OBSTETRICS 2

phenomena such
F.01 NEUROLOGIC AND PSYCHIATRIC DISEASES IN as visual scotoma
PREGNANCY or hallucination
Dr. Arcellana | April 10, 2019
Management:
OUTLINE: o Non-pharmacological – biofeedback techniques,
I. HEADACHE acupuncture and transcranial magnetic stimulation
II. SEIZURE DISORDERS (TMS)
III. CEREBROVASCULAR DISEASE o Pharmacologic – NSAID, Triptans, Amitriptyline,
IV. DEMYELINATING OR DEGENERATIVE DISEASES *Propanolol, *Metorpolol
V. NEUROPATHIES o Β-blockers are contraindicated in pregacy however we
VI. SPINAL CORD INJURY have to weigh the risks versus the benefits
VII. IDIOPATHIC INTRACRANIAL HYPERTENSION
VIII. MATERNAL VENTRICULAR SHUNTS II. SEIZURE DISORDERS
IX. MATERNAL BRAIN DEATH  Next most prevalent neurological condition encountered in
X. PSYCHIATRIC DISORDERS IN PREGNANCY pregnant women; 1 in 200 pregnancies
 Associated with altered mental development; adversely
NEUROLOGICAL DISORDERS IN PREGNANCY affect other pregnancy outcomes
1. Headache  Paroxysmal disorder on the CNS characterized by abnormal
2. Seizure Disorders neuronal discharge with or without loss of consciousness
3. Cerebrovascular Disease  Seizure disorder is different from eclampsia. In eclampsia
4. Demyelinating or Degenerative Diseases there should be a pre-eclampsia or hypertension with
5. Neuropathies proteinuria during pregnancy and then that patient develops
6. Spinal Cord Injury seizures, that is eclampsia
7. Idiopathic Intracranial Hypertension  When a patient finds out that she is pregnant what does she
8. Maternal Ventricular Shunts usually do with her anti-seizure medications? She stops.
9. Maternal Brain Death When she stops then there could be a recurrence of seizure
disorders. And also, because of the physiologic changes
I. HEADACHE (decreased gastric emptying type, increased glomerular
 Most common neurological complaint during filtration rate…) together with intake of antacids (for nausea
pregnancy and vomiting), what do you think happens to the serum
 Decrease in prevalence of all headache types during level of anti-convulsants? It decreases, and when the
pregnancy in nulliparas especially during 3rd trimester therapeutic dose is not achieved there is increased
 Primary headaches > secondary headaches frequency of seizure activity
 Headache is relieved during pregnancy MOST OF THE TIME  CAUSES: head trauma, alcohol- and other drug-induced
 Severe headache itself could cause hypertension in withdrawals, cerebral infarctions, brain tumors, biochemical
pregnancy abnormalities and AV malformations
 Some medications used for headache are teratogenic and  Pre-conceptional counseling is important
can cause adverse outcomes  Advise intake of Folic acid 1 month prior to conception, if
they have a higher risk then start it 3 months prior to
A. TENSION HEADACHE conception
 Most common  Goal of monotherapy using the least teratogenic medication
 FEATURES:  Major pregnancy-related risks: increased seizure
o Muscle tightness rates with attendant mortality risk and fatal
o Mild to moderate pain for hours in the back of the neck malformations
and head  Seizure control is the main priority
o No associated neurological disturbances or  Increased seizure frequency is seen
nausea  The effect of seizure in pregnancy:
o Responds to rest, massage, application of heat or ice, o Increased cesarean section rate
anti-inflammatory meds or mild tranquilizers  Patient in active seizure must be
stabilized first
B. MIGRAINE HEADACHE o Increased risk for hypertension and post-partum
 Frequently encountered during pregnancy depression
 FEATURES:
o Periodic sometimes incapacitating A. FOCAL SEIZURES
o Episodic attacks of severe headache and ANS  Originated in one localized brain area an affect a
dysfunction localized area of neurological functions
 Prevalence in 1st trimester: 2%  Result from trauma, abscess, tumor or perinatal factors
 Most have improvement during pregnancy
 May increase risk for fetus with limb-reduction defects, FOCAL SEIZURES WITHOUT FOCAL SEIZURES WITH
preeclampsia and other CV morbidities DYSCOGNITIVE FEATURES DYSCOGNITIVE FEATURES
3 TYPES: Start in region of the body and  Often preceded by an aura
Migraine Migraine with Chronic migraine progress toward ipsilateral areas – and followed by impaired
without aura aura tonic and then clonic movements awareness manifested by
Common migraine Classic migraine Occurring at least 15 sudden behavioral arrest or
days each month for motionless state
>3 months  Involuntary movements
Unilateral Similar symptoms such as picking motions or
throbbing HA, preceded by lip smacking are common
nausea, vomiting, premonitory
photophobia neurological

