Acute Neurological Emergencies During Pregnancy and Postpartum in a Sample of Upper Egypt Women

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1 September, ; Vol1; Issue8 Acute Neurological Emergencies During Pregnancy and Postpartum in a Sample of Upper Egypt Women Hussein Mohammed Hussein, Mohammed Aly Mohammed Abood, Hassan Gad Kwashty, Hussein Awad Elghareib, Zakarya Mohammed Moustafa Neurology department- Faculty of medicine Al-Azhar university- Cairo- Egypt Corresponding Author: Dr. Zakarya Mohammed Moustafa dr.zakarya1979@gmail.com ABSTRACT Background: Acute neurological emergencies in pregnant and postpartum women could be caused by exacerbation of a pre existing neurological condition (eg, multiple sclerosis or a seizure disorder), initial presentation of a non pregnancy related problem (eg, brain neoplasm) or pregnancy and postpartum related problems (eg, preeclampsia, eclampsia & PRES). Objective: Assessment of acute neurological emergencies during pregnancy and postpartum in a sample of Upper Egypt women for early diagnosis and proper management. Study design: It was a cross-sectional descriptive epidemiological study. Place and Duration of Study: This study was carried out at Sohag teaching hospital from 1st June 2014 to 31th May Materials and Methods: This study was applied for women during pregnancy and postpartum period (up to six weeks after delivery according to ICD-9) suffering from acute neurological emergencies then underwent detailed medical and neurological history and examination, routine labs, specialized labs, radiological and neuro physiological investigations. Results: There were 320 women classified into two groups; pregnant group (232 of them (72.5%) and postpartum group (88 of them (27.5%). The frequencies of all data were; for age of less than 30 years were 192 women (60%); for age of 30 years and more were 128 women (40%). As regard to residence; women live in rural area were 148 (77.5%) while women live in urban area were 72 (22.5%). According to initial presenting symptoms; headache were 205 (64%); seizures were 92 (28.8%); motor system affection were 34 (10.6%); cranial nerves affection were 31 (9.7%); disturbed conscious level (DCL) were 103 (32%); aphasia were 4 (1.3%); unsteady gait 7 (2.2%); urinary retention were 1 (0.3%). As regard to risk factors; preeclampsia were 87 (27.2%); thrombophilia 17 (5.3%); rheumatic heart disease were 9 (2.8%); hypertension were 2 (0.6%); diabetes were 4 (1.3%); systemic infections were 6 (1.9%); lowering or stop AEDs were 3 (0.9%). As regard to final diagnosis; preeclampsia were 150 (46.9%); eclamptic fits were 58 (18.1%); strokes were %); post dural puncture headache were 14 (4.4%); posterior reversible encephalopathy syndrome were 10 (3.1%); trigeminal neuralgia were 7 ( 2.2%); bell's palsy were 6 (1.9%); carpal tunnel syndrome were 8 (2.5%); sciatic neuropathy were 2 (0.6%); guillian baree syndrome was 1(0.3%); multiple sclerosis were 3 (0.9%); idiopathic increased intracranial pressure were 3 (0.9%); epilepsy were 3 (0.9%); Chorea gravidarum were 2 ( 0.6%); idiopathic thrombotic thrombocytopenic purpura were1 (0.3%); viral encephalitis was1(0.3%); transverse myelitis was 1 (0.3%); frontal meningioma was 1(0.3%). Conclusion: Frequancy of acute neurological emergencies during pregnancy and postpartum in a sample of upper Egypt women were higher in patients whose age less than 30 years old and live in rural than patients whose age 30 years old or more and live in urban area. Headache and seizures are the commonest among initial presenting sysmptoms. Preeclampsia, thrombophilia and rheumatic heart disease are the commonest among risk factors. As regard to final diagnosis; preeclampsia, eclamptic fits and strokes are the commonest among final diagnosis. Keywords: Acute Neurological Emergencies, Pregnancy, Postpartum

