Thread by @BRADLEYNEURO

Neurology of pregnancy - ch 112 - a thread.

ocps >80mcg estrogen - increased stroke risk.
safe dose <50mcg estrogen.
no concomitant smoking cigarettes since it increases stroke risk.

Combined ocps in migraineurs and tobacco smokers - Not advisable
first stop smoking.
high risk of complications in migraine with aura on ocp > migraine without aura on ocp

Cocps' effect on migraine -
worsening 18-50%
improving 3-35%
no change 39-65%

attacks mostly seen in pill free week.
continuing cocp's --> reduced migraine severity and frequency

medroxyprogesterone is ocp of choice in seizure disorders.but injectable to be take at 10 w intervals, rather than 12 w, since anticonvulsant are inducers.

unwanted pregnancies commonly seen in females on phenytoin and carbamazepine with LEVONORGESTREL.
no known interactions with
💊valproate
💊vigabatrin
💊gabapentin
💊tiagabin
💊levetiracetam
💊zonisamide
💊ethosux
💊bzd

No hormonal contraceptives in women with activated protein C resistance

Combined ocps lower lamotrigine levels by 33% ( shown in one study)

Estrogen containing OCPs worsen
🤢CIDP
🤢Moya Moya
🤢migraine
also Produce
🤢chorea
and unmask
🤢SLE

in patients with APLA

increased risk of CVT in women in ocps with prothrombin mutations / factor V gene mutations

thus increased safety evidence emerging with intrauterine devices for both nulliparous and multiparrous females, in females taking anticonvulsants

Now about imaging in pregnancy - CT
⬆️teratogenesis
⬆️mutagenesis
⬆️carcunogenesis

the most sensitive gestational period 8-15 weeks.

🤰<0.1 rad background radiation -average women in 9 m of pregnancy receives
🤰>15 rad - ⬆️ fetal malformation risk
🤰<5 rad - negligible risk of induced miscarriages, major congenital anomalies
🤰<0.050 rad - CT brain w precautionary lead shield
🤰3.5 rad - lumbar spine CT

iodinated contrast media depressed fetal thyroid production

very poor data regarding safety of MRI in pregnancy. some data on 1.5T, not on 3T, RRSTRUCTUIN OF MATERNAL BRAIN MRI ESPECIALLY IN 1ST TRIMESTER IS PRUDENT.

🍵gadolinium - crosses placenta and is swallowed by fetus. delay in fetal dvpmt seen in animals. ❌❌❌❌
abstain from breastfeeding for 24 h post receiving iodinated contrast including Gad

Royal college of radiologist UK - iodinated contrast in exceptional circumstances, no special precaution or cessation of breastfeeding required

HEADACHES
MC - tension headache
rx behavioral therapy, rest, moist heat, exercise, avoid triggers
can give acetaminophen, TCA's
no fluoxetine - since it has u go mon but serious fetal risks

Migraines in pregnancy
>80% show improvement
15% continue same
5% worsen

🙆‍♀️lessen in 2nd,3rd trimester

prognosis
migraine WITHOUT aura> with aura

headaches persisted if
🙆‍♀️menstrual migraine
🙆‍♀️hyperemesis
🙆‍♀️pathological pregnancy

Migraine ⬆️risk of
🤢preeclampsia, esp in prepregnancy obesity patients
🤢peripartum stroke
🤢LBW babies
🤢preterm birth
🤢caeserean section

prophylaxis
💊no valproate, topiramate in child bearing age. if pregnant on valproate, add folate.
rx
💊ergotamine and dihydroergotamine- high rates of fetal malformation

💊triptans - poor data, not advisable except in - psychologically& physiologically disabling headaches ; headaches responsive to triptans; in whom safer medications have failed.

💊DOC - opiods & antiemetics, esp prochlorperazine (oral or suppository)
💊May benefit - metoclopramide, acetaminophen, meperidine.
💊fetal toxicity - atenolol(⬆️IUGR risk), propranolol, etc BBs
💊metoprolol / verapamil - benefit slightly > risks in pts where ppx MUST

no lithium
single dose naproxen ( in first 2 trimester - safe)
no NSAIDs - ⬆️ miscarriage risk if used for >1 week.
no NSAIDs- after 31/32 w and breastfeeding to avoid fetal cardiovascular risks; spontaneous abortions.

