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¨
guidelines. Muscle Nerve 1999; 22: 1479“97. 104. Schmitt, H. J., Wick, S. & Munster T. Rocuronium for muscle relaxation in
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104: 21“5. 107. Wyatt, S. & Brighouse, D. Anaesthetic management of vaginal delivery in a
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82. Melber, D. Maternal“fetal transmission of myasthenia gravis with negative 110. Harmon, D. Anaesthesia for caesarean section in a parturient with
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165
2 Musculoskeletal disorders


111. Kumar, R., Healy, K. & Young, S. J. Combined spinal-epidural anesthesia 135. Roop, K. A. & Brost, B. C. Abnormal presentation in labor and fetal growth
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112. Oberoi, G. S., Kaul, H. L., Gill, I. S. & Batra, R. K. Anaesthesia in arthro- 136. Athanassiou, A. M. & Turrentine, M. A. Myocardial infarction and coronary
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113. Hall, J. G. Arthrogryposis multiplex congenital: etiology, genetics, classifi- 137. Kitazono, T., Imaizumi, T., Imayama, S. et al. Two cases of myocardial
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115. Hardwick, J. C. & Irvine, G. A. Obstetric care in arthrogryposis multiplex 2004; 127: 491“500.
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117. Oda, Y., Yukioka, H. & Fujimori, M. Anesthesia for arthrogryposis multi- 142. Goldstein, M. & Miller, R. Anesthesia for cesarean delivery in a patient with
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(UK). Am. J. Med. Genet. 1998; 77: 31“7. 152. Cubert, R., Cheng, E. Y., Mack, S., Pepin, M. G. & Byers, P. H. Osteogenesis
125. Pyeritz, R. E. Ehlers-Danlos syndrome. N. Engl. J. Med. 2000; 342: 730“2. imperfecta: mode of delivery and neonatal outcome. Obstet. Gynecol. 2001;
126. Pepin, M., Schwarze, U., Superti-Furga, A. & Byers, P. H. Clinical and 97: 66“9.
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130. Rudd, N. L., Nimrod, C., Holbrook, K. A. & Byers, P. H. Pregnancy compli- 156. Cho, E., Dayan, S. S. & Marx, G. F. Anaesthesia in a parturient with osteo-
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1987; 69: 428“31. in osteogenesis imperfecta. Blood 1972; 39: 500“9.




166
SECTION 3: NERVOUS SYSTEM DISORDERS
DISORDERS OF THE CENTRAL NERVOUS SYSTEM
9 IN PREGNANCY
J. Martinez-Tica and R. B. Vadhera