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B. GENERALIZED SEIZURES
 Involve both brain hemispheres and may be preceded
by an aura before an abrupt loss of consciousness

GENERALIZED TONIC-CLONIC ABSENCE SEIZURES – PETIT

SEIZURES MAL
Loss of consciousness is followed  Brief loss of consciousness
by tonic contraction of the muscles without muscle activity
and rigid posturing and then by  Immediate recovery of
clonic contractions of all the consciousness and
extremities while the muscles orientation
gradually relax

 Some identifiable causes of convulsive disorders in young

adults include head trauma, alcohol- and other drug-induced
withdrawals, cerebral infections, brain tumors, biochemical
abnormalities, and arteriovenous malformations
 Pre-conceptional counseling is very important

C. EPILEPSY DURING PREGNANCY

 The major pregnancy-related risks to women with epilepsy
are increased seizure rates with attendant mortality risks and
fetal malformations
 Seizure control is the main priority and increased seizure
activity during pregnancy.
 Increased CS rate, non-proteinuria HPN and labor induction,
postpartum depression
 Children with epileptic mothers have a 10% risk of
developing seizure disorder
 Untreated epilepsy is not associated with increased
fetal malformation, medications do.

MANAGEMENT IN PREGNANCY
 Major goal is seizure prevention
 Treatment for nausea and vomiting is provided
 Seizure-provoking stimuli are avoided
 Medication compliance is emphasized
 Breastfeeding – no obvious deleterious effects (of
anticonvulsant medications)
 Some anticonvulsants are associated with increased OCP
failures

TERATOGENIC EFFECTS OF COMMON ANTICONVULSANTS A. ISCHEMIC STROKE

 The known teratogenic drugs are valproate (embryo-fetal
risk)
 Higher risk in polydrug treatment over single drug therapy, it
is better to find a single drug that would have the least
teratogenic effect and take it in compliance
III. CEREBROVASCULAR DISEASES
1. Stroke: ischemic, hemorrhagic
2. AV malformations
3. Aneurysms
Risk factors: hypertensive disorders, GDM, obstetrical
hemorrhage, and CS
 Is pregnancy good for cerebrovascular events? No. Because
there’s increase risk because the physiologic changes in
pregnancy affect the coagulation system. Most strokes
manifest during labor. Patients are immobile. Advise patients
to ambulate after 8 hours.
 Pregnancy increases the immediate and lifetime risk of both
ischemic and hemorrhagic stroke
 Major strokes manifest during labor and delivery or in the
puerperium
 Common factor in ischemic and hemorrhagic stroke is
hypertension
 Acute occlusion or embolization of an intracranial blood
vessel causes cerebral ischemia which may result in death of
brain tissue
 Sudden onset of severe headache, hemiplegia or
other neurological deficits or seizures
 Evaluation: echocardiography and cranial imaging with CT,
MRI or angiography, serum lipids, antiphospholipid
antibodies and lupus anticoagulant
B. HEMORRHAGIC STROKE
1. INTRACEREBRAL HEMORRHAGE
 Bleeding into the brain parenchyma most common is caused
by spontaneous rupture of small vessels previously damaged
by chronic hypertension
 Higher mortality and morbidity rates
 Chronic hypertension is uniquely associated with Charcot-
Bouchard aneurysms
 Cautions for the importance of proper management for
gestational hypertension
2. SUBARACHNOID HEMORRHAGE
 Incidence is 5.8 per 100,000 pregnancies, half being
postpartum
 Bleeds are most likely caused by underlying CV malformation
in an otherwise normal patient
 80% secondary to ruptures saccular or “berry” aneurysms

