2. INTRODUCTION
• Pregnancy adds a unique and challenging facet to the
management of neurologic disease.
• The pregnant state can affect many neurologic diseases, while
certain neurologic diseases or their treatments may have a
significant negative effect on pregnancy, labor, or delivery.
6. • Fetal exposure with maternal head or cervical spine-< 0.01
rad.
• Fetal exposure with maternal lumbar spine or pelvis: 0.28 rad
to 2.4 rad and up to 3 rad for an abdomen/pelvis CT.
• The use of IV iodinated contrast should be avoided during
pregnancy .
• Iodinated contrast is classified by the US Food and Drug
Administration (FDA) as class B
7. • No evidence has shown that MRI exposure up to 3 Tesla is
associated with fetal harm
• MRI can be safely obtained when clinically indicated,
• Elective imaging should be deferred to the postpartum period
if possible.
• Use of gadolinium should be avoided unless it is likely to
result in changes in management that would directly benefit.
• Gadolinium contrast is classified by the FDA as class C.
10. Epilepsy and pregnancy:
Risks, challenges and goals of management
• Risks
Fetal risk with exposure to AED
IUGR
MCMs
Impaired cognitive and behavioural development
Fetal risk with uncontrolled seizures
Maternal risk with uncontrolled seizures
• Challenge
To balance risks caused by AEDs against those associated with poorly
controlled epilepsy
• Goals
Maintained sz control with minimised exposure to potentially teratogenic
drugs
11. Management opportunities at
different stages
I) PRECONCEPTION MANAGEMENT
1. Information about birth control, the potential of
antiepileptic drugs (AEDs) to cause contraceptive failure,
2. Contraceptive efficacy considering the AED prescribed,
3. The risks of AEDs on pregnancy outcomes,
4. Possible changes needed to optimize the AED regimen,
5. Importance of folic acid supplementation to prevent neural
tube defects .
12.
13.
14.
15.
16. • A 2019 ILAE concludes that women of childbearing potential
taking AEDs should take at least 0.4 mg daily of folate.
• For women on carbamazepine or valproate, or those with a
previous pregnancy affected by a neural tube defect or with a
neural tube defect affecting either parent, folic acid dose of 4
mg daily.
17. Management opportunities at
different stages
II) DURING PREGNANCY
1. Avoid seizure precipitants
2. Monitor treatment to maintain Seizure control
3. Caution with AED switch/withdrawl.
4. Consider prenatal diagnostics
5. Prepare for delivery
22. 65 percent rule
2019 ILAE report concluded
• that a decrease of more than 35 percent in the AED serum
level (i.e, a fall to less than 65 percent of the optimal pre-
pregnancy serum level) is associated with an increased risk of
worsening seizure.
23. Reasonable to increase the AED dose after the first trimester for
women with epilepsy when the following conditions apply :
• The treatment involves AEDs that are prone to marked
changes in clearance (lamotrigine, levetiracetam,
and oxcarbazepine) with pregnancy.
• The seizures include focal to bilateral or generalized tonic-
clonic seizures.
• The seizure control was sensitive to changes in AED levels
before pregnancy.
• The patient entered pregnancy on the lowest effective AED
dose.
2019 report from the International League Against Epilepsy (ILAE)
24. APPROACH TO A FIRST SEIZURE IN
PREGNANCY
Levetiracetam -favorable reproductive safety profile,
• can be started at a therapeutic dose immediately,
• broad spectrum of action across multiple seizure types.
Lamotrigine is a favorable choice during pre-conceptional
planning,
• not a good choice for initiation during pregnancy;
• cannot be started quickly due to the higher risk of rash with
accelerated titration ,
• difficult to get to a therapeutic concentration
Carbamazepine - If seizures are focal and begin after the first
trimester
25.
26. MANAGEMENT IN THE POSTPARTUM
PERIOD
• Decrease Lamotrigine and Levetiracetam over two to three
weeks postpartum, and do the same for other medications
that are cleared via hepatic glucuronidation or renal excretion
• For medications metabolized by the cytochrome P450
enzymes- taper more slowly, over approximately six weeks.
