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RANZCOG 2024 - maternal medical conditions > Neurology > Flashcards

Neurology Flashcards

1
Q

Discuss antiepileptic drug use in pregnancy
-General principles of prescribing (4)
-Class of drugs (2)
-General risks with anti-epileptic drugs (3)

A
  1. General principles of prescribing
    -Consider teratogenicity and seizure control in pregnancy planning
    -Aim for lowest dose of a single medication
    -Benefits of epilepsy control outweigh risks of teratogenicity
    -Avoid valproate. If required in split doses and wean to lowest dose
  2. Class of drug
    -All class D drugs
    -Levetiracetam class B3
  3. General risk of anti-epileptic drugs
    -Lamotrigine and Levetiracetam the safest 3% risk of congenital abnormalities
    -Monotherapy 4.5% risk of congenital abnormalities
    -Polytherapy 8.5% risk of abnormalities
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2
Q

Discuss abnormalities associated with:
-Valproate
-Phenytoin
-Carbamazepine
-Lamotrigene/levetiracetam

A
  1. Valproate
    -To be avoided if possible
    -NTD 1-2%, orofacial cleft 1.5% cardiac anomalies, urogenital anomalies
    -Neurodevelopmental delay - low IQ, ADHD, autism
  2. Phenytoin
    -NTD 1-2%, orofacial cleft 1.2%, cardiac, urogenital anomalies
  3. Carbamazapine
    -NTD 1%, orofacial 0.4%, cardiac 0.7%
  4. Lamotrigine/Levetiractam
    -NTD 0.2%
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3
Q

Discuss fetal anti-epileptic syndrome

A

-Dysmorphic features - V shaped eyebrows, epicanthal folds, low set ears, flat nasal bridge
-Hypertelorism
-Hypoplastic nails and digits
-Hypoplasia of the mid face

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4
Q

Discuss other effects from anti-epileptic drugs

A
  1. Neonatal withdrawal - mitigated by breastfeeding
  2. Neonatal coagulopathies
  3. Developmental delay
  4. Childhood neuroblastoma
  5. ADHD, Low IQ, autism spectrum
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5
Q

Discuss Bell’s palsy in pregnancy
-Incidence
-Causes
-Presentation
-Management

A
  1. Incidence
    -45:100,000
    -10x more common in pregnancy
  2. Causes
    -Motor neuron weakness of CN7 (Facial nerve)
    -Herpes zoster outside of pregnancy
    -Swelling of petrous temporal bone in pregnancy.
    -Increased risk in PET secondary to swelling of temporal bone
  3. Presentation
    -Unilateral facial weakness
    -Loss of blink reflex
    -Loss of taste to anterior 2/3rds of tongue
  4. Management
    -80-95% self resolve over several months
    -Short course of steroids (2 weeks) can improve time to recovery if started within 24-72hrs
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6
Q

Discuss ischaemic stroke in pregnancy
-Incidence (3)
-Common site of ischaemic stroke (2)
-Risk factors / causes in pregnancy (6)
-Management (4)

A
  1. Incidence
    -Pregnancy risk to 5-200:100,000
    -9 x increased risk in puerperium
    -Most occur in the first week PP
  2. Common sites of ischaemic stoke in pregnancy
    -Carotid arteries
    -MCA
  3. Risk factors
    -PET
    -Cardiac causes
    -APLS
    -Vasculitis
    -Sickle cell disease
    -Thrombotic thrombocytopenia purpura
  4. Management
    -Same as for non-pregnant women
    -Thrombolysis
    -Aspirin
    -Anticoagulation
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7
Q

Discuss haemorrhagic stroke in pregnancy
-Incidence (3)
-Causes (2)
-Management (3)

A
  1. Incidence
    -Very rare. Less common than ischemic stroke in pregnancy
    -Increased risk in pregnancy RR2.5
    -Increased risk in PP RR 28
  2. Causes
    -AVM - dilate in pregnancy
    -PET - due to cerebral vasospasm
  3. Management
    AVM
    - if identified treat before becoming pregnant
    - Can treat in pregnancy if required
    - If treated can have VB
    PET
    -Control BP
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8
Q

Discuss subarachnoid haemorrhage in pregnancy
-Incidence (3)
-Causes (2)
-Management (7)

A
  1. Incidence
    -2:10,000
    -2-3 increased risk in pregnancy
    -20 x increased risk PP
  2. Causes
    -Ruptured aneurysm
    -Ruptured AVM
  3. Management
    -Nimodipine
    -Neurosurgical or radiological management
    -Can aim for VB but consider CS if recent acute bleed or mother moribund
    -Shortened second stage with instrumental
    -Avoid spinal where risk of ICP
    -Avoid GA if possible - hypertensive response
    -Avoid ergometrine
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9
Q

