Treatment of AVMs in nonpregnant patients is largely individualized. No consensus guides whether all accessible lesions should be resected. Factors include AVM symptoms; its anatomy and size; presence of an associated aneurysm, which is found in up to 60 percent of cases; and especially, prior A VM bleeding. Mter hemorrhage, the risk of recurrent bleeding in unrepaired lesions is 6 to 20 percent within the first year, and 2 to 4 percent per year thereater (Friedlander, 2007; Smith, 2015). The mortality rate with a bleeding AVM is 10 to 20 percent. In pregnancy, the decision to operate is usually based on neurosurgical considerations, and Friedlander (2007) recommends strong consideration for treatment if bleeding occurs. Because of the high risk of recurrent hemorrhage from an unresected or inoperable lesion, we favor cesarean delivery.
The demyelinating diseases are neurological disorders characterized by immune-mediated focal or patchy destruction of myelin sheaths accompanied by an inflammatory response. The degenerative diseases are multifactorial and are characterized by progressive neuronal death.
In the United States, multiple sclerosis (MS) is second only to trauma as a cause of neurological disability in middle adulthood (Hauser, 2015b). The disease afects women twice as often as men, and it usually begins in the 20s and 30s. he familial recurrence rate of MS is 15 percent, and the incidence in ofspring is increased IS-fold. Studying California deliveries, Fong and colleagues (2018) reported that 0.03 percent of deliveries were complicated by MS between 2001 and 2009.
The demyelinating characteristic of this disorder results predominately from T cell-mediated autoimmune destruction of oligodendrocytes that synthesize myelin. here is a genetic susceptibility and likely an environmental trigger such as exposure to certain bacteria and viruses. Of these, Chlamydophila pneumoniae, human herpesvirus 6, or Epstein-Barr virus are implicated (Frohman, 2006; Goodin, 2009).
There are four clinical types of MS: 1. Relapsing-remitting MS accounts for initial presentation in 85 percent of afected individuals. With it, unpredictable recurrent episodes of focal or multifocal neurological dysfunction usually are followed by full recovery. Over time, however, relapses lead to persistent deficits.
2.
Secondary progressive MS disease is relapsing-remitting disease that begins to pursue a progressive downhill course after each relapse. All patients likely develop this type eventually.
3.
Primary progressive MS accounts for 15 percent of cases.
With it, disability gradually progresses from the time of initial diagnosis.
4.
Progressive-relapsing MS refers to primary progressive vIS with apparent relapses.
Classic findings of MS include sensory loss, visual symptoms from optic neuritis, weakness, paresthesias, and a host of other neurological symptoms. Almost 75 percent of women with isolated optic neuritis develop MS within 15 years. Clinical diagnosis is confirmed by MR imaging and cerebrospinal fluid analysis. In greater than 95 percent of cases, MR imaging shows characteristic multifocal white matter plaques that represent discrete areas of demyelination (Fig. 60-4). Their appearance and extent are less helpful for predicting treatment response. Similarly, identification of serum antibodies against myelin oligodendrocyte glycoprotein and myelin basic protein is not predictive of recurrent disease activity (Kuhle, 2007).
Efects of Pregnancy