, gabapentin,
lacosamide,
oxcarbazepine,
pregabalin, rufinamide
, topiramate,
, vigabatrin
carbamazepine,
clobazam, etho
suximide, felba
mate, perampa
nel, phenobarbi
tal, phenytoin,
primidone, zoni
samide
33. Breast-Feeding and Multiple Sclerosis Disease-
Modifying Therapies
• No evidence has shown that breast-feeding increases the risk
of postpartum relapses,
• Exclusive breast-feeding appears to reduce the risk of
postpartum MS activity,
• Resuming glatiramer acetate or interferon beta early in the
postpartum period does not reduce the risk of relapses within
the first 6 months
Beaber BE, Chi MD, Brara SM, et al. Immunomodulatory agents and risk of postpartum multiple sclerosis relapses.
Perm J 2014;18(1):9–13.
34. Treating Relapses During Pregnancy
or Breast-Feeding
• Short courses of high-dose methylprednisolone.
• Use only for clinically significant relapses and first-trimester
exposure should be avoided, if possible.
• Pregnant women to wait 3 to 4 hours after completion of the
infusion before nursing or, for the very risk averse, to “pump
and dump” for 24 hours after infusions.
• For disabling steroid-refractory relapses- plasma exchange
indicated.
35.
36. Fertility Treatments and Multiple
Sclerosis
• Treated according to the recommendations of
reproductive specialists.
• Small case series suggest that gonadotropin-releasing
hormone agonists (GnRH) may increase risk of relapse.
• Treatment during prolong fertility treatments-Glatiramer
acetate or Rituximab.
• Rituximab has been used successfully to achieve
pregnancies in women with recurrent miscarriages due
to antiphospholipid antibody syndrome.
Ng CT, O'Neil M, Walsh D, et al.
Successful pregnancy after rituximab in a women with recurrent in vitro fertilisation failures
and anti-phospholipid antibody positive.
Ir J Med Sci 2009;178(4):531–533.
40. PREPREGNANCY PLANNING
• Pre-pregnancy counseling should include a discussion
concerning safety of therapies for MG, with avoidance or
discontinuation of known teratogenic medications
(methotrexate and mycophenolate mofetil).
• Young women to proceed with thymectomy as soon as
possible, with the exception of those who are already
pregnant. In such cases, thymectomy should be performed
when feasible after pregnancy .
41.
42.
43. MANAGEMENT DURING PREGNANCY
• Treatment issues — Acetylcholinesterase inhibitors such
as pyridostigmine are the standard first-line treatment for
MG .
• Intravenous acetylcholinesterase inhibitors may produce
uterine contractions and should not be used during pregnancy
prior to delivery .
• During labor, however, anticholinesterase medications should
be administered parenterally to avoid erratic gastrointestinal
absorption.
44. • Prednisone is the immunosuppressant of choice in pregnancy
.
• Azathioprine and Cyclosporine may be used if
anticholinesterases fail to control MG exacerbations , they
should be reserved for pregnant women who are not
controlled, cannot tolerate glucocorticoids, or have
significant comorbidities that may worsen with glucocorticoid
administration .
• Mycophenolate mofetil and methotrexate increase the risk of
teratogenicity and should not be used in pregnancy .
International consensus guidance for management of myasthenia gravis
45. • In women with MuSK antibody-associated MG- prednisone,
plasma exchange, or other immunosuppressive therapies may
be required.
• Plasmapheresis and high-dose intravenous immune
globulin have been used for myasthenic crisis with variable
results .
International consensus guidance for management of myasthenia gravis
46. • Magnesium sulfate is contraindicated in patients who have
MG since it can precipitate a severe myasthenic crisis .
• Severe hypertension can be treated
with methyldopa or hydralazine.
• Levetiracetam or valproic acid can be used for seizure
prophylaxis, whereas phenytoin can potentially exacerbate
weakness and is therefore reserved for refractory seizures .
International consensus guidance for management of myasthenia gravis
47. LABOR AND DELIVERY
• Second stage of labor may be affected because the voluntary
striated muscles used during expulsive efforts may easily
weaken.
• Spontaneous vaginal delivery is the objective and should be
encouraged .
• Cesarean delivery should be reserved for the usual
obstetrical indications.
International consensus guidance for
management of myasthenia gravis
48. POSTPARTUM MANAGEMENT
• Breastfeeding — Glucocorticoids can be used safely in
lactation.
