neurological dis In Pregnancy Flashcards
Contraindicated anti-epileptic medications in pregnancy:
Valporic acid
Phenobarbital
Trimethadione
Topiramate
Diagnosis associated with Gravid migraneurs are:
- Stroke (x?)
- MI (? Fold)
- heart disease (x?)
- VTE (x?)
- PET/gestational HTN (x?)
Diagnosis associated with Gravid migraneurs are:
- Stroke (x16)
- MI (5-Fold)
- heart disease (x2)
- VTE (x2)
- PET/gestational HTN (x2)
Relapse risk of MS in pregnancy
Reduced by 70 %, higher rate in postpartum
Preconceptional Counseling of epileptic mother
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.
Pregnancy Complications of epilepsy
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.
the most common among the risk factors of stroke in pregnancy are
pregnancy-associated hypertensive disorders
cesarean delivery raises peripartum stroke risk ?-fold compared with vaginal delivery
cesarean delivery raises peripartum stroke risk 1.5-fold compared with vaginal delivery
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
Approximately 10 percent of these patients have a stroke by 1 year
The cardinal symptom of a subarachnoid hemorrhage from an aneurysm rupture is
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
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.
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
The familial recurrence rate of MS is — percent, and the incidence in offspring is increased —fold.
The familial recurrence rate of MS is 15 percent, and the incidence in offspring is increased 15-fold.
The demyelinating characteristic of this disorder results predominately from T cell-mediated autoimmune destruction of oligodendrocytes that synthesize myelin.
MS
four clinical types of MS:
- Relapsing-remitting MS accounts for initial presentation in 85 percent of affected individuals.
- Secondary progressive MS
- Primary progressive MS accounts for 15 percent of cases.
- Progressive-relapsing MS refers to primary progressive MS with apparent relapses.
Effect of pregnancy on MS
Relapse risk was reduced 70% during pregnancy, but with a significantly greater relapse rate postpartum.
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
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
Myasthenia gravis AND Preeclampsia
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.
MEDICATIONS TO AVOID WITH Myasthenia gravis
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.
pregnant women carry a —fold risk of bell’s palsy compared with nonpregnant women
pregnant women carry a fourfold risk of bell’s palsy compared with nonpregnant women
bell’s palsy in pregnancy has —fold greater rate for gestational hypertension or preeclampsia,
bell’s palsy in pregnancy has fivefold greater rate for gestational hypertension or preeclampsia,
the most frequent mononeuropathy in pregnancy
Carpal Tunnel Syndrome
ddx of Carpal Tunnel Syndrome
Differential diagnosis includes cervical radiculopathy of C6–C7 and de Quervain tendonitis.
what are the causes of ischemic cerebrovascular disorders related to pregnancy ?
Pre-eclampsia. Choriocarcinoma. Amniotic fluid embolism.
What is the impact of eclampsia on the cerebrovascular system?
Eclampsia leads to cerebral hemorraghe , with elevated blood pressure leads to vasospasm, loss of auto-regulatory function and rupture of the vessels .
Is tissue-plasminogen activator ( TPA ) safe in pregnancy ?
No , its contraindicated.
Whats the management of Cerebrovascular disorder?
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.
pleocytosis in CSF indicates what ?
Cerebral neoplasm.
HCG > choriocarcinoma
High level of glucose and protein > inflammation and infection
Which class of Tripitan drugs can be used in pregnancy to treat migraine ?
Sumatriptan . It’s the only approved triptan class to be used in pregnancy , FDA approved , no studies that showed major fetal effect ( PROLOG ).
What are the prophylactic medications options of migraine ?
Beta blockers TCA CCB Magnesium Riboflavin Topiramate
Whats the management of status epileptics ?
First line treatment : Lorazepam 2mg IV followed by 2 mg IV every 2 mins up to 0.1mg/kg. If it didn’t abort»_space; Phenytoin 20mg/kg slowly IV push at a rate of 50mg /min or fosphenytoin If it didn’t abort consider»_space; General anesthesia .
Whats fetal hydantoin syndrome ?
Associated with the use of phenytoin. Affects 3-5% Characterized by : Mental retardation, SGA, Carniofacial anomalies Limb defects
What medication have the highest NTD?
Carbamazepine 0.5-1% Valporic acid 1-5 % ( PROLOG )
What is the role of vitamin K in preventing hemorrhage disease of the newborn in women taking AED?
Enzyme inducer AED can cause fetal hemorrhage , so it is recommended for women to receive vitamin K 1 mg IM. (RCOG)
What is the risk of affecting the child if one of the parents is MS affected?
2 -2.5 % If a sibling is affected 2.7%.
Whats the effect of MS medications on pregnancy ?
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.
does MS flares increase or decrease postpartum?
During the first 3 months postpartum , relapses increase to 70% above prepregnancy level.
What is the effect of MG on the neonate?
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.
in patients with lower lesions ( T11 and below ) Whats the effect on labor ?
Likely perceive labor pain . Complications are related to recurrent UTI and decubitus ulcer
mid lesions ( T5 - T10 )Whats the effect on labor?
Painless deliveries . Patients should be use home uterine monitoring or taught uterine palpation. Weekly cervical examinations should be consisted.
Women with high lesions ( above T6 )Whats the effect on labor?
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.
is bell palsy associated with any adverse pregnancy outcome?
Fivefold increase risk for gestational hypertension. ( cannot identify the source!)
Effect of anti-epileptic on OCP and vice versa
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.
Posterior reversible encephalopathy syndrome (PRES) is
a neurological disorder which is characterised by variable symptoms, which include visual disturbances, headache, vomiting, seizures and altered consciousness.
