Preventive Approaches in Women's Neurology: Prepartum, Pregnancy, and Postpartum

Abstract

Women's neurology is the subspecialty within neurology concerned with the distinct healthcare needs of women. In this article, we review current literature and expert management strategies regarding disease-specific neurologic concerns of women, with an emphasis on issues related to contraception, pregnancy, and lactation. Health conditions that we discuss in this article include epilepsy, headache, stroke, multiple sclerosis, and Chiari I malformation. Current findings on neurologic disease in women suggest that many women with neurologic disease can safely manage their disease during pregnancy and have healthy children, though pregnancy planning is important in many conditions to mitigate risks and effective contraceptive management is important when pregnancy prevention is desired.

Keywords

women's neurology - pregnancy - contraception - breastfeeding - preeclampsia

Publication History

Accepted Manuscript online:
10 October 2022

Article published online:
17 November 2022

• References

• 1 Bialer M, Doose DR, Murthy B. et al. Pharmacokinetic interactions of topiramate. Clin Pharmacokinet 2004; 43 (12) 763-780
• 2 Crawford P. Interactions between antiepileptic drugs and hormonal contraception. CNS Drugs 2002; 16 (04) 263-272
• 3 Heaney D, Walker MC. Rufinamide. Drugs Today (Barc) 2007; 43 (07) 455-460
• 4 Highlights of prescribing information (Clobazam). Deerfield: Lundbeck. [updated February 2021]. Lundbeck. Accessed October 15, 2022 at: https://www.lundbeck.com/content/dam/lundbeck-com/americas/united-states/products/neurology/onfi_pi_us_en.pdf
• 5 Cannabidiol and Oral Contraceptive Pills. Exploring a Drug-Drug Interaction. Bethesda: U.S. National Library of Medicine. [updated April 2022, cited June 2022]. U.S. National Library of Medicine. Accessed October 15, 2022 at: https://clinicaltrials.gov/ct2/show/NCT04396730
• 6 Herzog AG, Mandle HB, Cahill KE, Fowler KM, Hauser WA. Predictors of unintended pregnancy in women with epilepsy. Neurology 2017; 88 (08) 728-733
• 7 Decker BM, Acton EK, Davis KA, Willis AW. Inconsistent reporting of drug-drug interactions for hormonal contraception and antiepileptic drugs - implications for reproductive health for women with epilepsy. Epilepsy Behav 2021; 114 (Pt 0A): 107626
• 8 Lazorwitz A, Davis A, Swartz M, Guiahi M. The effect of carbamazepine on etonogestrel concentrations in contraceptive implant users. Contraception 2017; 95 (06) 571-577
• 9 Dutton C, Mody S, Nippita S. et al. A pilot study to evaluate the interaction of enzyme-inducing antiseizure medications with depot medroxyprogesterone acetate. Poster presented at: Society of Family Planning Annual Meeting (virtual meeting); October 9–10, 2020
• 10 Bounds W, Guillebaud J. Observational series on women using the contraceptive Mirena concurrently with anti-epileptic and other enzyme-inducing drugs. J Fam Plann Reprod Health Care 2002; 28 (02) 78-80
• 11 Mandle HB, Cahill KE, Fowler KM, Hauser WA, Davis AR, Herzog AG. Reasons for discontinuation of reversible contraceptive methods by women with epilepsy. Epilepsia 2017; 58 (05) 907-914
• 12 Sabers A, Ohman I, Christensen J, Tomson T. Oral contraceptives reduce lamotrigine plasma levels. Neurology 2003; 61 (04) 570-571
• 13 Gaffield ME, Culwell KR, Lee CR. The use of hormonal contraception among women taking anticonvulsant therapy. Contraception 2011; 83 (01) 16-29
• 14 Tomson T, Battino D, Bonizzoni E. et al; EURAP Study Group. Comparative risk of major congenital malformations with eight different antiepileptic drugs: a prospective cohort study of the EURAP registry. Lancet Neurol 2018; 17 (06) 530-538
• 15 Veroniki AA, Cogo E, Rios P. et al. Comparative safety of anti-epileptic drugs during pregnancy: a systematic review and network meta-analysis of congenital malformations and prenatal outcomes. BMC Med 2017; 15 (01) 95