2 1. INTRODUCTION Acute neurological emergencies in pregnant and postpartum women could be caused by exacerbation of a preexisting neurological condition (e.g, multiple sclerosis or a seizure disorder) or by initial presentation of a non pregnancy related problem (e.g, brain neoplasm). Alternatively, patients can present with new acute onset neurological conditions that are either unique to or occur with increased frequency during and just after pregnancy (1). If specific treatments are not started promptly, many of these conditions can result in morbidity or mortality in these young, usually previously healthy individuals. The approach most commonly used to assess many of these symptoms non-contrast brain CT is often nondiagnostic. If a patient has a poor outcome, the medical, social, and medico-legal impact is often high. For all these reasons, prompt diagnosis is imperative (1). Raised oestrogen concentrations stimulate the production of clotting factors which increases the risk of thromboembolism; increased plasma and total blood volumes increase the risk of hypertension; and raised progesterone concentrations towards the end of pregnancy enhance venous distensibility and potential leakage from small blood vessels. The high oestrogen levels fall in the postpartum period. Combined these hormonal changes can result in leaky capillaries and vasogenic oedema (2). Pregnant or post partum patients who present with persistent acute motor, sensory, or visual findings might have more serious causes and usually need urgent thorough investigations (3). The hormonal changes accompanying the menstrual cycle, pregnancy, and the postpartum period are thought to be responsible for many headaches in women of reproductive age (4). Pregnant women with new headaches must be screened for Preeclampsia (5,6). Patients with abrupt onset of a severe unusual headache a so called thunderclap headache need prompt investigation to exclude Subarachnoid heamorrhage (SAH), cerebral venous thrombosis (CVT), reversible vasoconstrictive syndrome (RCVS) and posterior reversible encephalopathy syndrome (PRES) (7). Pregnant or post partum women with seizures can be grouped into three categories: first and most common, are patients with an established seizure disorder before pregnancy; second are patients with a new non pregnancy related seizure disorder, such as a new seizure from an undiagnosed brain tumour or hypoglycemia; third are patients with new seizures that are pregnancy related (caused by eclampsia, intracerebral heamorrhage (ICH), cerebral venous thrombosis (CVT), reversible vasoconstrictive syndrome (RCVS) or posterior reversible encephalopathy syndrome (PRES) (8). 2. RESULTS The study was carried out on three hundred and twenty patients classified into two groups, pregnant group (Two hundred Thirty two) and postpartum group (Eighty eight). As regard to age, residence, pregnancy stages and mode of delivery among pregnant and postpartum; there was statistically significant difference in age, pregnancy stages and mode of delivery between two groups (p<0.05) while there was no statistically differences in residence between two groups (p>0.05) (table 1). Table (1): Demographic data among pregnant and postpartum Variables No Pregnant, No.232 Postpartum, No.88 Total, No.320 P value Sig Less than 30 years 147(63.4%) 45 (51.1%) 192 (60%) Sig 30 years and more 85 (36.6%) 43 (48.9%) 128 (40%) Sig Urban 51 (22%) 21 (23.9%) 72 (22.5%) Not sig Rural 181 (78%) 67 (76.1%) 248(77.5%) Not sig 1st trimester 12 (5.2%) 0 12 (3.8%) 0.03 Sig 2nd trimester 155 (66.8%) 0 155(48.4%) Sig 3rd trimester 65 (28%) 0 65 (20.3%) Sig Normal delivery 29 (33%) 29 (9.1%) Sig Cesarean delivery 59 (67%) 59 (18.4%) Sig