Introduction difficulty in positioning the pregnant patient in the scanning
apparatus, shielding of the patient and anesthesiologist, and
Disorders of the central nervous system (CNS) during pregnancy
remote access to the patient.
remain a common cause of maternal morbidity and mortality.
The images from CT scanning are not as detailed as those from
Central nervous system disease was responsible for 34 of the 90
MRI, but CT scanning is more readily available and less expen-
indirect causes of death during the 1997“1999 Confidential
sive. Angiography is invasive and can alter neurological function
Enquiry into Maternal Deaths in England and Wales.
so it is performed ideally in an awake patient. Complications
Intracranial hemorrhage was responsible for 21 of these deaths.1
include: vessel occlusion from subintimal vascular dissection
Some disease processes pre-date pregnancy, such as epilepsy,
from dye, hematoma formation, irritation of cerebral vessels
Parkinson disease, multiple sclerosis, intracranial lesions, benign
including arterial necrosis, cerebral embolism from hyperosmo-
intracranial hypertension, or migraine. Other conditions have an
lar contrast media, as well as sepsis and temporary vasodilation
increased incidence during pregnancy, for example cerebrovas-
with intense pain. Hyperosmolar solutions produce an osmotic
cular disorders, including hemorrhagic or vaso-occlusive strokes.
diuresis, which can lead to dehydration, reduced fetal perfusion,
Few centers have extensive experience treating these CNS dis-
and fluid shifts in the fetal brain.2,10 Myelography can produce
orders, so management is based on isolated case reports, basic
headache, confusion, and coma from the irritation of hyperos-
principles, and common sense. Maternal vegetative states and
molar dyes and from cerebrospinal fluid (CSF) leak following
brain death situations present medico-legal and ethical dilem-
lumbar puncture. The small volume of dye used for a myelogram
mas. Issues important to the care of the parturient with a CNS
is unlikely to produce significant osmotic effects in the fetus.
disorder include:
 the pathophysiology of the lesion
Seizure disorders
 the impact of pregnancy on the lesion
 impact of medical management, monitoring, and surgery on
A seizure or convulsion is defined as an abrupt alteration in
the fetus
cortical electrical activity evidenced by a change in consciousness
 the potential for aortocaval compression from lead shielding
or by motor, sensory, or behavioral symptoms. Epilepsy is the
during diagnostic radiological procedures
term used for recurrent seizures and is the most common neuro-
 gastric aspiration during pregnancy in mentally obtunded
logical disorder in pregnant women (1.1 million women of repro-
patients
ductive age in the United States),12,13,14 with seizures usually
 maternal versus fetal priority with respect to surgical plan,
starting in childhood or early life.15 Eclampsia is the most com-
timing, and route of delivery
mon cause of seizure during the peripartum period. The neuro-
 communication and coordination among the patient, her
logical manifestations of epileptic seizures are varied and
family, and the medical team (neurologist, neurosurgeon,
conditions that are commonly confused with epilepsy are syn-
obstetrician, anesthesiologist, medical consultants, and nur-
cope, migraine, metabolic and cerebral disorders.15,16 The types
sing staff).
and differential diagnosis of epileptic seizures are shown in
Table 9.2. Epilepsy has an impact on many aspects of a woman™s
health, particularly with respect to reproduction.17,18 There is a
Diagnostic tests
twofold increase in congenital malformations associated with
epilepsy and antiepileptic drugs (AED).12 Epilepsy was responsi-
A number of intracranial conditions can produce similar signs
and symptoms in the parturient (see Table 9.1).2,3,4,5,6,7,8,9,10 A ble for 9 of the 75 indirect causes of maternal deaths in the
1997“1999 Confidential Enquiry in Maternal Deaths.1
high index of suspicion for unusual conditions is important
because aggressive treatment greatly affects outcome.
Special imaging techniques used for neurological diagnosis
Management of seizures and pregnancy
include magnetic resonance imaging (MRI), which appears safe
for the fetus; computerized tomography (CT) scan, and angiogra- The principles of seizure management are to stop the seizure and
phy, which require shielding of the fetus from potentially harmful maintain an unobstructed and protected airway, to ensure oxy-
radiation.9,10,11 Immobility is required for imaging and, although genation of both mother and fetus, and prevent aspiration.
anesthesia is seldom needed, it may be requested for uncoopera- Eclamptic seizures may be single or multiple, potentially leading
tive or unstable patients. Possible technical problems include to status epilepticus. The definitive treatment of eclampsia is to


Obstetric Anesthesia and Uncommon Disorders, eds. David R. Gambling, M. Joanne Douglas and Robert S. F. McKay. Published by Cambridge University Press.
# Cambridge University Press 2008.
3 Nervous system disorders


irreversible maternal brain injury and fetal hypoxia, ischemia, bra-
Table 9.1 Symptoms and signs of an intracranial lesion dycardia, and death. In 1982, Teramo and Hiilesmaa reported 29
cases of status epilepticus in labor with the death of 9 mothers and
Symptoms Signs
14 infants.21 In a recent report from the International Registry of
 Headaches (if mild may be a  Signs of increased intracranial Antiepileptic Drugs in Pregnancy (EURAP) there were 36 cases of
warning leak from aneurysm) pressure e.g. hypertension and
status epilepticus with no maternal deaths and only one stillbirth.22
 Nausea, vomiting bradycardia
There is a case report of prolonged generalized tonic-clonic mater-
 Diplopia, blurred or loss of  Nuchal rigidity
nal seizures associated with a reassuring fetal heart rate (FHR)

vision Altered consciousness
pattern and normal fetal acid-base status and oxygenation.23
 
Photophobia or orbital pain Focal neurologic signs
Adequate initial treatment with a benzodiazepine, rather than phe-
 
Epigastric pain Seizures
nytoin, is essential to stop and prevent further seizures. In the first
 
Dizziness Ataxia
trimester, the benefits of controlling a seizure outweigh the risks
 
