Pregnancy in Parkinson's disease: a review of the literature and a case report

Depression Treatment in Pregnancy: Is It Safe, or Is It Not?

Prenatal depression carries substantial risks for maternal and fetal health and increases susceptibility to postpartum depression. Untreated depression in pregnancy is correlated with adverse outcomes such as an increased risk of suicidal ideation, miscarriage and neonatal growth problems. Notwithstanding concerns about the use of antidepressants, the available treatment options emphasize the importance of specialized medical supervision during gestation. The purpose of this paper is to conduct a brief literature review on the main antidepressant drugs and their effects on pregnancy, assessing their risks and benefits. The analysis of the literature shows that it is essential that pregnancy be followed by specialized doctors and multidisciplinary teams (obstetricians, psychiatrists and psychologists) who attend to the woman's needs. Depression can now be treated safely during pregnancy by choosing drugs that have no teratogenic effects and fewer side effects for both mother and child. Comprehensive strategies involving increased awareness, early diagnosis, clear guidelines and effective treatment are essential to mitigate the impact of perinatal depression.

Deep Brain Stimulation during Pregnancy and Delivery: Review of Current Literature

Deep brain stimulation (DBS) is an established method in the treatment of not only Parkinson's disease motor complications but also dystonia and tremor, and there are data supporting the efficacy of DBS in epilepsy and some psychiatric problems. The alleviation of the neurologic problems may enable females of childbearing age to consider pregnancy because of being able to take care of their child. The aim of the study is to provide a review of the data available on the effect of DBS on the course of pregnancy and delivery in patients suffering from diseases amenable for DBS treatment (Parkinson's disease, dystonia, obsessive compulsive disorder, Tourette's syndrome, epilepsy). Although data available in the literature on pregnancy and childbirth in patients with an implanted active DBS system are limited to small case series and case reports, the number of younger patients implanted with DBS systems will potentially require more attention beyond specialized DBS centers. In emergency deliveries, general obstetricians and neurosurgeons should be provided with a protocol to prevent injuries to the implanted system with potentially devastating consequences for the patient.

A homozygous PRKN-associated juvenile Parkinson's disease with pregnancy in China

Background

Although Parkinson's disease (PD) is the second most common neurodegenerative disorder, pregnancy in patients with PD is a relatively rare occurrence because the most common age of onset of PD is beyond the childbearing age, except in patients with Young-Onset PD (YOPD) caused by parkin RBR E3 ubiquitin protein ligase (PRKN) mutations.

Case

In this study, we report the case of a 30-year-old Chinese woman who was affected by PRKN-associated YOPD and was treated with levodopa/benserazide during pregnancy. She gave birth to a healthy baby boy with an Apgar score of 9 through an uncomplicated vaginal delivery.

Conclusion

This case further suggests that levodopa/benserazide during pregnancy is safe in the treatment of PRKN-associated YOPD.

A compound heterozygous PINK1-associated juvenile Parkinson's disease with pregnancy in Chinese

BACKGROUND

PINK1 mutations are the second most common cause of recessive, early-onset Parkinson's disease (EOPD), of which 15% are cases of juvenile PD. PD is a progressive neurological disease that primarily affects middle-aged and older people. Thus PD patients experiencing pregnancy is uncommon, especially in patients with juvenile PD caused by PINK1 mutations. We are first to report a woman from a Chinese family diagnosed with sporadic juvenile PD and treated with levodopa/benserazide throughout pregnancy.

METHODS

Whole exome sequencing was performed on this patient, and pedigree verification was performed on her parents. This patient received levodopa/benserazide treatment with regular outpatient follow-up exams.

RESULTS

Whole exome sequencing and Sanger sequencing identified a heterozygous nonsense mutation (c.1474C > T, p.R492X) and a splicing mutation (c.1488 + 1G > A) that were in exon 7 of the PINK1 gene, co-segregating with the PD phenotype and exhibiting an autosomal recessive pattern. With regular outpatient follow-up exams, this patient delivered a healthy boy without complications. Her PD symptoms were stable with the levodopa/benserazide treatment throughout her pregnancy except in the postpartum period.

