Womens Health and Neurology Flashcards
T/F you can give triptans (normal first line therapy for migraines) to pregnant women with migraines
false. if acute: consider acetaminophen and metoclopramide
preventative: beta blockers, botulinum toxin
important factors to consider for pregnancy before concluding that a headache is just primary tension or primary migraine
Think about Headache Red Flags (SNOOP)
- S: systemic signs/symptoms
- N: neurologic signs/symptoms
- O: Onset sudden, thunderclap
- O: older age (new headache >50)
- P: pattern change or progressive
- P: postural
- P: Papilledema, pulsatile tinnitus, precipitated by valsalva
pregnancy leads to prothrombotic state; need to consider stroke and thrombosis
- Cerebral venous thrombosis
- Pituitary apoplexy
- preeclampsia/eclampsia
- Posterior reversible encephalopathy syndrome
- Reversible cerebral vasoconstriction syndrome
- Idiopathic intracranial hypertension
- Space occupying lesion
- Dissection
- Post-dural puncture
Migraine in Females
- 3x more prevalent in females than males
- Leading cause of disability for women of reproductive age
- __ __ of ___ one of most common migraine triggers
- Estrogen withdrawal before menses → __ __
- Usually improve during __nd and__rd trimesters, and suddenly worsen in __ __.
- Migraine aura can present for first time in pregnancy.
Migraine in Females
- 3x more prevalent in females than males
- Leading cause of disability for women of reproductive age
- Hormonal fluctuations of menstruation one of most common migraine triggers
- Estrogen withdrawal before menses → perimenstrual migraine
- Usually improve during 2nd and 3rd trimesters, and suddenly worsen in postpartum period.
- Migraine aura can present for first time in pregnancy.
Migraines and Contraception
- Increased risk of __ with combined __ in migraine
- Migraine with aura is listed as a contraindication to __ __ (an unacceptable health risk)
- Risk of stroke form pregnancy is __ than risk from OCP.
- Incidence of stroke in females of child-bearing age is very low to begin with, so with increased risk ,the rate is still low.
- Consider patient factors (age, comorbidities, smoking)–> individualized patient-centered approach
- Alternatives: __-only pill, __ __ (IUD).
Migraines and Contraception
Increased risk of stroke with combined OCP in migraine
Migraine with aura is listed as a contraindication to combined OCP (an unacceptable health risk)
Risk of stroke form pregnancy is HIGHER than risk from OCP.
Incidence of stroke in females of child-bearing age is very low to begin with, so with increased risk ,the rate is still low.
Consider patient factors (age, comorbidities, smoking)–> individualized patient-centered approach
Alternatives: progestin-only pill, intrauterine devices (IUD).
top 3 teratogenic ASMs in pregnancy
- valproid acid
- phenobarbital
- topiramate
How should you change folic acid supplementation in pregnant/conceiving women who are on ASMs
Some ASMS alter folic acid metabolism and may decrease folic acid levels in blood
• Valproic acid, carbamazepine, oxcarbazepine, phenobarbital, phenytoin, primidone
Although 0.4mg/day folic acid can help prevent neural tube defects, no solid data specifically for epilepsy– some recommend all patients taking ASMs to take 1mg/day regardless of plans as unplanned pregnancies can occur. Higher doses may be associated with SGA infants and poorer cognitive outcomes.
- 1mg/day 3 months prior to pregnancy through 1st trimester, then 0.4mg/day to end of pregnancy
Catamenial Epilepsy: which hormones are pro/anti convulsant
Cyclic exacerbation of seizures at certain points of menstrual cycle, associated with fluctuations of sex hormones
Patterns include: perimenstrual, periovulatory for normal ovulatory cycles, entire luteal phase in anovulatory cycles
General rule:
- ESTROGEN IS PROCONVULSANT
- PROGESTERONE IS ANTICONVULSANT.
Treatment of Catamenial epilepsy
- Non-hormonal: acetazolamide, benzodiazepine for hormonally-exacerbated seizure.
- Hormonal therapies.
Why should you consider IUD over OCP in people taking ASMs
Contraception in Epilepsy
Ensure contraception is used if prescribing teratogenic anti-seizure medications (ASMs)
Enzyme-inducing ASMS can result in contraceptive failure
- Lowers the progestin component
- Phenytoin, carbamazepine, phenobarbital, primidone, oxcarbazepine
- At higher doses: felbamate, perampanel, topiramate.
- Eslicarbazepine, clobazam, rufinamide also may cause contraceptive failure.
Interactions between lamotrigine and contraceptives
- Can decreased lamotrigine level → breakthrough seizures
- Fluctuating lamotrigine levels if taking 3 weeks OCP and 1 week placebo
IUDs are highly effective for epileptic patients.
Not affected by enzyme-inducing ASms → good choice for contraception in epilepsy.
• Discuss the safety of neuro-imaging modalities and contrast use in a pregnant patient
T/F: MS flares increase in pregnancy
false. risk of relapse decreases during pregnancy, and increases in the first 3-4 months post partum
outline how Myasthenia Gravis changes in pregnancy
