neurological dis In Pregnancy

Question 1

Contraindicated anti-epileptic medications in pregnancy:

Answer 1

Valporic acid
Phenobarbital
Trimethadione
Topiramate

Question 2

Diagnosis associated with Gravid migraneurs are:

• Stroke (x?)
• MI (? Fold)
• heart disease (x?)
• VTE (x?)
• PET/gestational HTN (x?)

Answer 2

Diagnosis associated with Gravid migraneurs are:

• Stroke (x16)
• MI (5-Fold)
• heart disease (x2)
• VTE (x2)
• PET/gestational HTN (x2)

Question 3

Relapse risk of MS in pregnancy

Answer 3

Reduced by 70 %, higher rate in postpartum

Question 4

Preconceptional Counseling of epileptic mother

Answer 4

Folic acid supplementation with 0.4 mg
per day is begun at least 1 month before conception. The dose is increased to 4 mg when the woman taking antiepileptic medication becomes pregnant. These
medications are assessed and adjusted with a goal of monotherapy using the least teratogenic medication. If this is not feasible, then attempts are made to reduce the number of medications used and to use them at the lowest effective dose. Medication withdrawal should be considered if a woman is seizure free for
2 years or more.

Question 5

Pregnancy Complications of epilepsy

Answer 5

spontaneous abortion, hemorrhage, hypertensive disorders, preterm birth, fetal-growth restriction, and cesarean delivery. also reported a tenfold higher maternal death rate, , children of epileptic mothers have a 10% risk of developing a seizure disorder.

Question 6

the most common among the risk factors of stroke in pregnancy are

Answer 6

pregnancy-associated hypertensive disorders

Question 7

cesarean delivery raises peripartum stroke risk ?-fold compared with vaginal delivery

Answer 7

cesarean delivery raises peripartum stroke risk 1.5-fold compared with vaginal delivery

Question 8

transient ischemic attack (TIA) is caused by reversible ischemia, and symptoms usually last less than 24 hours. Approximately ? percent of these patients have a stroke by 1 year

Answer 8

Approximately 10 percent of these patients have a stroke by 1 year

Question 9

The cardinal symptom of a subarachnoid hemorrhage from an aneurysm rupture is

Answer 9

sudden severe headache that is accompanied by visual changes, cranial nerve abnormalities, focal neurological deficits, and altered consciousness.
signs of meningeal irritation, nausea and vomiting, tachycardia, transient hypertension, low-grade fever, leukocytosis, and proteinuria. non-contrast CT is the 1st diagnostic test

Question 10

the risk of recurrence of hemorrhagic stroke in nonpregnant patients, the risk of subsequent bleeding with conservative treatment is 20 to 30 percent for the
first month and then 3 percent per year. The risk of rebleeding is highest within the first 24 hours, and recurrent hemorrhage leads to death in 70 percent.

Answer 10

prior AVM bleeding. After hemorrhage, the risk of recurrent bleeding in unrepaired lesions is 6 to 20% within the first year, and 2 to 4%per year thereafter

Question 11

The familial recurrence rate of MS is — percent, and the incidence in offspring is increased —fold.

Answer 11

The familial recurrence rate of MS is 15 percent, and the incidence in offspring is increased 15-fold.

Question 12

The demyelinating characteristic of this disorder results predominately from T cell-mediated autoimmune destruction of oligodendrocytes that synthesize myelin.

Answer 12

MS

Question 13

four clinical types of MS:

Answer 13

1. Relapsing-remitting MS accounts for initial presentation in 85 percent of affected individuals.
2. Secondary progressive MS
3. Primary progressive MS accounts for 15 percent of cases.
4. Progressive-relapsing MS refers to primary progressive MS with apparent relapses.

Question 14

Effect of pregnancy on MS

Answer 14

Relapse risk was reduced 70% during pregnancy, but with a significantly greater relapse rate postpartum.

Question 15

fingolimod (Gilenya) immunemodulating drug for MS, was associated with fetal malformations and spontaneous losses. Because of this and associated animal teratogenicity, its use in pregnancy is not recommended. Due to its prolonged persistence, contraception is recommended for 2 months after drug cessation

Answer 15

Prevention of relapses postpartum is afforded by treatment with IVIG, given in a dose of 0.4 g/kg daily for 5 days during weeks 1, 6, and 12

Question 16

Myasthenia gravis AND Preeclampsia

Answer 16

Preeclampsia is a concern because magnesium sulfate may precipitate a severe myasthenic crisis. Although
phenytoin use is also problematic in this regard, its adverse effects are less troublesome. Thus, many choose it for neuroprophylaxis in women with severe
preeclampsia.

Question 17

MEDICATIONS TO AVOID WITH Myasthenia gravis

Answer 17

Narcotics may cause respiratory depression, and close observation and respiratory support are essential during labor and delivery.
Curariform drugs are avoided—examples include magnesium sulfate discussed
above, muscle relaxants used with general anesthesia, and aminoglycosides.

Question 18

pregnant women carry a —fold risk of bell’s palsy compared with nonpregnant women

Answer 18

pregnant women carry a fourfold risk of bell’s palsy compared with nonpregnant women

Question 19

bell’s palsy in pregnancy has —fold greater rate for gestational hypertension or preeclampsia,

Answer 19

bell’s palsy in pregnancy has fivefold greater rate for gestational hypertension or preeclampsia,

Question 20

the most frequent mononeuropathy in pregnancy

Answer 20

Carpal Tunnel Syndrome

Question 21

ddx of Carpal Tunnel Syndrome

Answer 21

Differential diagnosis includes cervical radiculopathy of C6–C7 and de Quervain tendonitis.

