Headaches in pregnancy

Pregnancy complications and delivery outcomes in pregnant women with severe migraine

OBJECTIVE

The objective was to study the possible association among maternal migraine during pregnancy, pregnancy complications, and the delivery outcomes: sex ratio, gestational age/birth weight and preterm birth/low birth weight.

STUDY DESIGN

The population-based large data set of newborn infants without any defects of the Hungarian Case-Control Surveillance System of Congenital Abnormalities, 1980-1996 was analyzed.

RESULTS

Out of 38,151 newborn infants, 713 (1.9%) had mothers who had severe migraine during pregnancy; 68% were medically recorded. Pregnant women with severe migraine had a higher prevalence of preeclampsia and severe nausea/vomiting, but a lower occurrence of threatened abortion and preterm delivery. However, mean gestational age and birth weight, as well as the proportion of low birth weight and preterm births, were similar in newborn infants born to mothers with or without migraine.

CONCLUSION

Severe maternal migraine and its related drug treatment may increase the occurrence of preeclampsia and severe nausea/vomiting during pregnancy, but is not associated with unfavorable delivery outcomes.

Maternal severe migraine and risk of congenital limb deficiencies

BACKGROUND

Migraines occurs frequently during pregnancy; however, there are no published data on their possible teratogenic potential in a controlled epidemiological study. Therefore, we examined the risk of congenital abnormalities in infants born to women who had migraines and other headaches during pregnancy.

METHODS

Between 1980 and 1996, the Hungarian Case-Control Surveillance of Congenital Abnormalities evaluated 22,843 cases (newborns or fetuses) with congenital abnormalities, 38,151 control newborn infants without any abnormalities, and 834 malformed controls with Down syndrome.

RESULTS

Migraines anytime during pregnancy occurred in 565 (2.5%) mothers of the case group compared with 713 (1.9%) mothers in the control group (crude prevalence odds ratio [POR], 1.3; 95% confidence interval [CI], 1.2-1.5) and 24 (2.9%) pregnant women in the malformed control group (crude POR, 0.9; 95% CI, 0.6-1.3) The mothers of 247 cases, 533 controls, and 21 malformed controls had severe migraines during the second and/or third months of pregnancy. There was only 1 congenital abnormality group: limb deficiencies, which had a higher rate of maternal migraines during the second and third months of pregnancy both at the comparison of cases and matched controls (adjusted POR, 2.5; 95% CI, 1.1-5.8) and of cases and malformed controls (adjusted POR, 1.7; 95% CI, 1.3-3.0). There was no association between other headaches and different congenital abnormalities at the comparison of cases and controls.

CONCLUSIONS

Our data showed that maternal severe migraines during the second and/or third months of pregnancy were associated with an increased risk of congenital limb deficiencies. A similar association was not detected between congenital anomalies and other headaches during pregnancy. Our study was not based on a prior hypothesis; therefore, these data can be considered only as a signal that needs confirmation by independent data sets.

Cerebellar infarction as a cause of post-partum headache

A 32-year-old multiparous patient requested epidural analgesia during labour. The epidural was sited, apparently without complication, but the patient proceeded to an emergency caesarean section due to fetal distress, shortly after the insertion. The severity of the fetal distress meant that surgery was necessary before the epidural could be extended sufficiently and a general anaesthetic was administered. The next day the patient complained of a severe headache which she reported had started within ten minutes of epidural insertion. The headache persisted for many days. At no time were the features consistent with a post-dural puncture headache and she was investigated further by the neurologists. A magnetic resonance imaging (MRI) scan revealed an acute cerebellar infarct. The importance of correct diagnosis of post-partum headache and cerebellar infarction are discussed.

Ergotamine as a possible cause of Möbius sequence: additional clinical observation

A case of Möbius sequence after exposure to ergotamine during early development is reported. Vascular disruption is one of the theories explaining the pathogenesis of Möbius sequence. Ergotamine can cause vasospasm and a prolonged and marked increase in uterine tone. This is the second report suggesting a relation between maternal ingestion of ergotamine in early pregnancy and subsequent Möbius sequence in a child.

Pregnancy outcome following prescription for sumatriptan

BACKGROUND

Some 2.5% of fertile Danish women use sumatriptan, and the drug is also taken during pregnancy. Although sumatriptan reacts selectively in brain vessels, the possibility of reactions with placental blood flow and uterotonic activity cannot be ruled out. The aim of our study was to examine the association between sumatriptan exposure during pregnancy and the risk of preterm delivery and low birth weight.

METHODS

Data from the Pharmaco-Epidemiological Prescription Database of North Jutland county regarding all women who had given birth in the county of North Jutland from 1991 to 1996 were linked to the Danish Medical Birth Registry. Women who were exposed to sumatriptan during pregnancy were identified (n = 34), and using logistic regression models their pregnancy outcome was compared with two groups of pregnant women: (1) healthy women (n = 15 955) and (2) migraine controls (n = 89), defined as migraine patients who did not redeem prescriptions for migraine treatment during pregnancy.

RESULTS

The risk of preterm delivery was elevated among women exposed to sumatriptan compared with migraine controls (odds ratio [OR] 6.3, 95% confidence interval [CI] 1.2-32.0) and healthy women (OR 3.3, 95% CI 1.3-8.5). The odds ratio for having a newborn with a low birth weight was increased (OR 3.0, 95% CI 1.3-7.0) for all migraine patients who delivered at term (n=115) compared with the outcome of healthy pregnancies.

CONCLUSIONS

We found that sumatriptan exposure during pregnancy was associated with an increased risk of preterm delivery and low birth weight. These findings may be due to drug exposure, but they may also reflect the impact of disease severity rather than the treatment itself, or confounding, or chance.

Selected neurologic complications of pregnancy

Many neurologic disorders, such as eclampsia, pseudotumor cerebri, stroke, obstetric nerve palsies, subarachnoid hemorrhage, pituitary tumors, and choriocarcinoma, can develop in the pregnant patient. Maternal mortality from eclampsia, which ranges from 0 to 14%, can be due to intracerebral hemorrhage, pulmonary edema, disseminated intravascular coagulation, abruptio placentae, or failure of the liver or kidneys. Associated fetal mortality ranges from 10 to 28% and is directly related to decreased placental perfusion. Pseudotumor cerebri can be associated with serious visual complications; thus, the therapeutic goal is to prevent loss of vision. The risk of stroke in the pregnant patient is 13 times the risk in the nonpregnant patient of the same age. The major causes of stroke in pregnant patients are arterial occlusion and cerebral venous thrombosis. Lumbar disk prolapse is common in pregnant patients, and lumbosacral plexus injuries can occur during labor or delivery. In addition, peripheral nerve compression or entrapment syndromes are thought to be caused by the retention of fluid during pregnancy. The incidence of subarachnoid hemorrhage during pregnancy is 1 in every 10,000 patients, a rate 5 times higher than in nonpregnant women. Because of a proliferation of prolactin-secreting cells, the pituitary gland can enlarge dramatically during pregnancy, a change that can disclose a previously unknown tumor or cause a known pituitary tumor to become symptomatic. The incidence of choriocarcinoma is 1 in 50,000 full-term pregnancies but 1 in 30 molar pregnancies. This malignant tumor has a high rate of cerebral metastatic lesions. In addition to these disorders that develop during pregnancy, the pregnant state can affect numerous preexisting neurologic conditions, including epilepsy, headaches, multiple sclerosis, myasthenia gravis, spinal cord injury, and brain tumors. We discuss advice for patients with such conditions who wish to become pregnant, recommendations for medical and surgical management, and surgical considerations for neurologic complications during pregnancy.