• 16 Hernández-Díaz S, McElrath TF, Pennell PB, Hauser WA, Yerby M, Holmes LB. North American Antiepileptic Drug Pregnancy Registry. Fetal growth and premature delivery in pregnant women on antiepileptic drugs. Ann Neurol 2017; 82 (03) 457-465
• 17 Meador KJ, Baker GA, Browning N. et al; NEAD Study Group. Fetal antiepileptic drug exposure and cognitive outcomes at age 6 years (NEAD study): a prospective observational study. Lancet Neurol 2013; 12 (03) 244-252
• 18 Christensen J, Grønborg TK, Sørensen MJ. et al. Prenatal valproate exposure and risk of autism spectrum disorders and childhood autism. JAMA 2013; 309 (16) 1696-1703
• 19 Teramo K, Hiilesmaa V, Bardy A, Saarikoski S. Fetal heart rate during a maternal grand mal epileptic seizure. J Perinat Med 1979; 7 (01) 3-6
• 20 Vinten J, Adab N, Kini U, Gorry J, Gregg J, Baker GA. Liverpool and Manchester Neurodevelopment Study Group. Neuropsychological effects of exposure to anticonvulsant medication in utero. Neurology 2005; 64 (06) 949-954
• 21 Chen YH, Chiou H-Y, Lin H-C, Lin H-L. Affect of seizures during gestation on pregnancy outcomes in women with epilepsy. Arch Neurol 2009; 66 (08) 979-984
• 22 Tomson T, Battino D, Bromley R. et al. Executive summary: management of epilepsy in pregnancy: a report from the International League Against Epilepsy Task Force on Women and Pregnancy. Epilepsia 2019; 60 (12) 2343-2345
• 23 Pennell PB, French JA, May RC. et al; MONEAD Study Group. Changes in seizure frequency and antiepileptic therapy during pregnancy. N Engl J Med 2020; 383 (26) 2547-2556
• 24 Meador K, Pennell P, May R. et al. Effects of periconceptual folate on cognition in children of women with epilepsy: NEAD study. Neurology 2020; 94: 729-740 . Available at: https://pubmed.ncbi.nlm.nih.gov/31871217/
• 25 Management issues for women with epilepsy – focus on pregnancy: vitamin K, folic acid, blood levels, and breastfeeding. Minneapolis: American Academy of Neurology. 2009 [updated July 2013, cited June 2022]. Accessed October 15, 2022 at: https://www.aan.com/Guidelines/home/GuidelineDetail/335
• 26 Zhang YY, Song CG, Wang X. et al. Clinical characteristics and fetal outcomes in women with epilepsy with planned and unplanned pregnancy: a retrospective study. Seizure 2020; 79: 97-102
• 27 Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2012; 129 (03) e827-e841
• 28 Johnson EL, Burke AE, Wang A, Pennell PB. Unintended pregnancy, prenatal care, newborn outcomes, and breastfeeding in women with epilepsy. Neurology 2018; 91 (11) e1031-e1039
• 29 Birnbaum AK, Meador KJ, Karanam A. et al; MONEAD Investigator Group. Antiepileptic drug exposure in infants of breastfeeding mothers with epilepsy. JAMA Neurol 2020; 77 (04) 441-450
• 30 Veiby G, Bjørk M, Engelsen BA, Gilhus NE. Epilepsy and recommendations for breastfeeding. Seizure 2015; 28: 57-65
• 31 Burch R. Epidemiology and treatment of menstrual migraine and migraine during pregnancy and lactation: a narrative review. Headache 2020; 60 (01) 200-216
• 32 Øie LR, Kurth T, Gulati S, Dodick DW. Migraine and risk of stroke. J Neurol Neurosurg Psychiatry 2020; 91 (06) 593-604
• 33 Calhoun AH. Hormonal contraceptives and migraine with aura – is there still a risk?. Headache 2017; 57 (02) 184-193
• 34 Sheikh HU, Pavlovic J, Loder E, Burch R. Risk of stroke associated with use of estrogen containing contraceptives in women with migraine: a systematic review. Headache 2018; 58 (01) 5-21
• 35 Headache Classification Committee of the International Headache Society (HIS). The international classification of headache disorders, 3rd edition. Cephalalgia 2018; 38: 1-211
• 36 Maasumi K, Tepper SJ, Kriegler JS. Menstrual migraine and treatment options. Headache 2017; 57 (02) 194-208
• 37 Hu Y, Guan X, Fan L, Jin L. Triptans in prevention of menstrual migraine: a systematic review with meta-analysis. J Headache Pain 2013; 14: 7