3 As regard to initial presenting symptoms; there was statistically significant difference in headache (secondary headache as primary headache not emergency), seizures, motor, cranial nerves affection, disturbed conscious level (DCL), aphasia and International Annals of Medicine unsteady gait between two groups (p<0.05) but there was not statistically significant difference in sphincteric disturbances (unrinary retention) between two groups (p>0.05) (table 2). Table (2): Initial presenting symptoms amon pregnant and postpartum Variables, No Pregnant, No.232 Postpartum, No.88 Total P, value Sig Headache (secondary) 157 (67.2%) 48 (51.1%) 205(64%) Sig Seizures 51(22%) 41(46.6%) 92(28.8%) Sig Motor 14 (6%) 20 (22.7%) 34(10.6%) Sig Cranial nerves 16 (6.9%) 15 (17%) 31 (9.7%) Sig DCL 52(22.4%) 51(58%) 103(32%) Sig Aphasia 1 (0.4%) 3 (3.4%) 4 (1.3%) Sig Unstidness 2 (0.8%) 5 (5.7%) 7 (2.2%) Sig Sphincteric 1 (0.4%) 0 1 (0.3%) not sig As regard to risk factors; there was statistically significant difference in preeclampsia (preeclampsia is risk factor of 58 cases of eclamptic fits, 10 cases of PRES, 4cases of basal ganglia infarction, 2cases of thalamic infarction, 2cases of cerebellar infarction, 2cases of capsular infarction, 4cases of basal ganglia heamorrhage, 4cases of cerebellar heamorrhage and 1 case of subarachnoid heamorrhage), rheumatic heart disease (RHD is a risk for MCA occlusion), hypertension ( HTN is a risk factor of 1case of basal ganglia infarction and 1 case of cerebellar heamorrhage), diabetes mellitus (DM is a risk factor of 2cases of basal ganglia infarction, 1case of thalamic infarction and 1case of cerebellar infarction) and thrombophilia ( thromborhilia is a risk factor of 17 cases cerebral venous thrombosis) between two groups (p<0.05) and there was no statistically significant difference in decreased or stop antiepileptics (known epileptic) and systemic infections ( systemic infections are risk factor of 2cases of chorea gravidarum, 1case of viral encephalitis, 1case of transverse meylitis, 1case of guillian baree syndrome and 1case to multiple sclerosis) between two groups (p>0.05) (table 3). Table (3): Risk factors among pregnant and postpartum Variables, No Pregnant, No.232 Postpartum, No.88 Total, No.320 P value Sig Preclampsia 55(23.7% 32 (36.4%) 87(27.2%) Sig Eclampsia 4 (4.5%) 4 (1.3%) Sig R.H.D 1 (0.4%) 8 (9%) 9 (2.8%) Sig Thrombophilia 0 17 (19.3%) 17 (5.3%) Sig Hypertension 0 2 (2.3%) 2 (0.6%) Sig Diabetes 0 4 (4.5%) 4 (1.3%) Sig Stop anti epileptics 3 (1.3%) 0 3 (0.9%) Not sig (known epileptic) Systemic infections 4 (1.7%) 2 (2.3%) 6 (1.9%) Not sig As regard to final diagnosis; there was statistically significant difference in preeclampsia, strokes, sciatic neuropathy, P.R.E.S (posterior reversible encephalopathy syndrome), postdural puncture headache and multiple sclerosis between two groups (p<0.05) while there was no statistically significant difference in eclampsia, bell's palsy, trigeminal neuralgia, carbal tunnel syndrome, guillian baree' syndrome, idiopathic increased intracranial pressure, epileptic fits, idiopathic thrombotic thrombocytopenic purpura, transverse myelitis, chorea gravidarum, viral encephalitis and brain tumor (frontal meningeoma) between two groups (p>0.05).

