|Year : 2006 | Volume
| Issue : 3 | Page : 152-157
A study of neurological disorders during pregnancy and puerperium
S Gupta, A Rohatgi, SK Sharma, A Gurtoo
Department of Medicine, Lady Hardinge Medical College and Associated Smt. Sucheta Kripalani Hospital, New Delhi, India
Department of Medicine, Lady Hardinge Medical College and Associated Smt. Sucheta Kripalani Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
Objective: To study the clinical profile of patients presenting with primary and secondary neurological disorders during pregnancy and puerperium. Materials and Methods: This study was carried out at the Lady Harding Medical College between February 2004 and January 2005. All patients in pregnancy, postabortal or postpartum period attending to the Lady Harding Medical College between February 2004 and January 2005 and requiring neurological consultation were included in this study. Women with eclampsia were excluded. Results: There were 76 women included in this study (incidence of neurological disorders was 584 per 100,000 deliveries), with 46 cases of primary and 30 of secondary neurological disorders. The former included epilepsy (22), CNS infections (12), cerebrovascular disorders (9) [cerebral venous thrombosis - CVT (5), arterial infarctions (3) and haemorrhage (1)], CNS glioma (1), traumatic quadriparesis (1) and acute disseminated encephalomyelitis (1). The latter included hepatic encephalopathy [HE] (28), enteric encephalopathy (1) and critical illness polyneuropathy (1). In patients of epilepsy, the seizures had an equitable distribution in the trimesters and post-partum period, were mainly of generalized type (77.27%) and were controlled in the majority (90.9%). No fetal congenital malformations were seen. Tubercular meningitis [TBM] (7), pyogenic meningitis (4) and viral encephalitis (1) were the CNS infections encountered and pregnancy outcome was good in most cases. All cases of CVT presented in the postpartum period with fever and neurological signs following home delivery. Outcomes included recovery (2), residual deficits (1), persisting seizures (1) and death (1). HE affected patients mainly during the latter half of pregnancy or the post-partum period and was associated with 64.3% mortality. Death in HE showed correlation with grade of HE ( P =0.007); Glasgow Coma Scale ( P =0.006); Liver span ( P =0.049); bilirubin ( P =0.005) and retained foetus ( P =0.044). Conclusion: The incidence of neurological disorders in pregnancy and puerperium was fairly high. Epilepsy and hepatic encephalopathy were the commonest primary and secondary neurological disorders, respectively.
Keywords: Cerebrovascular disorders, CNS infections, hepatic encephalopathy, outcome, post-partum, pregnancy, seizure disorder
|How to cite this article:|
Gupta S, Rohatgi A, Sharma S K, Gurtoo A. A study of neurological disorders during pregnancy and puerperium. Ann Indian Acad Neurol 2006;9:152-7
A variety of neurological disorders may be encountered during pregnancy and puerperium. These disorders may be unrelated to the pregnant state (e.g., meningitis) or peculiar to or more prevalent during pregnancy (e.g., eclampsia, pelvic neural compression, cortical venous thrombosis). Pregnancy may affect the course of pre-existing neurological disorders such as epilepsy. A secondary neurological disorder (e.g., encephalopathy) can affect a pregnant patient with a nonneurological medical disease. Neurological disorders may influence the management of otherwise uncomplicated obstetric cases necessitating physician/neurologist referral by the obstetric team.
The present study was undertaken with an objective of finding the common primary and secondary neurological disorders in pregnant and postpartum patients and to study their clinical features and course in relation to pregnancy.
| Materials and Methods|| |
This study was conducted in Lady Hardinge Medical College and associated Smt. Sucheta Kripalani Hospital during a period of 1 year extending from February 2004 to January 2005. All pregnant, postabortal and postpartum patients (up to 6 weeks after the termination of pregnancy) presenting with predominantly neurological signs and symptoms, requiring medical referral were included in the study. Inclusion criteria for the patients were:
1. Patients with a pre-existing neurological disorder.
2. Patients developing a primary neurological disorder during the course of pregnancy or puerperium.
3. Patients with primary medical disorders presenting with neurological manifestations.
Patients with eclampsia managed exclusively in the obstetric unit were excluded.
