SWARAJ HOSPITAL & RESEARCH INSTITUTE
BOLANGIR, ODISHA • OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES
Clinician Reference Infographic
Neurological Disorders in Pregnancy — Seizures, Stroke & Neuromuscular Disease
Neurological disorders in pregnancy range from benign headache to eclampsia, stroke, and epilepsy. This guide covers seizures, headache, stroke, multiple sclerosis, myasthenia gravis, other conditions, and delivery planning, using the BRAIN approach.
ЁЯОп AT A GLANCE — THE NERVOUS SYSTEM AND PREGNANCY
Neurological symptoms in pregnancy are common; most are benign (headache, carpal tunnel, Bell's palsy), but a few are emergencies — eclampsia, stroke, cerebral venous thrombosis
Pregnancy and the first 6 weeks after delivery raise the risk of stroke, and change the course of epilepsy, migraine, multiple sclerosis, and myasthenia gravis
New seizure, severe headache, or focal deficit with hypertension is eclampsia or posterior reversible encephalopathy (PRES) until proved otherwise
Neurologist and obstetrician together, a planned delivery, and safe drug choices give good outcomes in most women
Do not stop essential medicines (antiseizure drugs, immunosuppressants, pyridostigmine) without specialist advice — uncontrolled disease usually harms the baby more than the drug.
ЁЯЧ║️ THE PATHWAY AT A GLANCE
1 · AssessABC, blood pressure, glucose, gestation, and a focused neurological exam
2 · ExcludePre-eclampsia and eclampsia first: BP, urine protein, platelets, liver tests
3 · ImageMRI (without gadolinium) preferred; CT with shielding if urgent
4 · TreatSeizure control, anticoagulation, steroids, or surgery by diagnosis
5 · PlanMedicines, timing and mode of delivery, anaesthesia
6 · Follow upPostpartum relapse watch, newborn care, breastfeeding, and contraception
⚡ ECLAMPSIA — SEIZURES WITH PRE-ECLAMPSIA
| Topic | Details |
|---|---|
| Features | Generalised seizure with hypertension and usually proteinuria; headache, visual disturbance, or epigastric pain often come first; up to a third occur postpartum (most within 48 hours) |
| Magnesium sulfate — Pritchard regimen | 4 g IV over 5–10 minutes plus 10 g IM (5 g in each buttock); then 5 g IM every 4 hours in alternate buttocks for 24 hours after the last seizure or delivery |
| Magnesium sulfate — Zuspan (IV) regimen | 4 g IV loading, then 1 g/hour IV for 24 hours (can reach 2 g/hour) |
| Monitor before each dose | Knee jerks present, respiratory rate at least 16/min, urine output at least 30 mL/hour (100 mL in 4 hours) |
| Toxicity | Loss of reflexes, respiratory depression: stop magnesium and give calcium gluconate 1 g (10 mL of 10%) IV over 10 minutes |
| Blood pressure | Labetalol 20 mg IV (then 40, 80 mg), nifedipine 10 mg orally, or hydralazine 5 mg IV; aim for about 140–150/90–100 |
| Delivery | Stabilise first, then deliver; mode by obstetric indication |
| Do not assume eclampsia if | Focal deficit, onset before 20 weeks, more than 48 hours after delivery, or no hypertension, or seizures recur on magnesium — do neuroimaging (PRES, venous thrombosis, haemorrhage) |
ЁЯза EPILEPSY IN PREGNANCY
| Issue | Advice |
|---|---|
| Seizure frequency | Unchanged in about 60–70%, worse in 15–30% (missed doses, sleep loss, vomiting, falling drug levels); over 90% of women have a normal baby |
| Before conception | Review the drug, aim for monotherapy at the lowest effective dose; folic acid 5 mg daily (4–5 mg), started before conception |
| Drug choice | Lamotrigine and levetiracetam have the lowest malformation risk; carbamazepine is moderate; valproate (about 10% malformations, lower IQ, autism) should be avoided; topiramate, phenytoin, phenobarbital carry higher risk |
| Do not | Stop or switch drugs after conception unless advised by the neurologist |
| Drug levels | Lamotrigine levels fall by up to 50% (also levetiracetam): check levels or adjust to seizures; reduce the dose again within 2 weeks of delivery |
| Antenatal care | Detailed anomaly scan at 18–20 weeks; sleep, adherence, and safety advice (bathing, baby care) |
| Newborn | Vitamin K 1 mg IM at birth (routine); breastfeeding is encouraged with most antiseizure drugs |
| Seizure in labour | Lorazepam 4 mg IV or diazepam; continue regular drugs; caesarean for obstetric reasons only |
| Contraception | Enzyme-inducing drugs (carbamazepine, phenytoin, phenobarbital, topiramate) reduce the pill's effect — use intrauterine devices or injectables; oestrogen lowers lamotrigine levels |
Status epilepticus (seizure over 5 minutes or repeated): airway, oxygen, IV lorazepam 4 mg, then levetiracetam or fosphenytoin; obstetric review for fetal distress; deliver if unresponsive.
