Neurology Flashcards
Discuss antiepileptic drug use in pregnancy
-General principles of prescribing (4)
-Class of drugs (2)
-General risks with anti-epileptic drugs (3)
- General principles of prescribing
-Consider teratogenicity and seizure control in pregnancy planning
-Aim for lowest dose of a single medication
-Benefits of epilepsy control outweigh risks of teratogenicity
-Avoid valproate. If required in split doses and wean to lowest dose - Class of drug
-All class D drugs
-Levetiracetam class B3 - General risk of anti-epileptic drugs
-Lamotrigine and Levetiracetam the safest 3% risk of congenital abnormalities
-Monotherapy 4.5% risk of congenital abnormalities
-Polytherapy 8.5% risk of abnormalities
Discuss abnormalities associated with:
-Valproate
-Phenytoin
-Carbamazepine
-Lamotrigene/levetiracetam
- Valproate
-To be avoided if possible
-NTD 1-2%, orofacial cleft 1.5% cardiac anomalies, urogenital anomalies
-Neurodevelopmental delay - low IQ, ADHD, autism - Phenytoin
-NTD 1-2%, orofacial cleft 1.2%, cardiac, urogenital anomalies - Carbamazapine
-NTD 1%, orofacial 0.4%, cardiac 0.7% - Lamotrigine/Levetiractam
-NTD 0.2%
Discuss fetal anti-epileptic syndrome
-Dysmorphic features - V shaped eyebrows, epicanthal folds, low set ears, flat nasal bridge
-Hypertelorism
-Hypoplastic nails and digits
-Hypoplasia of the mid face
Discuss other effects from anti-epileptic drugs
- Neonatal withdrawal - mitigated by breastfeeding
- Neonatal coagulopathies
- Developmental delay
- Childhood neuroblastoma
- ADHD, Low IQ, autism spectrum
Discuss Bell’s palsy in pregnancy
-Incidence
-Causes
-Presentation
-Management
- Incidence
-45:100,000
-10x more common in pregnancy - Causes
-Motor neuron weakness of CN7 (Facial nerve)
-Herpes zoster outside of pregnancy
-Swelling of petrous temporal bone in pregnancy.
-Increased risk in PET secondary to swelling of temporal bone - Presentation
-Unilateral facial weakness
-Loss of blink reflex
-Loss of taste to anterior 2/3rds of tongue - Management
-80-95% self resolve over several months
-Short course of steroids (2 weeks) can improve time to recovery if started within 24-72hrs
Discuss ischaemic stroke in pregnancy
-Incidence (3)
-Common site of ischaemic stroke (2)
-Risk factors / causes in pregnancy (6)
-Management (4)
- Incidence
-Pregnancy risk to 5-200:100,000
-9 x increased risk in puerperium
-Most occur in the first week PP - Common sites of ischaemic stoke in pregnancy
-Carotid arteries
-MCA - Risk factors
-PET
-Cardiac causes
-APLS
-Vasculitis
-Sickle cell disease
-Thrombotic thrombocytopenia purpura - Management
-Same as for non-pregnant women
-Thrombolysis
-Aspirin
-Anticoagulation
Discuss haemorrhagic stroke in pregnancy
-Incidence (3)
-Causes (2)
-Management (3)
- Incidence
-Very rare. Less common than ischemic stroke in pregnancy
-Increased risk in pregnancy RR2.5
-Increased risk in PP RR 28 - Causes
-AVM - dilate in pregnancy
-PET - due to cerebral vasospasm - Management
AVM
- if identified treat before becoming pregnant
- Can treat in pregnancy if required
- If treated can have VB
PET
-Control BP
Discuss subarachnoid haemorrhage in pregnancy
-Incidence (3)
-Causes (2)
-Management (7)
- Incidence
-2:10,000
-2-3 increased risk in pregnancy
-20 x increased risk PP - Causes
-Ruptured aneurysm
-Ruptured AVM - Management
-Nimodipine
-Neurosurgical or radiological management
-Can aim for VB but consider CS if recent acute bleed or mother moribund
-Shortened second stage with instrumental
-Avoid spinal where risk of ICP
-Avoid GA if possible - hypertensive response
-Avoid ergometrine
Discuss the effect of pregnancy on epilepsy (5 points)
- Pregnancy doesn’t change seizure frequency or type
- 2/3rds of women will not experience a change in seizure frequency
- 1/6th of women will experience a drop in seizure frequency
