Neurologists are often slightly nervous when their patients start planning a family. It’s even worse when the patients fall pregnant–unexpectedly. This is because neurologists need super thinking hats not only to anticipate the potential impact of pregnancy on their patients neurology, but also to preempt the adverse effects of neurological treatments on the developing baby. The nervousness of the neurologist transforms into a cold sweat when they learn that their pregnant patient is on the obstetric ward or in the labour room. In these settings, the stakes to the mother and child are very high indeed, and superduper thinking hats are required.
What are the conundrums neurologists confront in pregnancy? What are the considerations they bring to bear on these challenges? What are 6 major perplexing neurological concerns in pregnancy, followed by 21 worrying neurological issues in pregnancy and labour.
1. Cerebral vein thrombosis (CVT)
Cerebral vein thrombosis comes immediately to the mind of neurologists whenever they hear the word ‘pregnancy’. CVT is most likely to develop in the third trimester of pregnancy, or immediately after labour, and there are several risk factors for CVT in pregnancy. There are also several therapeutic and prophylactic approaches to the management of CVT in pregnancy. Amongst other things, low molecular weight heparin (LMWH) is used and Warfarin is contraindicated in pregnancy.
The management of epilepsy in pregnancy requires the neurologist to finely balance many conflicting issues, from risk of seizures on the baby to the teratogenic effect of anti-epileptic drugs. This is because both the disease and the treatment are hazardous to the developing foetus. Neurologists therefore need to know the features of seizures in pregnancy, the management of epilepsy in pregnancy, and the teratogenic effects of antiepileptic drugs.
Headache in pregnancy is always a red flag for the neurologist. Migraine is a common culprit here but there is a long list of causes of headache in pregnancy. Migraine is relatively easy to recognise but treatment is a different matter because pregnancy places many restrictions on what may safely be used. Neurologists therefore need a good handle on the nature and management of migraine in pregnancy, and indeed on the management of all headaches in pregnancy.
Stroke is devastating, and this is more so when it occurs in pregnancy. The developing foetus is at high risk, but the foetus also unfortunately limits the treatments that may be safely used. Many factors increase the risk of stroke in pregnancy, from gestational hypertension to HELPP syndrome. As with all things obstetric, neurologist need to have a good knowledge of the management of stroke in pregnancy.
5. Myasthenia gravis (MG)
The treatment of myasthenia gravis is complicated enough in non-pregnant sufferers. Add a developing foetus into the cauldron and you have a complex recipe. On the one hand, myasthenia gravis influences the course and outcome of pregnancy, such as a higher risk of miscarriage and premature rupture of membranes. On the other hand, pregnancy affects the course of myasthenia gravis, for example causing deterioration in the third trimester. For these reasons, neurologists have to master the management of myasthenia gravis in pregnancy
6. Preeclampsia and eclampsia
These quintessential neurological conditions are well recognised by obstetricians and hardly ever need a neurologist to manage, unless of course the disorders present atypically. For these rare occasions, neurologists need to be familiar with the 15 risk factors, clinical features and management of preeclampsia and eclampsia.
- Amniotic fluid embolism
- Bell’s palsy
- Brain tumours
- Carpal tunnel syndrome
- Chorea gravidarum
- Chronic inflammatory demyelinating polyneuropathy (CIDP)
- Metastatic choriocarcinoma
- Multiple sclerosis (MS)
- Pituitary apoplexy
- Restless legs syndrome (RLS)
- Thrombotic thrombocytopenic purpura; in late pregnancy
- Wernicke’s encephalopathy complicating hyperemesis gravidarum
Obstetric lower limb nerve injuries
Sciatic nerve injury with regional block
Lumbosacral plexus injury
Transient neurologic symptoms (TNSs) with Caesarean delivery
Persistent pain or sensory disturbance
Epidural haematoma or abscess
Cauda equina syndrome (CES)
Post lumbar puncture headache (PLPH)