For all subjects, a detailed history was taken, a detailed examination including obstetric examination; basic investigations (complete blood count, liver and kidney function tests, serum electrolytes) and Ultasonogram of pelvis to rule out evidence of pelvic sepsis were done. Radiological imaging (CT/MRI brain or MRI spinal cord) was done in all 46 cases of primary neurological disorders. Other relevant investigations (e.g., NCV/EMG) were done according to the merits of individual conditions. Wherever possible, a definitive diagnosis was established based upon standard diagnostic criteria for individual conditions. All patients were followed up as to the outcome of the neurological disorder as well as the outcome of pregnancy for a minimum period of 6 weeks following the termination of pregnancy. Where applicable, the relation of outcome to various clinical parameters was statistically ascertained using the Mann-Whitney U- test or the Chi-square test.
| Results|| |
A total of 76 patients presented during pregnancy or puerperium with neurological disorders during the study period. The total number of deliveries in this hospital during this period was 13022, giving an incidence of 584 cases per 100,000 deliveries. 46 cases were of primary neurological disorders (incidence of 353 cases per 100,000 deliveries) and 30 cases were of secondary neurological disorders (incidence of 230 cases per 100,000 deliveries). The distribution of various disorders is given in [Table - 1].
The details of patients presenting with Epilepsy are shown in [Table - 2]. Out of 22 patients, 10 had no abnormality on radiological imaging and 9 had a single granuloma (most commonly in the parietal lobe). Other findings on CECT/ MRI brain included lacunar infarct (1), gliosis (1) and a combination of haemorrhage, infarct and granuloma in three different regions (1). Seizures were controlled in 20 cases (90.9%) on one or more anti-epileptic drugs (AED) including phenytoin, carbamazepine and valproate. Among the 16 patients with epilepsy during pregnancy; 10 had uncomplicated deliveries, three patients presenting in status epilepticus underwent MTP due to teratogenic risk, one had a spontaneous abortion at 20 weeks and one had a term still-birth. Gross congenital malformations were not seen in any neonate.
Of the 12 patients with CNS infections, there were seven cases of tubercular meningitis (TBM), four cases of acute pyogenic meningitis and one case of viral encephalitis. All seven patients presented during the postpartum period, while the rest presented during pregnancy. Clinical features included fever; headache; altered sensorium (12), seizures (2), focal neurological deficits (3) and evidence of extra-neural involvement (6). Laboratory findings were consistent with disease presentations. Three patients of pyogenic meningitis recovered completely, while one who had developed focal neurological deficits expired. Six patients with TBM improved on ATT with steroids, whereas one with a concurrent subdural empyema expired. The patient with viral encephalitis had residual psychiatric disturbance. Out of the five pregnant patients, one patient of TBM underwent MTP in the first trimester due to teratogenic risk in view of steroid intake. Rest of the patients had normal deliveries.
Out of 9 cases of cerebrovascular disorders, 5 were of CVT; all of whom presented within the first fortnight after home deliveries by untrained dais . Clinical features included fever (5), headache (3), generalized seizures (4), altered sensorium (4), focal neurological deficits (4) and features of pre-eclampsia (1). All cases showed anaemia, leucocytosis and sterile blood cultures. USG pelvis revealed retained products of conception in one case. Venous sinus thrombosis was seen on MRI brain in three cases and three patients had haemorrhagic infarcts in the venous distribution. All patients were treated with anti-coagulants. Two patients recovered completely, one had residual sixth nerve palsy; seizures persisted in one and one expired.
Three patients presented with arterial infarctions: one had rheumatic mitral stenosis with atrial fibrillation; she presented on the ninth postpartum day with left hemiparesis and left VII nerve palsy and was found to have an infarct in the right capuloganglionic region. Two patients presented on the 10th postpartum day-one had aphasia, left hemiparesis with left III nerve palsy; the other presented with bilateral cerebellar signs, more on the left side. The former was found to have multiple infarcts in the internal capsule, basal ganglia, mid-brain and cerebellum, while the latter had bilateral cerebellar infarcts on neuroimaging. Both these patients were diagnosed as anti-phospholipid antibody syndrome with positive lupus anticoagulant and anti-cardiolipin antibodies, which were found on repeat testing 6 weeks later as well. All three were treated with aspirin and anti-coagulants and had residual neurodeficits.