CONCLUSION

Our findings further demonstrated the safety of levodopa with dopa-decarboxylase treatment in PINK1-associated juvenile PD during pregnancy.

Management of Parkinson's Disease During Pregnancy: Literature Review and Multidisciplinary Input

Background

There are no standardized clinical guidelines for the management of Parkinson's disease (PD) during pregnancy. Increasing maternal age would suggest that the incidence of pregnancy in women diagnosed with PD is likely to increase.

Objective

To evaluate the evidence for the treatment of PD during pregnancy and to canvass opinion from patients and clinical teams as to the optimum clinical management in this setting.

Methods

This involved (1) a literature review of available evidence for the use of oral medical therapy for the management of PD during pregnancy and (2) an anonymized survey of patients and clinical teams relating to previous clinical experiences.

Results

A literature review identified 31 publications (148 pregnancies, 49 PD, 2 parkinsonism, 21 dopa-responsive dystonia, 32 restless leg syndrome, 1 schizophrenia, and 43 unknown indication) detailing treatment with levodopa, and 12 publications with dopamine agonists. Adverse outcomes included seizures and congenital malformations. Survey participation included patients (n = 7), neurologists (n = 35), PD nurse specialists (n = 50), obstetricians (n = 15), and midwives (n = 20) and identified a further 34 cases of pregnancy in women with PD. Common themes for suggested management included optimization of motor symptoms, preference for levodopa monotherapy, and normal delivery unless indicated by obstetric causes.

Conclusions

This study demonstrates the paucity of evidence for decision-making in the medical management of PD during pregnancy. Collaboration is needed to develop a prospective registry, with longitudinal maternal and child health outcome measures to facilitate consensus management guidelines.

Parkinson's Disease in Pregnancy: A Case Report and Review of the Literature

Background: Pregnancy in Parkinson's disease is a rare occurrence, and to date, clinical experience with its management is rather limited. In clinical practice, doubts concern mainly the impact of PD on gestation, labor, and delivery as well as the safety of dopaminergic drugs. Case and review of the literature: We report the case of a 40-year-old woman with an 8-year history of PD. In the first trimester of her pregnancy, her motor status was similar to the pre-conceptional period. In gestation week 16, her motor status dramatically worsened and she complained of predictable "off" periods in the afternoon. For this reason, her dose of L-DOPA/carbidopa was increased up to 500/125 mg per day. At 39 gestational weeks, she gave birth to a healthy girl with an Apgar score of 9 by an uncomplicated cesarean delivery. The child was not breast fed to avoid exposure to antiparkinsonian drugs. The L-DOPA/carbidopa dosage remained constant during the postpartum period. We performed a systematic review of the literature using Ovid Medline, Scopus, and PubMed (including Cochrane database). We used the search terms "Parkinson disease" AND "pregnancy." We identified 20 studies of PD in pregnancy with a total of 37 pregnant women with PD. The most important available data concern the safety of L-DOPA therapy during pregnancy. There seems to be some risk of worsening of the condition or upcoming of new PD symptoms during or shortly after pregnancy. Conclusion: More data concerning the safety of antiparkinsonian drugs in PD treatment, as well as the effect of pregnancy on parkinsonian symptoms are needed. According to the current state of the art, L-DOPA therapy should be considered preferable to other drugs during pregnancy.

Sex differences in movement disorders

In a range of neurological conditions, including movement disorders, sex-related differences are emerging not only in brain anatomy and function, but also in pathogenesis, clinical features and response to treatment. In Parkinson disease (PD), for example, oestrogens can influence the severity of motor symptoms, whereas elevation of androgens can exacerbate tic disorders. Nevertheless, the real impact of sex differences in movement disorders remains under-recognized. In this article, we provide an up-to-date review of sex-related differences in PD and the most common hyperkinetic movement disorders, namely, essential tremor, dystonia, Huntington disease and other chorea syndromes, and Tourette syndrome and other chronic tic disorders. We highlight the most relevant clinical aspects of movement disorders that differ between men and women. Increased recognition of these differences and their impact on patient care could aid the development of tailored approaches to the management of movement disorders and enable the optimization of preclinical research and clinical studies.

