Disorders of The Nervous System During Pregnancy

1. Disorders of The Nervous System During Pregnancy Dr. Ahmad S. Alkatheri MD

2. Seizure Disorders (Epilepsy)

3. Epidemiology: • 0.5% of pregnant women have epilepsy. • The frequency of seizure during pregnancy: • Increase 25% Decrease 25% No change 50% • 95% of patient who have seizures during pregnancy • have a history of seizure • or have been receiving anticonvulsant. • Patient with adequate control of seizurebefore pregnancy • will have no deterioration. • Patient with frequent seizure before pregnancy • will have the same pattern during pregnancy.

4. Differential Diagnosis • from other form of loss of conscious: •  Syncopal episodes  Hysteria attack •  Hyperventilation  Hypoxia •  Hypoglycemia  Hypocalcemia •  Eclampsia  • - Diagnosis: • Skull x-ray Electroencephalogram • CT MRI

5. Management: (Patient is caught between fearing her seizures and her medication) + If patient have had no seizure for few years  Discontinued the medication before conception. + If patient are pregnant and their seizures are controlled  No changes in the therapy OR  change the drug if it is teratogenic. Give folic acid to all patient Because anticonvulsant drugs may caus Fetal malformation and Maternal megaloblastic anemia. Screen for congenital anomalies before 18W

6. Treatment: Patient on anticonvulsant drugs during pregnancy has decrease in plasma level of the drugs taken due to:  Increased protein binding  Increase plasma volume  Change in absorption and secretion. Therefore blood level measurement of antiseizure medication should be used to document a therapeutic range  The most common drug used:  Diphenyl Hhydantoin (Dilantin)  Phenobarbitol less teratogenic (dose 100-250 mg/day)  Primidone Patient with seizures on medication should receive the maximum dose of one medication before switching to another Then second medication can be added to control seizures.

7. Treatment of status epilaptics during pregnancy: • Hospitalization • Patency of airway • Mesur plasma level of anticonvulsant used. •  Give 10 mg I.V. dizepam slowly •  If seizures continue give: •  Phenytoin 750 mg • OR  Dipheniyl hydantion 200 mg •  If no improvement give:  General anesthesia •  Give Dexamethasone and Mannitol to reduce the effect of cerebral edemia accompanied by status epileptic.

8. + No change in management oflabor + Give the anti epileptic drugs during labor. + Give the anti epileptic drugs during post partum then lower the dose during puerperium. +Give the anti epileptic drugs with breast feeding Use mainly:  Carbamazepine or  Phenytoin Do not give  phenobarbital with breast feeding. + Test cord blood for coagulation of neonate. + Give the neonate vit k to prevent hemorrhage. + Give the neonate vit D supplements because diphenylhydantion may interfere with intestinal ca absorption. + For Contraception :Use I.U.D. Oral contraceptive maybe not effective.

9. Complication (Effect of epilepsy on pregnancy) • On motherNo increase in maternal complication • On Fetus: • - Increase risk of still birth in un-control cases. • Increase risk of hemorrhage disease of the newborn(dueto anticonvulsants). • - Increase risk of epilepsy in the child. • - Increase risk of congenital anomalies : •  There are 5% risk of major congenital anomalies: •  Cleft lip  Cleft palat  Heart defects •  The risk even without exposure to anticonvulsant. •  Phenobarbital are safe for the fetus. •  Fetal hydantoin syndrome are associated with phenytoin therapy include: Mental retardation Limb defect. -----------

10. ASTHMA

11. Asthma is the most common obstructive pulmonary disease occur in pregnant. • - The incidence of asthma during pregnancy is 0.5-1.5%. • The incidence of severe asthma during pregnancy is 0.1%. • Asthma is a major problem for adolescents who become pregnant • The curse of asthma during pregnancy: • 50% has no changes. • 30% has improvement. • 20% has exacerbation • The most frequent factors associated with exacerbation during pregnancy included respiratory tract infections. • - 30% of patients with asthma reacted differently in the subsequent pregnancies.

12. The effect of asthma in pregnancy: The old study: Suggested it cause increase in IUGR, preterm birth, perinatal morbidity and mortality. The new study: No increase in IUGR,preterm,perinatal mortality. In steroid-dependent asthmatics there is increase ingestational diabetes,preterm labor, premature rupture, In well controlled actively managed patients there is no increase in perinatal complications.

