Chorea gravidarum: a case report

Chorea gravidarum: Case report and review of the literature

OBJECTIVE

To present a case of chorea gravidarum and conduct a review of the published literature on the treatment for this condition, and on maternal and fetal prognosis.

METHODS

Case presentation of a 16-year-old primiparous patient admitted to a Level III public hospital at 8 weeks of gestation complaining of involuntary head and limb movements and right lower limb hyperreflexia lasting three days. The patient had a history of Sydenham chorea. Treatment with antipsychotics and benzodiazepines was given to manage symptoms, and with benzathine penicillin to address the etiology, achieving control at 14 weeks. Treatment was discontinued at 35 weeks and the patient went on to have normal delivery at 39 weeks. A search was conducted in the Medline via PubMed, UptoDate, Medscape and Google Scholar databases using the terms "Pregnancy and Chorea Gravidarum". The search was limited to case reports and case series or review articles published between 2000 al 2019.

RESULTS

Seven case reports and one review of the topic were found. In 4 of the 7 cases, treatment was based on haloperidol, benzodiazepines and chlorpromazine. Penicillin was used in one of two cases with a history of Sydenham chorea. Maternal and fetal prognosis was good in 6 of 7 cases, there was 1 case of intrauterine growth restriction.

CONCLUSIONS

Treatment of gestation chorea is primarily expectant and the goal is to reduce symptoms. Maternal and fetal prognosis is good.

Rheumatologic manifestations of pregnancy

Pregnancy, whether normal or complicated, induces change in nearly every system of the body. Because most rheumatologic disorders are multisystemic and often affect young women, it may be difficult to differentiate pregnancy-related change from new onset or exacerbation of rheumatic disease. Familiarity with common manifestations of pregnancy is important in evaluating young women of childbearing age,whether or not they have known rheumatologic disease. Presentation of new connective tissue disease during pregnancy is often associated with poorer prognosis, so it is especially important to distinguish between pregnancy-induced change and true autoimmune inflammation requiring prompt and aggressive therapy.

Consecutive pregnancy with chorea gravidarum associated with moyamoya disease

Chorea gravidarum is uncommon movement disorder of pregnancy, characterized by involuntary, abrupt, non-rhythmic movements. It can be idiopathic or secondary to the underlying pathology. A 28-year-old, primigravida woman who was 8 weeks and 6 days of gestation presented with a history of involuntary choreiform movements in the left side limbs and facial twitch for 2 weeks. The symptoms started just after onset of severe emesis gravidarum. There was no meaningful medical history or family history, and she was taking no regular medication. Magnetic resonance imaging of the brain revealed moyamoya disease. The symptoms, as well as the hyperemesis gravidarum, improved with gestational age; however, they were sustained up to 30 weeks of gestation. She delivered 2.61 kg, healthy male neonate at 40 weeks' pregnancy by vaginal delivery under epidural analgesia. After 3 years later, she got pregnant again, and delivered at 41 weeks of pregnancy without complication. She experienced similar but milder symptoms to that of the first pregnancy until the late second trimester. After the delivery, full evaluation was lost due to her refusal. In this report, we present the case of a patient with chorea gravidarum in which moyamoya disease acts as an etiologic factor and a review of literature with management proposal.

Seminar on choreas

Chorea is one of the major types of involuntary movement disorders originating from dysfunctional neuronal networks interconnecting the basal ganglia and frontal cortical motor areas. The syndrome is characterised by a continuous flow of random, brief, involuntary muscle contractions and can result from a wide variety of causes. Diagnostic work-up can be straightforward in patients with a positive family history of Huntington's disease or acute-onset hemichorea in patients with lacunar stroke, but it can be a challenging and complex task in rare autoimmune or genetic choreas. Principles of management focus on establishing an aetiological classification and, if possible, removal of the cause. Preventive strategies may be possible in Huntington's disease where genetic counselling plays a major part. In this review we summarise the current understanding of the neuroanatomy and pathophysiology of chorea, its major aetiological classes, and principles of diagnostic work-up and management.