Movement disorders in pregnancy

Movement disorders in women during pregnancy are uncommon. Therefore, high quality studies are limited, and guidelines are lacking for the treatment of movement disorders in pregnancy, thus posing a significant therapeutic challenge for the treating physicians. In this chapter, we discuss movement disorders that arise during pregnancy and the preexisting movement disorders during pregnancy. Common conditions encountered in pregnancy include but are not limited to restless legs syndrome, chorea gravidarum, Parkinson disease, essential tremor, and Huntington disease as well as more rare movement disorders (Wilson's disease, dystonia, etc.). This chapter summarizes the published literature on movement disorders and pharmacologic and surgical considerations for neurologists and physicians in other specialties caring for patients who are pregnant or considering pregnancy.

Pregnancy in Parkinson's disease with PARK2 mutations

We report a pregnancy in a patient with Parkinson's disease with PARK2 mutations. Although pregnancy is uncommon in patients with Parkinson's disease, an early-onset Parkinson's patient with three silent and two missense mutations in the PARK2 gene is presented here.

Pregnancy management and outcome in patients with four different tetrahydrobiopterin disorders

INTRODUCTION

Inborn errors of tetrahydrobiopterin (BH4) biosynthesis or recycling are a group of very rare neurometabolic diseases. Following growing awareness and improved availability of drug treatment the number of patients with BH4 disorders reaching adulthood is constantly increasing. Pregnancy care of patients with these disorders is therefore a new challenge for clinicians.

METHODS

This retrospective study summarises for the first time clinical and biochemical monitoring data of 16 pregnancies in seven women with different disorders of BH4 metabolism and evaluates treatment regimens before and during pregnancy in relation to the obstetrical outcome and paediatric follow-up.

RESULTS

Worsening of pre-existing neurological symptoms or occurrence of new symptoms during pregnancy was not observed in most of the cases. Treatment regimens remained mostly unchanged. Pregnancies were not complicated by disease-specific features. Organ abnormalities, miscarriage, prematurity, IUGR and chromosomal changes were occasionally reported, without showing any association with the standard drug treatment for BH4 deficiencies.

CONCLUSION

Although our data on 16 pregnancies in seven patients did not present any association of standard drug treatment with an increased rate of pregnancy complications, abnormal obstetrical or paediatric outcome, an intensive clinical and biochemical supervision by a multidisciplinary team before, during and after the pregnancy in any BH4 deficiency is essential since available data on pregnancies in patients with BH4 deficiencies is limited.

Use of anti-Parkinson medication during pregnancy: a case series

INTRODUCTION

Experience about the use and safety of anti-Parkinson (anti-PD) medication during pregnancy is scarce.

METHODS

We have retrospectively evaluated the course and outcome of pregnancy in PD patients who used anti-PD medication during their pregnancy.

RESULTS

14 PD patients who used anti-PD medication during part or whole of their pregnancy were included. Dopamine agonists were used in 13 patients, levodopa/benserazide in 4, levodopa/carbidopa/entacapone in 1, rasagiline in 7, amantadine in 4, and biperiden in 1 patient. Nine patients were on combination treatment at the time of their pregnancy. During their whole pregnancy, dopamine agonists had been used in six patients, levodopa in four, and rasagiline in one. Four patients experienced adverse outcomes: one had spontaneous abortion while receiving pramipexole, one elderly mother gave birth to a child with Down syndrome, while receiving pramipexole and rasagiline, in one case, there was fetal distress under levodopa/benserazide, piribedil, and rasagiline which resolved spontaneously, in one case, one of the twins did not survive after the birth while the mother was receiving pramipexole and rasagiline. In none of these cases an association with the use of anti-PD medication and adverse outcomes was clearly established. In one patient, motor symptoms worsened despite high dose levodopa, four others experienced transient worsening upon dose reduction.

CONCLUSION

Results in our case series suggest that levodopa, rasagiline, pramipexole, and ropinirole alone or in combination with each other may be considered relatively safe during pregnancy. Expected benefits and risks should be considered when prescribing anti-PD medication in pregnant women.

