Neurological disease in pregnancy Flashcards
Congenital defects associated with lamotrigine?
Risk?
facial cleft
2.9%
Aim of pre conceptual counselling in women with epilepsy?
- stabilise disease
- mono therapy with AED
- pre conceptual HDFA
- offer genetic counselling if FHx strong
Treatment for acute flares of MS in pregnancy?
corticosteroids in second and third trimester
Myasthenia gravis prenatal counselling points
- risk of exacerbation
- fetal syndromes
+/- thymectomy - TFTs
exacerbation less likely if thymectomy. antibodies can cause fetal arthrogryposis, transient neonatal MG syndrome
Recommendations regarding myasthenia gravis in pregnancy
- dose increase may be required
- continue normal therapy
- +/- plasmapheresis
- anaesthetic rv
- avoid certain medications
- polyhydramnios
Contraindicated medications in myasthenia gravis?
amnioglycosides
b-blockers
b-adrenergics
MgSO4
Effects of pregnancy on myotonic dystrophy?
increased flares, worse in third trimester
idiopathic benign intracranial hypertension presents with…?
retro-orbital headache, diplopia
Relative risk of ischaemic, hemorrhagic and subarachnoid stroke in pregnant vs. non=pregnant?
ischaemic = RR 9 in puerperium
hemorrhagic: RR 2.5 pregnancy, RR28 puerperium
SA= RR 3 in pregnancy, RR20 puerperium
Relative risk of Bell’s palsy in pregnancy vs. non pregnant population
RR 10x. Usually occurs in the 2 weeks prior to delivery.
Risk of seizure in patient with epilepsy in labour/peripartum period
3.5%
Risk of epilepsy in child if a) one parent, b) sibling, c) both parents affected.
a) 4-5%, b) 10%, c)15-20%
congenital defects associated with valproate? Risk of defects?
cleft, NTD’s, cardiac, hypospadias. 10.7%
Congenital defects associated with carbamazepine? Risk?
cleft palate 4.6%
Treatment of seizure in labour?
- BZDs
- +/- tocolysis
- expedite delivery if non-terminating
What form of labour analgesia avoided in labour if you have epilepsy?
pethidine
Discuss vitamin K and AED therapy?
Decrease in clotting factor precursors in mum and baby due to enzyme induction with AEDs. Can offer vitamin K at 36+ weeks + neonatal vitamin K.
Recommended scans in pregnancy with epilepsy + AED?
fetal echo, fetal growth 28,32,36 weeks.
Acute pharmacotherapy of migraines/headaches in pregnancy
paracetamol, metoclopramide, codeine, +/-sumatriptam.
Migraine prophylaxis in pregnancy
aspirin, propanolol, amitriptyline, verapamil, gabapentin in order of preference
Effect of migraine on pregnancy
increased risk of PET
Recommendations regarding DMARDs for multiple sclerosis in pregnancy
No DMARDs approved in pregnancy. Recommended stopped prior to conception (b-interferons, flatiramer, natalizumab).
Considerations for MS and postnatal period
Some DMARDs not recommended with breastfeeding.
Effect of pregnancy on MS
No increased rate of progression. Less likely to have relapse in pregnancy. May have increased relapse PP, may be reduced with breastfeeding.
Peripartum considerations myasthenia gravis
May require assistance second stage, CS obstetric indications, parenteral anti cholinesterase drugs, observation neonate 2 days in hospital.
Myotonic dystrophy inheritance
autosomal dominant, chromosome 19. Number of repeats = severity.
Effects of myotonic dystrophy on pregnancy
reduced ovarian reserve, increased risk ectopic pregnancy, PTD, prolonged labour, PPH, polyhydramnios (if foetus affected)
Pregnancy considerations benign intracranial hypertension
Thiazide diuretics can cause neonatal thrombocytopenia if being used to treat. Acetazolamide contraindicated in 3rd trimester. Can have spinal/epidural anaesthesia.
Intrapartum considerations if previous hemorrhagic stroke
BP/symptom monitoring. No benefit of CS vs NVD if AVM present.
intrapartum considerations if previous subarachnoid haemorrhage
no benefit of cs over nod, epidural unless recent SAH. short second stage with assisted delivery.
What is posterior reversible encephalopathy syndrome
Vasogenic brain oedema, associated with PET. Can present with cortical blindness, headache and seizures. Treated with MgSO4
Pathophysiology of Bells palsy
reactivation of latent HSV from cranial ganglia. PET can also be causative of oedema.
Management Bell’s palsy
corticosteroids administered within 3 days of onset. Can also be managed expectantly. Consider eye drops and eye patch.
incidence myasthenia gravis?
1-4/10,000
Cause of myasthenia gravis?
90%= Acetylcholine receptor antibodies 10% = other post synaptic antigens
Effect of pregnancy on myasthenia gravis?
40% exacerbation
30% nil change
30% remission
PP exacerbations in 30%
Effect of myasthenia gravis on pregnancy?
transplacental passage of antibodies
arthrogryposis due to lack of movement
no swallowing leads to polyhydramnios
smooth muscle of uterus unaffected. Won’t be able to use striated muscle to push as effectively.
10-20% neonatal MG (less risk if maternal thymectomy)
Inheritance myotonic dystrophy?
autosomal dominant disorder chromosome 19 (type one)
Effect of myotonic dystrophy on pregnancy?
miscarriage
stillbirth
Risk of congenital malformations due to levetiracetam mono therapy?
2.8%.