ЁЯдХ HEADACHE IN PREGNANCY
| Cause | Clues | Management |
|---|---|---|
| Migraine | Throbbing, one-sided, nausea, aura; often improves in the 2nd and 3rd trimester; may flare after delivery | Paracetamol first; metoclopramide; sumatriptan if needed; propranolol or amitriptyline for prevention; avoid NSAIDs after 20 weeks, ergotamine, valproate, topiramate |
| Tension-type headache | Band-like, no nausea | Paracetamol, rest, hydration, relaxation |
| Pre-eclampsia or PRES | Headache with hypertension, visual change, seizures | BP control, magnesium sulfate, delivery |
| Cerebral venous thrombosis | Progressive headache, seizures, focal signs, papilloedema; peak 2–3 weeks postpartum | MRI with venography; therapeutic low-molecular-weight heparin (even with haemorrhagic infarct) |
| Subarachnoid haemorrhage | Thunderclap headache, neck stiffness | CT, then angiography; neurosurgery or endovascular coiling; nimodipine |
| Idiopathic intracranial hypertension | Obesity, daily headache, papilloedema, visual loss | Visual fields; weight control; acetazolamide (after the first trimester); therapeutic lumbar puncture |
| Meningitis, pituitary apoplexy, and others | Fever, rash; or sudden visual loss with hormone failure | Lumbar puncture and antibiotics; endocrine and neurosurgical care |
Red-flag headache (SNOOP): Systemic signs, Neurological signs, Onset sudden or after 20 weeks, Older or new pattern, Papilloedema or positional — image, don't just treat.
ЁЯзм STROKE IN PREGNANCY AND THE PUERPERIUM
| Topic | Details |
|---|---|
| Risk | About 3 times higher during pregnancy and the first 6 weeks; highest around delivery and postpartum |
| Causes | Pre-eclampsia and eclampsia, cerebral venous thrombosis, cardioembolism (peripartum cardiomyopathy, valve disease), reversible cerebral vasoconstriction syndrome, PRES, aneurysm or arteriovenous malformation, antiphospholipid syndrome, sickle cell disease, thrombotic microangiopathy, and drugs |
| Imaging | MRI (diffusion) and MR venography without gadolinium; CT head is acceptable if urgent (abdominal shielding) |
| Ischaemic stroke | Alteplase and thrombectomy may be considered in selected women (weigh bleeding risk); aspirin 75–150 mg after haemorrhage is excluded |
| Haemorrhage | Control blood pressure; neurosurgical review; reverse anticoagulation; deliver for obstetric reasons |
| Venous thrombosis | Therapeutic LMWH, continue for at least 6 weeks postpartum |
| Prevention | Control BP, treat pre-eclampsia, thromboprophylaxis where indicated |
ЁЯЫб️ MULTIPLE SCLEROSIS AND MYASTHENIA GRAVIS
| Condition | In pregnancy | Management |
|---|---|---|
| Multiple sclerosis (MS) | Relapses fall by about 70% in the 3rd trimester and rise in the first 3 months postpartum; no effect on fertility or fetal outcome | Acute relapse: IV methylprednisolone 1 g daily for 3–5 days; interferon beta and glatiramer are acceptable; stop teriflunomide (washout), fingolimod, cladribine, mitoxantrone before conception; natalizumab or ocrelizumab only with specialist advice; vaginal delivery and epidural are safe |
| Myasthenia gravis | Unpredictable: worse in about a third; crisis risk postpartum | Continue pyridostigmine, prednisolone, azathioprine; IVIG or plasma exchange for exacerbation; avoid magnesium sulfate (worsens weakness) — use levetiracetam for eclampsia if needed; avoid aminoglycosides, macrolides, quinolones, beta-blockers; assist the second stage |
| Neonatal myasthenia | 10–20% of babies; onset at 1–4 days, lasts weeks | Neonatal unit monitoring for feeding, breathing, and tone; pyridostigmine if needed |
| Guillain–Barr├й syndrome | Ascending weakness, areflexia; often after infection | IVIG or plasma exchange; respiratory and bulbar monitoring; vaginal delivery is possible |
