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Neurological Disorders in and Puerperium Sarella LK, Rao DS,

knowledge of impact of illness on Abstract maternal and fetal outcomes, risks of investigations, specific treatments Objectives: To study the clinical profile of the patients presenting with neurological disorders and safety of breast feeding. As during pregnancy and puerperium. many are unplanned, Methods: The study was carried out at Government General Hospital, Kakinada, Andhra diagnostic and therapeutic decisions Pradesh, India between June 2006 and May 2007. Patients in pregnancy, postabortal should be taken to balance their and evaluated in out-patient and in-patient departments and beneficial and adverse effects on referred to Neurology department, Government General Hospital, Kakinada during this time mother or child1. It is ideal to consider were included in this study. every woman in reproductive age to Results: A total of 55 patients presented during pregnancy and puerperium with neurological be potentially pregnant from the very disorders. Age of the patients ranged from 17 to 31 years. The total number of deliveries first visit1. in this hospital during this period was 9726. Out of 55 patients —27[49.09%], —11[20%], Cerebro vascular disorders—6[10.9%], Neuropathies —4[7.27%], Extrapyramidal disorders---2[3.64%], CNS infections—Tubercular –1[1.81%], METHODS Myelopathy—1[1.81%], Toxic/ metabolic —1[1.81%]. This study was conducted in Conclusions: Epilepsy was the most common neurological condition followed by Eclampsia Government General Hospital, and Cerebrovascular diseases. Health education measures for prospective mothers Kakinada between June 2006 and regarding the appropriate, adequate and regular use of anti-epileptic drugs should be taken May 2007. All patients in pregnancy, up. Diligent care is to be taken to watch for neurological deficit in cases of Pre-eclampsia/ post abortal and postpartum period, Eclampsia to identify special investigation team—Obstetrician, Neurologist, Physicians and evaluated with detailed history, Neurologist. The treating team should have the complete knowledge of the effects of rare clinical examination and basic neurological disorders during pregnancy and puerperium. investigations in department of Keywords: Epilepsy, Eclampsia, Cerebrovascular disorders, gravidarum, Guillain- Neurology were included in this Barre syndrome. study. CT, MRI nerve conduction studies and other investigations were done as required. Wherever possible INTRODUCTION symptoms which occur only with a definitive diagnosis was established pregnancy. (eg: Pre eclampsia/ based upon standard diagnostic Pregnancy is a time of major hormonal Eclampsia). criteria. and other physiological changes that can precipitate new neurological Identification and management 1 of neurological disorders during and psychiatric symptoms . Though OBSERVATIONS neurological disorders during pregnancy and puerperium pregnancy and puerperium (NDDPP) (NDDPP) pose a special challenge A total of 55 patients presented represent a small subgroup, their to Neurologists and Obstetricians, during pregnancy and puerperium range is broad2. NDDPP can be and they should have thorough with neurological disorders. Age of classified into three subgroups3. 1) Diseases which existed already Table 1. Distribution of Neurological Disorders during Pregnancy and Purperium before pregnancy or appear just by Disease No. of Cases Percentage chance (eg: ) 2) Diseases that can display a higher incidence Epilepsy 27 49.09 in pregnancy (eg: Cerebrovascular Eclampsia 11 20.00 disease) 3) Diseases with neurological 6 10.90 Neuropathies 4 7.27 Rangaraya Medical College, Kakinada, Extra pyramidal disorders 2 3.64 Andhra Pradesh, India. Primary muscle disorders 2 3.64 Correspondence: Dr. Lavanya Kumari Sarella CNS infections 1 1.81 E-mail: [email protected] Myelopathy 1 1.81 Competing interests: None Toxic/metabolic encephalopathy 1 1.81

