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Maternal Medicine > Neurological Disease > Flashcards

Neurological Disease Flashcards

1
Q

What is the prevalence of epilepsy?

A

0.5% women of childbearing age

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2
Q

For a first seizure in pregnancy, what are the appropriate investigations?

A

BP, urinalysis, FBC, clotting screen, U+Es, LFTs (PET)
BSL
CT / MRI Brain
EEG

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3
Q

What is the effect of pregnancy on epilepsy?

A

For most women, no effect on seizure frequency

Those with poorly controlled epilepsy more likely to deteriorate

Highest risk of seizures postpartum

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4
Q

What is the effect of epilepsy on pregnancy?

A

No increased risk (unless seizure results in abdominal trauma)
Status epilepticus is dangerous for mother and fetus

Fetus relatively resistant to short episodes of hypoxia

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5
Q

What is the risk of a fetus developing epilepsy if
A) Either parent has epilepsy
B) Previously affected sibling
C) Both parents have epilepsy

A

A) 4-5%
B) 10%
C) 15-20%

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6
Q

What are the major congenital anomalies caused by anti-epileptics?

A

Neural tube defects
Orofacial clefts
Congenital heart defects

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7
Q

In epilepsy, what should be prescribed for women taking hepatic enzyme-inducing AEDs? And when?

A

Vitamin K
Last 4 weeks of pregnancy

Vitamin K clotting factors may be reduced
Risk of Haemorrhagic disease of the newborn is increased

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8
Q

When are women with epilepsy most at risk of having a seizure?

A

1-2% during labour
1-2% in the first 24h postpartum,

Therefore, women should not be left unattended in labour or for the first 24h postpartum
And should continue their regular AEDs in labour

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9
Q

When does the neural tube close?

A

Gestational day 26

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10
Q

What is relevant when considering contraception and epilepsy?

A

Women taking hepatic enzyme-inducing antiepileptics
Require higher doses of oestrogen to achieve adequate contraception
Same with the POP
Need double dose of ECP

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11
Q

Most headaches in pregnancy are due to…

A

Tension headache or migraine

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12
Q

What are the clinical features of a migraine?

A

Throbbing, unilateral severe headache
Prodromal symptoms: visual - transient hemianopia, aphasia, sensory symptoms
Nausea and vomiting
Photophobia or noise sensitivity

Hemiplegic migraine may rarely lead to cerebral infarction

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13
Q

What is the pathogenesis of tension headaches?

A

Muscle contraction

Often related to periods of stress

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14
Q

What is the pathogenesis of migraines?

A

Primary neurovascular disorder
Inflammatory component
Vasodilation of cerebral blood vessels, possibly related to platelet aggregation and serotonin release

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15
Q

What are the differential diagnoses of a headache in pregnancy?

A 
PET
Post-dural puncture headache
SAH
Meningitis
Cerebral venous thrombosis
Idiopathic (benign) intracranial hypertension 
Intracranial mass lesions
Reversible cerebral vasoconstriction syndrome
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16
Q

Pre-existing migraine is associated with an increased risk of…

A

PET

Outside pregnancy:
Stroke
IHD
VTE
HTN
Diabetes
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17
Q

What is the management for migraines in pregnancy?

A

LDA prophylaxis
Beta blockers (propranolol)
TCA: amitriptyline

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18
Q

What are the clinical features of Multiple Sclerosis?

A

Relapsing and remitting clinical course

Optic neuritis, diploid, sensory symptoms, weakness of the limbs

Variable course

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19
Q

What is the pathogenesis of Multiple Sclerosis?

A

Exact pathogenesis unknown

Multiple areas of demyelination within the brain and spinal cord

20
Q

What is the effect of pregnanc on MS?y

A

Decrease relapse rate in 3rd trimester ? Decrease in cell mediated immunity
Neuropathic bladder: may have increased problems with UTIs
Rate of relapse increases in the first 3 months postpartum

21
Q

How is a severe acute relapse of MS managed, in pregnancy?

A

High dose steroids

22
Q

Is there any contraindication to epidural anaesthesia in MS?

A

No

23
Q

What is the pathogenesis of Myasthenia Gravis?

A

IgG antibodies directed against post-synaptic antigens on the motor end plate
Block neuromuscular transmission
Causing weakness and fatigue or skeletal, but not smooth muscle

24
Q

What is the effect of myasthenia Gravis on pregnancy?

A

Transplacental passage of antibodies
Fetal Arthrogryposis (can be fatal)
- contractures due to lack of movement
- polyhydramnios due to impaired swallowing

25
Q

How is labour affected by Myasthenia Gravis?

