Neurological disorders in pregnancy

Neuroanatomical changes observed over the course of a human pregnancy

Pregnancy is a period of profound hormonal and physiological change experienced by millions of women annually, yet the neural changes unfolding in the maternal brain throughout gestation have not been studied in humans. Leveraging precision imaging, we mapped neuroanatomical changes in an individual from preconception through two years postpartum. Pronounced decreases in gray matter volume and cortical thickness were evident across the brain, which stand in contrast to increases in white matter microstructural integrity, ventricle volume, and cerebrospinal fluid, with few regions untouched by the transition to motherhood. This dataset serves as the first comprehensive map of the human brain across gestation, providing an open-access resource for the brain imaging community to stimulate further exploration and discovery.

Acute neurological conditions during pregnancy and their management: a review

Less vascular resistance, higher vascular permeability and improved cardiac output include anatomical and physiological changes related to pregnancy. These are needed to accommodate an increase in plasma volume and ensure significant organ infusion. Nevertheless, increases in oestrogen levels may lead to an increase in the risk of coagulation and thrombosis. Increased levels of progesterone increase the risk of thrombosis due to vasodilation, vascular stasis and edoema in these situations. The increased resistance in preeclampsia maternal systemic blood arteries can create high blood pressure that can interfere with blood flow in numerous organs (including liver, kidneys, brain and placenta). The risk of issues such as pulmonary edoema, placental abruption, pneumonia of aspiration, renal failure, hepatic failure and stroke in pregnant women is increased by Preeclampsia and eclampsia. Some peripheral neuropathies (carpal tunnel syndrome, peripheral facial palsy) and central neurological conditions (seizure, migraine, stroke, epilepsy) may become more common during pregnancy because of the exacerbation of the pre-existing neurologic condition or the onset of neurological disturbance caused by pregnancy physiological changes (such as headache or vascular disorders). During the three trimesters of pregnancy, neurological disorders are both peripheral and central. Therefore, an early and correct diagnosis is required to improve pregnancy care, treatment and perinatal outcomes. The aims of this paper are to identify, define and manage the most prevalent peripheral and centrally occurring neurological disorders in the pregnancy.

Safe Use of Epidural Analgesia in a Parturient With Spinocerebellar Ataxia: A Case Report

A 28-year-old, gravida 7, para 4 woman with medical history of sickle cell trait presented to labor and delivery at 39 weeks of gestation for rupture of membranes. The patient had a history of suspected spinocerebellar ataxia with incomplete workup before the current admission. The patient requested epidural analgesia for labor. Epidural was placed at L3-L4 interspace without any complications and the rest of the labor was uneventful. Magnetic resonance imaging of the brain was performed after the delivery and the diagnosis of spinocerebellar ataxia was confirmed. The patient's neurological status remained stable after the procedure.

Sheehan syndrome

Sheehan syndrome or postpartum hypopituitarism is a condition characterized by hypopituitarism due to necrosis of the pituitary gland. The initial insult is caused by massive postpartum haemorrhage (PPH), leading to impaired blood supply to the pituitary gland, which has become enlarged during pregnancy. Small sella turcica size, vasospasms (caused by PPH) and/or thrombosis (associated with pregnancy or coagulation disorders) are predisposing factors; autoimmunity might be involved in the progressive worsening of pituitary functions. Symptoms are caused by a decrease or absence of one or more of the pituitary hormones, and vary, among others, from failure to lactate and nonspecific symptoms (such as fatigue) to severe adrenal crisis. In accordance with the location of hormone-secreting cells relative to the vasculature, the secretion of growth hormone and prolactin is most commonly affected, followed by follicle-stimulating hormone and luteinizing hormone; severe necrosis of the pituitary gland also affects the secretion of thyroid-stimulating hormone and adrenocorticotropic hormone. Symptoms usually become evident years after delivery, but can, in rare cases, develop acutely. The incidence of Sheehan syndrome depends, to a large extent, on the occurrence and management of PPH. Sheehan syndrome is an important cause of hypopituitarism in developing countries, but has become rare in developed countries. Diagnosis is based on clinical manifestations combined with a history of severe PPH; hormone levels and/or stimulation tests can confirm clinical suspicion. Hormone replacement therapy is the only available management option so far.

