Neurological and psychiatric disorders encountered during pregnancy are those that are common to reproductive-aged women. Some may be even more common in pregnancy. Examples are Bell palsy, some types of stroke, and depression.
A number of neurological diseases are relatively common in women of childbearing age. Many of these once precluded childbearing, but less so now. Somewhat related, neurological disorders can profoundly disrupt normal sexual function (Rees and colleagues, 2007). That said, many women with chronic neurological disease become pregnant and have successful pregnancy outcomes. Conversely, neurological diseases do contribute to maternal mortality rates, and there are specific risks with which the clinician should be familiar.
Diagnosis of Neurological Disease during Pregnancy
Many women with chronic neurological disease have been diagnosed before pregnancy. In others, neurological symptoms appear for the first time and must be distinguished from pregnancy complications. Because these symptoms may involve cognitive as well as neuromuscular functions, they must also be distinguished from psychiatric disorders. In general, pregnant women should receive the same evaluation as any other patient.
Central Nervous System Imaging
Computed tomography (CT) and magnetic resonance (MR) imaging have opened new vistas for the diagnosis, classification, and management of many neurological and psychiatric disorders (Dineen and colleagues, 2005). As discussed in Chapter 41, Diagnostic Radiation, both imaging methods can be used safely during pregnancy. Computed tomography is commonly used whenever rapid diagnosis is necessary. However, in less acute situations, MR imaging is often preferred because of its low radiation exposure. It is particularly helpful to diagnose demyelinating diseases, screen for arteriovenous malformations, evaluate congenital and developmental nervous system abnormalities, identify posterior fossa lesions, and diagnose spinal cord diseases. MR imaging is superior for detecting acute ischemia and acute and chronic hemorrhage, and therefore, is preferable for stroke evaluation (Chalela and associates, 2007). For either test, the woman should be positioned in a left lateral tilt with a wedge under one hip to prevent hypotension as well as to diminish aortic pulsations, which may degrade the image.
Cerebral angiography with contrast injection, usually via the femoral artery, is a valuable adjunct to the diagnosis and treatment of some cerebrovascular diseases. Fluoroscopy involves more radiation but can be performed if necessary with careful abdominal shielding.
According to the National Health Interview Survey updated annually by the Centers for Disease Control and Prevention (2006a, b), a fourth of women aged 18 to 44 years report a severe headache or migraine within the past 3 months. And the most common neurological complaint during pregnancy is headache. The classification of headaches by the International Headache Society (2004) is shown in Table 55-1. Cluster headaches are not commonly reported in pregnancy and were reviewed by Giraud and Chauvet (2009). Thunderclap headaches can be primary or may be due ...