Neurologic Emergencies in Pregnancy

Seizures in pregnancy: epilepsy, eclampsia, and stroke

Seizures during pregnancy complicate <1% of all gestations; however, they are associated with increased adverse maternal and perinatal outcomes (acute and long term). The differential diagnosis of seizures in pregnancy is extensive. Determining the underlying etiology is crucial in the management of these patients. Medical providers caring for pregnant women should be educated about possible etiologies of seizures during pregnancy and the importance of prompt management of these women in a timely fashion. Evaluation and management should be performed in a stepwise fashion and may require a multidisciplinary approach with other specialties such as neurology. The objective of this review is to increase awareness and to provide a stepwise approach toward the diagnosis and management of pregnancies complicated by seizures.

Consecutive pregnancy with chorea gravidarum associated with moyamoya disease

Chorea gravidarum is uncommon movement disorder of pregnancy, characterized by involuntary, abrupt, non-rhythmic movements. It can be idiopathic or secondary to the underlying pathology. A 28-year-old, primigravida woman who was 8 weeks and 6 days of gestation presented with a history of involuntary choreiform movements in the left side limbs and facial twitch for 2 weeks. The symptoms started just after onset of severe emesis gravidarum. There was no meaningful medical history or family history, and she was taking no regular medication. Magnetic resonance imaging of the brain revealed moyamoya disease. The symptoms, as well as the hyperemesis gravidarum, improved with gestational age; however, they were sustained up to 30 weeks of gestation. She delivered 2.61 kg, healthy male neonate at 40 weeks' pregnancy by vaginal delivery under epidural analgesia. After 3 years later, she got pregnant again, and delivered at 41 weeks of pregnancy without complication. She experienced similar but milder symptoms to that of the first pregnancy until the late second trimester. After the delivery, full evaluation was lost due to her refusal. In this report, we present the case of a patient with chorea gravidarum in which moyamoya disease acts as an etiologic factor and a review of literature with management proposal.

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.

Diagnosis and management of women with stroke during pregnancy/postpartum

Although the incidence of stroke is extremely low, the complications are serious. Maternal mortality has been reported to be as high as 26%. It is important for doctors to be aware of the causes, diagnostic techniques, and management strategies for stroke in order to achieve the best outcome for the mother and fetus. Recurrence risk appears extremely low, so women should feel confident in future positive pregnancy outcomes.

Hemorragia intracraniana na gravidez e puerpério: experiência com quinze casos

A hemorragia intracraniana que acontece na gravidez é um fenômeno raro, porém, apresenta mortalidade e morbidades elevadas. Analisamos 15 pacientes com hemorragia intracraniana que ocorreu durante a gravidez ou puerpério. Em cinco casos a hemorragia decorria da ruptura de aneurisma, em 6, de malformação. A mortalidade materna foi 20%, e a fetal 33%. Quando a causa do sangramento é proveniente de ruptura de um aneurisma, deve-se realizar a oclusão cirúrgica do aneurisma durante a gravidez o que aconteceu em 4 pacientes desta série. Entretanto, se a hemorragia decorre de uma malformação arteriovenosa, o melhor tratamento ainda não está estabelecido.

Severe pre-eclampsia and eclampsia: a broad overview with discussion of the nursing care required for the eclamptic patient

Severe pre-eclampsia and eclampsia are conditions which are rarely seen in A & E departments today. Although the percentage of patients suffering from these conditions is extremely small, the author has been involved in the care and treatment of two patients with this severe complication of pregnancy. A lack of clear guidelines on this subject was the motivation which prompted further study. This paper covers definitions of pre-eclampsia, eclampsia, history, incidence, risks and pathophysiology. The main discussion is the nursing care and treatment of the eclamptic patient in the acute phase of the condition. The author hopes that by the end of this paper it is evident that all health care professionals should be aware of this dangerous condition and know the appropriate treatment to give to ensure the best quality of care possible.

Nonobstetric conditions causing hypoxia during pregnancy: asthma and epilepsy

Nonobstetric medical emergencies of hypoxia may be difficult to recognize in pregnant patients whose normal physiologic condition is altered by the pregnant state. Keys to early recognition of hypoxia in pregnancy may result in appropriate medical interventions for treatment of asthma and seizures that minimize ill effects to mother and fetus. Preventive measures and patient education are important to reducing the incidence of emergencies such as status asthmaticus and status epilepticus.