. Active plaques will enhance with contrast

Question 24

MS treatment

Answer 24

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

Question 25

Myasthenia Gravis, what is it

Answer 25

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.

Question 26

Myasthenia gravis clinical findings

Answer 26

fatigued small muscles (especially ocular causing double vision), weakness increases, easily diagnosed later in the day. may have difficulty swallowing and with speech.

Question 27

Myasthenia gravis diagnosis

Answer 27

administer edrophonium (tensilon) to assess improvement in muscular weakness. Perform radioimmunoassay for acetylcholine receptor antibody. Repetitive nerve stimulation would show decrement greater than 15%

Question 28

Myasthenia gravis complications of pregnancy

Answer 28

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.

Question 29

Myasthenia Gravis treatment

Answer 29

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

Question 30

Rheumatoid arthritis parthenogenesis

Answer 30

chronic autoimmune disease characterized by symmetric inflammatory synovitis

Question 31

Clinical findings of rheumatoid arthritis

Answer 31

insidious with prodrome of fatigue, weakness, generalized joint swelling and myalgias.

Question 32

Diagnosis of Rheumatoid arthritis

Answer 32

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

Question 33

Abnormal labs in rheumatoid arthritis

Answer 33

mild leukocytes, elevated ESR, positive rheumatoid factor.

Question 34

Treatment of rheumatoid arthritis

Answer 34

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.

Question 35

Meds to avoid for Rheumatoid arthritis in pregnancy

Answer 35

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

Question 36

Systemic Lupus Erythematosus (SLE) pathogenesis

Answer 36

chronic inflammatory dz that affects many organs. cause is unknown.

Question 37

SLE clinical findings

Answer 37

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

Question 38

Differential diagnosis SLE

Answer 38

rheumatoid arthritis, drug induced SLE symptoms, polyarteritis, chronic active hepatitis, and preeclampsia

Question 39

Complications of SLE

Answer 39

preeclampsia, fetal growth restriction, risk of lupus flare, preterm delivery, may have deterioration of renal function

Question 40

SLE treatment

Answer 40

Corticosteroids (may cause facial cleft, PROM, preterm delivery), hydroxychloroquine and azathioprine. Daily baby aspirin and heparin for those diagnosed with antiphospholipid antibody syndrome.

Question 41

SLE monitoring during pregnancy

Answer 41

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

Question 42

Drugs to avoid for SLE during pregnancy

Answer 42

Mycophenolate mofetil, cyclophosphamide, methotrexate, warfarin