• 38 Sances G, Martignoni E, Fioroni L, Blandini F, Facchinetti F, Nappi G. Naproxen sodium in menstrual migraine prophylaxis: a double-blind placebo controlled study. Headache 1990; 30 (11) 705-709
• 39 Al-Waili NS. Treatment of menstrual migraine with prostaglandin synthesis inhibitor mefenamic acid: double-blind study with placebo. Eur J Med Res 2000; 5 (04) 176-182
• 40 Negro A, Delaruelle Z, Ivanova TA. et al; European Headache Federation School of Advanced Studies (EHF-SAS). Headache and pregnancy: a systematic review. J Headache Pain 2017; 18 (01) 106
• 41 U.S. Food and Drug Administration. FDA Recommends avoiding use of NSAIDS in pregnancy at 20 weeks or later because they can result in low amniotic fluid. U.S. Food and Drug Administration. Accessed June 16, 2022 at: https://www.fda.gov/drugs/drug-safety-and-availability/fda-recommends-avoiding-use-nsaids-pregnancy-20-weeks-or-later-because-they-can-result-low-amniotic#:~:text=The%20U.S.%20Food%20and%20Drug,the%20baby%20and%20possible%20complications
• 42 Servey J, Chang J. Over-the-counter medications in pregnancy. Am Fam Physician 2014; 90 (08) 548-555
• 43 Alemany S, Avella-García C, Liew Z. et al. Prenatal and postnatal exposure to acetaminophen in relation to autism spectrum and attention-deficit and hyperactivity symptoms in childhood: meta-analysis in six European population-based cohorts. Eur J Epidemiol 2021; 36 (10) 993-1004
• 44 Liew Z, Yuan Y, Meng Q. et al. Prenatal exposure to acetaminophen and childhood asthmatic symptoms in a population-based cohort in Los Angeles, California. Int J Environ Res Public Health 2021; 18 (19) 10107
• 45 Childress K, Dothager C, Gavard JA, Lebovitz S, Laska C, Mostello D. Metoclopramide and diphenhydramine: a randomized controlled trial of treatment for headache in pregnancy when acetaminophen is ineffective. Am J Perinatol 2018; 35: 1281-1286
• 46 Pasternak B, Svanström H, Mølgaard-Nielsen D, Melbye M, Hviid A. Metoclopramide in pregnancy and risk of major congenital malformations and fetal death. JAMA 2013; 310 (15) 1601-1611
• 47 Gilboa SM, Ailes EC, Rai RP, Anderson JA, Honein MA. Antihistamines and birth defects: a systematic review of the literature. Expert Opin Drug Saf 2014; 13 (12) 1667-1698
• 48 Burch R. Headache in pregnancy and the puerperium. Neurol Clin 2019; 37 (01) 31-51
• 49 Ephross SA, Sinclair SM. Final results from the 16-year sumatriptan, naratriptan, and treximet pregnancy registry. Headache 2014; 54 (07) 1158-1172
• 50 Browne ML, Van Zutphen AR, Botto LD, Louik C, Richardson S, Druschel CM. Maternal butalbital use and selected defects in the national birth defects prevention study. Headache 2014; 54 (01) 54-66
• 51 Makrides M, Crosby DD, Bain E, Crowther C. Magnesium supplementation in pregnancy. Cochrane Database Syst Rev 2004; 2014: CD000937 . Available at: https://pubmed.ncbi.nlm.nih.gov/24696187/
• 52 Wu Y, Yao J-W, Xu L-J, Chen M, Wan L. Risk of congenital malformations in offspring of women using β-blockers during early pregnancy: an updated meta-analysis of observational studies. Br J Clin Pharmacol 2021; 87 (03) 806-815
• 53 Bateman BT, Patorno E, Desai RJ. et al. Late pregnancy beta blocker exposure and risks of neonatal hypoglycemia and bradycardia. Pediatrics 2016; 138 (03) e20160731
• 54 Sadovsky E, Pfeifer Y, Polishuk WA, Sulman FG. The use of antiserotonin-cyproheptadine HCL in pregnancy: an experimental and clinical study. Adv Exp Med Biol 1972; 27: 399-405
• 55 Holland S, Silberstein SD, Freitag F, Dodick DW, Argoff C, Ashman E. Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012; 78 (17) 1346-1353
• 56 Govindappagari S, Grossman TB, Dayal AK, Grosberg BM, Vollbracht S, Robbins MS. Peripheral nerve blocks in the treatment of migraine in pregnancy. Obstet Gynecol 2014; 124 (06) 1169-1174
• 57 Wong H-T, Khalil M, Ahmed F. OnabotulinumtoxinA for chronic migraine during pregnancy: a real world experience on 45 patients. J Headache Pain 2020; 21 (01) 129