4 Table (4): Final diagnosis among pregnant and postpartum Variables, No Pregnant, No.232 Postpartum, No.88 Total, No.320 P value Sig Preeclampsia 150 (64.7%) (46.9%) Sig Eclampsia 46 (19.8%) 14(13.6%) 60(18.8%) Not sig Stroke 4(1.7%) 43(48.9%) 47(14.7%) Sig PRES 0 10(11.4%) 10 (3.1%) Sig Postdural puncture headache 0 14 (15.9% 14 (4.4%) Sig Trigeminal neuralgia 6 (2.6%) 1 (1.1%) 6 (1.9%) Not sig Guillian barre syndrome 1 (0.4%) 0 1 (0.3%) Not sig Sciatic neuropathy 0 2 (2.3%) 2 (0.6%) Sig Epileptic fits 3 (1.3%) 0 3 (0.9%) Not sig Multiple sclerosis 0 3 (3.4%) 3 (0.9%) Sig Transverse myelitis 1 (0.4%) 0 1 (0.3%) Not sig IdiopathicI.I.C.P 3 (1.3%) 0 3 (0.9%) Not sig ITTP 0 1 (1.1%) 1 (0.3%) Not sig Chorea gravidarum 2 (.8%) 0 2 (0.6%) Not sig Viral encephalitis 1 (0.4%) 0 1(0.3%) Not sig Brain tumor 1 (0.4%) 0 1 (0.3%) Not sig Bell's palsy 6 (2.6%) 0 6 (1.9%) Not sig Cabral tunnel syndrome 8 (3.4%) 0 8 (2.5%) Not sig 3. DISCUSSION Acute neurological emergencies during pregnancy and postpartum were more common in rural than urban areas which is noticed in this study. This fact is proved by other investigators; Miguel et al., This may explained by law socioeconomic and educational level (10). According to initial presenting symptoms, we found that headache (Secondary) was more common in pregnant than postpartum groups with statistically significant differences between two groups. Thus we agree with Jonathan Edlow et al., 2013; Men-Jean Lee et al., 2016 who found the same result. This explained by Physiologic changes induced by pregnancy, The hormonal changes accompanying the pregnancy are thought to be responsible for many headaches (1,4). As regard to seizures, we found that headache was common in postpartum than pregnant groups with statistically significant differences between two groups. Thus we agree with Sidorov, Feng & Caplan, 2011 who found the same result. This explained by raised progesterone concentrations towards the end of pregnancy and postpartum periods, PRES, stop or lowering antiepileptics (2). According to risk factors, we found that preeclampsia was more common in pregnant than postpartum groups with statistically significant differences. Thus we agree with Kee-Hak Lim et al., 2016; Errol Norwitz et al., 2014.This explained by that preeclampsia occurs after 20 weeks' gestation and can present as late as 4-6 weeks post partum (11,12). As regard to rheumatic heart disease as risk factor, we found that R.H.D was more common in postpartum than pregnant groups with statistically significant differences. Thus we agree with Sahar Naderi & Russell Raymond, This explained by normal hemodynamic Changes During Pregnancy and postpartum (13). As regard to thrombophilia as risk factor, we found that thrombophilia was common in postpartum than pregnant groups with statistically significant differences. Thus we agree with Alyshah Abdul Sultan, This explained by women with preeclampsia/eclampsia, BMI >30 kg/m2, postpartum infection, having cesarean delivery, cardiac diseases, varicose veins, preterm and stillbirth. VTE risk remained elevated for 6 weeks postpartum (14). As regard to final diagnosis, we found that preeclampsia was more common in pregnant than postpartum groups with statistically significant differences. Thus we agree with Kee-Hak Lim et al., 2016; Errol Norwitz et al., 2014.This explained by

5 that preeclampsia occurs after 20 weeks' gestation and can present as late as 4-6 weeks post partum (11,12). Eclampsia was more common in pregnant than postpartum groups without statistically significant differences between two groups. We agree with Michael Ross, This explained by that eclampsia typically occurs during or after the 20th week of gestation or in the postpartum period (15). As regard to strokes, we found that strokes were more common in postpartum than pregnant groups with statistically significant differences between two gruops. We agree with Men-Jean Lee et al., 2014; Bateman et al., This explained by cesarean delivery, postpartum infections, preeclampsia/eclampsia, advanced maternal age, preexisting and gestational hypertension, coagulopathy, posterior reversible encephalopathy syndrome & postpartum cerebral angiopathy (4,16). As regard to postdural puncture headache, there was with statistically significant differences between two