Maria Stefanidou, MD, MSc
SPECTRUM OF NEUROLOGIC PROBLEMS IN PREGNANCY
The most common problems for which neurologists see pregnant patients in the ED and hospital are:
Most obstetricians do not consult neurology for eclampsia unless seizures are refractory or focal neurologic symptoms develop.
Headache
Headache has a broad differential diagnosis, almost all of which can potentially occur during pregnancy. Chapter 20 discusses headache in depth. However, there are some etiologies of particular note during pregnancy. Features of some of these, as well as their differential diagnoses, include:
•Migraine: Recurrent, episodic unilateral or bilateral headache lasting 4–72 hours and associated with nausea, vomiting, and/or photophobia. Migraines improve during pregnancy in 60–70% of women with pre-existing migraine, but may occasionally worsen or appear for the first time.
•Pre-eclampsia: Headache often with nausea; visual obscurations are common. Non-neurologic findings are key, including hypertension, proteinuria, and edema.
•Cerebral venous thrombosis: Headache often with encephalopathy or focal deficits. May develop seizure or signs of increased intracranial pressure.
•Intracerebral hemorrhage: Headache, focal deficit, and often encephalopathy related to intraparenchymal hemorrhage.
•Subarachnoid hemorrhage: Acute onset of headache often associated with neck stiffness. Aneurysmal bleed has an increased incidence during pregnancy, which peaks at 30–34 weeks gestational age and among older mothers (>35 years).
•Postpartum cerebral angiopathy: Severe headache developing in the 6 weeks postpartum and associated with reversible segmental narrowing and dilation of large and medium-sized cerebral arteries. Often complicated by seizures, reversible brain edema, intracerebral or nonaneurysmal subarachnoid hemorrhage.
•Arterial dissection: Acute onset of focal deficits, often with headache. In a woman of childbearing age, dissection must always be considered, but pregnancy may increase the risk.
•Pituitary apoplexy: Acute onset of headache and visual disturbance including visual loss and/or diplopia due to acute hemorrhage into the pituitary. Clinical signs of pituitary insufficiency follow.
•Meningitis: Headache associated with fever, stiff neck, nausea, and vomiting, often with encephalopathy.
•Pseudotumor cerebri: Headache and visual change with papilledema on exam. Must look for venous thrombosis if this diagnosis is considered.
MANAGEMENT of most of these does not markedly differ from that in the nonpregnant population (Chapter 20), but there are some differences that deserve note and these are discussed in the following sections.
Seizures
Seizure in pregnancy can have a variety of causes. Among some of the most important are:
•Psychogenic nonepileptic seizures
PRESENTATION is with any of the seizure manifestations discussed in Chapter 19. Associated symptoms will not be expected unless there is a new causative neurologic problem, such as stroke, tumor, or infection. Seizures can be focal-onset or primarily generalized.
DIAGNOSIS is established by the clinical seizure activity. Approach to diagnosis depends on the clinical scenario.
•Recurrent seizure with known epilepsy: Further study is often not needed unless change in seizure semiology or breakthrough in well-controlled epilepsy occurs.
•New seizure without neurologic deficit: Electroencephalogram (EEG) is performed. Brain imaging with computed tomography (CT) or magnetic resonance imaging (MRI) is recommended. LP is recommended if CNS infection is suggested by clinical parameters or imaging (e.g., temporal signal change suggesting HSV encephalitis).
•New seizure with new neurologic deficit: Brain imaging with CT or MRI is recommended. EEG is performed. Eclampsia is considered in patients with pregnancy-induced hypertension, edema, proteinuria, or evidence of hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome. LP is recommended if clinical findings suggest infection (fever, increased WBC) or subarachnoid hemorrhage (CSF signal change on CT or MRI)
•Suspected nonepileptic seizure: Recommend continuous video EEG if possible to document whether the paroxysmal activity is nonepileptic. Routine EEG may not capture a spell.
MANAGEMENT: Anticonvulsants used during pregnancy are similar to those used in nonpregnant patients (Chapter 19), but agents with increased incidence of developmental defects and cognitive effects, such as valproate, are to be avoided if possible.
Encephalopathy
Encephalopathy in pregnancy is usually pre-eclampsia or eclampsia, but there are a host of other potential causes. Some of the important causes of encephalopathy during pregnancy include:
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