Neurologic Emergencies

During Pregnancy

OB/GYN Grand Rounds

December 4th 2019

Carla Burford, PGY3

Neurologic Emergencies During Pregnancy

• Headache

• Seizures

• Altered Mental Status

• Paralysis

If she was not pregnant, what would you do?

• A pregnant woman with a neurologic emergency should receive the same imaging, care, medications, evaluation to improve maternal neurologic outcome regardless of stage of pregnancy

• Contrast studies

• Thrombolytics

• Surgery

Neuroimaging

• CT: fast, readily available, highly sensitive for subarachnoid blood, large masses, and early stroke evaluation

• Fetal radiation exposure is minimal (~10 mrads)

• MRI: magnetic based, no radiation

• Limited availability, may lead to delay in diagnosis over CT imaging

• If necessary, CT contrast dyes and cerebral angiography may be safely used in pregnancy

• Gadolinium

• Crosses the placenta, cleared by fetal kidneys, could potentially concentrate in amniotic fluid

Headache

Headache

• New?

• Chronic or recurrent?

• Sudden onset?

• Severity?

• Focal neurologic symptoms?

Headache DDx

• Chronic or recurrent:

• Tension HAs, migraine, sinusitis, pseudotumor cerebri

• New, acute, >20 wga: Preeclampsia

• Sudden/severe:

• Subarachnoid hemorrhage (SAH)/Intracerebral hemorrhage (ICH)

• Aneurysm or AVM, complication from Preeclampsia

• Central Venous Thrombosis

• Meningitis

• Mass lesion (tumor/abscess)

New-Onset Headaches

• #1: Rule out Preeclampsia – clinical and lab evaluation

• Rule out mass lesions – MRI, CT, or MRA

• Rule out infection – LP (after CT), labs, clinical evaluation

• Rule out AVM or aneurysm – MRI, CT, or MRA

• Rule out vascular event (stroke, SAH, CVT) – MRI, CT, or MRA

Subarachnoid Hemorrhage

• Responsible for 5-12% of maternal deaths in pregnancy

• Cannot distinguish etiology by symptoms, all present with:

• Sudden onset, severe headache

• Nausea and vomiting

• Meningeal signs

• May or may not have: focal neuro deficits, AMS, seizures, HTN

Subarachnoid Hemorrhage Cont’d

• Evaluation:

• CT with contrast +/- cerebral angiography

• Preeclampsia evaluation

• LP to confirm blood and rule out meningitis

• Treatment

• ABCs

• Reduce BP (goal is SBP < 140)

• Management of cerebral edema > Mannitol

• Seizure control

• Continuous vs intermittent fetal monitoring

• Position with lateral uterine displacement

Subarachnoid Hemorrhage- AVM

• General population prevalence: 18/100,000

• Annual rupture risk of 2-4%

• Most common cause of SAH in pregnant patient (25% of SAH in pregnancy)

• Maternal mortality 30-40%

• Tx PRIOR to pregnancy planning

• Tend to rupture earlier in pregnancy than aneurysms (peak b/w 20-24 wga), with a secondary peak postpartum

Subarachnoid Hemorrhage- AVM Tx

• Neurosurgery is necessary in those with acute clinical deterioration

• If patient is near term with an unstable condition or SAH, consider delivery prior to or simultaneously with the surgical repair

• Avoid hypotension during surgery

• Delivery mode if ruptured & repaired during pregnancy:

• Controversial, most undergo C/S

• OVD is reasonable for some women

• Stable and unruptured aneurysms: Vaginal delivery

• If surgically treated by excision or clipping: Vaginal delivery

Central Venous Thrombosis

• Uncommon, <1% of strokes

• 75% of these occur in women

• Rate in pregnancy: 11.6/100,000 deliveries

• Predisposing risk factors: infection, cancer, thyroid disease, prothrombotic conditions, dehydration/hyperemesis, autoimmune disease

• Presentation: Headache +/- signs of intracranial HTN, focal neuro signs, AMS, seizures

Central Venous Thrombosis

• Superior sagittal (62%) and transverse sinuses (45%) most commonly involved

• Deep venous sinuses are rarely involved (11%), but mortality is 3x higher than in other locations

Diagnosis and Management of CVT

• Diagnosis:

• MR venography is the most sensitive (90-100% accuracy)

• CT may be negative in up to 30% of documented cases of CVT

• CT venography may be used if MRI not available

• Management

• Anticoagulation (LMWH vs heparin drip)