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 Rare during pregnancy GOAL OF MANAGEMENT: Avoid systemic disease, concurrent
 Treatment: need to operate is usually based on neurological infections and emotional upset which exacerbates condition
considerations MANAGEMENT: manageable but not curable
 Thymectomy, anticholinesterase medications
C. CEREBRAL VENOUS THROMBOSIS (Pyridostigmine), immunosuppressive treatment
 7% associated with pregnancy  Myasthenia and pregnancy: pregnancy does not
 Greatest risk in late pregnancy and puerperium affect the overall course of MG, fatigue common to
 Diagnosis: MR imaging most pregnancies and may be exacerbated and
 Management: anticonvusants expanding uterus may compromise respiration
 Prognosis: better compared non-pregnant because after  MG has no significant adverse effects on pregnancy
delivery the physiology would go back to normal outcomes
 Neonatal effects – antibodies transported
IV. DEMYELINATING OR DEGENERATIVE DISEASES transplacentally causing hydramnios
 These are rare in pregnancy. So it’s nice to know, that I will
ask this in your exam . V. NEUROPATHIES
 General term used to describe disorders of the peripheral
A. MULTIPLE SCLEROSIS nerve/s of any cause
 Demyelinating characteristic of this disorder results from  Mononeuropathies are more common in pregnancy than
predominantly T cell-mediated autoimmune polyneuropathies
destruction of oligodendrocytes that synthesize myelin
 Genetic susceptibility and environmental trigger such A. GUILLAIN-BARRE SYNDROME
as exposure to Chlamydophila pneumonia, human herpes  Commonly associated with: Campylobacter jejuni, CMV, EBV,
virus 6 or EBV surgical procedures and immunizations
 Pregnancy in relation to multiple sclerosis is good. Relapse is  Sensory and motor conduction blockade
reduced during pregnancy but post-partum it could be  Not common in pregnancy
increased CLINICAL FEATURES: areflexic paralysis with or without
sensory disturbances
CLINICAL TYPES
B. BELL’S PALSY
RELAPSING- Unpredictable recurrent episodes of focal
 Pregnant women are at a four-fold risk
REMITTING MS or multifocal neurological dysfunction
 Facial nerve inflammation associated with reactivation of
usually followed by full recovery
HZV
SECONDARY Relapsing-remitting that begins to pursue
 Abrupt painful onset with maximum weakness by 48 hours
PROGRESSIVE MS a progressive downhill course after each
 Increased association in gestational hypertension and
relapse
preeclampsia
PRIMARY Gradual progression of disability from the
MANAGEMENT: supportive, Prednisone 1mg/kg, orally x 5 days
PROGRESSIVE MS time of initial diagnosis
 Corticosteroid improves outcome
PROGRESSIVE- Refers to primary progressive MS with
 Treatment includes facial muscle massage and eye
RELAPSING MS apparent relapses
protection against corneal lacerations from drying.
 The effect in pregnancy is bad because it increases the risk
CLASSIC FINDINGS: sensory loss, visual symptoms from optic for gestational hypertension leading to pre-eclampsia
neuritis, weakness, paresthesias
CLINICAL DIAGNOSIS: confirmed by MRI or CSF analysis C. CARPAL TUNNEL SYNDROME
 Effects of pregnancy on MS: (according to PRIMS study)  Compression of the median nerve
reduction in relapse rate during pregnancy but  Most frequent mononeuropathy in pregnancy
increased with postpartum  Symptoms: burning, numbness, or tingling along the inner
 Effects of MS on pregnancy: no adverse effects on half of 1 or both hands
outcome  Bilateral in 80% of pregnant women
MANAGEMENT: Goals to arrest acute or initial attacks, disease-  Among pregnant, range of symptoms is marked
modifying agents, symptomatic relief  Carpal tunnel syndrome is exacerbated by pregnancy
TREATMENT: High dose IV methylprednisolone - 500 to 1000 mg  Is there an adverse effect on the mother? When the patient
daily for 3 to 5 days, followed by oral prednisone for 2 weeks is in severe pain it can lead then they could simulate
gestational hypertension without proteinuria
B. MYASTHENIA GRAVIS MANAGEMENT: splint, surgical decompression, corticosteroid
CARDINAL FEATURES: weakness and easy fatigability of facial, VI. SPINAL CORD INJURY
oropharyngeal, extraocular and limb muscles  Not common
 Also rare  May cause preterm and LBV infants
 Diplopia and ptosis are common
 Clinical course is marked by exacerbation and remissions VII. IDIOPATHIC INTRACRANIAL HYPERTENSION
 Systemic diseases, concurrent infections and emotional upset may  “pseudotumor cerebri” or benign intracranial hypertension
precipitate exacerbations  Cause: unknown
 Cause is unknown but genetics may play a role  Symptoms: headache, visual disturbances, papilledema
 Self-limited, Acetazolamide, Furosemide, Topiramate
3 TYPES:  Pregnancy does not alter management
MYASTHENIA Severe muscle weakness, inability to swallow and  Pregnancy complications likely due to obesity
CRISIS respiratory muscle paralysis
REFRACTORY Same symptoms unresponsive to usual therapy; VIII. MATERNAL VENTRICULAR SHUNTS
CRISIS medical emergency (worst prognosis)  Have satisfactory outcomes
CHOLINERGIC Excessive cholinergic medication leads to nausea,  Vaginal delivery is preferred
CRISIS vomiting, weakness, abdominal pain and diarrhea