A

First stage unaffected (uterus has smooth muscle)

Second stage may be impaired (maternal effort using voluntary striated muscle is required)

26
Q

How is Myasthenia Gravis managed in pregnancy?

A

Measure thyroid function
Anticholinesterases
Immunosuppression

MgSO4 should be avoided for seizure prophylaxis in pre-eclampsia since it may precipitate a crisis

27
Q

What is the effect of Myasthenia Gravis on anaesthesia?

A

More resistant to the depolarising neuromuscular blocking agents such as succinylcholine

Extremely sensitive to non-depolarising muscle relaxants

28
Q

What % neonates born to mothers with Myasthenia Gravis may be affected by transient neonatal MG?

A

10-20%

Due to transplacental passage of IgG antibodies

29
Q

What are the clinical features of benign intracranial hypertension?

A 
Headache, often retro-orbital
Obesity, rapid weight gain
Diplopia 
Papilloedema
CSF pressure increased
30
Q

What is the effect of pregnancy on benign intracranial hypertension?

A

BIH tends to worsen in pregnancy, possibly related to weight gain

31
Q

What is the management of benign intracranial hypertension?

A

Limitation of weight gain
Monitor visual fields and acuity - in severe cases, infarction of the optic nerve may occur, leading to blindness Any impairment of VF / VA, should prompt treatment with corticosteroids
Thiazide diuretics and acetazolamide (outside of pregnancy)
Repeated CSF drainage of insertion of a shunt

32
Q

Most strokes associated with pregnancy occur in the distribution of…

A

The carotid and middle cerebral arteries

Most cases occur in the first week after delivery

33
Q

What are the causes of stroke in pregnancy?

A

Unusual causes are more common in pregnancy

  • Cardiac causes of arterial emboli, arrhythmia
  • MV prolapse / disease
  • Peripartum cardiomyopathy
  • Infective endocarditis
  • Paradoxical embolus
  • Aortic / carotid artery dissection
  • APS
  • Sickle cell disease
  • TTP
  • PET / eclampsia
34
Q

What is the pathogenesis of Haemorrhagic stroke in PET?

A

Cerebral vasospasm, loss of autoregulatory control and breakthrough of the vessel wall

35
Q

What is the effect of pregnancy on AVMs?

A

AVMs are oestrogen sensitive and therefore tend to dilate in pregnancy
Possible cause of Haemorrhagic stroke

36
Q

What does PRES stand for?

A

Posterior Reversible Encephalopathy Syndrome

37
Q

What are the clinical features of PRES?

A

Transient neurological disturbance
Causing occipital lobe related symptoms
Headache, seizures, cortical blindness

In pregnancy, usually related to PET

38
Q

What is the pathogenesis of PRES?

A

Vasogenic brain oedema

39
Q

What are the MRI findings in PRES?

A

Bilateral involvement of white and grey matter in the posterior regions of the cerebral hemispheres

40
Q

What is the increase in the incidence of Bell’s Palsy in pregnancy?

A

10x

41
Q

What are the clinical features of Bell’s Palsy?

A

Unilateral LMN lesion of facial nerve
Facial weakness
And loss of taste on anterior 2/3 of tongue

Most cases in pregnancy occur around term

42
Q

What is the pathogenesis of peripartum Bells’ Palsy?

A

Swelling of the facial nerve within the patrons temporal bone
May be related to oedema

43
Q

What is the management of Bell’s Palsy?

A

Short course corticosteroids

NB: Important to examine the ear for vesicles prior to prescribing steroids (as they are contraindicated in Ramsay Hunt)

44
Q

What are the clinical features of Carpal Tunnel Syndrome?

A

Paraesthesia and numbness in the thumb and lateral two and a half fingers

Tinel’s sign: Reproduction of symptoms on percussion over the carpal tunnel
Phalen’s sign: reproduction of symptoms on sustained flexion of the wrist

45
Q

What is the pathogenesis of Carpal Tunnel Syndrome?

A

Compression of the median nerve at the flexor retinaculum

46
Q

What is the management of Carpal Tunnel Syndrome?

A

Reassurance that the condition is likely to improve / abate after delivery
Wrist splints

If severe

  • local steroid injection
  • surgical division
47
Q

What is Meralgia paraesthetica?

A

Numbness or pain in the distribution of the lateral cutaneous nerve of the thigh (anterolateral aspect of the thigh)
Caused by compression of this nerve
At the lateral aspect of the inguinal ligament

Maternal Medicine (18 decks)

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