Discuss the effect of pregnancy on epilepsy (5 points)

A
  1. Pregnancy doesn’t change seizure frequency or type
  2. 2/3rds of women will not experience a change in seizure frequency
  3. 1/6th of women will experience a drop in seizure frequency
  4. 1/6th of women will experience an increase in seizure frequency
  5. Pregnancy can decrease anti-epileptic drug concentrations due to increased volume of distribution, increased renal and hepatic clearance
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10
Q

Discuss the impact of epilepsy on pregnancy (8)

A

Increased risk in:
-Spontaneous miscarriage OR 1.54
-APH OR 1.49
-PET / gHTN OR 1.37
-Abruption
-PTL OR 1.16
-PPH
-IUGR OR 3.5 if on AEDs
-CS rates
-Seizure can cause fetal bradycardia and fetal hypoxia
-Main risk is around anti-epileptic drugs causing fetal anomalies

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11
Q

Discuss management of women with epilepsy in pregnancy
-Pre-conception care (5)
-Antenatal care (6)
-Intrapartum care (4)
-Postpartum care

A
  1. Pre-conception care
    -Optimise control of epilepsy (single agent, lowest dose, avoid valproate)
    -Refer to neurologist for advice on ongoing medication
    -Counsel women about risks of anti-epileptic meds
    -Counsel women about risk of offspring with epilepsy
    -Commence on high dose folic acid 5mg
  2. Antenatal
    -If starting treatment in pregnancy choose levetiracetam or lamotrigine
    -General information about safety with epilepsy
    -Serum levels of AEDs not recommended
    -Check levels of lamotrigine in pregnancy as dose adjustment likely (not routinely recommended)
    -Fetal nucal translucency
    -Fetal anomaly scan with careful review of heart
    -Vit K supplementation 10-20mg PO for last 4 weeks as enzyme inducing antiepileptic drugs reduce vit K dependant clotting factors in newborns
    -Monitor mother for mood sx associated with AEDS
  3. Intrapartum care
    -1-2% of women will have a seizure in labour
    -Manage exhaustion and pain with epidural
    -Aim VB
    -If seizure in labour treatment with 4mg IV lorazepam
  4. Postpartum
    -Do not leave alone for 24hrs
    -Vit K for neonate
    -Review meds and reduce if increased in pregnancy
    -Breastfeeding encouraged. BF before taking meds
    -Safety advice around looking after baby
    -Contraception considerations - CuIUD, IUD, Depo (Not impacted by AEDs)
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12
Q

Discuss headache in pregnancy
-Types (2 groups)

A
  1. Headaches types
    Primary (99% of headaches)
    -Tension - most common type in pregnancy
    -Migraines
    -Cluster headaches - very rare
    Secondary (1% of headaches)
    -SAH
    -Reversible cerebral vasoconstriction syndrome
    -Posterior reversible encephalopathy syndrome
    -Dural puncture headache
    -PET
    -Idiopathic cranial hypertension
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13
Q

Discuss reversible cerebral vasoconstriction syndrome
-Onset
-Cause
-Diagnosis and findings
-Management

A
  1. Onset
    -Severe sudden headache. Occurs in postpartum period
  2. Cause
    -due to transient disturbance in CV tone
  3. Diagnosis
    -MRI
    -Shows multifocal segmental constriction of medium to large cerebral arteries - beading appearance
  4. Management
    -Nifedipine
    -Resolves after 3 months
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14
Q

Discuss posterior reversible encephalopathy syndrome (PRES)
-Cause
-Presentation
-Risk factor (1)
-Diagnosis and findings
-Management

A
  1. Cause
    -Transient neurological disturbance due to vasogenic brain oedema
  2. Presentation
    -Headache, seizures, cortical blindness
  3. Risk factors
    -Associated with PET
  4. Diagnosis and findings
    -MRI. Shows bilateral involvement of white and grey matter in posterior regions
  5. Management
    -MgSO4
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15
Q

Discuss post dural headache
-Onset
-Presenting symptoms
-Management

A
  1. Onset
    -1 day post epidural block
  2. Presenting symptoms
    -Headache relived by lying down, neck stiffness, tinnitus, visual symptoms
  3. Management
    -Blood patch
    -Caffeine
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16
Q

Discuss migraines in pregnancy
-Impact of pregnancy on migraines (2)
-Impact of migraines on pregnancy (1)

A
  1. Impact of pregnancy on migraines
    -50-80% improve typically in 2nd and 3rd trimester
    -10% worsen
  2. Impact of migraines on pregnancy
    -Increased risk of PET
17
Q

Discuss management of headaches in pregnancy
1. Conservative measures
2. Analgesia
3. Antiemetics
4. Prophylaxis