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IX. MATERNAL BRAIN DEATH
 Rare in obstetrics

X. PSYCHIATRIC ADJUSTMENTS IN PREGNANCY

 Biochemical factors – including hormonal effects – and
life stressors can markedly influence mental illness
 Exacerbates some coexisting mental disorders
 Indeed, pregnancy-related shifts in sex steroids and
monoamine neurotransmitter levels; dysfunction of the
hypothalamic-pituitary-adrenal axis; thyroid dysfunction; and
alterations in immune response are all associated with an
increased risk mood disorders
 What hormone is related to aggravating psychiatric changes
in pregnancy? ESTROGEN
 The level of perceived stress is significantly higher for
women whose fetus is at high risk for a malformation, for
those with preterm labor or delivery, and for those with
other medical complications

XI. THE PUERPERIUM

Puerperium: particularly stressful time and carries as increased risk for XIV. DEPRESSIVE DISORDERS
mental illness. Up to 15% of women develop a nonpsychotic 1. Unipolar – MAJOR DEPRESSION
postpartum depressive disorder within 6 months of delivery. 2. Bipolar – MANIC DEPRESSION
3. Others – dysthymia, which is chronic, mild depression
MATERNAL BLUES
 Postpartum blues: this is a time-limited period of heightened
emotional reactivity experienced by half of women within
approximately the rest week after parturition
 Postpartum blues is different from postpartum psychosis
because postpartum blues are usually limited to the first
week of puerperium, they usually resolve within 10 days. So,
if the symptoms persist beyond 10 days then reevaluate the
patient because they may already be having postpartum
psychosis
 Prevalence estimates for the blues range from 26% to
84% depending on criteria used diagnosis emotional state
generally peaks on the fourth or fifth post-partum day
and normalizes by day 10
 Predominant mood is happiness
 However, affected mothers are more emotionally labile, and
insomnia, weepiness, depression, anxiety, poor
concentration, irritability, and affective lability may be noted
 Management: supportive, TLC

XII. PRENATAL EVALUATION

 Screening for mental illness is generally done at the first
prenatal visit and during the rest of the prenatal visit.
 Factors include a search for psychiatric disorders, including
hospitalizations, outpatient care, prior or current use of
psychoactive medications, and current symptoms
 Check for family history, history of substance use
 Risk factors should be evaluated
 Because eating disorders may be exacerbated by pregnancy,
affected women should be followed closely
XIII. PREGNANCY OUTCOMES
 Only a few reports of psychiatric disorders and pregnancy
outcomes would have an unfavorable outcome. Some, but
not all, link maternal psychiatric illness with untoward
outcomes such as preterm birth, low birthweight, and
perinatal mortality.
A. MAJOR DEPRESSION
 Most common depressive disorder
 Lifetime prevalence is 17%, but only half ever seek care
 Estrogen has been implicated in increased serotonin
synthesis, decreased serotonin breakdown, and serotonin
receptor modulation
 Multi-factorial- both genetics and environmental factors
 Women who experience postpartum depression often have
higher pre-delivery serum estrogen and progesterone levels
and experience a greater decline postpartum
 Postpartum depression – major or minor – develops in 10 to
20 percent of parturients
 Recurrent
 Postpartum depression is generally under recognized and
undertreated
 Major depression during pregnancy or after delivery can
have devastating consequences for affected women, their
children, and families
 Recurrence some time after medication is discontinued
develops in 50 to 85% of women with an initial
postpartum depression episode.

