FREQUENCY OF NEUROLOGICAL DISORDERS DURING

PREGNANCY AND PUERPERIUM

Principal Investigator: Dr. Ayesha Farooq

Resident, Neurology

Training program: FCPS

RTMC # NEU-2023-059-814

Sir Ganga Ram Hospital Lahore

Supervisor: Dr. Faheem Saeed

MBBS, FCPS

Assistant Professor

Head of Department, Department of Neurology

Sir Ganga Ram Hospital Lahore

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INTRODUCTION

Pregnant and postpartum women experiencing acute neurological symptoms pose a critical

concern, necessitating diagnostic and therapeutic approaches that also account for the

newborn's well-being. The pathogenic mechanisms stem from hormonal shifts unique to non-

pregnant, pregnant, and postpartum states. Elevated estrogen levels contribute to increased

production of coagulation factors, elevating the risk of thromboembolism 1. Normal

pregnancy is marked by increased concentrations of factors VII, VIII, and X, von Willebrand

factor, and fibrinogen, alongside reduced levels of free protein S. Simultaneously, expanded

plasma and blood volume are factors influencing elevated pressure values and hypertension

development.2

Increased progesterone concentration in late pregnancy tends to increase venous wall

distention and the risk of small-vessel arterial bleeding. In the postpartum period, on the other

hand, there is a drop in high estrogen levels. These alterations can result in changes in brain

bioelectric activity and/or cerebral circulation, causing seizures, transient or permanent

cerebral ischemia, intraparenchymal or subarachnoid cerebral hemorrhage and cerebral

3, 4
venous thrombosis. Multidisciplinary approach in a tertiary care center improves both

maternal and fetal outcomes.5

In 2020, Gupta M conducted a study published in the International Journal focusing on

females during pregnancy or post-delivery. This studied reported that neurological diseases

contribute to 20% of maternal deaths. Among primary neurological disorders the prevalence

of cerebrovascular accidents was found to be highest (33.3%) followed by epilepsy

(32%) ,central nervous system infection (14.7%), neuropathy (2.7%) while that among

secondary neurological disorder was of Hepatic encephalopathy (92%). Majority (68%) had

recovery while 15% of women had residual deficit. There were 17 (17%) cases of maternal

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mortality. Additionally, miscellaneous neurological disorders collectively accounted for

5.3% of the cases studied.6

Rationale of this study is to assess the frequency of neurological disorders during pregnancy

and puerperium. Literature showed that the chances of neurological disorders are high after

delivery and even during pregnancy. But conflicting data has been retrieved from literature,

and also lack of local evidence noticed in local literature. Therefore, we have planned this

study to find the more appropriate and beneficial evidence in favor of post-pregnancy

Neuroradiology imaging and in order to timely diagnose the neurological disorders and

prevent further deterioration and complications of neurological disorders. This will help us to

improve our knowledge and practice and in future, we will implement findings of this study

in local setting.

OBJECTIVE:

To assess the frequency of neurological disorders during pregnancy and puerperium

OPERATIONAL DEFINITION:

The study aims to ascertain the incidence of neurological disorders

including epilepsy, cerebrovascular accidents, neuropathy, central system nervous infections,

metabolic encephalopathy and other related conditions during pregnancy and puerperium.

This will involve using Neuro-radiological imaging and to review and analyze diagnostic

results from neuro imaging (CT, MRI and MR venography) within a specified timeframe.

MATERIAL AND METHODS

Study Design: This study will be descriptive study.

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Settings: Department of Neurology, Sir Ganga Ram Hospital, Lahore

Duration of study: Six months after approval of synopsis

Sample Size: By using WHO calculator, sample size of 175 cases is calculated with 5%

margin of error and percentage of cerebrovascular accidents i.e. 33.3% in females.7

Sampling Technique: Non-probability, consecutive sampling

Sample Selection

Inclusion Criteria

1. Females of age between 20-40 years of age

2. Both pregnant and delivered females

Exclusion Criteria:

1. ASA score IV or coma

2. Females diagnosed with eclampsia (BP≥140/90 mmHg along with convulsions)

3. Women in whom MRI is contraindicated as those with claustrophobia, prosthetic

cardiac valve etc.

Data Collection Procedure:

After receiving approval from the ethical review board, we will enroll 175 females who meet

the eligibility criteria from both outpatient (OPD) and inpatient admissions. Written informed

consent will be secured from each participant. Bio-demographic details, including name, age,

gestational age, parity, Body Mass Index (BMI), education, occupation, residence,

socioeconomic status, and booking status, will be documented. Following this, females

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presenting with neurological signs and symptoms during pregnancy and the postpartum

period will be assessed using neuroradiology imaging and routine investigations. This

approach aims to ascertain the frequency of various neurological disorders, such as epilepsy,

cerebrovascular accidents, central nervous system infections, neuropathy, metabolic

encephalopathy, and others, in accordance with our operational definition. All data collected

will be systematically recorded in the proforma provided.

Data analysis: All the data will be entered and analyzed using SPSS 26. Normality will be

checked by applying Shapiro-Wilk test. Quantitative data like age, gestational age, BMI, will

be presented by the mean and standard deviation. Qualitative data, like parity, education,

occupation, residence, socioeconomic status, booking status, neurological disorder will be

presented by frequency and percentages. Stratification will be done based on age, gestational

age, BMI, parity, education, occupation, residence, socioeconomic status, booking status.

Post-stratification, Chi-Square test will be applied to compare neurological disorder in

stratified groups. P-value ≤ 0.05 will be taken as significant.

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REFERENCES

1. Abou-Ismail MY, Sridhar DC, Nayak L. Estrogen and thrombosis: a bench to bedside
review. Thrombosis research. 2020;192:40-51.
2. Lucia M, Viviana M, Alba C, Giulia DO, Carlo DR, Grazia PM, et al. Neurological
Complications in Pregnancy and the Puerperium: Methodology for a Clinical Diagnosis.
Journal of Clinical Medicine. 2023;12(8):2994.
3. Roeder HJ, Lopez JR, Miller EC. Ischemic stroke and cerebral venous sinus
thrombosis in pregnancy. Handbook of clinical neurology. 2020;172:3-31.
4. Bano S, Farooq MU, Nazir S, Aslam A, Tariq A, Javed MA, et al. Structural imaging
characteristic, clinical features and risk factors of cerebral venous sinus thrombosis: A
prospective cross-sectional analysis from a tertiary care hospital in Pakistan. Diagnostics.
2021;11(6):958.
5. Giliyar S, Kanavi JV, Thomas A. Neurological Disorders Complicating Pregnancy
and its Obstetric Outcomes. Int J Infertil Fetal Med. 2023;14(2):60-4.
6. Gupta M, Pradeep Y, Singh R, Shrivastava PK. A study of neurological disorders in
pregnancy and puerperium. International Journal of Reproduction, Contraception, Obstetrics
and Gynecology. 2020;9:4236+.
7. Gupta M, Pradeep Y, Singh R, Shrivastava P. A study of neurological disorders in
pregnancy and puerperium. International Journal of Reproduction, Contraception, Obstetrics
and Gynecology. 2020;9(10):4236-45.

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 PROFORMA

Frequency of neurological disorders during pregnancy and puerperium

Case NO: MR Number: Date:

Name: Age:

Gestational age: Parity:

BMI:

Education: Occupation:

Residence: Rural □ Urban □ Semi-urban □

Socioeconomic status:Low □ Middle □ High □

Neuroradiological imaging;

Epilepsy □ cerebrovascular accidents □ central nervous system infection□

Neuropathy □ metabolic encephalopathy □ others □