13. The goals in treating asthma during pregnancy are: • Reduction in the number of asthmatic attacks. • Prevention of severe asthmatic attacks. • Assurance of adequate maternal and fetal oxygenation. • Patients receiving allergen desensitization can continue the treatment throughout pregnancy. • Patients can receive yearly influenza immunization (it is a killed vaccine and can be given safely during pregnancy.)

14. Treating asthma during pregnancy: Inhaled -agonists are the main therapy during pregnancy(Albuteral and Metaprobernal) It can be used on an as needed basis in mild cases or in a scheduled basis in severe cases. No adverse effect for the drugs in fetus if used in the first trimester. Inhaled glucocorticoids: (Beclomethasone, triamcinolone, flunisolide) Its side effect is the oropharyngeal candidies. Inhaled Cromolyn: It prevent mast cell degranulation. Aminophylline: Its use is nowdeclined during pregnancy. GlucocorticoidsPrednosone it is safe during pregnancy or neonatal adrenal suppression, Prednisone and Methylpredinisolone are less in crossing the placenta.

15. Status Asthmaticus during pregnancy: •  Requires immediate therapeutic intervention. •  Patient should receive 30-40% concentration of humidified oxygen. •  Patient should be well hydrated. • Give subcutaneous catecholamins (it is both  and  agonist). • UseTerbutaline (  2 agonist). •  Do not use epinephrine because it cause decrease uterine blood flow. •  If no improvement give corticosteroids intravenous • Methylprednisolon 100mg every 6-8 hours • or Hydrocortosone 100mg every 4 hours •  If no improvement give Aminophylline intravenous 5mg/kg followed. •  If no improvement endotracheal intubation to maintenance adequate PO2.

16. - Acute asthma during labor: - It is unusual - It is treated in usual fashion - Anesthesia for asthmatic patient for C.S. - Epidural is preferred. If patient has been receiving oral cortocosteroids during pregnancy,, she should receive intravenous dosages during labor and for 24 hours after delivery100 mg hydrocortison every 6 hours. and 100 mg methylprednosolone I.V. every 6hours then patient resume her maintenance dose of oral cortocosteroids

17. Tuberculosis

18. TB is rising in urban areas. Diagnosis: * If PPD +ve (subcutaneous placement of purified protein derivative ) ( if patient had previously Calmette Gueril Vaccine she may be +ve for life.) (Screening PPD 80% +ve in case of reactivation of disease) *Or TB is suspected Chest x-ray after 20 weeks. Diagnosis of TB should be by : culture for Mycobacterium Tuberculosis or acid fast sputum stain in morning sputum collected for 3 consecutive days.

19. Treatment: Isoniazid (INH) 300 mg / day + Ethambutol 15 mg /kg/day + Pyridoxin hydrochlorid 20 mg / day (Rifompin and Streptomycin should be avoided in pregnancy because of the risk of fetal cranial nerve VIII damage) INH prophylaxis is recommended for asymptomatic patient under 35 years with +ve PPD and negative chest radiograph.

20. Pneumonia

21. Costive organism Streptococcus pneumonia or Mycoplasma, Pregnancy complications are preterm labor in 40% of cases. Diagnosis: Chest x-ray sputum +ve for Gram stain Treatment: Third generation Cephalosporin Erythromycin

22. Thyroid Disorders In Pregnancy

23.  The role of thyroid in reproductive is poorly understood. •  Disease of the thyroid are much common in women than men. •  Disease of the thyroid are common in pregnant women. •  Hormonal changes during pregnancy result in complex change in thyroid function. •  Metabolic demands during pregnancy result in complex change in thyroid function. •  Diagnose and treatment of thyroid disease is difficult during pregnancy. •  Thyroid function of the pregnant women are modulated by 4 factors: • HCTH stimulate the thyroid gland. • In kidney excretion of iodide. • In plasma iodine concentration. • In thyroxine binding globulin.