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 ECT in pregnancy is not “low risk” and that it should be
reserved for women whose depression is recalcitrant to
intensive pharmacotherapy
 Management: SSRIs (Citalopram, Fluoxetine, Sertraline);
linked to fetal toxicities
XVII. PERSONALITY DISORDERS
 Characterized by the chronic use of certain coping
mechanisms in an inappropriate, stereotyped, and mal-
adaptive manner
 Are rigid and unyielding personality traits

3 SUBTYPES BY ACOG:
Paranoid, schizoid, and Oddness or eccentricity
schizotypal personality
disorders
Histrionic, narcissistic, Dramatic presentations
antisocial, and borderline along with self-
disorders centeredness and erratic
behavior
Avoidant, dependent, Underlying fear and anxiety
compulsive, and passive-
aggressive personalities

 These cases are difficult to handle, but you just have to be

objective and be really patient with them because some are
not able to communicate or follow instructions well
 Are at increased risk for teen and unintended
pregnancies, however, it was not a risk factor for elective
or spontaneous abortion
 Personality disorders during pregnancy are probably no
different than in non-pregnant women
 Give epidural anesthesia so they will be in less pain and
B. BIPOLAR AND RELATED DISORDERS more comfortable and no added stress to the patient
 The lifetime prevalence for manic-depression illness is  Treatment: antipsychotic drugs such as: Chlorpromazine
3.9%.
 No difference in the prevalence of bipolar disorder between XVIII. FEEDING AND EATING DISORDERS
pregnant and non-pregnant reproductive-aged women  All eating disorders begin with the desire to be slim, and
 Periods of depression last at least 2 weeks. At other times, women with chronic eating disorders may migrate between
there are manic episodes, distinct periods during which there subtypes
is an abnormally raised, expansive, or irritable mood  Anorexia nervosa, in which the patient refuses to maintain
 Pregnancy frequently prompts medication discontinuation, minimally normal body weight
and this translates to a two-fold increased risk of relapse  Bulimia nervosa, there usually is binge eating followed by
during pregnancy purging or by excessive fasting to maintain normal body
 Up to 20% of patients with manic-depression illness commit weight. Has a higher risk for IUGR or large-for-gestational
suicide age infants with a concomitantly increased cesarean delivery
rate
XV. POST-PARTUM PSYCHOSIS  There is an increased risk for pregnancy complications with
 Usually a bipolar disorder, but it may be due to major both eating disorders, but especially in women with bulimia
depression nervosa
 Incidence is estimated to be 1 in every 1000 deliveries, and  Additional risk associated with eating disorders include poor
it is more common in primiparas, especially those with wound healing and difficulties with breast feeding
obstetrical complications
 Illness manifests within 2 weeks of delivery
 Most important risk factor for postpartum psychosis … DURING PREGNANCY
is a history of bipolar disease INCREASED RISK UNCHANGED DECREASED RISK
 Manic symptoms include feeling excited, elated, “high”; not Migraine Headache Myasthenia Gravis Subarachnoid
needing sleep or unable to sleep; feeling active or energetic; Seizure disorders (MG) Hemorrhage
and feeling “chatty” Bell’s Palsy (4x) Bipolar and Related Guillain-Barre
 Affected women have signs of confusion and disorientation Maternal Blues Disorders Syndrome (GBS)
but may also have episodes of lucidity Bulimia > Anorexia Personality Disorders Spinal Cord Injury
 Because those with underlying disease have a 10- to 15- Maternal Brain Death
fold risk for recurrence postpartum, close monitoring is
imperative
PREGNANCY…
INCREASES DECREASES
XVI. ANXIETY DISORDERS
 Include panic attack, panic disorder, social anxiety disorder, Seizures Multiple Sclerosis (but
specific phobia, separation anxiety disorder, and generalized Ischemic & Hemorrhagic Stroke increased post-partum)
anxiety disorder Fatigue in MG (But over-all MG is
 Characterized by irrational fear, tension, and worry, which unchanged)
Bell’s Palsy  GHTN, Pre-eclampsia
are accompanied by physiological changes such as
trembling, nausea, hot or cold ashes, dizziness, dyspnea, Carpal Tunnel Syndrome
Eating Disorders
insomnia, and frequent urination
 Treated with psychotherapy and medication, including
selective serotonin-reuptake inhibitors, tricyclic
antidepressants, and monoamine oxide inhibitors