Parkinson's disease and pregnancy: An updated review

Pregnancy does not often occur in the setting of Parkinson's disease (PD) as the most common age of onset is beyond the childbearing years, yet management of these two conditions is crucial for the health of both mother and child. Here we review treatment data of PD during pregnancy, primarily from case reports and drug registries, and focus on available evidence regarding the pregnancy risks for patient and fetus. Historically, it was reported that many women had worsening of symptoms during pregnancy but this may be because anti-parkinsonian medications were not recommended or were under dosed. Levodopa has the best safety data for use in pregnancy and amantadine should be avoided in women who are pregnant or trying to become pregnant. The data for other pharmacological and surgical treatments is less clear. There is no evidence that women with PD have higher rates of birth or fetal complications.

Deep Brain Stimulation during Pregnancy and Delivery: Experience from a Series of "DBS Babies"

Introduction

Deep brain stimulation (DBS) is widely used to improve quality of life in movement disorders (MD) and psychiatric diseases. Even though the ability to have children has a big impact on patients’ life, only a few studies describe the role of DBS in pregnancy.

Objective

To describe risks and management of women treated by DBS for disabling MD or psychiatric diseases during pregnancy and delivery.

Methods

We report a retrospective case series of women, followed in two DBS centers, who became pregnant and went on to give birth to a child while suffering from disabling MD or psychiatric diseases [Parkinson’s disease, dystonia, Tourette’s syndrome (TS), Obsessive Compulsive Disorder (OCD)] treated by DBS. Clinical status, complications and management before, during, and after pregnancy are reported. Two illustrative cases are described in greater detail.

Results

DBS improved motor and behavioral disorders in all patients and allowed reduction in, or even total interruption of disease-specific medication during pregnancy. With the exception of the spontaneous early abortion of one fetus in a twin pregnancy, all pregnancies were uneventful in terms of obstetric and pediatric management. DBS parameters were adjusted in five patients in order to limit clinical worsening during pregnancy. Implanted material limited breast-feeding in one patient because of local pain at submammal stimulator site and led to local discomfort related to stretching of the cable with increasing belly size in another patient whose stimulator was implanted in the abdominal wall.

Conclusion

Not only is it safe for young women with MD, TS and OCD who have a DBS-System implanted to become pregnant and give birth to a baby but DBS seems to be the key to becoming pregnant, having children, and thus greatly improves quality of life.

Restless legs syndrome and pregnancy: a review

Restless legs syndrome (RLS) is a common sensorimotor neurological disorder that is diagnosed according to the revised criteria of the International RLS Study Group (IRLSSG). The pathophysiology of RLS is still unknown and its prevalence is influenced by ethnicity, age, and gender. RLS is divided into two types by etiology: primary or idiopathic and secondary. Primary RLS is strongly influenced by a genetic component while secondary RLS is caused by other associated conditions such as end-stage renal disease or peripheral neuropathy. Another common condition associated with RLS is pregnancy. The prevalence of RLS during pregnancy is two to three times higher than in the normal population and is influenced by the trimester and the number of parity. The main mechanisms that may contribute to the pathophysiology of RLS during pregnancy are hormonal changes and iron and folate status. Standard medications for treating RLS during pregnancy are not established. Most medications have been used according to the evidence from non-pregnant patients. Therefore, consideration of the medical treatment for treating RLS during pregnancy should be balanced between the benefit of relieving the symptoms and maternal and fetal risk. In general, the prognosis of RLS during pregnancy is good and symptoms are usually relieved after delivery.

Neurosteroid and neurotransmitter alterations in Parkinson's disease

Parkinson's disease (PD) is associated with a massive loss of dopaminergic cells in the substantia nigra leading to dopamine hypofunction and alteration of the basal ganglia circuitry. These neurons, are under the control, among others, of the excitatory glutamatergic and inhibitory γ-aminobutyric acid (GABA) systems. An imbalance between these systems may contribute to excitotoxicity and dopaminergic cell death. Neurosteroids, a group of steroid hormones synthesized in the brain, modulate the function of several neurotransmitter systems. The substantia nigra of the human brain expresses high concentrations of allopregnanolone (3α, 5αtetrahydroprogesterone), a neurosteroid that positively modulates the action of GABA at GABAA receptors and of 5α-dihydroprogesterone, a neurosteroid acting at the genomic level. This article reviews the roles of NS acting as neuroprotectants and as GABAA receptor agonists in the physiology and pathophysiology of the basal ganglia, their impact on dopaminergic cell activity and survival, and potential therapeutic application in PD.