Mental changes Bruits
from potential teratogenicity associated with some anticonvul-
 
Respiratory distress Disseminated intravascular
sants.24 Midazolam, given in doses up to 5 mg, produces minimal
coagulation
depression of the fetus. If seizures should occur near delivery, the
respiratory depressant effects of higher doses of benzodiazepines
can be treated by ventilatory support of the neonate. Tracheal
intubation and assisted ventilation for mother may be required
and sodium thiopental (STP) helps control the status epilepticus.
Table 9.2 Classification and differential diagnosis of epileptic
Clinical presentation may indicate a need for further investiga-
seizures
tion and imaging (CT scan and/or MRI) to rule out intracerebral
Classification Differential diagnosis
pathology that is amenable to early neurosurgical intervention.
Fetal assessment should be performed using ultrasound and car-
1. Generalized seizures 1. Cerebrovascular
diotocography to determine the need for obstetric intervention
(a) Tonic-clonic seizures (a) Stroke
and operative delivery.
(grand mal) (b) Syncope
(b) Absences (petit mal) (c) Migraine
(c) Clonic seizures (d) Eclampsia
Effect of pregnancy on epilepsy
(d) Tonic seizures (e) Mass lesions
Studies on the influence of pregnancy on the frequency of epi-
(e) Bilateral myoclonus (f) Infections
leptic seizures have produced varying results, ranging from no
(f) Infantile spasms 2. Drugs
change in seizure frequency in 23“50%,25,26,27 a decrease in fre-
(g) Akinetic seizures (a) Local anesthetic toxicity
quency in 13“14%,22,25,26 and an increase in frequency in 17“32%
2. Partial seizures (b) Intoxication or withdrawal
of parturients.22,25,26 Reasons cited for the differences in the
(a) With elementary (morphine, cocaine)
results of these studies are interpretation problems, lack of accu-
symptoms 3. Metabolic
rate evaluation of seizure severity and frequency, lack of pregnant
(b) With complex symptoms (a) Hypoglycemia
controls, and differences in AED treatment before and during
(temporal lobe) (b) Acute intermittent
pregnancy in some patients.
(c) Partial seizures porphyria
Hormonal changes during pregnancy seem to affect seizure
becoming generalized 4. Cardiovascular
frequency with estrogen level peaks related to an increase in
3. Status epilepticus (a) Stokes Adam™s attacks
seizure frequency, while progesterone is associated with anti-
5. Obstetric
convulsant effects. Seizure susceptibility probably correlates
(a) Amniotic fluid embolism
best with the estrogen/progesterone ratio.28 Increased weight
(b) Acute fatty liver of
(water and sodium), mild respiratory alkalosis, and psychological
pregnancy
stress also might play a role.29
6. Others
Plasma concentrations of AED drop during pregnancy. Reasons
(a) Hysteria
for this include:
1. decrease in compliance (due to anxiety, nausea and vomiting,
and missed doses in labor)
deliver the baby after medical control of the seizure. A report from
2. decreased absorption and protein binding of the drug
the Eclampsia Trial Collaborative Group details evidence in favor
3. increased volume of distribution, hepatic and renal clearance,
of the use of magnesium sulfate for routine anticonvulsant man-
and body weight.29
agement of eclamptic mothers.19
Folic acid supplements prescribed during pregnancy may also
Status epilepticus is defined as recurrent seizures without a
result in lower AED levels. It is the unbound (free) portion of the
return to consciousness, or prolonged seizure activity beyond a 30
minute period.20 The management principles include seizure ces- AED that is biologically active and this level, rather than total drug
level, relates to seizure control and to the development of toxicity.
sation and prevention, airway management, and identifying a pre-
Ideally, this level should be established prior to conception and
cipitating cause. Maternal and fetal risks are high, including