• Prophylactic antiepileptic therapy not recommended

• Women diagnosed with CVT should be evaluated for acquired and inherited thrombophilia

• Avoid estrogen containing contraception in the future, progesterone only is safe

Meningitis

Headache +

Meningitis

• MCC: Herpes Simplex Virus (HSV)

• Viral meningitis

• Incidence: 7.9/100,000 adults each year

• HSV and Enterovirus

• Bacterial meningitis

• Incidence: 2.6-6/100,000 adults each year

• S. pneumoniae, N. meningitides, H. influenza, L. monocytogenes

• High mortality rate in pregnancy (28%) and fetal loss rate (38%)

Meningitis Cont’d

• Diagnosis: Lumbar puncture

• Must rule out intracranial mass/elevated intracranial pressure beforehand

• Empiric therapy:

• HSV (Acyclovir)

• Listeria (3rd or 4th gen cephalosporin + Vancomycin + Ampicillin)

• Bacterial meningitis: Dexamethasone

• Viral meningitis: Consider testing for fetal transmission and monitoring fetal growth and development

Mass lesions

• Brain tumor incidence in women of child-bearing age: ~12/100,000

• Volume expansion of pregnancy can unmask lesions in the 3rd trimester

• Common symptoms a/w increased ICP:

• Persistent nausea/vomiting

• HA worse with position change, cough, Valsalva and overnight

• NOT typically associated with hypertension or proteinuria

• Evaluation: MRI +/- contrast, CT if not readily available

• High risk for seizures, prophylactic antiepileptics not recommended

• Corticosteroids

• High risk for thrombosis > LMWH in perioperative and postpartum periods

Seizures

Seizures

• 1st question: Does she have a seizure disorder?

• 2nd question: Could this be an eclamptic seizure?

• Only 12% of women with eclampsia were known to have PreE with SF prior to the seizure

• Most Preeclampsia-related seizures are self-limited

• MgSO4 + BP control

• Move towards delivery once seizure is resolved

• Placental abruption in 20-50% of women

Seizure work-up

Work-up for new seizures

• If not 1 or 2 then need work-up for new seizures, DDX:

• Meningeal irritation (infection, intracranial bleeding, head trauma, tumor)

• Metabolic disturbance (uremia, hypoglycemia, hyponatremia, hypocalcemia)

• Drug or alcohol intoxication or withdrawal

• Neurodegenerative or autoimmune disease

• Neuro consultation as soon as work-up is started

Status epilepticus• Single seizure lasting > 5 mins OR 2+ seizures in 5 mins

• Can lead to lactic acidosis, CV instability, irreversible brain injury

• ABBBCD’s:

• Airway: Prevent aspiration (turn on side)

• Breathing:

• Apply additional oxygen

• Consider intubation (if prolonged)

• Benzodiazepines: First stage 5-20 minutes

• Blood: Blood glucose, electrolytes, tox screen, etc.

• Circulation: Monitor vital signs, get EKG

• Disability: Neuro exam

Preexistent/Known Seizure Disorder (WWE)

• Seizures occur in ~0.5% of the population and are the most common neurologic complication of pregnancy

• Up to 1.3% of WWE will experience status epilepticus in pregnancy

• Increase frequency of seizures in WWE:

• Etiology unclear and likely multifactorial

• 60% will have no seizures, but 15% will markedly worsen

• Increased susceptibility to seizures in pregnancy

• Declining blood levels of anti-epileptic drugs (AED’s)

• Changes in volume distribution, protein binding, absorption and hepatic clearance of AEDs

AEDs in pregnancy

• Seizure control is better than seizures (regardless of medication)

• Monotherapy if possible

• Lowest dose needed

• Least teratogenic medication possible

Altered Mental Status

Altered Mental Status

• Often accompanied or preceded by seizure, headache, or focal signs that may help determine etiology

• Evaluation is similar to that of new onset seizures

• DDx:

• Drug/intoxication

• All causes of seizure

• All causes of ICH

• Preeclampsia/eclampsia

• Hemorrhagic stroke (ruptured AVM)

• Ischemic stroke

AMS Evaluation

• CT scan with and without contrast +/-cerebral angiography

• If negative:

• Labs: CBC, CMP, VDRL, thrombophilia work-up

• Echo

• MRA/angiogram

• LP if clinically indicated

Ischemic/Thrombotic Stroke

• Rare in pregnancy: 1/20,000 live births

• 12% of maternal deaths

• 2nd leading cause of death in women in the US

• Mortality as high as 25%

• Hemorrhagic > Ischemic

• 50% occur in the first 10 days PP, 50% in late 2nd/3rd trimesters

Ischemic/Thrombotic Stroke Risk Factors

• Hypertensive Disorders of Pregnancy (risk increases 7x)

