Obstetric issues in women with neurologic diseases

E. R. Norwitz, John Repke

Research output: Contribution to journalReview article

Abstract

During pregnancy, the investigation and management of neurologic conditions is complicated by concern about the safety of the fetus. This manuscript is designed as a clinical reference for the practicing obstetrician. It will focus on the management of late pregnancy, labor, and delivery in patients with specific neurologic ailments. A systematic, anatomic approach has been taken. The review starts with a discussion of neurologic diseases of the brain and works its way down the spinal cord and peripheral nerves, across the neuromuscular junctions to the muscles. Movement disorders are considered separately. The monograph concludes with discussions of neurologic emergencies during pregnancy, as well as other situations specific to obstetric practice (such as drugs and breast-feeding, genetic counseling, and antenatal diagnosis for inherited neurologic diseases.) Disorders of the Brain includes discussions about the incidence, differential diagnosis, and management of a number of clinical conditions that center on the brain. These include headache; seizure disorders (focusing on management issues during pregnancy and implications for the fetus and newborn); cerebrovascular disease (stroke, Sheehan's syndrome, hypertensive encephalopathy); and demyelinating and degenerating diseases (multiple sclerosis, Huntington's disease). Infections of the nervous system (syphilis, polio, tetanus, toxoplasmosis, Lyme disease, HIV) occur in pregnancy, as they do in the nonpregnant state, but diagnosis and management might be different. The effects of inflammatory conditions of the central nervous system and intracranial tumors on pregnancy are reviewed briefly. There is a separate discussion about radiation exposure and its effects on the developing fetus. This discussion concludes that, in general, the use of radiographic technology (either diagnostic or therapeutic), if indicated, should not be restricted because the patient is pregnant. Psychiatric disorders affecting pregnancy (those that precede pregnancy, as well as conditions that result from pregnancy-such as postpartum depression and psychosis) often are overlooked. The warning signs and treatment of such conditions are discussed in detail. Disorders of the Spinal Cord includes discussions about specific topics (such as pregnancy in women with spinal-cord injuries and the entity of autonomic dysreflexia), as well as some more general topics (such as backache in pregnancy). Disorders of Peripheral Nerves covers both mononeuropathies (carpal tunnel syndrome, Bell's palsy, meralgia paresthetica) and polyneuropathies (Guillain-Barre syndrome, porphyric neuropathy, and the hereditary polyneuropathies). The 'lithotomy' position derives its name from Greek 'lithos,' meaning stone, and 'otomy,' meaning to cut. It is so named because it was the position in which elderly men were placed for surgical removal of obstructing bladder stones. It is not a natural position for childbirth and might create nerve injury as the result of compression and/or stretching of a particular peripheral nerve of nerve plexus. Symptoms of such obstetric neuropathies are usually mild and unilateral, and complete recovery can be expected in the majority of cases. These are reviewed in greater detail. Disorders of the Neuromuscular Junction focuses on myasthenia gravis, its effect on pregnancy, implications for the fetus and newborn, and management during labor and delivery. Disorders of Muscle includes brief discussions about muscle cramping and a number of specific muscular disorders, such as myotonic dystrophy, myotonia congenita, and polymyositis/dermatomyositis. Movement disorders are considered separately. These include a definition of some of the generalized involuntary movements, with specific reference to chorea gravidarum and Wilson's disease. Localized involuntary movements are discussed briefly, including the 'restless leg syndrome,' which is reputed to be the most common movement disorder in pregnancy. It usually occurs in the third trimester and has been reported in up to 11% to 12% of all pregnancies. Neurologic Emergencies During Pregnancy reviews the management of such conditions as status epilepticus and disorders of consciousness (coma) during pregnancy and delivery. Miscellaneous Neurologic Conditions Specific to Pregnancy includes such topics as neurologic birth injury (intracranial hemorrhage, brachial- plexus injury, fetal acidosis, cerebral palsy) and other congenital neurologic injuries (facial nerve paralysis, injuries to the neck and spine, multicystic encephalomalacia). Many factors might put a fetus at risk for a genetic disorder or neurologic birth defect. The section Neurologic Disorders in the Fetus explores the need for comprehensive genetic counseling both before and after conception. A number of preventative measures are outlined. They might ameliorate the risk of congenital neurologic anomaly, such as meticulous periconceptional glucose control in women with insulin-dependent diabetes, folic acid supplementation for women who have had a previous fetus with neural-tube defect, and parental karyotyping for couples at risk of having a fetus with one of the more common autosomal recessive disorders (Tay-Sachs disease, cystic fibrosis, sickle cell anemia). Recommendations for routine prenatal screening (including maternal serum alpha-fetoprotein, triple-panel serum screening, ultrasonography, and amniocentesis and other fetal genetic testing) are reviewed in detail. The section ends with a detailed discussion on drugs and breast-feeding. In general, most chronic neurologic disorders are compatible with normal pregnancy outcome. Diagnostic investigations (including imaging studies) and treatment protocols should be initiated, if indicated. The implications of such interventions for the developing fetus, however, should not be overlooked.

Original languageEnglish (US)
Pages (from-to)190-230
Number of pages41
JournalCurrent Problems in Obstetrics, Gynecology and Fertility
Volume20
Issue number6
StatePublished - 1997

All Science Journal Classification (ASJC) codes

  • Obstetrics and Gynecology

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