24.  Normal pregnancy can be considered to be Euthyroide state. •  Thyroid volume increase 20% during pregnancy. •  Thyroid function is under strained during pregnancy. •  Laboratory assessment of thyroid function during pregnancy are dramatically altered. •  Free T3 and T4  in first trimester  then decrease later •  TSH  increase slightly •  Thyroxine binding globulin  increase • - The most accurate method for assessing thyroid function in pregnancy: •  T4 determine the free thyroxin.It is not modified by pregnancy • T3 is elevated in hyperthyroidism and autoimmune thyroid nodule • TSH is suppressed in hyperthyroidism It is elevated in hypothyroidism

25. Hypothyroidism During Pregnancy

26. Pregnancy occur rarely with hypothyroidism because those women are usually infertile. However pregnancy may occur in subclinical hypothyroidism Incidence 0.1-2.5% (1/2000 deliveries) Etiology: Autoimmune disease. Destruction or removal of the thyroid gland. Sub acute thyroiditis, Congenital, Secondary to drug induced hypothyroidism (iodine epropylthiouracil)

27. Diagnosis: - Difficult to diagnose clinically. 1/3 show the classic symptoms 1/3 have moderate symptoms 1/3 has no symptoms. Symptoms include: Fatigue, sleepness, lethargy, mental slowing, depression, cold intolerance, constipation, hair loss, dry skin, weight gain, anemia. Laboratory diagnosis: TSH can diagnose very early. FT4 +ve thyroid proxidase antibodies, +ve antithyroglobulin antibodies.

28. Fetal Complication: •  Spontaneous abortion • Thyroid antibodies cross the placenta • may cause hypothyroidism in the newborn • which is transient but may lead to serious cognitive deficiencies. • Children born to women with elevated thyroid peroxide antibody has low IQs. • Maternal Complication: • Preeclampsia why is not yet fully understood.

29. The role of the maternal thyroid status on fetal development During the first trimester until midgestation the fetus is not able to provide enough thyroid hormone and depends on the mother for thyroid hormone supply Mild maternal hypothyroidism may cause deficient neuropsychological development of the child. Therefore it is strongly recommended for routine screening for hypothyroidism during pregnancy in high risk groups e.g.:  Women previously treated for hyperthyroidism.  Previous surgery of thyroid  Neck irradiation  History of postpartum thyroiditis  Goiter  Family history

30. Treatment: Hypothyroid pregnant women should be made euthyroid as soon as possible and that should be maintained throughout pregnancy. L-thyroxine The initial dose 2 ug/kilograms of actual body weight taken early in the morning on empty stomach. Further adjustments are made according to TSH The goal is to keep it within the normal range Dose changes should be made at 4 weeks interval.

31. Hyperthyroidism

32. - Occurs in 0.5% of pregnancies. - 85% of cases is associated with Graves diseases. - 15% of cases is associated with Nodular Toxic Goiter or Thyroiditis • A diffuse painless goiter, warm skin, moist palm, exaggerated reflex •  Serum TSH  T4 and T3. 

33. Once the diagnosis is confirmed start propylthiouracil. • (Blocks intrathyroid synthesis of T4 to T3). • Dose 200-400 mg/day until patient be euthyroid then decrease the dose to 100 mg/day until term. • Thyroid test improve in 2-3 weeks and become normal at 6 weeks reduce the dose to ½ and adjust the dose every 3 weeks. • propylthiouracil does not cross the placenta. • It is minimal transfer by breast milk. • T3 and T4 should be kept in upper limits of normal.

34. Guidelines in the management: • Use minimum amount of medication to keep the patient euthyroid. • Maintain the T3 and T4 in the upper 1/3 of normal range. • Evaluate the patient every 2-3 weeks to change the drugs therapy. • Drugs may be discontinued at 36 weeks when the patient become euthyroid or she in the minimum amount of the drugs therapy. • Detect the fetal growth retardation and fetal tachycardia. • Follow the patient during postpartum period for hyperthyroidism. • Infants should be follow by pediatrician for transient abnormal thyroid function.

35. Complication in untreated patient: Premature delivery, Small for gestation, Hypertension, Heart failure Complication in euthyroid patient: None for the mother and the baby.

36. Transient Hyperthyroidism of Hyperemesis Gravid rum: • Patients with hyperemesis gravidorum has high thyroid test in the range of hyperthyroid (50%). • It is a self limited abnormality. • It does not need antithyroid therapy.

37. Goiter: • It is an enlargement of thyroid gland. • During pregnancy in the areas of normal dietary iodine intake the thyroid gland has a minimal enlargement. • Any enlargement detected by physical examination should be considered abnormal and should be evaluated. • T4 and TSH will define the functional status of the goiter • The presence of thyroid antibodies is diagnostic of autoimmune disease. • The presence of single thyroid nodule should be investigated to rule out thyroid cancer (fine needle aspiration).