Post partum
🤱breastfeeding ⬇️migraine
💊avoid ergot, lithium
💊caution triptans, antidepressants
💊disabling migraine - give injectable sumatriptan
🤱BBs in lactation - DOC propranolol
🤱34% of migraines dvlp headache in 1st pp week(b/w 4-6 days)

DD of Pp headache (thunderclap)
🤢migraine
🤢low csf volume headache
🤢cvst
🤢preeclampsia/ eclampsia
🤢SAH
🤢Stroke syndromes
🤢postpartum cerebral angiopathy
🤢PRES
🤢sheehans
🤢lymphocytic hypophysis
🤢pit apoplexy

LEG Muscle cramps
-5-30% incidence
-resolves rapidly postpartum
-in morning evening, in 3rd trim
-ion imbalance can lead to this
rx
-mg citrate/ mg lactate in the dose of
122-0-244 mg (resolves in 80%)
-oral CA carbonate/gluconate 599mg tds/qds
-passive stretch/massage

Myasthenia Gravis
Before pregnancy:
fertility - unaffected
OCP's - do no weaken these patients
highest risk periods - pueperium & 1st trimester
thymectomy- effect delayed. should be planned 1 year prior to conception.

avoid
💊azathiprine
💊 cyclosporine
💊MMF
💊rituximab

MMF - ⬆️risk of congenital malformations, spontaneous Abortions.
need negative UPT 1 week before starting MMF
need reliable contraception 4w before & 6w after therapy
MMF affects hormonal contraception effectiveness

💊Rituximab crosses placenta
💊ADR- hematological abnormalities, infections, premature births, higher levels in infants
💊Contraception- must -during use of rituximab and 12 months post cessation.

MG During pregnancy
💡edrophonium, PLEX - safe
💡ivig - relatively safe
💡corticosteroids- may ⬆️risk of GDM, preeclampsia
💡AChe drugs - ⬆️rate / dose required
💡CS - regional anesthesia preferred(lidocaine>procaine)
💡MgSo4- contraindicated. may ppt myasthenia crisis.

MG postpartum
💡AchrAb, cyclosporine, aza - transferred to 👶 in breast milk
💡ache drugs transfered to 👶 - GI upset in 👶
💡corticosteroids also transferred in breast milk but small amounts

MG pregnancy outcomes
⬆️ PROM
⬆️ 2X Caeserean section
⬆️perinatal mortality 6-8% infants (5x that of normal)
-2% stillborn
-10-20%transient neonatal mg(within 1st day, can occur upto 4th day. resolved within 3-6 w)
-intrauterine achr ab exposure-arthrogryposis(high recurrence)

MYOTONIC DYSTROPHY
-Progressive ovarian failure, hence, pregnancy uncommon
-pregnancy can be hazardous
-MD worsens in second half of 🤰
-Cx of labour - poor contractions, Preterm labour, breech
tocolysis aggravates myotonia
-regional anesthesia > obstetric anesthesia

MD 50% inheritance
anticipation✅
neonatal morbidity⬆️
polyhydramnios( due to faulty fetal swallowing)
MD1> severe than >MD2

in MD2 - no stillbirth,no polyhydramnios, no congenital MD

LGMD & pregnancy - LGMD worsens in half of patients. prompts termination of pregnancy in 8.8%

Inflammatory myopathy
🤢polymyositis,dermatomyositis- worsens/ gets activated
🤢collagen vascular ds manifestations complicate pregnancy
⬇️myositis activity correlates with favorable fetal outcome
💊ivig,medium dose steroids used successfully in 3 cases of pregnant dermato

Bells palsy
3-4X more common in pregnancy, puerperium
Mc @ 35 weeks
prognosis worse in pregnancy(except in mild cases)
associated - ⬆️risk of toxemia, HTN
begin rx within 3 days of onset for favorable outcome
-poor data for acyclovir

#CTS in #pregancy
1/5 🤰
esp in last trimester
peripheral edema,nocturnal hand paresthesia
- Majority, resolve spontaneously post partition
-50% after 1y
-30% after 3y
rx conservative, splint in neutral position,local corticosteroids
sx-when median nerve muscles weaken

low back pain in pregnancy
>3/4th 🤰
sciatica dermatomal pain in <1%
⬆️after 5th month bcuz
✅lumbar lordosis
✅direct pressure from uterus
✅postural stress
✅hormone induced ligament laxity

MRI, emg rarely helpful

beneficial effects in low back pain in 🤰
✅tailored strengthening exercise
✅sitting pelvic tilt exercise
✅water gymnastics
✅physiotherapy<acupuncture

compressive disc ds in 🤰
sx only if
✅severe/ progressive neuro deficit
✅cauda equina syndrome

meralGia paraesthetica
💡affected at penetration of TFL or inguinal ligament
💡resolves 3m postpartum
⬆️during hip flexion & during
⬆️intrabdominal pressure of delivery
or when retracts are applied

GBS & 🤰
no cause effect/ association found.
🤰more vulnerable to complications
✅ivig-safe
✅plex-safe.preplex fluid loading to avoid hypotension
✅avoid tocolytics(autonomic instability)
✅Uterine contractions- unaffected
✅cautious use/ avoidance of depolarizing NM blockers.

CIDP and 🤰
3X more likely to relapse in last trim and pueprium
infants unaffected
OCPS worsened CIDP
rx - ivig/ plex / steroids

CMTD1 and 🤰
✅worsens in 1/3 to 1/2 pts
less risk if onset in adult life
epidural anesthesia- safe

Gestational polyneuropathy🤰
-distal symmetric neuropathy
-in malnourished women
in 3/4th month due to hyperemesis gravidarum induced thiamine Def

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