• Beastfeeding not recommended for patients with MG
taking azathioprine, cyclosporine, and methotrexate .
• Anticholinesterase drugs are found in breast milk in low levels
and are therefore considered safe in lactation unless high
doses are required .
49. EFFECTS OF MYASTHENIA GRAVIS ON
THE FETUS
• Maternal IgG antibodies cross the placenta, this transfer can
result in transient neonatal myasthenia in 10% to 20% of
newborns.
• Degradation of maternal antibodies take place and
spontaneous recovery occurs in 3 weeks to 4 weeks.
• Intrauterine exposure to receptor antibodies rarely may result
in arthrogryposis mutilplex, which has a high likelihood of
recurrence in future pregnancy
51. Acute reperfusion therapy in ischemic
stroke
• Alteplase does not cross the placenta but is considered
pregnancy category C (ie, risk cannot be ruled out ).
• IV Alteplase administration may be considered in pregnancy
when the anticipated benefits of treating moderate or severe
stroke outweigh the anticipated increased risks of uterine
bleeding.(COR IIb; LOE C-LD)
• The safety and efficacy of IV alteplase in the early postpartum
period d (<14 days after delivery) have not been established
(COR IIb; LOE C-LD)
Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early
Management of Acute Ischemic Stroke
52. • Stroke remote from term — <24 weeks of gestation, the
stroke should be managed as dictated by the patient's clinical
condition.
• Stroke near term — Between 24 and 32 weeks gestation,
antenatal glucocorticoids can be administered to accelerate
fetal lung maturation. Plan to continue the pregnancy with a
scheduled delivery between 34 to 39 weeks gestation to
optimize fetal outcome.
• Aspirin should be stopped within one or two weeks of a
planned delivery (ie, induction of labor or cesarean delivery).
53. Secondary Stroke Prevention of Ischemic
Stroke in Pregnancy/Puerperium
• Aspirin is by far the most widely used antithrombotic for
secondary stroke prevention.
• Safe for use in the second and third trimesters for fetus and
mother.
• Calcium supplementation (of ≥1 g/d, orally) should be
considered for women with low dietary intake of calcium
(<600mg/d) to prevent pre-eclampsia.
• The NOAC –NOT recommnded .
• Post delivery, nursing mothers - low-dose aspirin, warfarin,
UFH, and LMWH safe.
The American Heart Association and American Stroke Association issued a consensus guideline
56. CVT IN PREGNANCY
• Full anticoagulation with LMWH should be initiated and
continued throughout pregnancy.
• Holding for labor and delivery, commonly for 24 hours.
• Reinitiate LMWH 4 to 6 hours after vaginal delivery or 6 to 12
hours after Cesarean delivery
• Treatment continued for the duration of pregnancy and for at
least 6 weeks post-partum.
• The total duration of treatment should be no less than 6
months. 2012 ACCP guidelines
57. CVT IN PREGNANCY
• Subsequent pregnancy —treat with LMWH during pregnancy
and puerperium for women with a previous history of CVT to
reduce the risk of recurrent CVT and other venous
thromboembolic events.
• Oral contraceptives — the lowest risk is seen with combined
oral contraceptives that contain a second-generation
progestin such as levonorgestrel.
59. MIGRAINE
• First-line therapy: Acetaminophen alone or combination
therapy — Acetaminophen (1000 mg) can be an effective
treatment of migraine
• Migraine that does not respond to acetaminophen alone
,combination therapy must be tried such as:
• Acetaminophen 650 to 1000 mg and metoclopramide 10 mg
• Acetaminophen and codeine 30 mg
• Butalbital-acetaminophen-caffeine
• Butalbital use limited to only four to five days per month
and codeine to no more than nine days per month to avoid
development of medication overuse headache.
60. Second-line therapy:
• Aspirin
• Nonsteroidal anti-inflammatory drugs — such
as naproxen, ibuprofen, and ketorolac, are second-line
options and are safest in the second trimester before 20
weeks.
• From 20 weeks- use should be avoided
61. Third-line therapies
• Opioids — Opioids
(eg, oxycodone, hydromorphone, meperidine, morphine) are
a third-tier option.
• If used, use of all opioids should be limited to the lowest
effective dose and prescribed for the shortest time required
to control acute pain.
62. • Triptans — For moderate to severe symptoms in patients who
do not respond to other drugs, triptans can be considered .