38. Postpartum thyroid dysfunction syndromes: • 10% of women with autoimmune thyroid disease develop thyroid abnormalities within 1 year of delivery mainly hyperthyroidism in form of Grave’s disease and chronic thyroiditis • Some patient may go into hypothyroid phase after hyperthyroidism. • Patient with a history of Grave’s disease will have an exacerbation of symptoms 1-3 month after delivery. • Thyroid test are in hyperthyroid range and thyroid antibodies are +ve. • Spontaneous recovery occur within several months and goiter may decrease. • Treatment with beta blocker may be indicated • or with thyroid hormone in case of hypothyroidism.

40. Gastrointestinal Disorders

41. Gastroesophageal Reflux in Pregnancy: • 50% of pregnant women has gastroesophageal reflux mainly in third trimester. • It has no effect on mother or the fetus. • The cause: • Decrease lower esophageal sphincter tone. • Increased in intra abdominal pressure. • Treatment: • Elevating the lead of the. • Small frequent meals. • Antocid after meals and at bed time. • Metadoprammide (it increase the tone of esophagel sphincter).

42. Peptic Ulcer Disease in Pregnancy: • Pregnancy improvethe peptic ulcer • Progesterone may inhibit motility . • No change in acid secretion. • It should be differentiated from reflex esophagitis. • Treatment: Symptomatically during pregnancy •  H2 antagonist can be given •  Eradication of Helicobacter pylori • Treatment of hemorrhage from peptic ulcer: • Nasogastric suction •  Ice water lavage •  Blood replacement •  Surgery • Ulcer become very active again during postpartum.

43. Appendicitis in Pregnancy: • It is the most common surgical emergency in pregnancy. • Suspected appendicitis accounts for 2/3 of all laparotomy for non obstetric exploration during pregnancy. • Incidence 0.1% of pregnant. • Rupture of appendix occur 2-3 time more often in pregnancy. • Maternal mortality rate increase • 2% in 1st and 2nd trimester in non pregnant 0.25% • 10% in 3rd trimester • Fetal mortality  only with rupture appendix.

44. Symptoms and Signs: • Diagnosis is difficult. • Signs and symptoms are atypical. • In pregnancy there is upward displacement of the appendix above the McBurney point and by 32 weeks reach to subcostal area. • Clinically: • Vague pain in the right side of the abdomen. • Less muscle guarding. • Less rebound tenderness. • Nosea, vomiting, anorexia.

45. Laboratory Finding: • No significant. • Leuckocytosis with left shift in the differential. • Differential Diagnosis: • Ectopic,  Ruptured corpus luteme,  adnexal torsion, • round ligament pain,  preterm labor,  abruption placenta,  degenerating fibroid • Treatment Appendectomy: •  Fetal monitor •  Tocolytic •  Antibiotic •  Incision over maximum tenderness

46. Hepato Biliary Disease In Pregnancy: • Hepatitis • Intrahepatic cholectasio • Acute fatty liver of pregnancy • Cholelithiosis and cholecystitis • Help syndrome • Spontaneous hepatic rupture

47. Intrahepatic Cholestasis of Pregnancy: • It is an accumulation of bile acids in the liver that followed by accumulation of bile acids in the plasma that cause pruritus and jaundice with pregnancy without hepatocellular damage. • It is the most common liver disorder unique to pregnancy. • It occurs in 0.1% of pregnancy. • It is the 2nd most common cause of jaundice in pregnancy. • It occurs mainly in 3rd trimester. • The etiology is unclear, • it may be due to increase of susceptibility to elevated estrogen and progesterone in pregnancy.

48. Diagnosis: • Severe pruritus  mild jaundice • Dark urine  fatigue • Anorexia  stestorrhea • Laboratory  Serum bile acid  Bilirubin •  Alkaline phosphates • Differential Diagnosis • Viral hepatitis • Gallbladder disease

49. The effect on pregnancy: • Discomfort from prurites. • Abnormal coagulation due to decrease in vit. K. • It is recurrent condition in future pregnancy and with the use of oral contraceptive. • Increase in preterm birth.

50. Management: -The aim is to reduce the symptoms and observe abnormal coagulation. + Antipruritics: Diphenhydromin phenobarbital Skin preparation Dexomethasone + Inhibit absorption of bile acid and increase biliary secretion Urodexoycholic acid Cholestyramine + Vitamin K and check prothrombin time + No indication for termination of pregnancy + Induce at 38 week or wait for spontaneous lobes depend on tolerance for symptoms.