One patient presenting at 6 weeks of pregnancy with right hemiparesis and right VII nerve palsy was found to have a left basal ganglia bleed due to ruptured intracranial aneurysm on neuroimaging. She underwent Medical Termination of Pregnancy (MTP) and was referred for neurosurgical intervention, but succumbed in the postoperative period.
Other cases of primary neurological disorders are summarized in [Table - 1]. The patients with glioma and acute disseminated encephalomyelitis succumbed to their illnesses, while the one with traumatic quadriparesis was successfully operated upon and delivered a healthy baby by vacuum extraction.
In cases of HE, specific etiology could not be proved in most cases as deranged coagulation profile precluded attempts at liver biopsy. Sixteen patients presented in the second trimester, seven in the third trimester and five in the postpartum period. Clinical features included fever (23), altered sensorium (28), jaundice (28), seizures (1) and oliguria (5). Fourteen patients (50%) had Grade IV HE and 10, a Glasgow Coma Score of 3. Liver span could not be localized in 10 cases. Leucocytosis was present in 24 cases; LFT, coagulation profile, Kidney Function Tests (KFT) and electrolytes were deranged in all, all, 10 and 20 cases, respectively. Out of 28 patients, 18 (64.3%) died; of which 7 died undelivered; 9 after abortions/still-births and two after delivering healthy babies. Ten patients (35.7%) recovered completely: two after spontaneous abortions, one after a still-birth, three after delivering healthy babies and four with foetuses in situ . Statistically significant associations were seen between mortality and the grade of HE ( P =0.007); Glasgow Coma Score at presentation ( P =0.006); liver span on examination ( P =0.049); value of serum bilirubin ( P =0.005); retained foetus ( P =0.044).
Other cases of secondary neurological disorders are summarized in [Table - 1].
| Discussion|| |
A wide range of neurologic conditions can affect women during pregnancy and puerperium., The primary neurological disorders studied in relation to pregnancy include eclampsia, strokes, epilepsy, benign intracranial hypertension, CNS tumours, Bell's palsy, obstetric pressure palsies, demyelinating diseases of the central/peripheral nervous system and neuromuscular junction disorders (myasthenia gravis). Neurological diseases may be incidental to pregnancy (e.g., meningitis). Patients may also present with secondary neurological disorders such as metabolic encephalopathies secondary to hypoxia-ischaemia, hypoglycemia, hepatic failure, azotemia, hypercalcemia and nervous system disorders secondary to nutritional deficiencies and endocrine dysfunction. The studies carried out so far have included only primary neurological disorders,,,, and their incidence during pregnancy has not been studied systematically in most studies. The incidence of primary neurological disorders in this study was comparable to that in a study from Hong Kong [Table - 3].
A comparative chart of the distribution of neurological disorders among various studies is given in [Table - 3].