• Sumatriptan (50 to 100 mg orally, 4 to 6 mg subcutaneously,
or 5 to 20 mg intranasal solution)
• Rizatriptan are two selective serotonin agonists that are highly
effective in treating migraine headaches.
FDA CAT-C
63.
64. Preventive therapies
First-line preventive therapies:
• Beta blockers such as propranolol, metoprolol,
and atenolol are not teratogens, but fetal/neonatal effects
from beta blockade are possible with prolonged use.
• Short- and long-acting calcium channel blockers - Verapamil is
the preferred agent because it is relatively safe and has good
tolerability and ease of use.
65. Second-line preventive therapies:
• Low-dose antidepressants, such as the serotonin-
norepinephrine reuptake inhibitor (SNRI) venlafaxine, or SSRI
may be considered in refractory patients, particularly those
with suspected underlying chronic depressive illness or
postpartum depression.
• Gabapentin is an option for refractory patients. Some
anticonvulsants, particularly valproate, are teratogenic and
should be avoided .
66. TENSION-TYPE HEADACHE
• First line therapies – Acetaminophen
• Second-line : short course NSAIDs is a second-line medical
therapy,
• Third-line therapies – If monotherapy is ineffective, a
combination of acetaminophen 500 mg and caffeine 100 mg is
a reasonable third tier.
• Nonpharmacologic interventions — include heat, ice,
massage, rest, avoiding triggers and behavioral therapy.
67. REFERENCES
1. Bradley's Neurology in Clinical Practice.2016.7th ed, chapter
112
2. Michael S, Lina A. Neurology and Pregnancy Clinical
Management
3. Autumn Klein. Neurological illness in pregnancy Principles
and practice
4. Randolph w. Evans. Neurologic clinics. Neurology of
Pregnancy. February 2019 Volume 37 Number 1.
5. Dean M. Wingerchuk. Multiple Sclerosis and Other CNS Infl
ammatory Diseases. Continuum June 2019 vol. 25 no. 3
6. www.uptodate.com
Notes de l'éditeur
The FDA has recently discontinued this rating system, and replaced it with a summary of the risks of using a drug during pregnancy and breastfeeding, along with supporting data and “relevant information to help health care providers make prescribing and counseling decisions
The new labeling system will also reduce the “innocent until proven guilty” bias, where untested drugs with no known harmful side effects were perceived to be safer (Category B) than tested drugs with known side effects (Category C)
Postmarketing surveillance efforts have not been a priority for manufacturers in most cases, but the PLLR now requires pregnancy registries to become a routine part of postmarketing surveillance. This should provide adequate data to help physicians, pregnant patients, and breastfeeding mothers make complex healthcare decisions.
The most notable change of the PLLR is that it will remove arbitrary and often misinterpreted pregnancy-labeling categories for pharmaceuticals (A, B, C, D, X). Instead, package inserts will now contain individualized narrative summaries for each medication that includes the “risks of using a drug during pregnancy and lactation, a discussion of the data supporting that summary, and relevant information to help health care providers make prescribing decisions and counsel women about the use of drugs during pregnancy and lactation.
approximately 60% of patients, seizure frequency is similar to that of the prepregnancy baseline, whereas 15% experience an increase in frequency and 15% experience a decrease.
If the patient was seizurefree for 1 year before pregnancy, it is very likely (80%) that she will continue to remain seizure-free during pregnancy.12 Rates of status epilepticus in pregnant WWE are comparable to the annual frequency of 1.6% in the general epilepsy population.
Counseling all women of childbearing age
about potential future pregnancies is important because 50 percent of pregnancies are unplanned and the risks of complications can be minimized by interventions before and early on in pregnancy
It is ideal to use the long-acting reversible contraceptive (LARC) choices of intrauterine devices (IUDs) or intramuscular depot medroxyprogesterone acetate (DMPA)
International Registry of Antiepileptic Drugs and Pregnancy, or EURAP
4week before- 12week after
EURAP, a registry enrolling women treated with antiepileptic drugs (AEDs) in early pregnancy, in which the primary outcome is presence of MCMs at 1 year after birth. Exposure was defined as type and dose of AEDs at time of conception. A comparison was made among 3 exposure types: (1) VPA monotherapy (n = 1,224); (2) VPA combined with lamotrigine (LTG) (n = 159); and (3) VPA combined with another AED but not LTG (n = 205).
risk of MCMs associated with VPA exposure increases with increasing VPA dose, both in the presence and in the absence of one concomitant AED, and appears to be related primarily to the dose of VPA.