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XIX. TREATMENT

Checkpoint!
Identify:
1. Most common neurological complaint during
pregnancy
2. Most important risk factor for postpartum psychosis
3. Most common depressive order
4. Most common mononeuropathy in pregnancy
5. Hormone related to aggravation of psychiatric
disorders

Headache, history of bipolar disease, major depression, carpal tunnel

syndrome, estrogen

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SUMMARY TABLES
FEATURES MANAGEMENT
 Most common neurological NON-PHARMA PHARMA
TENSION HA MIGRAINE HA complaint during pregnancy  Biofeedback  NSAID
 MC  Frequent but improves during pregnancy  Decreased during 3rd  Acupuncture  Triptans
 Muscle tightness  Periodic sometimes incapacitating trimester  TMS  Amitryptiline
 Mild-mod pain x hours  Episodic attacks of severe HA and ANS dysfunction  Primary > secondary  Propanolol
 Back of neck and head  1st trimester: 2%  Metoprolol
 No associated neurological disturbances or nausea  May increase risk for fetus with limb-reduction
HEADACHE  Responds to remedies defects, preeclampsia and other CV morbidities
Migraine without aura Migraine with aura Chronic migraine
Common migraine Classic migraine Occurring at least 15 days each
month for >3 months
Unilateral throbbing HA, nausea, Similar symptoms preceded by
vomiting, photophobia premonitory neurological phenomena
such as visual scotoma or
hallucination
 Next most prevalent  Pre-conceptional counseling is important
neurological condition  Goal of monotherapy: using the least
FOCAL SEIZURES GENERALIZED SEIZURES EPILEPSY
 Paroxysmal disorder: teratogenic medication
 One localized brain area  Both brain hemispheres  increased seizure abnormal neuronal discharge  Seizure control is main priority
 Trauma, abscess, tumor or perinatal  Aura  abrupt loss of consciousness rates mortality with or without loss of  N/V tx
factors risks ,fetal consciousness  Avoid Seizure-provoking stimuli
FOCAL SEIZURES FOCAL GENERALIZED ABSENCE malformations
 Medication compliance
WITHOUT SEIZURES WITH TONIC-CLONIC SEIZURES –  Seizure control is
 Breastfeeding – no obvious
SEIZURE DYSCOGNITIVE DYSCOGNITIVE SEIZURES PETIT MAL the main priority deleterious effects
DISORDERS Region of body   Aura  impaired Loss of  Brief loss of  Increased CS rate,  Anticonvulsants – increased OCP failures
ipsilateral areas – awareness consciousness  consciousness HTN, postpartum
tonic-clonic  Involuntary tonic contraction without muscle depression
movements movements and rigid posturing activity  10% seizure
 clonic  Immediate disorder risk in
contractions, recovery children
muscles relax  Medications 
increased fetal
malformation
HEMORRHAGIC STROKE
CEREBRAL VENOUS
Risk factors: hypertensive
ISCHEMIC STROKE INTRACEREBRAL SUBARACHNOID disorders, GDM, obstetrical
THROMBOSIS
HEMORRHAGE HEMORRHAGE hemorrhage, and CS
 Acute occlusion or  Chronic hypertension   5.8/100,000, ½  7%
 Major strokes manifest
CEREBRO embolization  death of spontaneous rupture of small postpartum  Greatest risk: late preg %
brain tissue vessels  bleeding in brain  CV malformation  puerperium during labor, delivery or
VASCULAR puerperium
 Sudden onset of severe parenchyma bleeding  Puerperium: Lat/sup
DISEASES
headache, hemiplegia or  Higher mortality and morbidity  80% saccular or “berry” sagittal venous sinus
neurological deficits or rates aneurysms rupture  HA – MC presenting sx
seizures  Charcot-Bouchard  Rare during pregnancy  MRI venography
 Echocardiography, CT, MRI or aneurysms = Chronic HTN  Need to operate is usually  Mgt: anticonvulsants,
angiography, serum lipids,  Cautions for gestational based on neurological heparin
antiphospholipid antibodies hypertension management considerations  Prognosis: preg/non-preg
and lupus anticoagulant
DEMYELINATING OR DEGENERATIVE DISEASES
MULTIPLE Diagnosis: MRI/CSF analysis  T cell-mediated autoimmune  Goal: arrest acute or initial attacks,
SCLEROSIS RELAPSING- Unpredictable recurrent episodes of focal or multifocal  Pregnancy on MS destruction of oligodendrocytes disease-modifying agents, symptomatic
REMITTING MS neurological dysfunction usually followed by full recovery o  during pregnancy  Genetic susceptibility and relief
SECONDARY Relapsing-remitting that begins to pursue a progressive o  post-partum environmental trigger  High dose IV methylprednisolone
PROGRESSIVE MS downhill course after each relapse  MS on pregnancy Chlamydophila pneumonia, o 500-1000 mg daily x 3-5 days
PRIMARY Gradual progression of disability from the time of initial o no adverse effects HHV6 or EBV o Then oral prednisone x 2
PROGRESSIVE MS diagnosis  Sensory loss, visual symptoms weeks
PROGRESSIVE- Refers to primary progressive MS with apparent relapses from optic neuritis, weakness,
RELAPSING MS paresthesias
MYASTHENIA MYASTHENIA Severe muscle weakness, inability to swallow and respiratory  Pregnancy on MG CARDINAL FEATURES:  Goal: Avoid exacerbating conditions
GRAVIS CRISIS muscle paralysis o No effect weakness and easy fatigability of  Manageable but not curable
o Fatigue facial, oropharyngeal, extraocular  Thymectomy, anticholinesterase

