Neurologic Complications in Pregnancy

Cardiovascular multimodality imaging in women: a scientific statement of the European Association of Cardiovascular Imaging of the European Society of Cardiology

Cardiovascular diseases (CVD) represent an important cause of mortality and morbidity in women. It is now recognized that there are sex differences regarding the prevalence and the clinical significance of the traditional cardiovascular (CV) risk factors as well as the pathology underlying a range of CVDs. Unfortunately, women have been under-represented in most CVD imaging studies and trials regarding diagnosis, prognosis, and therapeutics. There is therefore a clear need for further investigation of how CVD affects women along their life span. Multimodality CV imaging plays a key role in the diagnosis of CVD in women as well as in prognosis, decision-making, and monitoring of therapeutics and interventions. However, multimodality imaging in women requires specific consideration given the differences in CVD between the sexes. These differences relate to physiological changes that only women experience (e.g. pregnancy and menopause) as well as variation in the underlying pathophysiology of CVD and also differences in the prevalence of certain conditions such as connective tissue disorders, Takotsubo, and spontaneous coronary artery dissection, which are all more common in women. This scientific statement on CV multimodality in women, an initiative of the European Association of Cardiovascular Imaging of the European Society of Cardiology, reviews the role of multimodality CV imaging in the diagnosis, management, and risk stratification of CVD, as well as highlights important gaps in our knowledge that require further investigation.

A Network-Based Analysis of Disease Complication Associations for Obstetric Disorders in the UK Biobank

BACKGROUND

Recent studies have found that women with obstetric disorders are at increased risk for a variety of long-term complications. However, the underlying pathophysiology of these connections remains undetermined. A network-based view incorporating knowledge of other diseases and genetic associations will aid our understanding of the role of genetics in pregnancy-related disease complications.

METHODS

We built a disease-disease network (DDN) using UK Biobank (UKBB) summary data from a phenome-wide association study (PheWAS) to elaborate multiple disease associations. We also constructed egocentric DDNs, where each network focuses on a pregnancy-related disorder and its neighboring diseases. We then applied graph-based semi-supervised learning (GSSL) to translate the connections in the egocentric DDNs to pathologic knowledge.

RESULTS

A total of 26 egocentric DDNs were constructed for each pregnancy-related phenotype in the UKBB. Applying GSSL to each DDN, we obtained complication risk scores for additional phenotypes given the pregnancy-related disease of interest. Predictions were validated using co-occurrences derived from UKBB electronic health records. Our proposed method achieved an increase in average area under the receiver operating characteristic curve (AUC) by a factor of 1.35 from 55.0% to 74.4% compared to the use of the full DDN.

CONCLUSION

Egocentric DDNs hold promise as a clinical tool for the network-based identification of potential disease complications for a variety of phenotypes.

Intravenous immunoglobulin in COVID-19 associated Guillain-Barré syndrome in pregnancy

The COVID-19 pandemic has led to a rise in cases of Guillain-Barré syndrome (GBS). This autoimmune sequela is a manifestation of the neurotropism potential of the virus. At present, knowledge regarding the pathophysiology, clinical features, management and outcomes of the condition is still evolving. This paper presents the case of a 22-year-old pregnant patient who came in with a history of upper respiratory tract symptoms followed by acroparaesthesia and progressive ascending weakness. She was confirmed to have COVID-19 and GBS and was subsequently managed with intravenous immunoglobulin (IVIg) followed by supportive therapy. To the authors' knowledge and based on their literature search, this is the first reported case of GBS in a COVID-19 confirmed pregnant patient who received IVIg.

A first trimester pregnancy with cerebrovascular accident treated with thrombolytic therapy: A case report

Pregnant patients are at increased risk of cerebrovascular accident due to the prothrombotic state of pregnancy. This risk is highest in those with pre-eclampsia and eclampsia as well as those of Asian descent. Despite this increased risk, pregnancy was an exclusion criterion for major stroke intervention trials. As a result, there are significant challenges concerning the management of this unique patient population. We describe a case of an early first trimester cerebrovascular accident treated with systemic thrombolysis.