March 2020
Statistical analysis of data collected in the Australian Pregnancy Register between 1999 and 2018 concerning 580 pregnancies previously treated with VPA, with the VPA dose reduced or the drug withdrawn prior to pregnancy in 158 cases.
Yellow – stable therapy 1588
Green – swith 38
Blue – withdrrawl 93
EURAP observational International registry of antiepileptic drugs (AEDs) and pregnancy, we assessed changes in seizure control and subsequent AED changes in women who underwent attempts to withdraw valproic acid (VPA) during the first trimester of pregnancy. Applying Bayesian statistics, we compared seizure control in pregnancies where VPA was withdrawn (withdrawal group, n = 93), switched to another AED (switch group, n = 38), or maintained (maintained‐therapy group, n = 1,588) during the first trimester. The probability of primarily or secondarily generalized tonic–clonic seizures (GTCS) was lower in the maintained‐therapy group compared with the other two groups, both in the first trimester and for the entire duration of pregnancy. GTCS were twice as common during pregnancy in the withdrawal (33%) and switch groups (29%) compared with the maintained‐treatment group (16%)
Seizure frequency significantly increased when the lamotrigine level decreased to <65 percent of the preconceptional individualized target lamotrigine concentration
seizure worsening occurs when the individual's serum concentration decreases to 65 percent or less of the non-pregnant baseline concentration
, carbamazepine may be a particularly good choice for women with focal-onset seizures when monitoring for AED blood levels during pregnancy is not readily available; additional favorable features of carbamazepine include its relatively low structural teratogenic risk [61,62] and the normal neurocognitive profiles of children following prenatal exposure
When AED blood levels are not available,
We suggest testing AED levels in the following fashion, and adjusting dosages as needed to maintain the patient's individualized target serum concentration:
●Routinely at four-week intervals throughout pregnancy, and beginning when pregnancy is reported
●Once at the six-week postpartum visit
●Immediately if the patient reports or presents with increased seizure activity or worsened seizure severity
●Immediately if the patient experiences dizziness, blurred vision, or other common complaints associated with AED medication toxicity
due to the enhanced clearance during pregnancy
is another option given the data supporting normal neuro-developmental profiles after in utero exposure.
Data were collected via an observational multicenter investigation (Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs [MONEAD])
For infants with mothers receiving lamotrigine and zonisamide therapy, infant
concentrations were associated with maternal concentration.
In this study, the overall drug exposure was low in infants who were breastfed by mothers with epilepsy who were receiving antiepileptic drug therapy, and the findings add further support to breastfeeding by these mothers.
antiepileptic drug concentrations in blood samples of infants who were breastfed were substantially lower than maternal blood concentrations.
Objective To provide direct, objective information on antiepileptic drug exposure through breast milk. Design, Setting, and Participants This prospective cohort study was conducted between December 2012 to October 2016, with follow-up in children until 6 years of age at 20 sites across the United States.
Avoiding sleep deprivation
Safety precautions with the newborn
Breastfeeding: AEDs does not contraindicate
breastfeeding.
Refractory SE” was defined as SE that does not respond to the initial anticonvulsant treatment with at least one first line intravenous (IV) antiepileptic drug (AED), benzodiazepines, and one or more of second line AEDs, and requiring general anesthetic agents, regardless of the delay since the onset of the seizure.[10]
Super refractory SE (SRSE) is defined as SE that continues for 24 hours or more after the use of anesthetic therapy, including cases that recur on weaning of the anesthestic agent
FDA category C: Animal reproduction studies have shown an adverse effect on the fetus and there
are no adequate and well-controlled studies in humans but potential benefits may warrant use of
the drug in pregnant women despite potential risks. FDA category D: There is positive evidence of
human fetal risk based on adverse reaction data from investigational or marketing experience or
studies in humans but potential benefits may warrant use of the drug in pregnant women despite
potential risks. There are currently no FDA Category A or B AEDs.
