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Parkinson’s in Pregnancy: Understanding an unusual clinical scenario

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This article has been written by Caitlin Young.  Caitlin is a final year medical student, working with Dr Kathryn Peall, an academic clinician from Cardiff University’s Movement Disorders Research Group.


As medical treatments improve, midwives are likely to see increasing numbers of pregnant women living with chronic conditions not related to pregnancy (1). From inflammatory bowel disease and rheumatoid arthritis to multiple sclerosis and epilepsy, healthcare providers are increasingly aware of the challenges that women with long-term health conditions face during pregnancy. In the UK and Australia, charities, advocacy groups, and health authorities have made progress in providing clinical guidance and improving understanding of chronic conditions in pregnancy. A clinical encounter with an expectant mother with Parkinson’s disease set in motion a project of our own…

Though Parkinson’s largely affects older people, 5 per cent of diagnoses are made in the under 40's, meaning the condition can occasionally affect women during child-bearing years (2). With limited data and systematic research, it’s difficult to estimate the number of women with Parkinson’s who become pregnant though most neurologists will only see 1 or 2 cases over the course of their careers.  

Since May 2018, we have been surveying women who have been pregnant since being diagnosed with Parkinson’s and gathering information from obstetricians, neurologists and midwives, with the aim of better understanding this rather unusual clinical scenario. The idea for our research was born out of a clinical encounter with a patient and the subsequent realisation that there are no guidelines as to the management of Parkinson’s in pregnancy and very little information for expectant mothers with the condition.

All pregnancies progress with a degree of uncertainty, though health providers and pregnant women with Parkinson’s must address additional complexities. Can pregnancy affect Parkinson’s symptoms? Could neurological symptoms affect pregnancy? Parkinson’s medication is vital for good control of motor symptoms; are these medications safe for use in pregnancy? How often should women visit their midwife? Should they receive medical input from obstetricians and neurologists too? With respect to birth planning, are there recommendations as to how a baby should be delivered? And after delivery; questions about breastfeeding, social and emotional support, and medication.

Fortunately, Parkinson’s itself appears to pose no risk to pregnancy, with no evidence to suggest higher rates of maternal or infant complications (2,3). There are several accounts in the literature of women with Parkinson’s who have had healthy babies, many by vaginal delivery (3-30). A particularly notable case report from Brazil describes 8 successful pregnancies in a mother first diagnosed with Parkinson’s at the age of just 36 years old (10). Most of the information we have about Parkinson’s in pregnancy comes from case reports recorded in the last 50 years or so. Whilst useful, it can be difficult to draw reliable conclusions from studies which are purely observational and gathered in such a range of countries, amongst heterogenous groups of women.

Recommendations surrounding the use of drugs to treat medical conditions would typically be made based on the findings of large-scale randomised controlled trials (RCTs). It would be unethical to run trials exposing pregnant women and unborn babies to drugs that are potentially unsafe. As such, there is very little clinical data to guide decisions surrounding the use of Parkinson’s medications in pregnancy and we again fall back on information from cases studies. In most case reports, expectant mothers have been exposed to some sort of Parkinson’s medication with no major complications (4-33). Though reassuring to some extent, the observational nature of research makes it impossible to draw firm conclusions as to the safety of Parkinson’s medication in pregnancy. Any mother with Parkinson’s is therefore faced with a difficult decision; withdraw from meds and face worsening neurological symptoms or continue medication and accept the unknown risk this may pose to their baby. By gathering as much information as possible from patients, doctors and midwives, we hope to begin to address some of these questions surrounding medication. We hope also to be able to provide more information about what women should expect in terms of Parkinson’s symptoms during pregnancy, and devise suggestions as to the provision and organisation of care during pregnancy, delivery and the post-partum period.

Case reports demonstrate powerfully that pregnancy and motherhood are a reality for some women with early-onset Parkinson’s. We aim to continue to gather evidence about Parkinson’s in pregnancy with the goal of eventually developing targeted clinical guidelines. If you are a midwife and would like to help us by completing our short electronic questionnaire, please follow the link below.

https://cardiff.onlinesurveys.ac.uk/parkinsons-in-pregnancy-midwifery-survey

Our survey takes no longer than 10 mins to complete and is entirely anonymous.  By gathering as much information as possible about Parkinson’s in pregnancy, we hope to improve the experiences of young women with Parkinson’s who are or plan to become pregnant.


References:

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3)       Kanter, A., & Klawans, A. (1939). Postencephalitic parkinsonism complicated by pregnancy. American Journal of Obstetrics and Gynaecology, 334-337

4)       Allain, H. et al. 1989. Pregnancy and Parkinsonism: A Case Report Without Problem. Clinical Neuropharmacology 12(3), pp. 217-219.

5)       Asha, B. et al. 2010. Successful birth of an IVF baby in a patient with Parkinson's disease. Journal of Human Reproductive Sciences 3(1), pp. 42-43. doi: 10.4103/0974-1208.63123

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