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Table 2. Clinical Features of Patients with Epilepsy parenchymal and subarachnoid haemorrhage on CT imaging. She Time In Relation to Pregnancy delivered a preterm still born baby. First trimester 4 [14.81%] Maternal condition continued to Second trimester 6 [22.22] be precarious and was discharged against medical advice. Third trimester 13 [48.14] Extrapyramidal Disorders: A 22 yr old Postpartum 4 [14.81] multi with 6months of gestation and Type of past history of chorea gravidarum, Partial 1 [3.70] presented with severe generalized Secondary generalized 10 [37.03] chorea. The other was a 23yr old multi in the first trimester with a past history Primary generalized 16 [59.25] suggestive of and 4 [14.81] chorea during her childhood. Both Treatment Pattern were treated with with good symptomatic improvement with Not on any antiepileptic drug 14 [51.85] good maternal and fetal outcome. Monotherapy 10 [37.03] Primary Muscel Diseases: A 25 yr Polytherapy 3 [11.11] old second gravida, a known case of Myotonia congenita, with h/o Table 3. Cerebrovascular Disorders , was followed up from 20th week gestation. She had an uneventful S. No Clinical Disorder Investigations Outcome course with good maternal and fetal 1 26yr old primi, known HTN right CT;Lt ganglionic Preterm delivery at outcome. A 19 yr old primipara hemiparesis hematoma, old lacunar 34 weeks. Low birth presented with quadriparesis on the infarct—Lt. PCA territory weight, residual fourth postnatal day was found to be hemiparesis having hypokalemia and recovered 2 20yr multi 1st trimester. CT-old Lt. MCA infarct Normal labour with oral potassium supplements. Recurrent syncopal attacks. MRA-s/o Takayasu’s Toxic Metabolic Encephalopathy: A Past h/o Rt. hemiparesis arteritis 25yr old multi, admitted on seventh 3 25yr multi known HTN, 2 weeks Expired within few postpartum day with h/o chills, rigors postpartum, sudden loss of hours of admission and altered sensorium, improved with consciousness, Lt. hemiparesis and antimalarial treatment. 4 22 yr multi 3-4 weeks CT-frontal venous infarct Recovered well Infectious Diseases: A 24yr old postpartum , empty delta sign—SSS. third gravida was evaluated in third , Lt. hemiparesis MR-bilateral venous infacts trimester for headache, vomiting MRV—SSS thrombosis and altered sensorium of 10 days 5 18yr primi, 2 weeks postpartum CT-Rt. Fronto temporal Recovered well duration, found to be having mild Lt. hemiparesis hemorrhagic venous infarct communicating , and basal meningitis. She improved with MRV-SSS thrombosis antituberculous treatment, delivered 6 20yr multipara 5th PO LSCS day CT-s/o bilateral transverse Improved with at 28weeks of gestation. She had headache, Lt. partial seizures sinus thrombosis minimal residual Lt. residual right sided seventh cranial hemiparesis nerve palsy. the patients varied from 17-31 years. in third trimester and seven in The total number of deliveries in this postpartum period. DISCUSSION hospital during this period was 9726. Two prime’s presented in third The incidence of NDDPP was found The incidence of NDDPP was 565 per trimester had focal neurological to be 566 per 100,000 deliveries. 100,000 deliveries. deficits. A 30 year old had right This was much higher than that in Epilepsy: Epilepsy constituted the hemiparesis with CT scan showing previous studies from Hongkong most common neurological disorder left hemispherical infarct. Course of which showed an incidence of 326 per 2 comprising 27 cases [49.09%]. pregnancy was complicated by ante- 100,000 pregnancies . A recent study of partum hemorrhage and intrauterine NDDPP revealed an incidence of 584 Eclampsia: Eclampsia was the second 4 most common neurological condition fetal death. Delivery was spontaneous cases per 100,000 deliveries , which is affecting 11[20%] patients. Out of without any maternal morbidity. A similar to that seen in our study. these, four patients had seizures 19 year old, was found to be having

September 2014 Sri Lanka Journal of Obstetrics and Gynaecology 75 Original Paper www.slcog.lk/sljog