A
  1. Conservative measure
    -Avoid precipitants
  2. Analgesia
    -Paracetamol 1st line.
    -NSAIDS second line in first and second trimester
    -Codeine
    3.Antiemetics
    -Metocloprimide
    -Prochlorperzine
  3. Prophylaxis
    -First line - low dose aspirin
    -Second line - beta blocker - propranolol
    -Third line - TCA NOCTE
    -Limited evidence for tryptans. Cat C
18
Q

Discuss multiple sclerosis in pregnancy
-Aetiology (1)
-Effect of MS on pregnancy (5)
-Effect of pregnancy on MS (3)

A
  1. Aetiology
    -Autoimmune disorder causing inflammation and demylenation of CNS
  2. Effect of MS on pregnancy
    -Nil effect of MS on pregnancy
    -Increased risk of offspring with MS 2%
    -No impact on breastfeeding
    -No impact on regional analgesia
    -No impact on mode or timing of delivery
  3. Effect of pregnancy on MS
    -Nil impact on progression of MS
    -Reduced relapse during pregnancy
    -40% relapse in postpartum period
19
Q

Discuss management of multiple sclerosis in pregnant women
-Pre-conception (4)
-Antenatal (3)
-Intrapartum (3)
-Postpartum (1)

A
  1. Pre-conception
    -Consult with neurologist regarding medication weaning to stop or continuing
    -Medications to reduce relapse B-interferones or glatiramer as usually discontinued in pregnancy
    -Discuss risk of offspring with MS 2%
    -Discuss high chance of relapse postpartum
  2. Antenatal care
    -Monitor for relapse or worsening of symptoms
    -Treat acute relapses with IV corticosteriods
    -Can continue immunosupression agents - azathioprine
  3. Intrapartum
    -Aim for spontaneous vaginal birth
    -Give IV hydrocortisone if on antenatal steroids
    -No contra-indications to regional or GA anaesthetic
  4. Postpartum
    -Observe for relapse
20
Q

Discuss myasthenia gravis in pregnancy
-Pathophysiology
-Effect of MG on pregnancy (5)
-Effect of pregnancy on MG (3)

A
  1. Pathophysiology
    -Autoimmune disorder with IgG made against acetylcholineserase receptors which leads to insufficient nerve impulses transmission of striated muscle
    -Results in striated muscle weakness
  2. Effect of MG on pregnancy
    -Increased risk of PROM
    -Increased risk IUGR
    -No impact to miscarriage
    -First stage of labour usually fine as relies on smooth muscle.
    -Second stage of labour may need assistance as relies on striated muscle
  3. Effect of pregnancy on MG
    -40% exacerbation in pregnancy.
    -30% improve in pregnancy
    -30% no change in pregnancy
21
Q

Discuss the impact to the fetus of mother’s with myasthenia gravis
1. Fetal impact (3)
2. Neonatal impact (4)

A
  1. Fetal impact
    -IgG can cross the placenta
    -Rarely fetus can develop arthrogyposis multiplex congenita, contractures from reduced movement
    -Polyhydramnios from reduced swallowing
  2. Neonatal impact
    -Transient neonatal MG 10-30%
    -Appears in first 2 days
    -Resolves after 4-8 weeks
    -Responds to anticholinesterases
22
Q

Discuss management of pregnancy in women with myasthenia gravis
-Pre-conception (2)
-Antenatal (5)
-Intrapartum
-Postnatal

A
  1. Pre-conception
    -Stop contra-indicated immunodsuppressants (MTX, ciclosporin etc)
    -Continue with anticholinesterases
  2. Antenatal
    -Anaesthetic referral
    -May need to increase anticholinesterases
    -Monitor for fetal movement
    -Monitor for polyhydramnios
    -Serial growth scans
    -MgSO4 contraindicated!!!
  3. Intrapartum
    -Epidural and spinal anaesthetic safe
    -Aim for VB but may need instrumental
  4. Postpartum
    -Risk of exacerbation 30%
    -Review immunosupressants and consider if safe in breastfeeding
    -Monitor neonate for 2 days
23
Q

Discuss myotonic dystrophy in pregnancy
-Pathophysiology
-Impact of pregnancy on MD (2)
-Impact of MD on pregnancy (6)

A
  1. Pathophysiology
    -Degenerative neuromuscular disorder characterised by progressive distal muscle weakness
    -Autosomal dominant inheritance
  2. Impact of pregnancy on MD
    -Can cause exacerbations typically in third trimester with improvement postpartum
    -Increased risk of offspring inheritance
  3. Impact of MD on pregnancy
    -Increase in PTB
    -Increase in first and second trimester miscarriage
    -Increase in polyhydramnios
    -Increase in still birth
    -Dysfunctional labour due to poor contractions.
    -Increased risk of PPH

RANZCOG 2024 - maternal medical conditions (14 decks)

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