Diabetes insipidus during pregnancy

Diabetes insipidus (DI) in pregnancy is a heterogeneous syndrome, most classically presenting with polyuria and polydipsia that can complicate approximately 1 in 30,000 pregnancies. The presentation can involve exacerbation of central or nephrogenic DI during pregnancy, which may have been either overt or subclinical prior to pregnancy. Women without preexisting DI can also be affected by the actions of placental vasopressinase which increases in activity between the 4th and 38th weeks of gestation, leading to accelerated metabolism of AVP and causing a transient form of DI of pregnancy. This type of DI may be associated with certain complications during pregnancy and delivery, such as preeclampsia. Management of DI of pregnancy depends on the pathophysiology of the disease; forms of DI that lack AVP can be treated with desmopressin (DDAVP), while forms of DI that involve resistance to AVP require evaluation of the underlying causes.

Management of intracranial pathology during pregnancy: Case example and review of management strategies

BACKGROUND

Intracranial tumors during pregnancy are uncommon, and they present an interesting challenge to both the neurosurgeon and the obstetrician. Special considerations must be made in every aspect of care. The authors use the rare case of a 27-year-old pregnant female with suspected pineal region tumor eventually diagnosed as a thalamic region ganglioglioma to review the current literature on management of pathology in this unique patient population.

CASE DESCRIPTION

A 27-year-old female who was 26 weeks pregnant presented to her obstetrician with complaints of headaches, blurriness of vision, and left-sided numbness and tingling. She was diagnosed with 1-cm mass in the pineal region and obstructive hydrocephalus. She initially underwent an endoscopic third ventriculostomy with biopsy of what appeared grossly to be a thalamic mass. The child was delivered via cesarean section at 39 weeks. Serial postpartum imaging demonstrated increasing tumor size and enhancement, which led the authors to proceed with subtotal resection via a supracerebellar infratentorial approach with stereotactic neuronavigation. Tissue specimens obtained for pathological analysis resulted in a revised diagnosis of World Health Organization (WHO) grade II ganglioglioma.

CONCLUSIONS

Pregnancy presents a challenge for any patient requiring neurosurgical intervention. We present an interesting case example with a rare central nervous system neoplasm and discuss the management of intracranial pathology in pregnant patients.

Pharmacology and pharmacogenomics of neurological medications used in pregnancy

Pregnancy increases the pharmacological management challenge of numerous neurological diseases as a result of complex physiological changes. Understanding pregnancy-induced changes in pharmacokinetic and pharmacodynamic parameters can lead to better outcomes for both the mother and baby. Although the application of pharmacogenomics in maternal-fetal medicine is in its infancy, further research and developments will provide important new developments for managing the efficacy of drug treatments during pregnancy and improving maternal-fetal safety. Although a wide variety of neurological medications are used during pregnancy, this article will focus on the drugs with currently known pharmacogenomic implications.

Headache and neurological disease in pregnancy

A review of the approach in pregnancy to a very commonly encountered neurological disorder (headache), along with less commonly encountered neurological entities that none the less deserve the obstetrician's attention. Definitions of specific disorders and differential diagnoses are reviewed, along with treatment options and pregnancy-associated morbidities. Headache is reviewed first including the common primary headaches migraine and tension-type headache. The disabling neurological disorders-multiple sclerosis, cerebral palsy, and spinal cord injury are grouped due to common morbidities affecting pregnancy. Finally, Bell palsy is also reviewed.