Table 4. Neuropathies the trimesters and the postpartum period4. In our study majority of S. No Presentation Nerve Conduction Outcome cases [48.1%] were seen in the third Studies trimester. Primarily GTCS constituted Guillain-Barre Syndrome the commonest type, constituting 59.25%, consistent with the incidence 1 28yr old multi with 20weeks Axonal motor and Developed respiratory of previous study 59.38%9. There is a gestation with symptoms of 2 sensory neuropathy paralysis. Expired after variation in the reports of incidence of weeks duration 4days Status epilepticus during pregnancy th 2 24 yr old primi at 5 postpartum Demyelinating Recovered and puerperium—0.8% 9and 31.8%4 week neuropathy and 4 [14.81%] in our study. This can Idiopathic Facial Palsy be explained by lack of awareness 1 25 yr old primi with term gestation ———— Labor induced in the public, inadequate medical with severe hypertension resources, inability to purchase drugs Good maternal and fetal and poor compliance. outcome Regarding drug therapy, monotherapy Bilateral Carpal Tunnel Syndrome with the appropriate drug and 1 31 yr old primi in 1st trimester ———— Improved least effective dose to the epilepsy with diabetes, hypertension and syndrome is recommended during hypothyroidism pregnancy8. Polytherapy increases the incidence of major and minor fetal Table 5. Distribution of Neurological Disorders during Pregnancy and Puerperium malformations—around 3% for one Comparision with Previous Studies drug, 5% for two, 10% for three and greater than 20% in women taking Condition TO et al Janaki Srinivasan Agarwal Gupta Present more than three antiepileptic drugs10. et al et al et al et al study In our study, 51.85% of the woman Total number 161 97 68 87 76 55 with pregnancy and epilepsy were not NO [%] NO [%] NO [%] NO [%] NO [%] NO [%] receiving any treatment at the time Epilepsy 102 [63.3] 30 [30.9] 17[23.5] 5[6.7] 22[28.9] 27 [49.9] of presentation and 37.03% were on monotherapy compared to 28.1% and CVD 7 [4.9] 48 [49.5] 41 [60.3] 72 [82.7] 9 [11.9] 6 [10.9] 59.38% in other study9 which is higher CNS infections ——— 4 [4.1] 3 [4.4] 5 [5.7] 12 [15.8] 1 [1.81] and lower respectively. 11.1% were on CNS tumors 12 [7.5] 7 [7.2] 16 [23.5] 16 [23.5] 1 [1.3] ——— polytherapy similar to 12.5% of other study9. Most of our patients receiving PE/E 19 [11.9] NI NI NI NI 11 [20] monotherapy were on phenytoin as it Demyelinating 4 [2.5] 1 [1.03] 3 [4.4] 1 [1.1] 1 [1.3] ——— is dispensed in Government hospital. diseases Eclampsia: The occurrence of Peripheral 12 [7.5] 1 [1.03] 1 [1.5] 2 [2.3] 1 [1.3] 4 [7.27] eclampsia is higher [63.6%] than that neuropathies in Hongkong study [44-48%]11. Of the Metabolic NI NI NI NI 28 [36.8] 1 [1.1] two cases that had focal neurological deficits, one had ischemic and Cord affections ——— ——— 5 [7.4] ——— 1 [1.3] 1 [1.81] the other hemorrhagic stroke. Pre eclampsia (PE)/Eclampsia (E) were Extrapyramidal ——— ——— ——— ——— ——— 2 [2.64] found to be an etiological factor for disorders stroke in previous studies12, and are Primary muscle ——— ——— ——— ——— ——— 2 [3.64] the major leading cause of stroke in disorders the peripartum maternal mortality 13 NI—not included and morbidity . Eclampsia was found to be associated with ischemic stroke in 24-47% of cases and cerebral Table 5 shows the results of previous from the later study can be explained 11 2,4,5,6,7 hemorrhage in 14-44% . Association and present studies. . by the presence of a large number of between history of PE and ischemic metabolic encephalopathies, which Epilepsy: Epilepsy was found to stroke remote from pregnancy be the most common neurological constituted majority of cases. necessitates close monitoring of disorder in our study and was similar Trimester wise analysis showed least women beyond postpartum period14. to Hongkong study. The incidence occurrence during third trimester Cerebral hemorrhage is reported of epilepsy is lower than that in and postpartum period in previous to be the most common cause of Hongkong study2 and higher than studies8. In a recent study there death in patients with eclampsia12. that in Delhi study4. This disparity was a uniform distribution across These observations indicate careful

76 Sri Lanka Journal of Obstetrics and Gynaecology June 2014 www.slcog.lk/sljog Original Paper evaluation of PE/E cases to detect Recurrence can occur in subsequent Myotonia Congenita: A case of additional cerebral infarction or pregnancies. Most improve within myotonia congenita complicated by hemorrhage. Maternal outcome was a few weeks postpartum20. In still birth was reported36. Our patient good in rest of the cases with adverse our subject, associated diabetes had normal delivery without any fetal outcome in six cases. and hypothyroidism might have maternal and fetal adverse effects. Cerebrovascular Disorders: Reported contributed to the occurrence of As the referred patients from various incidence of stroke during pregnancy symptoms in the first trimester. departments were also evaluated and the puerperium ranges from She improved with conservative referral bias cannot be avoided. Many 5-67 per 100,000 pregnancies15, management. of previous studies included PE/E contributing to more than 12% of all Facial Palsy: An increase in the related under CVD. We have 12 maternal deaths . Fetal and maternal incidence of idiopathic facial palsy included them under PE/E as it is a outcome may be adversely affected during pregnancy and postpartum well-established clinical entity in the with premature delivery, fetal period was found in previous resources for work up and follow up mortality, and residual neurological studies2,26, and in third trimester and in the general hospital setting. The 15 deficits . 89% of pregnancy related immediate postpartum in recent number of cases in the study is small strokes occur at the time of delivery or study27,28. Prognosis is excellent and and a longer duration of study will postpartum12. Out of two cases with reveal more neurological disorders. similar to that observed in non- past h/o hypertension, one had stroke In view of the broad range of the pregnant patients20. Favourable in the third trimester and the other neurological disorders occurring results with oral prednisolone were two weeks postpartum. All cases of during pregnancy, a single study reported2 but opinions against cerebral venous thrombosis were seen is unlikely to show all the entities. therapy also exist29. The association postpartum. As such each study contributes its of idiopathic facial palsy and own component to the spectrum of Takayasu’ arteritis is a rare vasculitis, was noted neurological diseases in this context. ■ in which both ischemic and previously30. Our patient presented 16 hemorrhagic strokes are reported . in the third trimester and labour was Our patient presented in first trimester induced in view of severe gestational and had good outcome. Course of the hypertension. 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