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Movement disorders in women during pregnancy are uncommon. #link# Therefore, high quality studies are limited, and guidelines are lacking for the treatment of movement disorders in pregnancy, thus posing a significant therapeutic challenge for the treating physicians. In this chapter, we discuss movement disorders that arise during pregnancy and the preexisting movement disorders during pregnancy. Common conditions encountered in pregnancy include but are not limited to restless legs syndrome, chorea gravidarum, Parkinson disease, essential tremor, and Huntington disease as well as more rare movement disorders (Wilson's disease, dystonia, etc.). This chapter summarizes the published literature on movement disorders and pharmacologic and surgical considerations for neurologists and physicians in other specialties caring for patients who are pregnant or considering pregnancy.Many neuromuscular disorders preexist or occur during pregnancy. In some cases, pregnancy unmasks a latent hereditary disorder. Most available information is based on case reports or series or retrospective clinical experience or patient surveys. Of special interest are pregnancy-induced changes in disease course or severity and likelihood for baseline recovery of function postpartum. Labor and delivery present special challenges in many conditions that affect skeletal but not smooth (uterine) muscle; so labor complications must be anticipated. Anesthesia for cesarean section surgery requires special precautions in many disorders. The types of conditions reviewed are broad and include examples of autoimmune, hereditary, and compressive/mechanical processes. Disorders include carpal tunnel syndrome and other focal neuropathies, Bell palsy, myasthenia gravis, and other neuromuscular junction disorders, acute and chronic inflammatory neuropathy, hereditary and acquired muscle diseases, spinal muscular atrophy, amyotrophic lateral sclerosis, channelopathies, autonomic neuropathy, and dysautonomia. Many commonly used therapies have fetal animal but no proven human toxicity concerns, complicating treatment and risk decisions. Weaning off effective therapeutic agents or preemptive aggressive treatment or surgery prior to planned pregnancy is an option in some conditions.Migraine prevalence is three times higher in women than in men during fertile years, which is mainly due to sex hormone differences. The majority of women suffering from migraine without aura report improvement of their migraine attacks during pregnancy. link2 Migraine attacks with aura can also improve during pregnancy, but more often remain the same or worsen. Anovulation caused by lactation is generally associated with a decrease in migraine attacks in breastfeeding women. This chapter describes the current knowledge on acute and prophylactic treatment options of migraine and other primary headache disorders during pregnancy and lactation. Further, clinical profiles of secondary headaches during pregnancy and the postpartum period are summarized.Pregnancy is associated with a number of physiologic changes in the body including hormonal, anatomical, and mechanical. These changes alter many physiologic functions including sleep. The literature suggests that a number of women develop changes in duration, pattern, and quality of sleep during pregnancy. In addition, these changes also pave the way for expression of sleep disorders (e.g., insomnia, obstructive sleep apnea, and restless legs syndrome). Change in sleep and appearance of sleep disorders not only influence pregnant women, but also have negative influences on the fetus and outcomes of pregnancy. However, optimal management of these disorders may reverse adverse consequences. In this chapter, risk factors, clinical presentation, and management of insomnia, obstructive sleep apnea, and restless legs syndrome during pregnancy are discussed in view of the available literature.The management of epilepsy during pregnancy involves optimizing seizure control for the mother, while ensuring the best outcome for the developing fetus. Preconception counseling regarding contraception, folic acid, and antiseizure medications (ASMs) will maximize positive outcomes. Folic acid supplementation is recommended to decrease risk of neural tube defects, similar to the general population, and has been associated with improved cognitive outcomes and decreased risk of autistic traits in offspring. Efforts should be made to optimize the ASM regimen before pregnancy to the fewest number of ASMs, lowest effective doses, with avoidance of more teratogenic agents such as valproic acid. Valproic acid is associated with the highest increased risk of major congenital malformations, as well as reduced cognitive outcomes and neurodevelopmental disorders. Decreasing or changing ASMs during pregnancy should be done with caution, as convulsive seizures have been associated with adverse fetal outcomes including cognitive impairment. Physiologic changes during pregnancy affect ASM levels and in turn, risk for seizures, necessitating frequent monitoring of ASM serum concentrations. Mothers should also be counseled postpartum about how the benefits of breastfeeding outweigh the transmission of medication into breast milk. Communication between providers (obstetrics and neurology) and pregnant women with epilepsy is essential.While signs and symptoms of peripheral neuropathy may appear to be similar among all patients, further evaluation both at the bedside and beyond demonstrate distinct differences in the pattern of certain neuropathies. A working knowledge of these differences and of the available tools to distinguish them is quite useful to the clinician. This chapter provides an overview of the distinction among various neuropathy profiles. Focal neuropathies may occur from compression or from entrapment. Neurologic examination aids in anatomic localization, which further refines and directs electrodiagnostic and ultrasound testing. Subsequent therapeutic approaches vary depending on the location of the focal neuropathy. Focal neuropathy may occur outside of pregnancy but the outcome is more predictable in this situation.Pregnancy and the puerperium do not protect against acute psychiatric illness. During click here , the chance of acute psychiatric illness, such as a psychotic episode or relapse of bipolar disorder, is greatly increased. Suicide is a leading cause of maternal death. Both psychiatric disease and ongoing drug addiction impact not only the pregnant woman's somatic and mental health but also impact short-term and long-term health of the child. Indeed, prompt recognition and expeditious treatment of acute psychiatric illness during pregnancy and the puerperium optimize health outcomes for two patients. Pregnancy and puerperium represent a stage of life of great physiologic adaptations, as well as emotional and social changes. This conjunction of changes in somatic, emotional health and social health may mitigate the occurrence, clinical presentation, and clinical course of acute psychiatric illness and call for a multidisciplinary approach, taking into account both the medical and social domains. This chapter describes acute psychiatric illnesses during pregnancy and the puerperium and illicit substance abuse, from a clinical perspective, while also describing general principles of diagnosis and clinical management during this stage of life, which is an important window of opportunity for both the pregnant woman and the child.Pregnancy influences the course of neuroimmunologic conditions, which include multiple sclerosis (MS), neuromyelitis optica spectrum disorder, and autoimmune encephalitis. The outcomes differ significantly for each disorder, reflecting the impact of hormonal changes, T-cell subsets, and placental factors on disease pathogenesis. In recent years, numerous data have emerged regarding MS activity throughout pregnancy and postpartum. Historically, the misconception that pregnancy worsens MS outcomes led patients to abstain from childbearing. Now, more women with these disorders, empowered by up-to-date information and better baseline disease control, are choosing to conceive. Nevertheless, the management of MS and related disorders in the pregnancy and postpartum period is complicated and requires a nuanced approach. Since standardized treatment guidelines around pregnancy are currently lacking, neurologists, together with obstetricians, must engage patients in a shared decision-making process that weighs the benefits to the mother and risks to the fetus. This chapter outlines the pathophysiology of neuroimmunologic disorders during pregnancy and postpartum, the impact of these diseases on childbearing, including fertility, pregnancy, delivery, and peurperium, as well as existing recommendations for treatment.

