Neurological health in pregnancy is a pertinent topic for patients and practitioners. Pregnancy is a state of systemic change that can alter the risks and prognosis of certain conditions. Gestational diabetes is common in the United States, 7.8 percent of women who give birth are diagnosed with this condition. Gestational diabetes requires careful management to prevent adverse pregnancy outcomes such as preterm birth, excessive amniotic fluid, macrosomia (high gestational weight), and other conditions.
Gestational diabetes mellitus (GDM) is not strictly a neurological condition but presents possible neurologic complications such as neuropathy and impaired fetal brain development. Bell’s palsy is a neurological condition that can affect pregnant and non-pregnant patients. It causes facial nerve palsy or paralysis of the muscles that control blinking and smiling. This article aims to describe the management of these conditions in pregnant women.
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Overview of Neurological Health in Pregnancy
Physiological changes in pregnancy present the potential for certain conditions that may alter the health of the mother and fetus. Neurological health, in particular, should be managed carefully to prevent adverse pregnancy outcomes and long-term health. Neurological conditions that may arise during pregnancy include migraines, facial nerve palsy, cerebrovascular disease, and the exacerbation of existing neurological disease (e.g. multiple sclerosis). Pregnancy can present other neurological complications such as hemolysis, elevated liver enzymes, low platelets syndrome (HELLP), hypertension, and pre-eclampsia/eclampsia.
Understanding Bell’s Palsy in Pregnancy
Bell’s palsy is defined as palsy of the peripheral facial nerve. The facial nerve is cranial nerve seven and provides innervation for the musculature controlling facial expression, parts of the tongue, and the lacrimal gland. Inflammation of this nerve causes weakness and partial paralysis. Bell’s palsy is not uncommon in pregnancy and there appears to be an association between the two conditions. Most cases of Bell’s palsy (BP) in pregnancy occur in the later stages including the third trimester and after childbirth.
The exact cause of BP is not fully understood, but viral infections seem to be a major cause. Viral activation may cause inflammation of the nerve and interrupted blood flow. Echovirus, Herpes simplex virus, Epstein-Barr virus, Cytomegalovirus, HIV, and herpes are associated viral conditions. In pregnancy, BP may be more likely to develop due to edema (causing compression of the nerve), elevated cortisol levels, and hypercoagulability leading to thrombosis (blood clots).
High body mass index, hypertension, and pre-eclampsia are also risk factors for Bell’s palsy development in pregnancy. Clinical presentation is weakness of the facial muscles, often a drooping corner of the mouth, and weakness of the eyebrows and or forehead. The palsy can be unilateral or bilateral and there is a severity grading scale. Imaging is typically not indicated to diagnose BP and start treatment.
Managing Bell’s Palsy During Pregnancy
The mainstay of Bell’s palsy treatment is corticosteroids (often prednisolone) and antivirals (when indicated). Corticosteroid use in the first trimester of pregnancy is associated with a slight increase in cleft palate development risk, so many pregnant women are not treated with corticosteroids. Even without medication treatment, most cases of BP resolve within six months. The choice of whether or not to treat Bell’s palsy with medication in a pregnant patient involves a careful analysis of risk versus benefit for the patient and fetus. The use of acupuncture in Bell’s palsy patients is associated with some relief for facial nerve palsy and pain, but more evidence is needed to assess this treatment.
Multidisciplinary care can improve outcomes for pregnant patients with Bell’s palsy. If recovery is not progressing, referral to a facial palsy specialist may be indicated. Additionally, if the palsy is affecting one or both eyes, the patient should be referred to an ophthalmologist. Pregnant patients appear to have poorer recovery outcomes compared to non-pregnant patients.
The recovery prognosis for most non-pregnant patients is good, especially for younger patients. Timely intervention with steroids early in the condition is associated with better outcomes. Outcomes may be less optimistic for patients with hypertension and diabetes. Thorough treatment can prevent adverse outcomes such as eye dryness, vision loss, and inability to close the eye. Careful follow-up should be integrated, especially for pregnant patients to assess healing and the need for specialty referral.
Managing Gestational Diabetes
Dietary management of gestational diabetes (GD) is an important part of medical management. The goals of medical nutrition therapy are to normalize glucose levels, provide nutrients, prevent ketosis, support healthy pregnancy weight gain, and promote the health of the fetus. Many patients can achieve target blood glucose levels with physical activity and medical nutrition. Foods with a low glycemic index and high levels of fiber should be encouraged, and intake of processed foods should be limited.