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REFRACTORY Same symptoms unresponsive to usual therapy; medical o Expanding uterus may and limb muscles medications (Pyridostigmine),
CRISIS emergency (worst prognosis) compromise respiration  Common: diplopia and ptosis immunosuppressive treatment
CHOLINERGIC Excessive cholinergic medication leads to nausea, vomiting,  MG on Pregnancy  With exacerbation and
CRISIS weakness, abdominal pain and diarrhea o No effect remissions
 Unknown cause ( genetic)
 Hydramnios – due to
transplacental Ab transfer
NEUROPATHIES
 Campylobacter jejuni, CMV,
EBV, surgical procedures and
immunizations
 Sensory and motor
GUILLAIN-BARRE SYNDROME
conduction blockade
 Not common in pregnancy
 Areflexic paralysis with or
without sensory disturbances
 Pregnant – 4x risk  Supportive
 HZV reactivation  Facial nerve  Prednisone 1mg/kg, orally x 5 days
inflammation  Corticosteroid improves outcome
 Abrupt painful onset with  Facial muscle massage and eye
BELL’S PALSY maximum weakness by 48 protection against corneal lacerations
hours from drying
 Increased association in
gestational hypertension and
preeclampsia
 Compression of the median  Splint
nerve  Surgical decompression
 Most frequent mononeuropathy  Corticosteroid
in pregnancy
CARPAL TUNNEL SYNDROME
 Symptoms: burning,
numbness, or tingling along the
inner half of 1 or both hands
 80% bilateral
 Not common MATERNAL VENTRICULAR  Satisfactory outcomes
SPINAL CORD INJURY
 Preterm and LBV infants SHUNTS  Vaginal delivery is preferred
 “pseudotumor cerebri” or benign intracranial hypertension  Rare
 Unknown cause
 Symptoms: headache, visual disturbances, papilledema
IDIOPATHIC INTRACRANIAL HYPERTENSION MATERNAL BRAIN DEATH
 Self-limited, Acetazolamide, Furosemide, Topiramate
 Pregnancy does not alter management
 Obesity  complications