Highly effective disease-modifying therapies are defined as those that have demonstrated superiority to a modestly effective disease-modifying therapy in head-to-head randomized controlled trials or have demonstrated potency in randomized controlled trials via testing only high-risk patients (alemtuzumab, fingolimod, natalizumab, rituximab/ocrelizumab)
Modestly effective agents are defined as those that failed to demonstrate superiority in efficacy in head-to-head randomized controlled trials (glatiramer acetate, interferon beta, dimethyl fumarate, teriflunomide).
For patients who have continued disease activity on modestly effective disease-modifying therapies (defined as relapses or unequivocally new lesions on MRI scans after ≥6 months on disease-modifying therapy), the author also recommends escalating to a highly effective disease-modifying therapy rather than switching to another modestly effective agent
Low biological plausibility exists that natalizumab,rituximab,51 or ocrelizumab exposure through breast milk would adversely affect the infant52
Because a slight increased risk of adverse fetal outcomes, including cleft palate and low birth weight from corticosteroid exposure
these concerns have not been substantiated and were most likely due to confounding, as the effect was seen only in women with higher prepregnancy relapse rates in whom the fertility treatment was unsuccessful.59
For women who require treatment with MS disease-modifying therapies during prolonged periods of fertility treatments, the author usually recommends
EFFECTS OF PREGNANCY ON MYASTHENIA GRAVIS
41% of women had worsening , 29% improved, and 30% remained unchanged. Disease exacerbation is more likely in the first trimester and the postpartum period
20% of women with myasthenia gravis require ventilatory assistance during pregnancy and the postpartum period.
Because myasthenic crisis and mortality tend to occur within the first 1 year to 2 years after diagnosis as well as in early pregnancy and the postpartum period, delaying pregnancy until after the first 1 year to 2 years of presentation is widely advocated
]. Myasthenic flare may occur after therapeutic abortion secondary to the stress of surgery, but it usually remits following spontaneous abortion [5,6
The course of myasthenia gravis for a future pregnancy is not predictable by the course of previous pregnancies.
the physician should use drugs other than azathioprine and cyclosporine.
Mycophenolate is associated with an increased risk of congenital malformations and spontaneous abortion, prompting the manufacturers to recommend a negative pregnancy test within 1 week before beginning therapy and use of two reliable forms of contraception 4 weeks before and 6 weeks after therapy.
Mycophenolate may affect the effectiveness of hormonal contraception.
Rituximab Use is not recommended during pregnancy to treat nonlife-threatening myasthenia and the manufacturer recommends effective contraception during use of rituximab and for 12 months following its use
The effect of thymectomy on myasthenia gravis usually is delayed. The potential mother can be advised that the procedure may be helpful for a pregnancy beginning approximately 1 year after surgery
Dose adjustment may be required in pregnancy as a result of increased renal clearance, expanded maternal blood volume, delayed gastric emptying, and frequent emesis [20].
Increasing the dose of pyridostigmine should first be accomplished by decreasing the interval of administration, followed by increasing the dose if symptoms persist
These medications have been well studied in pregnancy, mainly in transplant recipients and patients with autoimmune diseases other than MG, and have been found to be relatively safe [21,22]. However, high doses of cyclosporine and azathioprine have been linked to spontaneous abortion, preterm labor, low birth weight, chromosomal damage [2,21,22], and hematologic suppression
Patients with anti-acetylcholine receptor antibodies (AChR-Ab)-negative MG who are MuSK-Ab positiveare generally less responsive to acetylcholinesterase inhibitors
These interventions should be reserved for cases where conventional therapy has failed and developing respiratory failure or profound dysphagia and weakness threatens the mother and fetus .
is commonly administered in contemporary obstetrics for management of preeclampsia/eclampsia and preterm labor but
while beta blockers and calcium channel blockers should be avoided if possible
The first stage of labor is not affected by MG because the uterus is composed of smooth muscle and lacks the postsynaptic acetylcholine receptor. In contrast,
Regional anesthesia is recommended for mild to moderate disease when vaginal delivery is anticipated.
General endotracheal anesthesia is recommended for the patient with severe disease and compromised respiratory or bulbar status
EFFECTS OF MYASTHENIA GRAVIS ON PREGNANCY AND DELIVERY
Myasthenia gravis does not increase the risk of miscarriage or preeclampsia/ eclampsia.