• 58 Baigi K, Stewart WF. Headache and migraine: a leading cause of absenteeism. Handb Clin Neurol 2015; 131: 447-463
• 59 Skajaa N, Szépligeti SK, Xue F. et al. Pregnancy, birth, neonatal and postnatal neurological outcomes after pregnancy with migraine. Headache 2019; 59 (06) 869-879
• 60 Tanos V, Raad EA, Berry KE, Toney ZA. Review of migraine incidence and management in obstetrics and gynaecology. Eur J Obstet Gynecol Reprod Biol 2019; 240: 248-255
• 61 Robbins MS, Farmakidis C, Dayal AK, Lipton RB. Acute headache diagnosis in pregnant women: a hospital-based study. Neurology 2015; 85 (12) 1024-1030
• 62 O'Neal MA. Headaches complicating pregnancy and the postpartum period. Pract Neurol 2017; 17 (03) 191-202
• 63 Mol BWJ, Roberts CT, Thangaratinam S, Magee LA, de Groot CJM, Hofmeyr GJ. Pre-eclampsia. Lancet 2016; 387 (10022): 999-1011
• 64 Eunice Kennedy Shriver National Institute of Child Health and Human Development. Pre-eclampsia and eclampsia. Accessed June 16, 2022: https://www.nichd.nih.gov/health/topics/preeclampsia
• 65 Turbeville HR, Sasser JM. Preeclampsia beyond pregnancy: long-term consequences for mother and child. Am J Physiol Renal Physiol 2020; 318 (06) F1315-F1326
• 66 Bartsch E, Medcalf KE, Park AL, Ray JG. High Risk of Pre-eclampsia Identification Group. Clinical risk factors for pre-eclampsia determined in early pregnancy: systematic review and meta-analysis of large cohort studies. BMJ 2016; 353: i1753
• 67 American College of Obstetricians and Gynecologists Committee on Obstetric Practice and Society for Maternal-Fetal Medicine. AGOC committee opinion #743: low-dose aspirin use during pregnancy. Obstet Gynecol 2018; 132 (01) e44-e52
• 68 U.S. Preventive Services Task Force. Aspirin use to prevent pre-eclampsia and related morbidity and mortality. JAMA 2021; 326: 1186-1191 . Available at: https://pubmed.ncbi.nlm.nih.gov/34581729/
• 69 Rolnik DL, Wright D, Poon LC. et al. Aspirin versus placebo in pregnancies at high risk for pre-term pre-eclampsia. N Engl J Med 2017; 377 (07) 613-622
• 70 Altman D, Carroli G, Duley L. et al; Magpie Trial Collaboration Group. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet 2002; 359 (9321): 1877-1890
• 71 Lucas MJ, Leveno KJ, Cunningham FG. A comparison of magnesium sulfate with phenytoin for the prevention of eclampsia. N Engl J Med 1995; 333 (04) 201-205
• 72 The Eclampsia Trial Collaborative Group. Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial. Lancet 1995; 345 (8963): 1455-1463
• 73 Redman EK, Hauspurg A, Hubel CA, Roberts JM, Jeyabalan A. Clinical course, associated factors, and blood pressure profile of delayed-onset postpartum preeclampsia. Obstet Gynecol 2019; 134 (05) 995-1001
• 74 Roach REJ, Helmerhorst FM, Lijfering WM, Stijnen T, Algra A, Dekkers OM. Combined oral contraceptives: the risk of myocardial infarction and ischemic stroke. Cochrane Database Syst Rev 2015; 8 (08) CD011054
• 75 Lima ACS, Martins LCG, Lopes MVO. et al. Influence of hormonal contraceptives and the occurrence of stroke: integrative review. Rev Bras Enferm 2017; 70 (03) 647-655
• 76 Dulicek P, Ivanova E, Kostal M. et al. Analysis of risk factors of stroke and venous thromboembolism in females with oral contraceptive use. Clin Appl Thromb Hemost 2018; 24 (05) 797-802
• 77 Swartz RH, Cayley ML, Foley N. et al. The incidence of pregnancy-related stroke: a systematic review and meta-analysis. Int J Stroke 2017; 12 (07) 687-697
• 78 Camargo EC, Feske SK, Singhal AB. Stroke in pregnancy: an update. Neurol Clin 2019; 37 (01) 131-148
• 79 Dicpinigaitis AJ, Sursal T, Morse CA. et al. Endovascular thrombectomy for treatment of acute ischemic stroke during pregnancy and the early postpartum period. Stroke 2021; 52 (12) 3796-3804
• 80 Leffert LR, Clancy CR, Bateman BT. et al. Treatment patterns and short-term outcomes in ischemic stroke in pregnancy or postpartum period. Am J Obstet Gynecol 2016; 214 (06) 723.e1-723.e11
