Pseudotumor cerebri and pregnancy

A Narrative Review on Neuro-Ophthalmological Manifestations That May Occur during Pregnancy

AIM

As a medical condition, pregnancy mandates the simultaneous treatment of both the mother and the fetus, making it a distinctive aspect of clinical medicine.

MATERIAL AND METHOD

We analyze the physiological changes occurring in the eyes and brain during pregnancy, as well as the neuro-ophthalmological manifestations that can occur during pregnancy. Studies published in both English and other languages, case reports, and reviews from 2011 to 2023 onwards were included. All surveys were acquired by exploring the databases.

RESULTS

We found a total of 2135 articles that showcase neuro-ophthalmic changes related to pregnancy: review and research articles (Science Direct 804, Web of Science 923, Scopus 345, and 63 Pub Med). In total, 86 studies were examined after applying the inclusion and exclusion criteria. Bilateral papilledema can be a warning sign for intracranial hypertension or cerebral venous sinus thrombosis. Additionally, when unilateral, it is important to differentially diagnose anterior ischemic optic neuropathy secondary to a hypercoagulant, compressive or inflammatory optic neuropathy, optic neuritis, or even orbital pseudotumor state. Severe eclampsia and preeclampsia can manifest as choroidal infarction, serous retinal detachment, and even cortical blindness. There can also be implications at the level of cranial nerves or transient Horner syndrome.

CONCLUSIONS

Evaluating and treating a pregnant woman with neuro-ophthalmological manifestations is challenging. The obstetrician closely follows and has a medical relationship with the pregnant woman; hence he/she might be the first to be informed about the general condition of the pregnant woman or might request an ophthalmologic examination tailored to each specific case.

Management and Outcome of Pregnancy in Patients With Idiopathic Intracranial Hypertension: A Prospective Case Series Study

Background and Objectives

Idiopathic intracranial hypertension (IIH) is a syndrome of increased intracranial pressure without an identifiable cause that mostly affects obese persons of childbearing age. In this prospective case series, we have evaluated the overall outcome of pregnancy and birth in participants with IIH and their newborn children. We also provide a proposal for the management of pregnant persons with IIH.

Methods

In this observational study, neuro-ophthalmological findings, the course of IIH-related symptoms, disease management, and pregnancy outcomes were evaluated. The participants were divided into 3 groups according to the course of the disease during pregnancy: stable, worsened, and new diagnosed. Furthermore, the type of delivery and outcome of newborn children such as gestational age, weight at birth, and the presence of asphyxia were compared between the groups.

Results

We observed 47 pregnancies in 42 participants; 2 had spontaneous abortions. There were 19 (47%) participants in the stable, 18 (45%) in the worsened, and 3 (8%) in the new diagnosed groups, respectively. A relapse of IIH occurred in 2 (5%). Worsening of IIH-related symptoms was experienced by 18/37 (49%) participants: headache by 17/18 (94%), tinnitus by 11/18 (61%), and vision by 7/18 (39%) (mostly in the first and second trimester). In 8/18 (44%), the symptoms were transient or alleviated in the second and third trimester. Body mass index before and after pregnancy did not significantly differ among the groups. A total of 8 participants were treated with acetazolamide. The frequency of cesarean section was 17/40 (43%). Preterm delivery occurred in 22%. No increased risk of asphyxia was observed, and all infants, but one, were healthy.

Discussion

Worsening of headache, tinnitus, and/or vision were experienced by half of pregnant participants with IIH, mostly transient in the first and second trimester, rarely required specific treatment, and were not identified as a relapse of IIH. There was no difference in gestational age and weight at birth in children among the groups, and no perinatal asphyxia was noted. Weight gain in the participants was not identified as a risk factor for relapse of IIH in pregnancy. The rate of cesarean and preterm delivery was higher than in the non-IIH population. A proposal for the management of IIH in pregnancy is provided.

Pregnancy complicated by neurological and neurosurgical conditions - The evidence regarding mode of delivery

Neurological and neurosurgical conditions complicating pregnancy may precipitate considerable concern regarding the risk of complications, and uncertainty regarding the preferred mode of delivery and anaesthesia. Caesarean section is known to be associated with significantly increased risk of adverse maternal outcomes compared with vaginal delivery in healthy pregnancy. Nevertheless, a common perception exists among the general population and some health professionals that caesarean section is safer for the mother and baby in high-risk pregnancies. This manuscript examines the literature regarding the risks and outcomes related to mode of delivery in pregnancy complicated by disorders of the central nervous system. With the exception of women with raised intracranial pressure, and some women with Von Hippel-Lindau syndrome, the available evidence suggests that the mode of delivery should be based upon obstetric indications.

[Idiopathic intracranial hypertension and pregnancy. A report of two cases]

The authors describe two cases of idiopathic intracranial hypertension (IIH) during pregnancy. The first case was discovered in a 21-year-old primigravida at 15 weeks gestation and thereafter six evacuation lumbar punctures were necessary, and a treatment by acetazolamide, 1000mg/day, was prescribed until parturition. Labor was induced at 37 weeks for intrauterine growth retardation associated with oligohydramnios. The second patient, a 38-year-old tertigravida primipara presented clinical signs of IIH at 28 weeks gestation in the context of preterm labour after a suicide attempt by massive ingestion of venlafaxine. She was given an evacuation lumbar puncture and went into labour at 29 weeks, after tocolysis failure. The diagnosis of IIH is to be done only by exclusion, in front of a normal biological composition of the spinal fluid at lumbar puncture with increased opening pressure, and after a brain imaging excluding any expansive intracranial process or hydrocephaly. Obstetrical prognosis is usually favourable. The main complication of this pathology resides in the ocular impact. Outside pregnancy the risk factors of IIH which have been evoked are polycystic ovary syndromes and blood coagulation anomalies as thrombophilia or hypofibrinolysis. Treatment of this pathology should be medical in the first instance and surgical only in the case of resistance or for severe ocular involvement.