168
Chapter 9


the medication regimen modified to achieve monotherapy. Free
Table 9.3 Criteria for cesarean section in the epileptic
drug levels should be measured monthly during the first and
parturient
second trimesters and every two weeks in the third trimester.
Close monitoring of serum levels after delivery is essential to Elective Emergency
identify any changes that might require dose adjustment.25
 Neurologic deficit  Generalized seizure in labor
 Deterioration in third trim-  Threat of fetal asphyxia
 Maternal somnolence and lack
ester seizure control
Effect of epilepsy on pregnancy
 Occurrence of seizures with of cooperation in labor
Some studies suggest that there is an increase in complications exercise and stress
and adverse outcomes such as hyperemesis, vaginal bleeding,  Unable to cooperate
preeclampsia, premature labor, postpartum hemorrhage, and
higher obstetric intervention rates in pregnancies of epileptic
Infants of epileptic mothers have a twofold increased (to 6%)
mothers.29,30 Other studies found no difference in outcomes
risk of congenital malformations such as orofacial clefts, congen-
when compared to nonepileptic parturients.31 Antiepileptic
ital heart defects, microcephaly, mental retardation, distal limb
drugs are membrane stabilizers and may increase the incidence
hypoplasia, and nail dysplasia. Antiepileptic drugs are implicated
of vaginal bleeding and duration of labor by reducing the strength
in teratogenesis,39,40 but a contribution from a genetic compo-
of uterine contractions, decreasing coagulation factors and plate-
nent related to epilepsy is postulated as children of epileptic
let number and function.32,33
fathers have a similar increase in malformations.


Effect of epilepsy on the fetus and neonate Obstetric management
The effect of maternal epilepsy on the fetus and neonate may be Pregnancies in epileptic mothers are regarded as high risk.
due to the condition itself, AED use, or a combination of both. Anticonvulsant drug withdrawal or conversion to monotherapy,
Seizures during pregnancy, especially status epilepticus, expose ideally prior to conception, is the goal along with use of minimal
the fetus to the risk of blunt trauma, hypoxia, and acidosis, all of doses of AED for seizure control. This minimizes fetal drug expo-
which may produce neurological damage. As seizures increase the sure while maintaining maternal seizure control. Obstetric man-
risk of fetal and maternal death they require rapid intervention. agement goals include the abolition of seizures during pregnancy,
Treatment of the seizures with intravenous diazepam may cause and a seizure-free delivery of a healthy infant. Counseling the
loss of baseline variability within two minutes of administration. epileptic mother is necessary to ensure compliance with medica-
These changes may be interpreted as fetal compromise, leading to tion, provide information on fetal malformation rates, and possi-
an unnecessary urgent delivery. Chronic anticonvulsant therapy is ble infant withdrawal symptoms. Breast-feeding is not
associated with an increase in breech presentation possibly from a contraindicated unless the infant shows signs of lethargy.
lowering of the frequency and strength of fetal limb movements Anticonvulsant drug levels must be maintained throughout
and hence an inhibition of spontaneous version.33 labor and intravenous administration may be necessary due to
The application of a fetal scalp electrode carries a potential risk decreased gastrointestinal absorption. The epileptic parturient is
of scalp bleeding through AED effect on fetal coagulation. at higher risk for emergency obstetric intervention due to general-
Infants born to mothers taking AED can develop potentially ized seizures during labor, fetal bradycardia following a grand mal
life-threatening hemorrhagic disease from vitamin K deficiency, seizure, maternal postictal drowsiness and CNS depression, and
so vitamin K supplements are recommended during the last loss of FHR variability following rapid intravenous control of
month of pregnancy.34 The American Academy of Pediatrics seizures. Indications for elective cesarean section (C/S) are
recommends that newborns of epileptic mothers receive vitamin shown in Table 9.3.
K intramuscularly immediately after delivery34 and Aminoff
recommended that cord blood prothrombin and activated partial
Anesthetic management
thromboplastin times be tested at delivery.32 Infants with abnor-
mal laboratory values can be treated with fresh frozen plasma or There are many potential interactions among anesthetic drugs
factor concentrates, as appropriate. and AED as well as anesthetic drugs and epilepsy itself.
All AED are excreted in the breast milk; barbiturates, primi- Phenytoin induces hepatic microsomal enzymes, which affect
done, ethosuccimide, and the benzodiazepines have the highest AED metabolism and enhance the breakdown of opioids, neuro-
concentration in breast milk, while phenytoin and valproate pro- muscular blocking drugs, and volatile anesthetic agents. In turn,
duce lower concentrations. Lethargy and poor feeding in the this affects drug dosing and production of toxic metabolites (e.g.
neonate may necessitate a change to bottle feeding to prevent fluoride ions from sevoflurane).

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