• 81 Nana M, Morgan H, Moore S, Lee ZX, Ang E, Nelson-Piercy C. Antiplatelet therapy in pregnancy: A systematic review. Pharmacol Res 2021; 168: 105547
• 82 National Library of Medicine (US). Drugs and Lactation Database (LactMed). 2006 Accessed June 16, 2022 at: https://www.ncbi.nlm.nih.gov/books/NBK501922/
• 83 McLintock C. Anticoagulant therapy in pregnant women with mechanical prosthetic heart valves: no easy option. Thromb Res 2011; 127 (Suppl. 03) S56-S60
• 84 Dias MS, Sekhar LN. Intracranial hemorrhage from aneurysms and arteriovenous malformations during pregnancy and the puerperium. Neurosurgery 1990; 27 (06) 855-865 , discussion 865–866
• 85 Miller EC, Sundheim KM, Willey JZ, Boehme AK, Agalliu D, Marshall RS. The impact of pregnancy on hemorrhagic stroke in young women. Cerebrovasc Dis 2018; 46 (1-2): 10-15
• 86 Kim YW, Neal D, Hoh BL. Cerebral aneurysms in pregnancy and delivery: pregnancy and delivery do not increase the risk of aneurysm rupture. Neurosurgery 2013; 72 (02) 143-149 , discussion 150
• 87 Kleinloog R, de Mul N, Verweij BH, Post JA, Rinkel GJE, Ruigrok YM. Risk factors for intracranial aneurysm rupture: a systematic review. Neurosurgery 2018; 82 (04) 431-440
• 88 Barbarite E, Hussain S, Dellarole A, Elhammady MS, Peterson E. The management of intracranial aneurysms during pregnancy: a systematic review. Turk Neurosurg 2016; 26 (04) 465-474
• 89 Ogilvy CS, Stieg PE, Awad I. et al; Special Writing Group of the Stroke Council, American Stroke Association. AHA Scientific Statement: recommendations for the management of intracranial arteriovenous malformations: a statement for healthcare professionals from a special writing group of the Stroke Council, American Stroke Association. Stroke 2001; 32 (06) 1458-1471
• 90 Ferro JM, Canhão P, Stam J, Bousser M-G, Barinagarrementeria F. ISCVT Investigators. Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke 2004; 35 (03) 664-670
• 91 Cho S, Lee MJ, Chung C-S. Effect of nimodipine treatment on the clinical course of reversible cerebral vasoconstriction syndrome. Front Neurol 2019; 10: 644
• 92 Cappelen-Smith C, Calic Z, Cordato D. Reversible cerebral vasoconstriction syndrome: recognition and treatment. Curr Treat Options Neurol 2017; 19 (06) 21
• 93 Davis RL, Eastman D, McPhillips H. et al. Risks of congenital malformations and perinatal events among infants exposed to calcium channel and beta-blockers during pregnancy. Pharmacoepidemiol Drug Saf 2011; 20 (02) 138-145
• 94 Houtchens MK, Zapata LB, Curtis KM, Whiteman MK. Contraception for women with multiple sclerosis: guidance for healthcare providers. Mult Scler 2017; 23 (06) 757-764
• 95 Langer-Gould AM. Pregnancy and family planning in multiple sclerosis. Continuum (Minneap Minn) 2019; 25 (03) 773-792
• 96 Confavreux C, Hutchinson M, Hours MM, Cortinovis-Tourniaire P, Moreau T. Pregnancy in Multiple Sclerosis Group. Rate of pregnancy-related relapse in multiple sclerosis. N Engl J Med 1998; 339 (05) 285-291
• 97 Kaplan S, Zeygarnik M, Stern T. Pregnancy, fetal, and infant outcomes following maternal exposure to glatiramer acetate during pregnancy and breastfeeding. Drug Saf 2022; 45 (04) 345-357
• 98 Herbstritt S, Langer-Gould A, Rockhoff M. et al. Glatiramer acetate during early pregnancy: a prospective cohort study. Mult Scler 2016; 22 (06) 810-816
• 99 Gold R, Phillips JT, Havrdova E. et al. Delayed-release dimethyl fumarate and pregnancy: preclinical studies and pregnancy outcomes from clinical trials and postmarketing experience. Neurol Ther 2015; 4 (02) 93-104
• 100 Waters JFR, OʼNeal MA, Pilato M, Waters S, Larkin JC, Waters JH. Management of anesthesia and delivery in women with Chiari I malformations. Obstet Gynecol 2018; 132 (05) 1180-1184
• 101 Knafo S, Picard B, Morar S. et al. Management of Chiari malformation type I and syringomyelia during pregnancy and delivery. J Gynecol Obstet Hum Reprod 2021; 50 (03) 101970