Pregnancy outcome following use of levodopa, pramipexole, ropinirole, and rotigotine for restless legs syndrome during pregnancy: a case series

BACKGROUND

Restless legs syndrome (RLS) is related to parity, and its symptoms may worsen during pregnancy. Treatment with levodopa or dopamine agonists is the first-line therapy for RLS; however, there are limited data on treatment in pregnancy. We therefore assessed the safety of levodopa, pramipexole, rotigotine, and ropinirole in pregnancy.

METHODS

Prospective documentation of pregnancies exposed to levodopa, pramipexole, rotigotine, and ropinirole between 1998 and 2011 was evaluated as to their outcome (teratogenicity or fetotoxicity) by the Berlin Institute for Clinical Teratology and Drug Risk Assessment in Pregnancy.

RESULTS

We were able to complete 59 pregnancy outcomes exposed to RLS pharmacotherapy. For specific treatments, the numbers of exposed pregnancies/live born children/spontaneous abortions/induced abortions/malformations were as follows: levodopa only: 38/29 (one pair of twins)/3/7/3; pramipexole only: 12/9/3/0/0; rotigotine only: 2/2/0/0/0; ropinirole only: 3/2/0/1/0; levodopa combined with pramipexole: 3/3/0/0/0; levodopa combined with ropinirole: 1/1/0/0/0. No major birth defects were found with any RLS treatment, and three infants exposed to levodopa had minor anomalies.

CONCLUSIONS

In our small prospective case series, there was no increased risk above baseline for major malformations or other adverse outcomes for levodopa and pramipexole. If necessary, levodopa treatment may be considered as an alternative to cabergoline, for which safety has been well documented in pregnancy.

Pregnancy in multiple system atrophy: a case report

Introduction

Multiple system atrophy is a late, adult-onset α-synucleinopathy with no data on the effect of pregnancy on the disease course. Early stage multiple system atrophy can be difficult to distinguish from Parkinson's disease.

Case presentation

We describe the case of an Irish woman with parkinsonism starting at age 31, initially diagnosed as having dopa-responsive, idiopathic Parkinson's disease, who successfully delivered a full-term child at age 35. Her pregnancy was complicated by severe orthostatic hypotension and motor fluctuations. Two years post-partum, she underwent bilateral subthalamic nuclei deep brain stimulation for intractable motor fluctuations and disabling dyskinesia. After this treatment course she experienced deterioration of motor symptoms and death eight years after disease onset. Post-mortem neuropathological examination revealed striatonigral degeneration and α-synuclein-positive glial cytoplasmic inclusions in brain stem nuclei, basal ganglia and white matter tracts, consistent with a neuropathological diagnosis of multiple system atrophy.

Conclusions

Multiple system atrophy can affect women of child-bearing age and pregnancy may be associated with marked disease progression.

Male/Female differences in neuroprotection and neuromodulation of brain dopamine

The existence of a sex difference in Parkinson's disease (PD) is observed as related to several variables, including susceptibility of the disease, age at onset, and symptoms. These differences between men and women represent a significant characteristic of PD, which suggest that estrogens may exert beneficial effects against the development and the progression of the disease. This paper reviews the neuroprotective and neuromodulator effects of 17β-estradiol and progesterone as compared to androgens in the nigrostriatal dopaminergic (NSDA) system of both female and male rodents. The 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) mice model of PD and methamphetamine toxicity faithfully reproduce the sex differences of PD in that endogenous estrogen levels appear to influence the vulnerability to toxins targeting the NSDA system. Exogenous 17β-estradiol and/or progesterone treatments show neuroprotective properties against NSDA toxins while androgens fail to induce any beneficial effect. Sex steroid treatments show male and female differences in their neuroprotective action against methamphetamine toxicity. NSDA structure and function, as well as the distribution of estrogen receptors, show sex differences and may influence the susceptibility to the toxins and the response to sex steroids. Genomic and non-genomic actions of 17β-estradiol converge to promote survival factors and the presence of both estrogen receptors α and β are critical to 17β-estradiol neuroprotective action against MPTP toxicity.