- 1/6th of women will experience an increase in seizure frequency
- Pregnancy can decrease anti-epileptic drug concentrations due to increased volume of distribution, increased renal and hepatic clearance
Discuss the impact of epilepsy on pregnancy (8)
Increased risk in:
-Spontaneous miscarriage OR 1.54
-APH OR 1.49
-PET / gHTN OR 1.37
-Abruption
-PTL OR 1.16
-PPH
-IUGR OR 3.5 if on AEDs
-CS rates
-Seizure can cause fetal bradycardia and fetal hypoxia
-Main risk is around anti-epileptic drugs causing fetal anomalies
Discuss management of women with epilepsy in pregnancy
-Pre-conception care (5)
-Antenatal care (6)
-Intrapartum care (4)
-Postpartum care
- Pre-conception care
-Optimise control of epilepsy (single agent, lowest dose, avoid valproate)
-Refer to neurologist for advice on ongoing medication
-Counsel women about risks of anti-epileptic meds
-Counsel women about risk of offspring with epilepsy
-Commence on high dose folic acid 5mg - Antenatal
-If starting treatment in pregnancy choose levetiracetam or lamotrigine
-General information about safety with epilepsy
-Serum levels of AEDs not recommended
-Check levels of lamotrigine in pregnancy as dose adjustment likely (not routinely recommended)
-Fetal nucal translucency
-Fetal anomaly scan with careful review of heart
-Vit K supplementation 10-20mg PO for last 4 weeks as enzyme inducing antiepileptic drugs reduce vit K dependant clotting factors in newborns
-Monitor mother for mood sx associated with AEDS - Intrapartum care
-1-2% of women will have a seizure in labour
-Manage exhaustion and pain with epidural
-Aim VB
-If seizure in labour treatment with 4mg IV lorazepam - Postpartum
-Do not leave alone for 24hrs
-Vit K for neonate
-Review meds and reduce if increased in pregnancy
-Breastfeeding encouraged. BF before taking meds
-Safety advice around looking after baby
-Contraception considerations - CuIUD, IUD, Depo (Not impacted by AEDs)
Discuss headache in pregnancy
-Types (2 groups)
- Headaches types
Primary (99% of headaches)
-Tension - most common type in pregnancy
-Migraines
-Cluster headaches - very rare
Secondary (1% of headaches)
-SAH
-Reversible cerebral vasoconstriction syndrome
-Posterior reversible encephalopathy syndrome
-Dural puncture headache
-PET
-Idiopathic cranial hypertension
Discuss reversible cerebral vasoconstriction syndrome
-Onset
-Cause
-Diagnosis and findings
-Management
- Onset
-Severe sudden headache. Occurs in postpartum period - Cause
-due to transient disturbance in CV tone - Diagnosis
-MRI
-Shows multifocal segmental constriction of medium to large cerebral arteries - beading appearance - Management
-Nifedipine
-Resolves after 3 months
Discuss posterior reversible encephalopathy syndrome (PRES)
-Cause
-Presentation
-Risk factor (1)
-Diagnosis and findings
-Management
- Cause
-Transient neurological disturbance due to vasogenic brain oedema - Presentation
-Headache, seizures, cortical blindness - Risk factors
-Associated with PET - Diagnosis and findings
-MRI. Shows bilateral involvement of white and grey matter in posterior regions - Management
-MgSO4
Discuss post dural headache
-Onset
-Presenting symptoms
-Management
- Onset
-1 day post epidural block - Presenting symptoms
-Headache relived by lying down, neck stiffness, tinnitus, visual symptoms - Management
-Blood patch
-Caffeine
Discuss migraines in pregnancy
-Impact of pregnancy on migraines (2)
-Impact of migraines on pregnancy (1)
- Impact of pregnancy on migraines
-50-80% improve typically in 2nd and 3rd trimester
-10% worsen - Impact of migraines on pregnancy
-Increased risk of PET
Discuss management of headaches in pregnancy
1. Conservative measures
2. Analgesia
3. Antiemetics
4. Prophylaxis
- Conservative measure
-Avoid precipitants - Analgesia
-Paracetamol 1st line.
