neurological disorders

1. NEUROLOGICAL DISORDERS
IN PREGNANCY
By
Dr.Hafsa

2. INTRODUCTION
• Studies in intensive care units(ICUs) suggest that up to 50% of critically
ill obstetric patients have neurologic involvement .
• Neurologic manifestations may result from a variety of obstetric
illnesses, including eclampsia, acute fatty liver of pregnancy, and
amniotic fluid embolism.
• In some patients, preexisting medical disorders such as hypertension,
rheumatological disorders, or intra-cranial neoplasms may worsen
during pregnancy or puerperium.
• Pregnancy itself may predispose to some medical conditions.

3. CLASSIFICATION
• Epilepsy ● Pre eclampsia
• Migraine ● Eclampsia
• Mysthenia Gravis ● cerebral venous thrombo
• Multiple sclerosis ● Cerebral hemorrhage
● RPLE
● Compression and stretch
Pre existing disorders New onset disorders

4. EPILEPSY
• It is estimated that 7% of epileptic patients become pregnant.
• 0.5% of all pregnancies are complicated by epilepsy.
• status epilepticus is associated with high maternal as well as fetal mortality.

5. MATERNNAL EFFECTS
• Lactic acidosis
• Increased cardiac output
• transient elevation of blood pressure
• Increased intra-abdominal pressure
• Redistribution of blood flow to the brain and muscles, with consequent
decrease in visceral and uterine flow.
• The risk of developing a seizure during labor is nine times that during the rest of
pregnancy

6. FETAL EFFECTS
• Perinatal mortality is 1.2 to three times higher.
• Stillbirth
• Prematurity
• perinatal death
• congenital anomalies (associated with antiepileptic drugs)
• hemorrhagic diseases of the newborn
• Intracranial hemorrhage

7. MANAGEMENT
• ANTENATAL
• Measures to prevent seizures during pregnancy must be emphasized.
• The benefits of seizure prevention must be balanced against the
teratogenic risk of antiepileptic drugs
• Women should preferably be on a single antiepileptic agent
• Regular therapeutic drug monitoring of antileptic drug level
• Sleep deprivation should be avoided.
• Folate supplements before pregnancy.
• Regular prenatal monitoring for fetal malformations.

8. • Seizures during pregnancy should be treated aggressively.
• Left lateral position to increase uterine blood flow and
prevent aspiration
• Oxygen should be administered.
• Intravenous lorazepam 2-mg boluses, repeated every 5
mins(preferred drug)
• Diazepam in 5- to 10-mg boluses(alternative)
• Check blood glucose, electrolytes, calcium.
• Intravenous magnesium is preferred if the seizures are due
to eclampsia.
• Patients may deliver normally or by cesarean section
because of the risk of fetal hypoxia.

9. MIGRAINE
• Migraine headaches are a type of vascular headache that results from
blood vessels dilating in the brain. These are different from stress or
tension headaches.
• It starts out as a dull ache and then eventually becomes a throbbing,
constant, and pulsating pain in the temples, front of the head, or base
of the head.
• Sometimes accompanied by nausea and vomiting. Or also experience
tunnel vision or blind spots.

10. MANAGEMENT
• Look for triggering factor
• Home made remedies
• Tylenol (acetaminophen)
• Caffeine( in moderation may help alleviate acute migraine attack)
• Anti-nausea medications (such as Zofran, Reglan, and Phenergan)
• Tylenol with Codeine; Vicodin (hydrocodone); Fioricet (Butalbital) to rescue if
severe migraine attack
• IV (Intravenous) fluids

11. MYASTHENIA GRAVIS
• It is an autoimmune neuromuscular disease characterized by weakness and
fatigue of the skeletal muscles of the face and extremities
• It is advisable for women to delay pregnancy for at least 2 years following diagnosis as
mortality is highest.
• Severity of symptoms and risk of maternal mortality is lowest 7 years after onset of the
disease.
• Exacerbations of symptoms are most likely to occur in the first trimester or following
delivery.

12. FETAL EFFECTS
• It is possible for infants to develop transient neonatal MG. (10% to 20%)
• The neonate typically develops symptoms 2 to 4 days after birth, including
respiratory problems, muscle weakness, feeble cry, poor sucking, and ptosis.

13. MANAGEMENT
• Optimal management of MG for pregnant women should involve obstetricians and
neurologists.
• Acetylcholine esterase inhibitors, such as pyridostigmine and neostigmine, are
frequently used in treatment of MG in addition with corticosteriods.
• vaginal delivery is recommended for women with MG.Assistance might be required
in the second stage with the help of forceps or vacuum extraction, as striated muscles
are involved
• Cesarean section should be performed only for obstetric indications
• There is no evidence that MG can adversely affect pregnancy outcome.

14. MULTIPLE SCLEROSIS
• Multiple sclerosis (MS) is a disease of the central nervous system (brain and spinal
cord) that is characterized by both neuroinflammation and neurodegeneration.
• MS is usually diagnosed between 20 and 50 years old, and so women with MS will
therefore become pregnant relatively early in the course of their illness and usually
have correspondingly little associated disability.

15. MANAGEMENT
• Preconceptional counseling
• Many people with relapsing and remitting MS are treated with disease modifying
drugs
• Although the risk of relapse is reduced during pregnancy, this ‘protective’ effect is
less pronounced during the first and second trimesters.
• If relapse occur, management is the same as for non-pregnant women.
• Mild relapses require no treatment.

16. PRE ECLAMPSIA

18. •
Recommend birth for women who have pre-eclampsia with severe hypertension
after 34 weeks when their blood pressure has been controlled and a course of
corticosteroids has been completed (if appropriate).
• Offer birth to women who have pre-eclampsia with mild or moderate hypertension at
34+0 to 36+6 weeks depending on maternal and fetal condition, risk factors and
availability of neonatal intensive care.
• Recommend birth within 24–48 hours for women who have pre-eclampsia with mild
or moderate hypertension after 37+0 weeks.

19. ECLAMPSIA

25. CEREBRAL VENOUS THROMBOSIS
• Cerebral venous thrombosis, usually associated with dural sinus
thrombosis,affecting 12% pregnancies.
• There is a 120% to 300% increase in circulating levels of clotting factors during
pregnancy.
• Levels of factors II,VII, and X are also increased.
• The level of protein S is decreased, but that of protein C remains unchanged
• Headache is the commonest symptom of
• cerebral venous thrombosis and occurs in 95% of patient.
• Other manifestations include focal seizures (47%), paresis (43%), papilledema
(41%), altered consciousness (39%), and isolated intracranial hypertension. (20%)

26. TREATMENT
• Treatment of cerebral venous sinus thrombosis with unfractionated heparin or low-
molecular-weight heparin has been shown to be safe and effective, even in
patients with a preexisting intracranial hemorrhage.
• The activated partial thromboplastin time is maintained at twice the baseline value.
• Recombinant tissue type plasminogen activator or urokinase has been used with
variable success

27. THANK YOU