Ischemic stroke and floating thrombosis in dissection of the common carotid artery in patient at third week of pregnancy: Surgical technical success and maintenance of pregnancy

Thrombosis, especially in pregnancy, is due to a prothrombotic state and involves the venous system. Localization in an arterial segment is rare. Floating carotid arterial thrombosis is a very rare occurrence, but it is very devastating. The authors report the case of a pregnant patient in whom are associated a thrombotic predisposition and a traumatic event of the neck which resulted in a limited dissection and a floating thrombosis of the common carotid artery. The onset was characterized by sudden neurological deficits, including numbness of the right-hand fingers and right limb weakness, which regressed after admission. The patient underwent a surgical operation with success. Her pregnancy continued, and an ultrasound scan 12 months later confirmed the patency of the prosthesis, in the absence of neurological symptoms. Hormonal changes may reveal the condition of thrombophilia, which, however, occurs more frequently in the venous system and is a condition related to the free-floating thrombus. No guidelines exist for medical or surgical management. The endovascular approach appears to present a greater risk of embolization as an alternative to open surgery. This case demonstrates that the prothrombotic state and the presence of neurological symptoms are suggestive of arterial thrombosis in pregnancy and that the multidisciplinary approach is mandatory to achieve good results.

Functional hemispheric asymmetry in female prefrontal hemodynamics corresponding to changes in auditory sense during pregnancy and child raising

We carried out further research into the prefrontal hemodynamics corresponding to changes in a women's auditory sense during pregnancy and child raising. A total of forty-six volunteers took part in our experiment, and we divided them into several groups in accordance with the progress of their child raising. For the auditory tasks performed by the volunteers, we used two auditory stimulations: the sound of baby crying, and a classical music as a control. Hemodynamic changes at the prefrontal regions were measured using a 2 ch functional near-infrared spectroscopy (fNIRS) along with a 47 ch fNIRS instrument equipped with 3×5 probes (22 ch). Judging the results of the female groups about their prefrontal hemodynamics, there were almost no significant differences across the groups in the dynamics with the music task. However, in the section of the baby crying task, their hemodynamics were regarded as significant compared to the control. Concerning the time scale of the changes in the hemodynamic response to the two tasks, especially in the postnatal group, we took notice of the possibility that higher activations were clearly observed at the right sides of their brains than their left sides. Our experimental results not only demonstrated that postnatal women within one and a half years of their childbearing might have acute ears, but also revealed the hemispheric asymmetry in their prefrontal hemodynamics, as compared to pregnant and nonpregnant volunteers. We inferred that the pregnancy-inducing expression of such women's special capabilities is definitely due to a boost-up of a built-in female disposition, which is destined for expressions of maternal love.

Emergency Department Medical Clearance of Patients with Psychiatric or Behavioral Emergencies, Part 2: Special Psychiatric Populations and Considerations

Patients who present to the emergency department (ED) with mental illness or behavioral complaints merit workup for underlying physical conditions that can trigger, mimic, or worsen psychiatric symptoms. However, there are wide variations in quality of care for these individuals. Psychiatry and emergency medicine specialty guidelines support a tailored, customized approach to patients. Our group has long advocated a dynamic comanagement approach for medical clearance in the ED, and this article summarizes best-practice approaches to the medical clearance of patients with psychiatric illness, tips on history taking, system reviews, clinical/physical examination, and common pitfalls in the medical clearance process.

Inhibition of T-cell activation attenuates hypertension, TNFα, IL-17, and blood-brain barrier permeability in pregnant rats with angiogenic imbalance

PROBLEM

Angiogenic imbalance during pregnancy is associated with immune activation, hypertension, increased T cell infiltration, and neurological insults.

METHOD OF STUDY

On gestational day (GD) 12, timed-pregnant rats were infused with anti-angiogenic factors sFlt-1 and sEndoglin (4.7 and 7 μg/kg) to create HELLP syndrome via mini-osmotic pumps for 8 days, with a subset of these rats having Orencia (2 mg/kg) infused on GD13. On GD19, blood-brain barrier (BBB) permeability was evaluated via Evan's Blue infusion, blood was collected for T-cell measurements, inflammatory cytokine secretion. Brain tissues were also collected to examine inflammatory cytokine infiltration.

RESULTS

T-cell attenuation with Orencia decreased circulating CD4(+) and CD8(+) T cells, circulating tumor necrosis factor alpha (TNFα) and IL-17, BBB permeability and significantly decreased biochemical evidence of HELLP compared to untreated HELLP rats.

CONCLUSIONS

These data support the hypothesis that T cells have a critical role in contributing to the pathophysiology that is seen in angiogenic imbalance during pregnancy.