Treatment of Neurocritical Care Emergencies in Pregnancy

OPINION STATEMENT: Neurologic emergencies are a major cause of morbidity and mortality in pregnant women. In part because the patient population is young, the nihilistic approach that often accompanies neurologically devastating disorders in other contexts is largely absent. A number of studies have demonstrated improved patient outcomes in the setting of aggressive care delivered by neurointensivists in a specialty-specific environment. It stands to reason that young, pregnant women who suffer from neurologically devastating disorders and who have a wide range of prognosis may also benefit from such specialized care. Close collaboration between obstetricians and neurointensivists is critical in this context. A number of unique considerations in diagnosis and management present dilemmas in the context of pregnancy, such as radiation dose from diagnostic neuroimaging, choice of pharmacotherapy for seizures, anticoagulation, and the method of delivery in the context of cerebral mass lesions and elevated intracranial pressure. Patients and their physicians are often faced with the additional challenge of balancing the relative risks and benefits of the impact of a management approach on both mother and fetus. In general, this balance tends to favor the interests of the mother, but the impact on the fetus becomes more relevant over the course of the pregnancy, especially in the third trimester. A low threshold for admission to an intensive care unit (ideally one that specializes in neurointensive care) should be used for pregnant patients. Because of the limited information regarding long-term outcomes in this population, rigid prognosis formation and early care limitations should be deferred in the immediate period. After the patient is stabilized and a plan has been charted for the remainder of the pregnancy, every effort should be made to engage patients in aggressive, urgent neurologic rehabilitation.

Pregnancy and other pituitary disorders (including GH deficiency)

The pituitary gland is one of the most affected organs with altered anatomy and physiology during pregnancy. Acromegaly is the second most common pituitary adenoma seen in relation to gestation after prolactinomas. Acromegaly should be treated before conception to prevent potential tumor growth in patients who desire fertility. Medical therapy can be ceased safely after confirmation of pregnancy in acromegalic patients, but octreotide may be used in selected cases with compressive signs. Other hormonal and non-functional tumors are rarer and have been presented as case reports. Sheehan's syndrome, which is one of the most common causes of hypopituitarism in developing countries, and lymphocytic hypophysitis are known to be associated with pregnancy. They usually result in hypopituitarism, sometimes with delays in diagnosis and difficulties in differential diagnosis. Pregnancy is not common among patients with hypopituitarism or pituitary adenomas due to altered gonadotroph functions. Ovulation induction is essential for fertility achievement, but the replacement of other deficient pituitary hormones, including GH, seems to play an important role in the preparation of the uterus for implantation of the embryo.

Neurologic disorders in pregnancy

BACKGROUND

Neurologic dysfunction, coma, and seizures are common in obstetric patients in the intensive care unit.

OBJECTIVE

To review common neurologic disorders resulting in critical illness in pregnancy.

REVIEW

Obstetric disorders causing coma and seizures include eclampsia, acute fatty liver of pregnancy, and amniotic fluid embolism. Preexisting disorders such as epilepsy may worsen in one-third of pregnant patients, and seizures are common during labor. Changes in hemodynamics, blood volume, and hormonal effects on the vessel wall increase risk of bleeding from berry aneurysms and arteriovenous malformations during pregnancy and the postpartum period. Acute intermittent porphyria produces seizures and hypertension, closely mimicking eclampsia. Cerebral venous sinus thrombosis is common in postpartum patients, especially in developing countries. Brain tumors invariably enlarge during pregnancy because of fluid retention and the presence of estrogen and progesterone receptors on tumor cells. Infections such as cerebral malaria and acute viral hepatitis with fulminant hepatic failure are common causes of coma and seizures during pregnancy in tropical regions of Asia, Africa, and Latin America. Patients may be admitted to the intensive care unit with type II respiratory failure due to myasthenic crisis, Guillain-Barre syndrome and spinal cord disease. Relapses of multiple sclerosis are infrequent during pregnancy but increase in the postpartum period.

CONCLUSIONS

In all instances, the effects of the disorders, diagnostic tests, and treatment on the fetus must be carefully weighed. Prompt delivery may be lifesaving for mother and fetus in conditions such as eclampsia and acute fatty liver of pregnancy; expectant treatment may be more appropriate in others.