PRENATAL EVALUATION
 Screening for mental illness is generally done at
the first prenatal visit and during the rest of the
prenatal visit
 Factors include a search for psychiatric disorders,
including hospitalizations, outpatient care, prior
or current use of psychoactive medications, and
current symptoms
 Risk factors should be evaluated
 Because eating disorders may be exacerbated by
pregnancy, affected women should be followed
closely
PSYCHOLOGICAL ADJUSTMENTS IN
PREGNANCY
 Screening: first prenatal visit and
during the rest of the prenatal
visit
 Search: psychiatric disorders, including
hospitalizations, outpatient care, prior
or current use of psychoactive
medications, and current symptoms
 Risk factors should be evaluated
PUERPERIUM PREGNANCY OUTCOMES
 15% nonpsychotic postpartum depressive disorder within 6 months of delivery  Few – unfavorable outcome
MATERNAL BLUES  Some
 Postpartum blues: time-limited, heightened emotional reactivity o Preterm birth
 Half of women within rest week after parturition o Low birthweight
 26%-84% prevalence o Perinatal mortality
 Peaks on the fourth or fifth post-partum day and normalizes by day 10
 Predominant mood: happiness
 Emotionally labile, and insomnia, weepiness, depression, anxiety, poor
concentration, irritability, and affective lability may be noted
 Management: supportive

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 OBSTETRICS 2
FEATURES MANAGEMENT
MAJOR  Most common depressive disorder  ECT – for those recalcitrant to intensive
DEPRESSION  17% lifetime prevalence pharmacotherapy
 10-20% parturients
 Recurrent
 Estrogen
o serotonin synthesis
o serotonin breakdown
o Serotonin receptor modulation
o Higher pre-delivery, same with progesterone
o Greater decline postpartum
 Recurrence: 50-85% of women with an initial postpartum depression episode
BIPOLAR AND  3.9% lifetime prevalence
RELATED  Pregnant and non-pregnant: no difference in prevalence of bipolar
DISORDERS  At least 2 weeks
 Manic episodes: abnormally raised, expansive, or irritable mood
 Pregnancy  stop meds  2% relapse
 20% commit suicide
POST-  Usually a bipolar disorder, but may be due to major depression
PARTUM  Incidence: 1/1000 deliveries, primiparas with obstetrical complications
PSYCHOSIS  2 weeks after delivery
 Most important risk factor: history of bipolar disease
 Manic symptoms include feeling excited, elated, “high”; not needing sleep or unable to sleep; feeling active or energetic; and feeling “chatty”
 Signs of confusion and disorientation but may also have episodes of lucidity
 10-15x recurrence risk postpartum
ANXIETY  Include panic attack, panic disorder, social anxiety disorder, specific phobia, separation anxiety disorder, and generalized anxiety disorder Psychotherapy and medication
DISORDERS  Irrational fear, tension, and worry, which are accompanied by physiological changes such as trembling, nausea, hot or cold ashes, dizziness,  SSRI
dyspnea, insomnia, and frequent urination  TCA
 MAOI
FEEDING AND  Anorexia nervosa: refuses to maintain minimally normal body weight
EATING  Bulimia nervosa: binge eatingpurging or by excessive fasting to maintain normal body weight
DISORDERS  Higher risk for IUGR or LGA infants  increased cesarean delivery rate
 Increased risk for pregnancy complications with both eating disorders (bulimia nervosa > anorexia nervosa)
 Additional risk with poor wound healing and difficulties with breast feeding
PERSONALITY  Chronic use of inappropriate, stereotyped, and mal-adaptive manner of coping mechanisms
DISORDERS  Rigid and unyielding personality traits
 Increased risk for teen and unintended pregnancies
 Not a risk factor for elective or spontaneous abortion
 Not different than in non-pregnant women
Paranoid, schizoid, and schizotypal Oddness or eccentricity
personality disorders
Histrionic, narcissistic, antisocial, and Dramatic presentations along with self-
borderline disorders centeredness and erratic behavior
Avoidant, dependent, compulsive, and Underlying fear and anxiety
passive-aggressive personalities

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