Neurologic emergency in pregnancy is one that typically presents in a similar manifestation to the nonpregnant patient. The presentation, constellation of findings, and timing of symptoms help develop the differential diagnosis; however, the pregnant state increases the differential diagnosis with pregnancy specific and pregnancy related diseases. Pregnancy physiology and concern for the fetus can additionally make the evaluation and treatment more complex because of changing maternal physiology, as well as need to care for the maternal-fetal dyad.
In this chapter, we will consider the following presentations: headache, seizures, altered state of consciousness, and motor or sensory changes. These signs and symptoms are common in pregnancy, and the differential wide. The focus will be on acute, life-threatening events as opposed to the management of known chronic neurological conditions. Using this approach will provide a more “real life” approach—one of evaluating the pregnant women with a complaint and moving forward to a diagnosis.
GUIDING PRINCIPLES FOR CARE OF NEUROLOGIC EMERGENCY IN PREGNANCY
As a general guiding principle, the pregnant women with neurologic emergency should receive the same imaging, care, medications, evaluation, including contrast studies, thrombolytics, and surgery as needed to improve the maternal neurologic outcome regardless of stage of pregnancy. Care should not be delayed to the mother for fetal evaluation or delivery, but often fetal evaluation including monitoring and ultrasound can be accomplished simultaneously and provide valuable clinical information to aid in decision making. Consultation and coordination of care with neurology, neurosurgery, anesthesia, neonatology, and maternal-fetal medicine (MFM) are needed to allow the best outcomes for the maternal-fetal dyad—and should be accomplished as rapidly as possible. However, as the common adage so eloquently says—“time is brain”—and immediate and aggressive care for the woman with an acute neurologic event should be prioritized to optimize the maternal neurologic outcome.
Neuroimaging and Evaluation in Pregnancy
If an intracranial process is suspected, the patient should undergo emergent central nervous system (CNS) imaging with either computerized tomography (CT) or magnetic resonance imaging/magnetic resonance angiography (MRI/MRA) as needed. CT has the advantage of being rapidly and readily available, and being highly sensitive for subarachnoid blood, large masses, and early stroke evaluation. The fetal radiation exposure during cerebral CT imaging with shielding is minimal (~10 mrads). The American College of Obstetricians and Gynecologists (ACOG) guidelines are clear that if CT is the better or more readily available test than it should not be withheld from a pregnant patient.1 MRI has the advantage of being magnetic based, and therefore having no radiation exposure—but has limited availability and may be lead to delay in diagnosis over CT imaging. If necessary, CT contrast dyes and cerebral angiography may be safely used in pregnancy. The use of MRI contrast (gadolinium) is controversial in pregnancy due to fetal concerns. However, the utilization of gadolinium contrast may be justified ...