Analysis of various studies,,, shows a wide variation in the occurrence of epilepsy [Table - 3]. In the current study, the timing of seizures in relation to pregnancy showed an almost uniform distribution across the trimesters and the postpartum period, whereas in other studies,, the seizure frequency was found to be least during the third trimester and postpartum period. Most seizures in this study were encountered in the peripartum period and were attributable to noncompliance, physical exhaustion or metabolic derangements. The distribution of type of seizures (generalized vs. partial) was similar to other studies.,,, However, a significantly greater number of patients presented with status epilepticus in this study in comparison to other studies,, (31.8% vs. 0.53 to 5.3%), which can be explained by: delayed presentation of patients to the hospital after the onset of seizures, noncompliance, and discontinuation of AED. A higher proportion of patients had seizure occurrence for the first time during pregnancy as compared to other studies., Out of nine patients who were on AED, three had stopped medication due to the fear of adverse effects. Seizures occurring in the other three patients despite adequate compliance lends credence to the fact that seizure frequency may change during pregnancy in the absence of alterations in the doses of AED due to changes in AED protein binding or clearance. There was no incidence of gross congenital malformations, unlike other studies where it varied between four and 12%.,,
From [Table - 3], a higher occurrence of cerebrovascular disorders in the previous Indian studies,, is noted in comparison to the present study. The difference is due to less cases of CVT (6.6%) as compared to these studies where CVT accounted for 35-65% of the cases.,, CVT has an exceptionally high incidence in India, attributable to a combination of dehydration; infection; and the traditional fat-rich diet fed to postpartum women causing a hypercoagulable state. However, the lower incidence in this study could be explained by the increased awareness among patients and their families, with better facilities for asepsis during delivery as compared to the other studies,,, which were carried out around four decades back. All cases presented with classical clinical features, similar to those in other studies.,,,,, Anaemia, a predisposing factor for CVT, was uniformly present. All cases were treated with anti-coagulants according to accepted treatment strategies. No patient had residual motor paralysis, but 20% mortality was seen. Mortality rate in cases of CVT was ~28% in most studies.,,, Current mortality rates are estimated to be as low as 5.5% with anti-coagulation.
The incidence rates for ischemic strokes associated with pregnancy or puerperium vary in literature from five to 210 (23 in this study) per 100,000 deliveries. The incidence of arterial thrombosis in most studies.,,, varied between 8 and 64% of the total cases, which is higher than in the present study (3.8%). Residual paralysis as seen in this study, is a common sequlae of ischemic arterial occlusion.,
Intracranial haemorrhage constituted from 2 to 7% of the total cases of neurological disorders in most studies,, (1.3% in this study). About one in 10,000 pregnancies is reported to be complicated by the rupture of an intracranial aneurysm, roughly the same as in this study. However, this patient presented in the first trimester, though aneurysmal rupture is more likely in the second and third trimesters.,
CNS infections showed a higher incidence in this study than in others. TBM usually presents with classical manifestations during pregnancy, commonly between the 5th and 7th months or in the postpartum period. Most patients improve with treatment, as in this study.
The sole patient with a CNS tumour (glioma) presented in the postpartum period, which is relatively rare. Usually there is an increase in the size of the tumour during pregnancy due to hormonal changes and amelioration of symptoms in the postpartum period.
HE in pregnancy may be related to a wide variety of acute and chronic liver diseases, out of which Hepatitis E virus infection is an important cause in India., Acute fatty liver of pregnancy (AFLP) generally presents after the 30th week of pregnancy. Fulminant viral hepatitis (FVH) leading to hepatic encephalopathy may be seen in any trimester. All patients presented with jaundice and altered sensorium of less than 10 days' duration, in accordance with the definition of fulminant hepatic failure. Leucocytosis can be observed in HE due to AFLP, FVH or complicating infection; and was observed in most of our cases. In a recent study from Delhi, mortality of HE due to FVH was to the tune of 85.7%. In our study, the overall mortality from HE was 64.3%, however the proportion due to FVH cannot be commented upon. The factors determining outcome in patients with HE have been highlighted in the results. Many patients who recovered, particularly after abortion/ delivery, could have been those of AFLP as this condition improves after pregnancy termination.
Many neurological conditions that may be seen during pregnancy were not observed in this study, probably because the period of study was relatively short. A study spanning at least 5 years would be more inclusive of all varieties of neurological diseases.
| Conclusion|| |
To conclude, epilepsy and hepatic encephalopathy emerge as the predominant neurological disorders during pregnancy and puerperium with a substantial contribution by cerebrovascular diseases and CNS infections. A comparative analysis with previous Indian studies and international studies has been highlighted. Effects of these conditions and their treatments on pregnancy and the effects of pregnancy on the course of these disorders should be kept in mind when dealing with these conditions in pregnancy. Appropriate management, preferably under the joint care of neurologists, obstetricians and neurosurgeons, is required to optimize maternal and foetal outcomes.
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[Table - 1], [Table - 2], [Table - 3]
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