A 59-year-old woman presented to the ED with syncope. She had progressive shortness of breath with minimal activity and precordial resting chest pain for 1month prior to presentation. She had a medical history of heart failure with preserved ejection fraction, severe OSA well controlled with CPAP of 11cm H

O, and a history of DVT and pulmonary embolism, diagnosed 10 years ago for which she was maintained on warfarin. The patient also had chronic myeloid leukemia in the chronic phase; she had initially been treated with imatinib but was later switched to dasatinib about 4.5 years prior to presentation. The patient had achieved major molecular remission with dasatinib 140mg daily. Her family history was noncontributory and specifically negative for pulmonary hypertension and heart failure. She had a history of smoking (50 pack years) but had quit 23 years ago.

A 59-year-old woman presented to the ED with syncope. She had progressive shortness of breath with minimal activity and precordial resting chest pain for 1 month prior to presentation. She had a medical history of heart failure with preserved ejection fraction, severe OSA well controlled with CPAP of 11 cm H2O, and a history of DVT and pulmonary embolism, diagnosed 10 years ago for which she was maintained on warfarin. The patient also had chronic myeloid leukemia in the chronic phase; she had initially been treated with imatinib but was later switched to dasatinib about 4.5 years prior to presentation. The patient had achieved major molecular remission with dasatinib 140 mg daily. Her family history was noncontributory and specifically negative for pulmonary hypertension and heart failure. She had a history of smoking (50 pack years) but had quit 23 years ago.

An 8-year-old boy was referred to our institution because of nausea and vomiting for 1day. He had also been experiencing shortness of breath for more than 1 year. This symptom had progressed so that he could no longer run or walk upstairs without chest discomfort. There was no associated fever, diarrhea, or coughing. He had a history of heart murmur that was diagnosed in another clinic 4 years ago. Echocardiogram 4 years prior suggested mild to moderate biatrial enlargement with trivial mitral valve regurgitation. He did not go in for any follow-up until this admission. He had no other associated diseases, nor use of medicine.

An 8-year-old boy was referred to our institution because of nausea and vomiting for 1 day. He had also been experiencing shortness of breath for more than 1 year. This symptom had progressed so that he could no longer run or walk upstairs without chest discomfort. link3 There was no associated fever, diarrhea, or coughing. He had a history of heart murmur that was diagnosed in another clinic 4 years ago.