-NSAIDS second line in first and second trimester
-Codeine
3.Antiemetics
-Metocloprimide
-Prochlorperzine - Prophylaxis
-First line - low dose aspirin
-Second line - beta blocker - propranolol
-Third line - TCA NOCTE
-Limited evidence for tryptans. Cat C
Discuss multiple sclerosis in pregnancy
-Aetiology (1)
-Effect of MS on pregnancy (5)
-Effect of pregnancy on MS (3)
- Aetiology
-Autoimmune disorder causing inflammation and demylenation of CNS - Effect of MS on pregnancy
-Nil effect of MS on pregnancy
-Increased risk of offspring with MS 2%
-No impact on breastfeeding
-No impact on regional analgesia
-No impact on mode or timing of delivery - Effect of pregnancy on MS
-Nil impact on progression of MS
-Reduced relapse during pregnancy
-40% relapse in postpartum period
Discuss management of multiple sclerosis in pregnant women
-Pre-conception (4)
-Antenatal (3)
-Intrapartum (3)
-Postpartum (1)
- Pre-conception
-Consult with neurologist regarding medication weaning to stop or continuing
-Medications to reduce relapse B-interferones or glatiramer as usually discontinued in pregnancy
-Discuss risk of offspring with MS 2%
-Discuss high chance of relapse postpartum - Antenatal care
-Monitor for relapse or worsening of symptoms
-Treat acute relapses with IV corticosteriods
-Can continue immunosupression agents - azathioprine - Intrapartum
-Aim for spontaneous vaginal birth
-Give IV hydrocortisone if on antenatal steroids
-No contra-indications to regional or GA anaesthetic - Postpartum
-Observe for relapse
Discuss myasthenia gravis in pregnancy
-Pathophysiology
-Effect of MG on pregnancy (5)
-Effect of pregnancy on MG (3)
- Pathophysiology
-Autoimmune disorder with IgG made against acetylcholineserase receptors which leads to insufficient nerve impulses transmission of striated muscle
-Results in striated muscle weakness - Effect of MG on pregnancy
-Increased risk of PROM
-Increased risk IUGR
-No impact to miscarriage
-First stage of labour usually fine as relies on smooth muscle.
-Second stage of labour may need assistance as relies on striated muscle - Effect of pregnancy on MG
-40% exacerbation in pregnancy.
-30% improve in pregnancy
-30% no change in pregnancy
Discuss the impact to the fetus of mother’s with myasthenia gravis
1. Fetal impact (3)
2. Neonatal impact (4)
- Fetal impact
-IgG can cross the placenta
-Rarely fetus can develop arthrogyposis multiplex congenita, contractures from reduced movement
-Polyhydramnios from reduced swallowing - Neonatal impact
-Transient neonatal MG 10-30%
-Appears in first 2 days
-Resolves after 4-8 weeks
-Responds to anticholinesterases
Discuss management of pregnancy in women with myasthenia gravis
-Pre-conception (2)
-Antenatal (5)
-Intrapartum
-Postnatal
- Pre-conception
-Stop contra-indicated immunodsuppressants (MTX, ciclosporin etc)
-Continue with anticholinesterases - Antenatal
-Anaesthetic referral
-May need to increase anticholinesterases
-Monitor for fetal movement
-Monitor for polyhydramnios
-Serial growth scans
-MgSO4 contraindicated!!! - Intrapartum
-Epidural and spinal anaesthetic safe
-Aim for VB but may need instrumental - Postpartum
-Risk of exacerbation 30%
-Review immunosupressants and consider if safe in breastfeeding
-Monitor neonate for 2 days
Discuss myotonic dystrophy in pregnancy
-Pathophysiology
-Impact of pregnancy on MD (2)
-Impact of MD on pregnancy (6)
- Pathophysiology
-Degenerative neuromuscular disorder characterised by progressive distal muscle weakness
-Autosomal dominant inheritance - Impact of pregnancy on MD
-Can cause exacerbations typically in third trimester with improvement postpartum
-Increased risk of offspring inheritance - Impact of MD on pregnancy
-Increase in PTB
-Increase in first and second trimester miscarriage
-Increase in polyhydramnios
-Increase in still birth
-Dysfunctional labour due to poor contractions.
-Increased risk of PPH