| Bell's palsy | More common in the 3rd trimester and the first week postpartum | Prednisolone 50 mg daily for 10 days within 72 hours; eye protection; exclude stroke and pre-eclampsia; most recover |
| Carpal tunnel syndrome | Night hand numbness from fluid retention | Wrist splints; steroid injection if severe; resolves after delivery |
| Spinal cord injury | Autonomic dysreflexia above T6 (severe hypertension, headache, sweating) | Epidural analgesia prevents it; treat pressure sores and UTI |
ЁЯФН OTHER NEUROLOGICAL CONDITIONS TO KNOW
| Condition | Key points |
|---|---|
| Brain and pituitary tumours | Meningiomas and prolactinomas can enlarge in pregnancy; visual field checks; cabergoline or bromocriptine for prolactinoma; surgery in the second trimester if needed |
| Neurocysticercosis (common in India) | New seizures, headache; MRI; antiseizure drugs; delay albendazole until after delivery unless severe; steroids for oedema |
| Cerebral malaria and meningitis | Fever with altered consciousness; IV artesunate for severe malaria; antibiotics and lumbar puncture for meningitis; tuberculous meningitis treated with standard anti-tuberculosis drugs and steroids |
| Wernicke encephalopathy | Confusion, ataxia, eye signs with prolonged vomiting (hyperemesis); thiamine 100–500 mg IV before glucose |
| Hypoglycaemia and eclampsia mimics | Check capillary glucose in every convulsing or unconscious woman |
| Anaesthesia | Epidural and spinal are safe in most neurological diseases; avoid with raised intracranial pressure or active infection; document the neurological status first |
ЁЯПе DELIVERY, NEWBORN AND AFTER BIRTH
Delivery planning: birth in a unit with neurology and neonatal care; mode by obstetric indication in most conditions; shorten the second stage (forceps or ventouse) in myasthenia, raised intracranial pressure, and unclipped aneurysm
Continue antiseizure and immunosuppressive drugs in labour; give them intravenously if she is vomiting or nil by mouth
Newborn: vitamin K; watch for neonatal myasthenia, antiseizure drug withdrawal, and hypoglycaemia
Postpartum: relapse risk (MS, myasthenia), seizure risk with sleep loss, migraine flare, and stroke or venous thrombosis in the first 6 weeks
Breastfeeding: encouraged with most antiseizure drugs, pyridostigmine, prednisolone, azathioprine, and interferon beta; avoid breastfeeding on certain MS drugs
Safety counselling: bathe the baby with someone present, feed sitting down, and keep medicines regular
⚠️ COMMON PITFALLS
Calling every seizure in a pregnant woman 'epilepsy' or 'eclampsia' without checking blood pressure, glucose, and imaging
Using valproate or stopping antiseizure drugs because of pregnancy, or missing the fall in lamotrigine levels
Giving magnesium sulfate to a woman with myasthenia gravis without a plan
Missing cerebral venous thrombosis in a postpartum woman with headache and seizures; withholding heparin for fear of haemorrhage
Ignoring thunderclap headache or treating postpartum headache as a post-dural puncture headache without excluding other causes
Memory Aid
BRAIN
Five rules for neurological disease in pregnancy.
B
Blood pressure first — seizure or headache with hypertension is eclampsia until proved otherwise; give magnesium sulfate
R
Red flags and imaging — thunderclap, focal signs, onset after 20 weeks or after delivery: MRI
A
Antiseizure drugs — lamotrigine or levetiracetam, folic acid 5 mg, no valproate; check levels
I
Immune disease — MS and myasthenia: continue treatment; avoid magnesium in myasthenia; watch postpartum relapse
N
Newborn and next steps — vitamin K, neonatal myasthenia, breastfeeding, contraception, and follow-up
Remember: exclude pre-eclampsia, image early, choose safe drugs, plan delivery, and watch the 6 weeks after birth.
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