• Majority (>80%) occur without HDP

• Other risk factors:

• Cesarean delivery

• Infection

• Thrombophilias/prothrombotic states (3x increased risk)

• AVM/Aneurysm

• Cardiac disease/cardiomyopathy

• Higher parity

• DM/HLD/Smoking/Collagen vascular disease

Ischemic/Thrombotic Stroke Evaluation

• CT main imaging study for acute events

• ABC’s

• During the first 24 hrs should:

• Maintain normal blood glucose

• Maintain adequate arterial pressure to ensure cerebral perfusion

• If develop increased ICP: Dexamethasone and Mannitol

• In the absence of vascular instability: minimal risk to fetus

Ischemic/Thrombotic Stroke- Thrombolytics

• Role of thrombolytic therapy in pregnancy for acute ischemic stroke is uncertain-no RCTs or large observational studies in pregnant patients

• rt-PA and urokinase have been used

• Intrauterine hematoma, miscarriage, maternal ICH, death

• Data on the use of rt-PA in pregnancy for acute VTE and valvular thrombosis

• 8% complication rate, 27% risk of bleeding, 6-23% pregnancy loss rate

• Risks/benefits depend on gestational age, size of thrombosis, prognosis for mother without therapy

Anticoagulation

• Little role in the acute phase, but can be useful in preventing recurrence

• LDA + LMWH/Heparin

Paralysis

Chronic Paralysis: Autonomic Dysreflexia (AD)

• Potentially life-threatening complication of a chronic SC injury at or above T6

• Sympathetic hyperactivity due to lack of higher CNS control

• Can be triggered by different stimuli below the level of the injury

• Occurs in between 20-75% of patients with a SCI above T6

• Prior NTD repair, traumatic injury, transverse myelitis, Guillain-Barre

• Complete injury are at higher risk than partial or incomplete injury

• 85% of patients who are prone to it, will develop it in labor

Autonomic Dysreflexia

• Symptoms:

• Hypertension, headache, nasal congestion, facial erythema

• Sweating, piloerection

• Bradycardia, tachycardia, arrhythmia

• Seizure

• Myocardial infarction

• Intracranial/retinal hemorrhage

• Loss of consciousness

Autonomic Dysreflexia Triggers

• General:

• Bladder distention (75-85% of cases)

• Fecal impaction, constipation, anal fissures, hemorrhoids (13-19% of cases)

• Bed sores

• Infection (UTI)

• OB:

• Pelvic exams, cold speculum

• Delivery, contractions, labor

• Infection: Chorio, endometritis

Autonomic Dysreflexia Treatment

Acute Paralysis

• Postpartum epidural abscess: 0.5-1.5/100,000

• Risk factors: duration of epidural, infection, immunocompromise, diabetes

• Spontaneous abscess:

• Risk factors: Diabetes, IVDU, renal failure, alcoholism, sepsis

• Epidural hematoma: 0.5-3/100,000

• Risk factors: Anticoagulation, low platelets

Epidural hematoma/abscess

• Clinical presentation:

• Spinal pain with point tenderness

• Radiating root pain followed by progressive limb weakness

• Fever (abscess)

• Later findings:

• Neck stiffness

• Increasing sensory defects

• Loss of bowel/bladder function

Epidural hematoma/abscess: Evaluation & Tx

• Imaging: MRI preferred over CT

• Prognosis for both epidural abscess and hematoma is related to early aggressive therapy

• Urgent surgery to evacuate hematoma/abscess and decompress nerve roots

• Antibiotics if suspect infection- broad range coverage of staph, anaerobes, and gram negative organisms (parenteral therapy typically required for 6-8 wks)

Epidural Hematoma/Abscess

• Length of time with neurologic deficit is an important diagnostic factor

• Abscess

• Paralysis > 12 hrs = permanent loss of function

• Paralysis > 36 hrs = often die

• Hematoma

• Paralysis > 8 hrs = permanent loss of function

Conclusion

• Neurologic disease in pregnancy should be managed similarly to non-pregnant patients

• Imaging and evaluation should be completed promptly

• CT scans of the head are safe and rapidly available

Sources

• Obstetric Intensive Care Manual 5th Edition; Foley, Strong, Garite

• Acute Neurologic Disease in Pregnancy Society for MFM lecture by LoraleiL. Thornburg, MD