This issue of CONTINUUM is dedicated to the memory of Dr Autumn Klein, whose too-short career was devoted to the care of pregnant women with neurologic disease and to the education of neurologists—and other physicians who care for women of childbearing age—about these critically important and complex neurologic issues that can impact both the mother and her child. As the guest editor of this issue, Dr Klein carefully planned and organized these topics and invited this group of expert authors to inform us about the current and optimal diagnosis and management of the variety of neurologic disorders that can affect women during pregnancy and the postpartum period.
The issue begins with an overview by Drs Riley Bove and Joshua Klein of the considerations involved in the neuroradiologic investigation of women who are pregnant or breast-feeding. This article provides an important introduction to the diagnostic issues involved in nearly all of the subsequent articles with regard to the risks and benefits of the various imaging modalities available to us and their current role in our diagnostic armamentarium in these settings. Next, Dr Patricia Coyle discusses multiple sclerosis in pregnancy and the postpartum state, an issue that we deal with frequently given the prevalence of multiple sclerosis in women of childbearing age. This comprehensive review will provide readers with a very current understanding of the issues regarding risk of relapse and current recommendations regarding the role, or lack thereof, of acute and preventive therapy in these settings. Dr Cynthia Harden then discusses the commonly encountered issue of epilepsy and pregnancy. All clinicians who care for women with seizure disorders who are of childbearing age will benefit from the very practical, thorough, and up-to-date analysis she provides to guide us in our management of these patients.
Drs Steven Feske and Aneesh Singhal discuss the cerebrovascular disorders that may complicate pregnancy. In this article, the authors thoroughly review ischemic and hemorrhagic strokes that may be associated with pregnancy and provide us with an expert discussion of preeclampsia/eclampsia, the posterior reversible encephalopathy syndrome (PRES), and the reversible cerebral vasoconstriction syndrome (RCVS); their state-of-the-art review will help us recognize and manage these overlapping syndromes. Next, Drs E. Wayne Massey and Amanda Guidon review the diagnosis and management of peripheral neuropathies in pregnancy. These authors provide a thorough discussion of the diagnosis and management of the variety of cranial neuropathies, radiculopathies, mononeuropathies, and polyneuropathies that can occur coincident with, or as a consequence of, pregnancy or delivery. The next article, by Drs Janice Massey and Carolina De Jesus-Acosta, is devoted to the specific neuromuscular disease of myasthenia gravis, which may complicate—or even occasionally present in—pregnancy. We will benefit from their expertise, which we can emulate as we counsel and manage our patients with this potentially life-threatening, but treatable, neuromuscular disease.
Dr E. Anne MacGregor provides her expertise to help us counsel and manage our pregnant patients with primary headache disorders, as well as to recognize and manage those secondary headache disorders—some of which may carry significant morbidity and mortality if not recognized and treated expeditiously—that may occur in association with (and in some cases as a consequence of) pregnancy or the postpartum state. Drs Janis Miyasaki and Amaal AlDakheel discuss the movement disorders that may occur in pregnant women. In their thorough review, these authors provide their approach to the counseling, diagnosis, and management of patients whose movement disorders may specifically arise during pregnancy (such as restless legs syndrome and chorea gravidarum), as well as to the many management issues that arise among patients with preexisting movement disorders who become pregnant. In the final review article of this issue, Drs Kathleen Digre and Krista Kinard review neuro-ophthalmic disorders that may occur in association with pregnancy. These authors provide us with their very practical symptom- and finding-based approach to the diagnosis and management of the neuro-ophthalmic disorders that can affect vision and eye movements, whether caused by, or just coincident with, pregnancy.
In this issue’s Ethical Perspectives section, Drs Bethanie Morgan-Followell, Jacqueline Nicholas, and Pedro Weisleder carefully analyze the complex ethical considerations involved in the counseling of a postpartum breast-feeding woman with multiple sclerosis in regard to the timing of restarting disease-modifying therapy. In the Practice section, Dr Joseph Kass shares his neurologic and legal expertise by providing practical case examples involving epilepsy and pregnancy to illustrate several issues involved in mitigating legal risk as we provide our highest level of care to pregnant patients with neurologic disease. Finally, Drs Mark Yerby and Laura Powers outline the issues involved in coding of the pregnant patient with neurologic disease, including a focus on specific considerations related to coding of the pregnant patient with epilepsy.
As with every CONTINUUM issue, a number of opportunities exist for CME. If you need to earn credits specifically approved by the American Board of Psychiatry and Neurology (ABPN) for self-assessment, submit your answers to the multiple-choice questions in the Self-Assessment Pretest crafted by Drs Eduardo Benarroch and Ronnie Bergen before you read the issue; review your results to better tailor your learning needs; and then complete the Postreading CME Test after reading the issue. By doing so you may earn up to 12 AMA PRA Category 1 CME CreditsTM toward self-assessment. Alternatively, you may wish to receive credits toward CME only, in which case, reading the issue and submitting the Postreading CME Test will allow you to earn up to 10 AMA PRA Category 1 CME Credits. The Patient Management Problem, written by Dr Riley Bove, involves the management of a woman presenting to the emergency department with neurologic symptoms in her third trimester of pregnancy. By following her case and answering multiple-choice questions corresponding to important diagnostic and therapeutic decision points along the rest of her pregnancy and delivery (reinforcing many of the issues discussed in the previous articles), you will have the opportunity to earn up to 2 AMA PRA Category 1 CME Credits.
I would like to give my special and sincere gratitude to Drs Steven Feske and Riley Bove, who provided their valuable time and considerable expertise in assisting in the editing of this issue and in bringing Dr Klein’s volume to fruition after her passing. My special thanks also to each of the contributors to this issue, who accepted Dr Klein’s invitation to impart their expertise to our readers and whose outstanding contributions serve as a lasting tribute to her memory.
All of us on the editorial staff of CONTINUUM are honored to have been able to work with Dr Klein during the planning and creation of this issue, through which each of us and our patients can continue to benefit from the knowledge and dedication of this remarkable physician.
—Steven L. Lewis, MD, FAAN