Sugary beverages such as juice and soda should be limited and water encouraged. Whole grain intake appears to improve the body’s sensitivity to insulin. A well-planned nutritional intervention for gestational diabetes supports appropriate pregnancy weight gain while managing carbohydrate intake. Physical activity is an important component of managing gestational diabetes. Individuals with GD are encouraged to exercise 150 minutes per week (moderate activity) and no more than two days without exercise. Resistance exercise in particular can help prevent insulin sensitivity and strengthen bones and muscles. Any exercise program started by pregnant women should be carefully planned with their obstetrician to promote safety and take into account any obstetric restrictions.
Glucose monitoring is prescribed for most patients with GD and they are encouraged to track their values before breakfast and one or two hours after the beginning of a meal. Most patients with GD do not require continuous glucose monitoring. Insulin therapy may be indicated depending on blood glucose levels. The treatment of gestational diabetes with lifestyle interventions and insulin (when necessary) lowers the risk of shoulder dystocia, delivery via cesarean, preeclampsia, and high fetal birth weight. Preeclampsia is a severe obstetric complication and treating gestational diabetes decreases the risk of this condition.
Careful follow-up is essential in the care of gestational diabetes. Gestational diabetes increases the risk of type two diabetes, cardiovascular disease, and metabolic syndrome. Typical practice is the integration of a glucose tolerance test four to twelve weeks postpartum to monitor glucose response. Insulin needs may drastically reduce after delivery, so glucose levels require careful monitoring. Lifestyle interventions should be continued after delivery as tolerated, and metformin may be necessary to prevent further insulin resistance. Breastfeeding should be encouraged as it appears to reduce the risk of type two diabetes onset. A history of gestational diabetes prompts screening for glucose intolerance throughout the lifespan to promote early intervention.
The Intersection of Bell’s Palsy and Gestational Diabetes
The correlation between Bell’s palsy and gestational diabetes is still being studied, but there appears to be a link between the two conditions. Bell’s palsy is more common in individuals with diabetes and may be associated with poorer outcomes. A group of conditions called late pregnancy-associated disorders (LPADs) include gestational diabetes mellitus and may be linked to the onset of BP, which often occurs during late pregnancy. The exact correlation of these conditions is not known, but the link may be due to microvascular inflammation. A pregnant patient with gestational diabetes and Bell’s palsy requires careful management, often involving multidisciplinary care.
Psychological and Emotional Support
The emotional impact of neurological conditions in pregnancy cannot be understated. Pregnancy involves many changes and emotions for every woman, and an additional diagnosis can significantly increase stress levels. Identifying the psychosocial challenges a woman is undergoing is a first step. Her coping and support systems should also be discussed. Mental health challenges a woman may experience when diagnosed with a neurological condition during pregnancy may be socio-cultural, communication-based, health-care related, information-based, and challenges associated with medical interventions. Psychosocial support is vital for these women during pregnancy and the postpartum period. This support promotes the mental health of the mother but also supports adherence to treatment. A multidisciplinary approach is important involving obstetricians, mental health professionals, and social workers (when indicated). Integrative mental health can help identify the root causes of mental health challenges and provide solutions.
Future Directions and Research
Future directions in this field involve gathering more knowledge about the cause of Bell’s palsy. Currently, many cases of facial nerve palsy are idiopathic, but further knowledge about possible causes can aid in prevention and treatment. Much discussion and study have been invested in restoring facial movement and expression after Bell’s palsy. Viral causes and treatment are an important aspect of the ongoing management strategies for facial nerve palsy.
Many studies are ongoing about treating gestational diabetes most effectively and preventing adverse fetal outcomes. Because this condition can be very dangerous for both the fetus and mother, ongoing research about prevention and treatment is well worth the investment.
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Key Takeaways
Healthcare providers should understand the significance of prevention, screening, diagnosis, and management of neurological conditions in pregnancy. These diagnoses can cause significant physical and mental stress as well as reduce overall quality of life.
Early diagnosis, especially for conditions such as gestational diabetes, can prevent associated conditions such as preeclampsia and adverse fetal outcomes. Prompt diagnosis and treatment of Bell’s palsy can improve outcomes and speed recovery. For these and all conditions in pregnancy, supporting the overall well-being of the child and mother is the utmost priority.
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