Neurological Illness in Pregnancy
Autumn Klein University of Pittsburgh Medical Center, Pittsburgh, USA M. Angela O'Neal Brigham and Women's Hospital, Boston, USA Christina Scifres University of Oklahoma College of Medicine, Oklahoma City, OK, USA Janet Waters University of Pittsburgh Medical Center, Pittsburgh, USA Jonathan H. Waters Magee Women's Hospital of University of Pittsburgh Medical Centre, Pittsburgh, USA
Neurological Illness in Pregnancy
The history and examination
Mary A. O'Neal
Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
The focus of this chapter will be on the information most helpful to understand, counsel, and treat female neurology patients in their reproductive years. The key elements of the neurologic history and examination will be systematically reviewed with emphasis on gender differences. It will conclude with a few clinical cases. The goal is to enable neurologists to develop the knowledge and skills to maximize care for their female patients with regard to family planning and pregnancy. The objective of this chapter is to help physicians to perform a history and examination that focuses on and identifies the specific family planning concerns of the female patient and how these concerns relate to their neurologic disease.
Many common neurological diseases preferentially affect young women. How we, as neurologists, approach treatment depends on our patients' needs at that point in her life cycle. This is different for each disease process.
Migraine is a very common disorder with lifetime prevalence in women of up to 25%. Because of hormonal influences, the ratio of affected women over men is 3:1 [ 1]. The history should include usual triggers, of which menses and ovulation are common. Birth control pills (BCPs) have a variable influence on migraine frequency and in some women may aggravate the disorder [ 2]. However, many women with menstrual headaches report that cycle suppression (which can be obtained using the subdermal implant, injectable contraception, a pill, patch, or ring) improves their symptoms. The type of migraine is important when discussing contraception. Women with classic migraines should be counseled to avoid estrogen-containing contraceptives (e.g., the pill, patch, or ring), given the increased risk of ischemic stroke. However, common migraine does not preclude use of estrogen-containing contraceptives unless associated with other cerebrovascular risk factors such as an underlying hypercoaguable state. [ 3] Furthermore, when choosing medications (abortive or prophylactic), you should take into account, whether the woman are trying to get pregnant, or, if not trying to conceive, what birth control they are utilizing. For instance, topiramate in doses above 200 mg/day may reduce the effectiveness of oral contraceptives [ 4]. Does the patient have regular menses? Could she have polycystic ovarian syndrome? If so, Valproate would not be a good choice as a prophylactic medication [ 5]. Another concern with patients already predisposed to obesity is that many prophylactic medications can contribute to weight gain.
Multiple sclerosis is another example of a neurologic disease that affects women in their childbearing years [ 6]. Many of these patients are on an immunomodulatory medication. Interferons are pregnancy class C, copaxone pregnancy class B, and methotrexate a pregnancy class D medication. Because immunomodulatory medications are not recommended during pregnancy, birth control should be discussed if the woman is not planning pregnancy. What should we recommend to our patients who would like to become pregnant? [ 7] They should discontinue their immunomodulatory medication when they discontinue their hormonal or intrauterine contraceptive, as the only contraceptive that typically delays return to fertility is depot medroxyprogesterone acetate. They should be counseled that pregnancy does not worsen overall MS disability [ 8] Treatment needs to be appropriately adjusted to best address our patient's needs at each particular point in her life cycle.
Past medical history
Patients' medical background allows us to frame a more accurate diagnosis for their current complaints. The disorders from which women suffer are different from those that affect men. A woma