Prenatal L-DOPA exposure produces lasting changes in brain dopamine content, cocaine-induced dopamine release and cocaine conditioned place preference

Dopamine, its receptors and transporter are present in the brain beginning from early in the embryonic period. Dopamine receptor activation can influence developmental events including neurogenesis, neuronal migration and differentiation raising the possibility that dopamine imbalance in the fetal brain can alter development of the brain and behavior. We examined whether elevated dopamine levels during gestation can produce persisting changes in brain dopamine content and dopamine-mediated behaviors. We administered L-3,4-dihydroxyphenylalanine (L-DOPA) in drinking water to timed-pregnant CD1 mice from the 11th day of gestation until the day of parturition. The prenatal L-DOPA exposure led to significantly lower cocaine conditioned place preference, a behavioral test of reward, at postnatal day 60 (P60). However, in vivo microdialysis measurements showed significant increases in cocaine-induced dopamine release in the caudate putamen of P26 and P60 mice exposed to L-DOPA prenatally, ruling out attenuated dopamine release in the caudate putamen as a contributor to decreased conditioned place preference. Although dopamine release was induced in the nucleus accumbens of prenatally L-DOPA exposed mice at P60 by cocaine, the dopamine release in the nucleus accumbens was not significantly different between the L-DOPA and control groups. However, basal dopamine release was significantly higher in the prenatally L-DOPA exposed mice at P60 suggesting that the L-DOPA exposed mice may require a higher dose of cocaine for induction of cocaine place preference than the controls. The prenatal L-DOPA exposure did not alter cocaine-induced locomotor response, suggesting dissociation between the effects of prenatal L-DOPA exposure on conditioned place preference and locomotor activity. Tissue concentration of dopamine and its metabolites in the striatum and ventral midbrain were significantly affected by the L-DOPA exposure as well as by developmental changes over the P14-P60 period. Thus, elevation of dopamine levels during gestation can produce persisting changes in brain dopamine content, cocaine-induced dopamine release and cocaine conditioned place preference.

Maternal tetrahydrobiopterin deficiency: the course of two pregnancies and follow-up of two children in a mother with 6-pyruvoyl-tetrahydropterin synthase deficiency

No reports are available about the course of pregnancies in women with tetrahydrobiopterin (BH(4)) deficiencies or the effects of treatment with BH(4), L-dopa/carbidopa and 5-hydroxytryptophan (5-OHTrp) on fetal development. We present for the first time the case of a mother with late-diagnosed mild form of 6-pyruvoyl-tetrahydropterin synthase (PTPS) deficiency, the course of her two subsequent pregnancies and clinical evaluation with follow-up of two offspring. In both pregnancies neurotransmitter precursors, as well as BH(4) dosages were increased proportionally to the mother's weight gain. To prevent maternal phenylketonuria (MPKU) syndrome, special attention was paid to increasing BH(4) dosages. Both pregnancies were complicated by threatened premature labour, by the mother's nicotinism and additionally, in the first pregnancy, by gestational diabetes mellitus and vaginitis. The first child was born in the 31st week of pregnancy with the symptoms of moderate intrauterine growth retardation (IUGR) and brain malformation in the form of right sided closed-lip schizencephaly with absence of septum pellucidum. Although the girl demonstrates mild left-sided hemiparesis, her psychological development at the age of 8 years is above average. The second child was born in the 37th week of pregnancy without brain anomalies and at the age of 5 years his psychomotor development is appropriate for the age. As the cause of brain malformations resulting in physical impairment in the first child is unknown, more data are essential to verify conclusions about the influence of the mother's BH(4) deficiency and the safety of her treatment for fetal development.