Myasthenia gravis may be a factor in causing spontaneous preterm birth
All infants of myasthenic mothers should be observed and monitored in a special care nursery for the first 48 to 72 hours of life for any evidence of weakness caused by transient neonatal MG .
Symptoms of respiratory distress, poor feeding, and flaccid tone can appear within hours after birth and may persist for up to three months.
The study included 338 pregnant or postpartum women and over 24,000 nonpregnant women ages 18 to 44 years with ischemic stroke
Rates of acute stroke reperfusion therapy were similar in pregnant or postpartum women (40/338 [11.8 percent]) compared with nonpregnant women (2545/24,303 [10.5 percent])
symptomatic intracranial hemorrhage in pregnant or postpartum women (3/40 [7.5 percent]) compared with nonpregnant women (66/2545 [2.6 percent]); the difference did not achieve statistical significance, although limited by small numbers of patients
no significant difference between pregnant or postpartum women and nonpregnant women for rates of in-hospital death (2.1 versus 2.7 percent), discharge to home (75 versus 73 percent), or independent ambulation at home (74 versus 71 percent).
In the first trimester, however, aspirin use has been reported to have an association with increased incidence of fetal gastroschisis and other fetal malformations.
aspirin dose of 60 to 81 mg/day is considered safe
, unless there was significant intra-operative or postpartum bleeding.
Because it is a risk factor for CVT, women with prior CVT should be informed about the risks of combined estrogen-progestin hormonal contraception and advised against its use. Risk is associated with the dose of ethinyl estradiol (less risk with doses <50 mcg
Acute migraine treatment — in pregnant women differs somewhat from treatment of non pregnant women because of concerns about adverse fetal drug effects.
More than 80% of women with migraine clearly show improvement during pregnancy, but 15% continue to have headaches, and in 5% headaches worsen. The prognosis for women with migraine without aura is better than that for women with migraine with aura
Migraine usually lessens during the second and third trimesters.
●Prolonged use of butalbital or codeine near term can cause neonatal withdrawal in the neonate.
●Prolonged use of barbiturates can cause vitamin K responsive bleeding in the neonate, but prophylactic vitamin K1 (phytonadione) is routinely given to all newborns in the United States shortly after birth to prevent vitamin K deficient bleeding. Butalbital has not been associated with an increased risk of congenital anomalies.
●The safety of short-term opioid use in the first trimester is unclear.
These medications are generally safe for the fetus.
●Caffeine doses in medications for migraine range from 40 to 50 mg; daily caffeine intake less than 200 mg from all sources is unlikely to be associated with adverse pregnancy effects
or limited to fewer than 48 hours due to concerns about prenatal constriction of the ductus arteriosus, persistent pulmonary hypertension of the newborn, oligohydramnios and its sequelae, necrotizing enterocolitis, renal dysfunction or failure, and intracranial hemorrhage
These drugs should not be used on a chronic basis since they are addictive and can contribute to the development of medication overuse and chronic daily headaches [32,33]. They may also worsen the nausea/vomiting and constipation associated with pregnancy. All opioids have potential for maternal addiction and neonatal withdrawal
]. Other triptans can also be used, but frovatriptan and naratriptan are less desirable than other triptans because of their longer half-life, and naratriptan is the least effective triptan. Preparations and dosing are discussed in more detail separately.
). In a 2015 systematic review of pregnancy outcome following prenatal exposure to triptans (n = 6 studies, n = 4208 infants), triptan-exposed migraineurs had similar rates of major congenital malformations, prematurity, and early pregnancy loss as migraineurs not using triptans [36]. When the triptan-exposed group was compared with the healthy controls, rates of major congenital malformations and prematurity were similar, but early pregnancy loss was increased.
and include mild fetal growth restriction and mild transient neonatal bradycardia, respiratory depression, hyperbilirubinemia, and/or hypoglycemia. Growth restriction may be more of an issue with atenolol than with other beta blockers
Tension-type headaches are the most common type of headache. They are characterized by feelings of pressure or tightness all around the head, and have a tendency to wax and wane in intensity. Gastrointestinal upset and heightened sensitivity to light, sound, and smell may occur, but are more typical of migraine
(eg, relaxation training, biofeedback, cognitive behavioral therapy)
