Neurological disease in pregnancy

Question 1

Congenital defects associated with lamotrigine?

Risk?

Answer 1

facial cleft

2.9%

Question 2

Aim of pre conceptual counselling in women with epilepsy?

Answer 2

• stabilise disease
• mono therapy with AED
• pre conceptual HDFA
• offer genetic counselling if FHx strong

Question 3

Treatment for acute flares of MS in pregnancy?

Answer 3

corticosteroids in second and third trimester

Question 4

Myasthenia gravis prenatal counselling points

Answer 4

• risk of exacerbation
• fetal syndromes
  +/- thymectomy
• TFTs

exacerbation less likely if thymectomy. antibodies can cause fetal arthrogryposis, transient neonatal MG syndrome

Question 5

Recommendations regarding myasthenia gravis in pregnancy

Answer 5

• dose increase may be required
• continue normal therapy
• +/- plasmapheresis
• anaesthetic rv
• avoid certain medications
• polyhydramnios

Question 6

Contraindicated medications in myasthenia gravis?

Answer 6

amnioglycosides
b-blockers
b-adrenergics
MgSO4

Question 7

Effects of pregnancy on myotonic dystrophy?

Answer 7

increased flares, worse in third trimester

Question 8

idiopathic benign intracranial hypertension presents with…?

Answer 8

retro-orbital headache, diplopia

Question 9

Relative risk of ischaemic, hemorrhagic and subarachnoid stroke in pregnant vs. non=pregnant?

Answer 9

ischaemic = RR 9 in puerperium
hemorrhagic: RR 2.5 pregnancy, RR28 puerperium
SA= RR 3 in pregnancy, RR20 puerperium

Question 10

Relative risk of Bell’s palsy in pregnancy vs. non pregnant population

Answer 10

RR 10x. Usually occurs in the 2 weeks prior to delivery.

Question 11

Risk of seizure in patient with epilepsy in labour/peripartum period

Answer 11

3.5%

Question 12

Risk of epilepsy in child if a) one parent, b) sibling, c) both parents affected.

Answer 12

a) 4-5%, b) 10%, c)15-20%

Question 13

congenital defects associated with valproate? Risk of defects?

Answer 13

cleft, NTD’s, cardiac, hypospadias. 10.7%

Question 14

Congenital defects associated with carbamazepine? Risk?

Answer 14

cleft palate 4.6%

Question 15

Treatment of seizure in labour?

Answer 15

1. BZDs
2. +/- tocolysis
3. expedite delivery if non-terminating

Question 16

What form of labour analgesia avoided in labour if you have epilepsy?

Answer 16

pethidine

Question 17

Discuss vitamin K and AED therapy?

Answer 17

Decrease in clotting factor precursors in mum and baby due to enzyme induction with AEDs. Can offer vitamin K at 36+ weeks + neonatal vitamin K.

Question 18

Recommended scans in pregnancy with epilepsy + AED?

Answer 18

fetal echo, fetal growth 28,32,36 weeks.

Question 19

Acute pharmacotherapy of migraines/headaches in pregnancy

Answer 19

paracetamol, metoclopramide, codeine, +/-sumatriptam.

Question 20

Migraine prophylaxis in pregnancy

Answer 20

aspirin, propanolol, amitriptyline, verapamil, gabapentin in order of preference

Question 21

Effect of migraine on pregnancy

Answer 21

increased risk of PET

Question 22

Recommendations regarding DMARDs for multiple sclerosis in pregnancy

Answer 22

No DMARDs approved in pregnancy. Recommended stopped prior to conception (b-interferons, flatiramer, natalizumab).

Question 23

Considerations for MS and postnatal period

Answer 23

Some DMARDs not recommended with breastfeeding.

Question 24

Effect of pregnancy on MS

Answer 24

No increased rate of progression. Less likely to have relapse in pregnancy. May have increased relapse PP, may be reduced with breastfeeding.

Question 25

Peripartum considerations myasthenia gravis

Answer 25

May require assistance second stage, CS obstetric indications, parenteral anti cholinesterase drugs, observation neonate 2 days in hospital.

Question 26

Myotonic dystrophy inheritance

Answer 26

autosomal dominant, chromosome 19. Number of repeats = severity.

Question 27

Effects of myotonic dystrophy on pregnancy

Answer 27

reduced ovarian reserve, increased risk ectopic pregnancy, PTD, prolonged labour, PPH, polyhydramnios (if foetus affected)

Question 28

Pregnancy considerations benign intracranial hypertension

Answer 28

Thiazide diuretics can cause neonatal thrombocytopenia if being used to treat. Acetazolamide contraindicated in 3rd trimester. Can have spinal/epidural anaesthesia.

Question 29

Intrapartum considerations if previous hemorrhagic stroke

Answer 29

BP/symptom monitoring. No benefit of CS vs NVD if AVM present.

Question 30

intrapartum considerations if previous subarachnoid haemorrhage

Answer 30

no benefit of cs over nod, epidural unless recent SAH. short second stage with assisted delivery.

Question 31

What is posterior reversible encephalopathy syndrome

Answer 31

Vasogenic brain oedema, associated with PET. Can present with cortical blindness, headache and seizures. Treated with MgSO4

Question 32

Pathophysiology of Bells palsy

Answer 32

reactivation of latent HSV from cranial ganglia. PET can also be causative of oedema.

Question 33

Management Bell’s palsy

Answer 33

corticosteroids administered within 3 days of onset. Can also be managed expectantly. Consider eye drops and eye patch.

Question 34

incidence myasthenia gravis?

Answer 34

1-4/10,000

Question 35

Cause of myasthenia gravis?

Answer 35

90%= Acetylcholine receptor antibodies
10% = other post synaptic antigens

Question 36

Effect of pregnancy on myasthenia gravis?

Answer 36

40% exacerbation
30% nil change
30% remission

PP exacerbations in 30%

Question 37

Effect of myasthenia gravis on pregnancy?

Answer 37

transplacental passage of antibodies
arthrogryposis due to lack of movement
no swallowing leads to polyhydramnios

smooth muscle of uterus unaffected. Won’t be able to use striated muscle to push as effectively.

10-20% neonatal MG (less risk if maternal thymectomy)

Question 38

Inheritance myotonic dystrophy?

Answer 38

autosomal dominant disorder chromosome 19 (type one)

Question 39

Effect of myotonic dystrophy on pregnancy?

Answer 39

miscarriage

stillbirth

Question 40

Risk of congenital malformations due to levetiracetam mono therapy?

Answer 40

2.8%.