Circuit-based framework for understanding neurotransmitter and risk gene interactions in schizophrenia

Many risk genes interact synergistically to produce schizophrenia and many neurotransmitter interactions have been implicated. We have developed a circuit-based framework for understanding gene and neurotransmitter interactions. NMDAR hypofunction has been implicated in schizophrenia because NMDAR antagonists reproduce symptoms of the disease. One action of antagonists is to reduce the excitation of fast-spiking interneurons, resulting in disinhibition of pyramidal cells. Overactive pyramidal cells, notably those in the hippocampus, can drive a hyperdopaminergic state that produces psychosis. Additional aspects of interneuron function can be understood in this framework, as follows. (i) In animal models, NMDAR antagonists reduce parvalbumin and GAD67, as found in schizophrenia. These changes produce further disinhibition and can be viewed as the aberrant response of a homeostatic system having a faulty activity sensor (the NMDAR). (ii) Disinhibition decreases the power of gamma oscillation and might thereby produce negative and cognitive symptoms. (iii) Nicotine enhances the output of interneurons, and might thereby contribute to its therapeutic effect in schizophrenia.

Multiparity after an initial diagnosis of Parkinson's disease: a report on a rare case

OBJECTIVE

To report a very rare case of multiparity after a diagnosis of Parkinson's disease (PD).

DESIGN

Case report.

SETTING

Department of neurology and gynecology of a university teaching hospital.

PATIENT(S)

A 36-year-old multiparous woman.

INTERVENTION(S)

Treatment of PD during pregnancy.

MAIN OUTCOME MEASURE(S)

The effect of multiparity on PD.

RESULT(S)

Multiparity had no effect on the progression of PD, and treatment of the disease during pregnancy appears to have been safe.

CONCLUSION(S)

Multiparity after a diagnosis of PD is extremely rare and, in the present case, had no effect on the progression of the disease.

Young onset Parkinson's disease. Practical management of medical issues

Young Onset Parkinson's disease (YOPD) is defined as Parkinson's disease diagnosed between the ages of 21 and 40 years. Problems faced by this group are different from those faced by older subjects because they face decades with the illness. This article reviews current literature and offers suggestions for intervention when appropriate and practical suggestions in the areas of drug treatment, rehabilitation, nutrition, sexuality, pregnancy, menstruation and menopause. The suggestions are not exclusively restricted to the management of YOPD, but emphasis is placed on items where people with YOPD have either had particular difficulties or where they can proactively self-manage their illness.

Synthesis and Study ofl-Dopa−Glutathione Codrugs as New Anti-Parkinson Agents with Free Radical Scavenging Properties

A series of novel molecular combinations (1-4), in which L-dopa (LD) is linked covalently via an amide bond with glutathione (GSH), were synthesized and evaluated as potential anti-Parkinson agents with antioxidant properties. These conjugates were characterized by evaluating solubility, chemical and enzymatic stabilities, and apparent partition coefficient (log P). Derivatives 2 and 4 were tested for their radical scavenging activities, by use of a test involving the Fe(II)/H2O2-induced degradation of deoxyribose. In this study, the antioxidant efficacy of codrugs 1 and 3 was also assessed through the evaluation of plasmatic activities of superoxide dismutase (SOD) and glutathione peroxidase (GPx). Furthermore, the central nervous effects and rat striatal concentration of LD and dopamine (DA) have been evaluated after oral administration of codrugs 1 and 3. Tested compounds prolonged the plasma LD levels and were able to induce sustained delivery of DA in rat striatum with respect to an equimolar dose of LD. The results suggest that compounds 1 and 3 could represent useful new anti-Parkinson agents devoid of the pro-oxidant effects associated with LD therapy and potentially able to restore the GSH depletion evidenced in the substantia nigra pars compacta (SNpc) of PD patients.

Maladie de Parkinson juvénile et prématurité récidivante. À propos d'un cas

The association of Parkinson's disease and pregnancy is very rare. Some thirty cases are found in the literature. We report the case of a pregnancy in a 30-year-old patient with juvenile Parkinson's disease. During this pregnancy treated by levodopa and bromocriptine, no aggravation of the symptoms was been observed. However, the pregnancy was complicated by a premature delivery at 31 weeks of amenorrhoea.