Pre-travel vaccination and medical prophylaxis in the pregnant traveler

BACKGROUND

Practitioners are often fearful of giving vaccinations and prophylactic medications to pregnant travelers. And yet pregnancy is often a time of heightened danger from travel-related infections and illnesses.

METHOD

Literature search and communication with researchers.

RESULTS

With a few exceptions, there is little systematic research regarding the use of prophylactic medications and vaccines during pregnancy. Case reports and small studies do, however, indicate an increased risk in pregnancy from many of the preventable illnesses, and there is some data to support the use of preventive measures.

CONCLUSIONS

The authors present some non-medical interventions that may be used to limit exposure to a number of disease processes. They then review the available information regarding the safety and efficacy of routine and travel-related vaccines as well as prophylactic medications for malaria, diarrhea, motion sickness and altitude sickness. When there are no obstetrical or medical contraindications, travel-related illness can usually be safely prevented during pregnancy in much the same ways as in the non-pregnant state.

Managing headache during pregnancy and lactation

Headache patterns for both primary and secondary headaches are often modified in women during pregnancy. Although approximately two thirds of women with migraines experience headache improvement during pregnancy; women who continue to suffer from migraine or other headaches during pregnancy need effective clinical care to include appropriate diagnostic studies, counseling about expectations during pregnancy and lactation, and modifications in therapeutic regimens to minimize risk to the fetus and nursing baby. This review describes the epidemiology of headache during pregnancy and lactation, to include both effects of these conditions on headache activity and possible concerns about how a maternal headache diagnosis may influence the course and outcome of pregnancy. Although restrictions in diagnostic testing and medication interventions are often necessary during pregnancy and breastfeeding, this review describes evaluation and management strategies that provide effective clinical care while minimizing risk to the developing baby.

The use of acetazolamide in idiopathic intracranial hypertension during pregnancy

PURPOSE

To describe the pregnancy outcomes after the use of acetazolamide in pregnant patients with idiopathic intracranial hypertension (IIH).

DESIGN

Observational case series.

METHODS

setting: Two tertiary care academic neuro-ophthalmology units. patient population: Patients with IIH treated with acetazolamide. observation procedure: Documentation of pregnancy outcome. main outcome measures: Normal pregnancy, fetal loss, or congenital malformation.

RESULTS

Twelve patients were treated with acetazolamide for IIH during pregnancy, and there were no adverse pregnancy outcomes. A critical review of the English language literature on the subject failed to demonstrate any convincing evidence for any adverse effect on pregnancy for acetazolamide.

CONCLUSIONS

Acetazolamide at high doses may produce birth defects in animals, but there is little clinical or experimental evidence to support any adverse effect of the drug on pregnancy outcomes in humans. If the clinical situation warrants the use of acetazolamide in IIH, then the drug probably can be offered after appropriate informed consent.

Medical and surgical management of idiopathic intracranial hypertension in pregnancy

Idiopathic intracranial hypertension (IIH) is a syndrome of increased intracranial pressure without hydrocephalus or mass lesion with elevated cerebrospinal fluid (CSF) pressure but otherwise normal CSF composition. It has been found that pregnancy occurs in IIH patients at about the same rate as in the general population, that IIH can occur in any trimester of pregnancy, that patients have the same spontaneous abortion rate as the general population, and that the visual outcome is the same as for nonpregnant patients with IIH. Although it is also stated that pregnant patients with IIH should be managed and treated the same way as any other patient with IIH, the use of imaging and drug contraindications do make a difference between the two groups. The treatment has two major goals, which are to preserve vision and to improve symptoms. The medical therapy includes weight control, nonketotic diet, serial lumbar punctures, diuretics, steroids, and certain analgesics. When medical therapy fails, surgical procedures should be considered. The two main procedures are optic nerve sheath fenestration and lumboperitoneal shunt. Anesthetic considerations in the pregnant patient are an additional factor when surgeries are contemplated. It is also noted that therapeutic abortion to limit progression of disease is not indicated and that subsequent pregnancies do not increase the risk of recurrence.

Headache in pregnancy

Headache is a frequent symptom in women of childbearing age and during pregnancy. Benign and pathologic headaches may change in response to changes in estrogen after conception. Expected patterns of change are described for headaches that occur commonly during pregnancy. In addition, although treatment options are limited during pregnancy, a variety of effective medication and nonmedication treatments are available and should be offered to women with benign headaches that persist into the second trimester of pregnancy.

Benign intracranial hypertension associated with the withdrawal of a non-ergot dopamine agonist

The cases are reported of two patients who developed benign intracranial hypertension after the withdrawal of the novel non-ergot derived dopamine agonist CV 205 502 (quinagolide).