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Neurological disease in pregnancy 

Neurological disease in pregnancy

Chapter:
Neurological disease in pregnancy
Author(s):

G.G. Lennox

and John D. Firth

DOI:
10.1093/med/9780199204854.003.1412
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date: 27 April 2017

Neurological conditions of particular note in pregnancy

Thiamine deficiency—caused by the combination of the nutritional demands of pregnancy and hyperemesis gravidarum, presenting as a subacute sensory neuropathy or (less commonly) acute Wernicke’s encephalopathy.

Chorea—all types are exacerbated in pregnancy, an effect termed chorea gravidarum.

Malignancies—choriocarcinoma (see Chapter 14.17) can cause brain or spine metastases, the former giving rise to strokes through infarction or haemorrhage, and the latter to cord or cauda equina compression.

Obstetric nerve palsies—seen in cases of prolonged or complicated labour; pressure on the lower lumbosacral plexus leads to foot drop, and on the upper lumbosacral plexus to weakness of iliopsoas and quadriceps; obturator neuropathy leads to weakness of hip adduction and rotation; pudendal nerve damage may be asymptomatic initially, but probably contributes to later stress incontinence.

Cerebrovascular disorders—‘postpartum angiopathy’ is a rare syndrome of segmental cerebral vasoconstriction in the puerperium, which usually presents with headaches, seizures, or focal deficits (especially visual field defects).

Pregnancy in other common neurological conditions

Epilepsy—most women with pre-existing epilepsy have no change in the frequency of their seizures during pregnancy, but in 30% they become more frequent. Sodium valproate used as part of polytherapy for epilepsy, or as a single agent, is clearly associated with increased risk of major congenital malformations, but other antiepileptic drugs probably are not. Carbamazepine is probably the safest antiepileptic drug in pregnancy, but use of valproate at doses less than 1 g daily should not be discounted for the treatment of women with conditions for which it is particularly effective. Anticonvulsant plasma levels tend to fall in the later stages of pregnancy: close monitoring and adjustment of dosing are required.

Multiple sclerosis—the incidence of relapses falls during pregnancy itself, but 20 to 40% of women report exacerbation of symptoms in the puerperium. Relapses in pregnancy are treated in the normal way, with rest supplemented by a short course of oral or intravenous steroid if there is serious new disability. Patients with impaired bladder emptying are predisposed to urinary tract infection, and severe spinal cord disease may mask the usual symptoms of such infection; regular urine culture is a sensible precaution.

Muscle diseases—most congenital myopathies and muscular dystrophies cause no special problems in pregnancy unless they are severe enough to compromise ventilation, either because of respiratory muscle weakness or associated scoliosis. Mothers with myotonic dystrophy may have prolonged labour, increased risk of postpartum haemorrhage, and may develop symptoms of cardiomyopathy during labour, and their infants are high risk of perinatal death.

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