Identification of Rotenone-Induced Modifications in α-Synuclein Using Affinity Pull-Down and Tandem Mass Spectrometry

Parkinson's disease is a movement disorder that results from a loss of dopaminergic neurons in the substantia nigra. The disease is characterized by mitochondrial dysfunction, oxidative stress, and the presence of "Lewy body" inclusions enriched with aggregated forms of alpha-synuclein, a presynaptic protein. Although alpha-synuclein is modified at various sites in Lewy bodies, it is unclear how sequence-specific posttranslational modifications modulate the aggregation of the protein in oxidatively stressed neurons. To begin to address this problem, we developed an affinity pull-down/mass spectrometry method to characterize the primary structure of histidine-tagged alpha-synuclein isolated from catecholaminergic neurons. Using this method, we mapped posttranslational modifications of alpha-synuclein from untreated neurons and neurons exposed to rotenone, an inhibitor of mitochondrial complex I. Various posttranslational modifications suggestive of oxidative damage or repair were identified in a region comprising a 20-residue stretch in the C-terminal part of the protein. The results indicate that alpha-synuclein is subject to discrete posttranslational modifications in neurons with impaired mitochondrial function. Our affinity pull-down/mass spectrometry method is a useful tool to examine how specific modifications of alpha-synuclein contribute to neurologic disorders such as Parkinson's disease.

Movement disorders in pregnancy

Movement disorders are not particularly common during pregnancy, with a few exceptions. RLS occurs most commonly followed by CG. Currently, with the incidence of rheumatic fever lower than previously, any woman who develops CG should be checked for illness other than rheumatic heart disease. The differential includes systemic lupus erythromatosis and antiphospholipid antibody syndrome. Regarding the use of dopaminergic agents, the dopamine agonist, pergolide, can be maintained during pregnancy for the treatment of PD, Segawa disease, and RLS. The use of levodopa and ropinirole should be limited during pregnancy because of the possible teratogenic effects. Amantadine is contraindicated during pregnancy. The data on selegiline are controversial; animal studies show possible serotonergic effects and teratogenic effects. If treatment is indicated in patients who have Tourette syndrome, the high potency neuroleptics drugs (haloperidol) are preferred to treat associated symptoms. Depression is a common comorbidity in patients who have PD, HD,Tourette syndrome, or other chronic neurologic diseases. Depression treatment during pregnancy is covered by Levy et al elsewhere in this issue. As discussed previously, most of the data on the use of drugs during pregnancy, especially the dopaminergic agents, are limited to animal studies and case reports. Therefore, it is in part left to the neurologist to decide on treatment based on the individual patient, clinical judgment, and inferences from animal studies and limited case reports.

Pramipexole-treated Parkinson's disease during pregnancy

There are few reports about drug-related effects on PD pregnancy. We describe the case of a woman affected by PD treated with pramipexole monotherapy during pregnancy. The child, born by caesarean delivery, is healthy, whereas motor disability of the mother progressively increased to the point that levodopa therapy was necessary.

Transient parkinsonism: Induced by progesterone or pregnancy?

We report on the development of transient parkinsonism after progesterone injection in a pregnant patient with a risk of abortion. Etiological possibilities are discussed, including pregnancy itself, possible toxic effects of the dead fetus, and progesterone injection. Progesterone-induced parkinsonism seems the most likely diagnosis in this case.

The effect of pregnancy in Parkinson's disease

Pregnancy in patients with Parkinson's disease (PD) is a rare occurrence. Previous reports based on retrospective analysis suggest that pregnancy may have a deleterious effect on PD. We describe the effects of pregnancy on the symptomatology of a 33-year-old woman with PD using quantitative neurologic and quality-of-life scales prepartum, intrapartum, and postpartum. During her pregnancy, she was only treated with carbidopa/levodopa. The pregnancy resulted in a normal full-term vaginal delivery of a healthy infant. Significant worsening of this patient's motor symptoms occurred during pregnancy without return to baseline at 15 months postpartum. Pregnancy may exacerbate PD and may have a long-term negative impact on the course of the illness. This report may assist physicians in the counseling of patients with young-onset PD who wish to consider pregnancy.