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  • Updated 08.14.2021
  • Released 02.02.2000
  • Expires For CME 08.14.2024

Pregnancy: CNS complications

Introduction

Overview

Given the severity of possible outcomes, as well as the effect on the unborn child, the pregnant patient can be a challenge for the neurologist. As well, the postpartum period carries with it significant and unique neurologic risks. In this article, the author reviews the common complications of the central nervous system seen in pregnancy and the postpartum period. The key presenting features of eclampsia are discussed as well as ischemic and hemorrhagic cerebrovascular events.

Key points

• Pregnancy and delivery are associated with multiple physiologic changes that may trigger complications specific to pregnancy or influence the course of multiple neurologic and systemic disorders.

• Intractable vomiting may lead to Wernicke encephalopathy, a potentially fatal condition that requires early recognition and urgent administration of thiamine.

• Most untreated or insufficiently treated patients who survive the acute Wernicke encephalopathy develop Korsakoff syndrome, characterized by anterograde and retrograde amnesia.

• The risk of ischemic and hemorrhagic stroke is increased mostly in the peripartum and postpartum periods.

• The risk factors of stroke in young pregnant women may differ from those in elderly women and are related to venous thrombosis, reversible cerebral vasoconstriction, and preeclampsia/eclampsia. Investigating causes of stroke in the young is equally important.

• Although the clinical trials of tPA excluded pregnant women, it was used successfully in the treatment of acute ischemic stroke.

• Imaging selection and new thrombectomy devices have improved the treatment of stroke due to large vessel occlusion.

• Low dose aspirin may cause gastroschisis during the first trimester but may be given safely thereafter for prevention of most types of stroke.

• Preeclampsia may be prevented by careful blood pressure control and a small dose of aspirin; eclampsia should be treated with intravenous magnesium sulfate.

• Heparin is the preferred treatment in patients with thrombophilia and cardioembolism, except in those with an older mechanical mitral valve and history of thromboembolism who may benefit from warfarin.

• Subarachnoid hemorrhage should be treated according to the guidelines for nonpregnant women.

Historical note and terminology

The physiologic changes that occur during pregnancy and the puerperium can adversely affect the central nervous system and complicate the management of preexisting neurologic conditions. The effect of pregnancy on chronic neurologic conditions such as epilepsy, multiple sclerosis, myasthenia gravis, and migraine will not be discussed here.

Additionally, complications of anesthesia during and after delivery may be difficult to distinguish from those of pregnancy. Headache following dural puncture and cerebrospinal fluid leak are the most frequent CNS complications of anesthesia. A retrospective cohort study consisting of 1,003,803 women who received neuraxial anesthesia for delivery revealed that headache after dural puncture is associated with cerebral venous thrombosis, subdural hematoma, meningitis, depression, and low back pain. Seventy percent of the cerebral venous thrombosis and subdural hematoma were diagnosed during readmission, which occurred after a median time of 5 days (45).

Spinal cord lesions due to trauma, compression, ischemia, or total spinal block occur rarely, but the high morbidity and mortality associated with them demand early recognition and rapid intervention. Seizures during anesthesia may also be triggered by selective inhibition of the inhibitory neurons.

Diagnosis and management of the central nervous system disorders associated with pregnancy will be specifically addressed. Eclampsia is reviewed in this article, and it is also covered as an individual article.

Wernicke encephalopathy, a potentially fatal and yet treatable complication of thiamine deficiency, was described initially by Carl Wernicke in 1881 in 2 alcoholic patients and 1 woman with intractable vomiting from gastric stenosis caused by sulfuric acid ingestion (65). Its association with hyperemesis gravidarum was later noted (106). In 1888 Sir William Gowers described eclampsia or toxemia of pregnancy characterized by convulsions in pregnant women with hypertension, proteinuria, and edema. This syndrome is uniquely associated with pregnancy-induced hypertension. In 1899 Edward Lazard described the first intracerebral hemorrhage in pregnancy, noted at autopsy, to be the result of a ruptured aneurysm. John Abercrombie made the first autopsy description of puerperal cerebral phlebothrombosis in 1828; however, the clinical syndrome of central venous thrombosis was not described until Gowers in 1893.

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