Question 22

what are the causes of ischemic cerebrovascular disorders related to pregnancy ?

Answer 22

Pre-eclampsia. Choriocarcinoma. Amniotic fluid embolism.

Question 23

What is the impact of eclampsia on the cerebrovascular system?

Answer 23

Eclampsia leads to cerebral hemorraghe , with elevated blood pressure leads to vasospasm, loss of auto-regulatory function and rupture of the vessels .

Question 24

Is tissue-plasminogen activator ( TPA ) safe in pregnancy ?

Answer 24

No , its contraindicated.

Question 25

Whats the management of Cerebrovascular disorder?

Answer 25

Mainly management is supportive:
1) normalize blood pressure.
2) Adequate respiratory support.
3) Therapy for metabolic complications
4) Treatment of coagulopathies or cardiac abnormalities.
Surgery is for cases of Anseyrum or AV malformation. Anticoagulation with heparin may be required according to the etiology. Dexamethasone 10 mg IV followed by 5 mg q6h for 24 hours may decrease cerebral edema prior to surgery or in recovery. Hyperventilation , mannitol infusion , phenobarbital coma and cerebral pressure monitoring may be helpful in cases of severe cerebral edema.

Question 26

pleocytosis in CSF indicates what ?

Answer 26

Cerebral neoplasm.

HCG > choriocarcinoma
High level of glucose and protein > inflammation and infection

Question 27

Which class of Tripitan drugs can be used in pregnancy to treat migraine ?

Answer 27

Sumatriptan . It’s the only approved triptan class to be used in pregnancy , FDA approved , no studies that showed major fetal effect ( PROLOG ).

Question 28

What are the prophylactic medications options of migraine ?

Answer 28

Beta blockers TCA CCB Magnesium Riboflavin Topiramate

Question 29

Whats the management of status epileptics ?

Answer 29

First line treatment : Lorazepam 2mg IV followed by 2 mg IV every 2 mins up to 0.1mg/kg. If it didn’t abort&raquo_space; Phenytoin 20mg/kg slowly IV push at a rate of 50mg /min or fosphenytoin If it didn’t abort consider&raquo_space; General anesthesia .

Question 30

Whats fetal hydantoin syndrome ?

Answer 30

Associated with the use of phenytoin. Affects 3-5% Characterized by : Mental retardation, SGA, Carniofacial anomalies Limb defects

Question 31

What medication have the highest NTD?

Answer 31

Carbamazepine 0.5-1% Valporic acid 1-5 % ( PROLOG )

Question 32

What is the role of vitamin K in preventing hemorrhage disease of the newborn in women taking AED?

Answer 32

Enzyme inducer AED can cause fetal hemorrhage , so it is recommended for women to receive vitamin K 1 mg IM. (RCOG)

Question 33

What is the risk of affecting the child if one of the parents is MS affected?

Answer 33

2 -2.5 % If a sibling is affected 2.7%.

Question 34

Whats the effect of MS medications on pregnancy ?

Answer 34

Most of the medications are teratogenic , and should be stopped pre pregnancy . Interferon B , glatiramer acetate , dimethyl fumarate should be stopped 1 months pre conception. Fingolimod should be stopped 2 months preconception. Natalizumab should be stopped 3 months preconception.

Question 35

does MS flares increase or decrease postpartum?

Answer 35

During the first 3 months postpartum , relapses increase to 70% above prepregnancy level.

Question 36

What is the effect of MG on the neonate?

Answer 36

It does not increase the risk of the neonate developing MG but there is 10-20 % risk of developing MG postpartum lasting up to 3 months.

Question 37

in patients with lower lesions ( T11 and below ) Whats the effect on labor ?

Answer 37

Likely perceive labor pain . Complications are related to recurrent UTI and decubitus ulcer

Question 38

mid lesions ( T5 - T10 )Whats the effect on labor?

Answer 38

Painless deliveries . Patients should be use home uterine monitoring or taught uterine palpation. Weekly cervical examinations should be consisted.

Question 39

Women with high lesions ( above T6 )Whats the effect on labor?

Answer 39

Autonomic dysreflexia leads to potentially life threatening sympathetic hyperactivity. Manifested by severe hypertension , loss of consciousness , headache , nasal congestion , facial flushing , sweating , piloerection , bradycardia , tachycardia or arrhythmia.

Question 40

is bell palsy associated with any adverse pregnancy outcome?

Answer 40

Fivefold increase risk for gestational hypertension. ( cannot identify the source!)

Question 41

Effect of anti-epileptic on OCP and vice versa

Answer 41

Antiepileptics such as carbamazepine (Tegretol), topiramate (Topamax), and phenytoin (Dilantin) are fairly well known for decreasing contraceptive effectiveness of OCPs by induce the hepatic p450 enzyme, whereas the use of lamotrigine (Lamictal) and an OCP increases metabolism of lamotrigine.

Question 42

Posterior reversible encephalopathy syndrome (PRES) is

Answer 42

a neurological disorder which is characterised by variable symptoms, which include visual disturbances, headache, vomiting, seizures and altered consciousness.