groups. We agree with Klein & Loder, 2010 who found the same result. This explained by low intracranial pressure due to a CSF leak and dural tears from labour-related pushing (17). As regard to multiple sclerosis, we found that multiple sclerosis occured in postpartum group with statistically significant differences between two groups. We agree with Salemi et al., 2004 Who claimed that the suppression of MS seen during pregnancy may be more potent than that achieved with currently available treatments (18). In this study, we found that epileptic fits occured in pregnant group without statistically significant differences between two groups. We agree with Aaron Caughey, Thomas Chih & Cheng Peng, This explained by the volume of distribution and the hepatic metabolism of AEDs are increased. This, along with decreased compliance with AEDs because of concerns about their effects on the fetus, stop or lowering antiepileptics leads to an increase in seizure frequency (19). In this study, we found that Idiopathic increased intracranial pressure occured in pregnant group without statistically significant differences between two groups. Thus we agree with Glueck, Aregawi, Goldenberg et al, 2005 This explained by thrombophilia and hypofinrinolysis seen in high estrogen condition as in pregnancy or obesity lead to thrombosis of arachnoid villi and reduced CSF absorption (20). 4. CONCLUSION Frequancy of acute neurological emergencies during pregnancy and postpartum in a sample of upper Egypt women were higher in patients whose age less than 30 years old and live in rural than patients whose age 30 years old or more and live in urban area. Headache and seizures are the commonest among initial presenting sysmptoms. Preeclampsia, thrombophilia and rheumatic heart disease are the commonest among risk factors. As regard to final diagnosis; preeclampsia, eclamptic fits and strokes are the commonest among final diagnosis. REFERENCES 1. Jonathan A Edlow, Louis R Caplan, Karen O Brienetal (2013). Diagnosis of acute neurological emergencies in pregnant andpostpartum women. Lancet Neurol; 12: Sidorov EV, Feng W, Caplan LR (2011). Stroke in pregnant and postpartum women. Expert Rev Cardiovasc Ther; 9: Ertresvg JM, Stovner LJ, Kvavik LE, et al (2007). Migraine aura or transient ischemic attacks? A five-year follow-up case-control study of women with transient central nervous system disorders in pregnancy. BMC Med; 5: Men-Jean Lee & Susan Hickenbottom (2016). Cerebrovascular disorders complicating pregnancy. uptodate. 5. Bushnell C, Chireau M (2011). Pre-eclampsia and stroke: risks during and after pregnancy. Stroke Res Treat; 2011: Steegers EA et al (2010). Preeclampsia. Lancet; 376: Schwedt (2006). Thunderclap headache. Lancet Neurol; 5: Laura A, Hart & Baha M et al., (2013). Seizures in pregnancy: Epilepsy, eclampsia, and stroke, Pages Stead LG (2011). Seizures in pregnancy/eclampsia. Emerg Med Clin North Am; 29: Miguel et al, Jose M, Ruby C et al (2012). Different neurological conditions between urban and rural samples from central Colombia. Journal of the neurological sciences. Volume 320, Issues 1-2, Pages Kee-Hak Lim MD, Ronald M & Ramus MD (2016). Preeclampsia. Uptodate. 12. Errol R Norwitz, John T Repke, Charles J Lockwood et al (2014). Preeclampsia: management and prognosis. Uptodate.

6 13. Sahar Naderi & Russell Raymond (2014). Pregnancy and Heart Disease. Cleveland clinic. 14. Alyshah Abdul Sultan, Matthew J. Grainge, Joe West et al (2014). Impact of risk factors on the timing of first postpartum venous thromboembolism: a population-based cohort study from England. Blood; 124(18): Michael G Ross (2016). Eclampsia. Uptodate. 16. Bateman BT, Schumacher HC, Bushnell CD et al (2006). Intracerebral hemorrhage in pregnancy: frequency, risk factors, and outcome. Neurology; 67: Klein AM &Loder E (2010). Postpartum headache. Int J ObstetAnesth; 19: Salemi G, Callari G, Gammino M et al (2004). The relapse rate of multiple sclerosis changes during pregnancy: a cohort study. ActaNeurol Scand;110 (1): Aaron Caughey B, Thomas Chih & Cheng Peng (2015). Seizure Disorders in Pregnancy. Uptodate. 20. Glueck CJ, Aregawi D, Goldenberg N et al (2005). Idiopathic intracranial hypertension, polycystic ovary syndrome and thrombophilia. Journal of laboratory clinical medicine. Vol. 145, No. 2, pp