Time is Making Fools of Us Again (J. K. Rowling)

Once again, it is my great pleasure to introduce this issue of Seminars in Neurology. It has been almost 5 years since the last edition on neurologic issues in pregnancy. I know the passing of this time well since my daughter was just born when I was working on the last edition. I wish I could tell you that there have been great strides in research on neurologic issues in pregnancy over the past 5 years. I wish that I could tell you which is the best antiepileptic drug for a pregnant woman, or if a postpartum migraine will recur in subsequent pregnancies, but according to J. K. Rowling, I am (we are) just fools. I wish I had more new information to report; as an alternative to that, most topics in this edition were not in the last. There are a few topics which are so commonly encountered in pregnant women (e.g., neuroimaging, headache, epilepsy), that I have included them again, but with a different focus (e.g., postpartum headache) and using case illustrations. Where possible, authors have presented cases to illustrate their topics. I have included colleagues who have an expertise in evaluating, diagnosing, and treating pregnant women, and I have asked participants from outside the neurologic world to contribute to encourage interdisciplinary collaborations. For all participants, I asked them to include a Resident or Fellow if possible to promote mentorship and to further interest in this area.

We cannot talk about pregnant women without discussing how to image them properly. With such technology available to make accurate diagnoses, it is important to understand the safety issues associated with exposure of the pregnant woman to CT or MRI. Drs. Joshua Klein and Liangge Hsu, both at the Brigham and Women's Hospital in Boston, have clearly presented neuroimaging practices and procedures in pregnancy and have chosen illustrative images. They emphasize the importance of using MRV in the pregnant population.

I am especially grateful to my obstetric anesthesia colleague, Dr. William Camann, who has taught me a great deal about anesthesia management of the pregnant patient. Dr Camann, Dr. Jeanne Carabeuna, and Dr. Laura Chang have written an outstanding review of what the neurologist needs to know about obstetric anesthesiology. The illustrations are excellent and the cases are typical of consultations that are called from the obstetric service. They beautifully dispel the myth that many postpartum complications are from the epidural.

Dr Luzma Cardona, who practices headache at the Faulkner Headache Center, and I wrote a targeted case series focusing on postpartum headache. We decided to focus on this period because from a neurologic standpoint, headache in the postpartum period has a broad differential, including benign primary headache diagnoses as well as concerning secondary causes of headache. We present our recommendations on headache evaluation and treatment. Given the lack of evidence on some of these more rare occurrences, there is no clear “correct” answer to many of our cases.

Because I liked the case-based format Dr. Cardona and I presented for headache, I replicated this for the epilepsy chapter. Given my experience with caring for and consulting on pregnant women with epilepsy, I chose the most frequently asked questions I have encountered over the years and answered them referencing the recent American Academy of Neurology guidelines for women with epilepsy, and then included comments on my own personal management style.

There are many interesting changes in sleep in women across the lifespan that Dr. Milena Pavlova and Dr. Lubna Sheikh have presented. They have done a thorough job discussing insomnia, restless legs, and obstructive sleep apnea in a case-based approach. Many pregnant women have trouble with sleep and there is definitely more to it than just the physical discomfort associated with pregnancy. In addition, as women go through menopause sleep becomes a major concern. I thank them for their thoughtfulness in including my own patients as examples.

Drs. Kelly Baldwin and Karen Roos have written a very informative discussion on neurologic infections in pregnant women. It is not often that one encounters infectious diseases of the nervous system in pregnancy but when they do occur, they are diseases not usually seen in immunocompetent patients. They have discussed two issues that many neurologists do not encounter often: antibiotic and antiviral safety during pregnancy and the effects of infections in the newborn. I am very grateful for Dr Roos participation given her busy schedule, and for sharing her knowledge on such a unique topic.

Musculoskeletal symptoms in pregnancy are incredibly common, and many people disregard them as a consequence of the changes of the pregnant physique. However, many of us do not know how to adequately evaluate them or recommend treatment for them. Drs. Joanne Borg-Stein, David Fogelman, and Kathryn Ackerman draw on their unique expertise to discuss this topic thoroughly. Their practical approach and emphasis on exercise in pregnancy is refreshing and incredibly useful for neurologists and obstetricians.

Dr. Edward Laws, who is a world-renowned neurosurgeon for pituitary tumors, and his nurse practitioner, Sherry Iuliano, have written a pertinent case-based approach to pituitary tumors in pregnancy. Neurologists are consulted on these patients due to the presenting symptoms of headache and visual field disturbances, but because many of these women do not go on to surgery, subsequent management is critical to ensure an uneventful delivery and proper hormonal balance.

For many neurologists, neurologic care of the pregnant woman is anxiety-provoking and a vast unknown. The authors included in this edition have a very unique skill set. I encourage you to take advantage of this information to better care for our pregnant patients. I thank all the contributing authors for their time and effort. Hopefully, in 5 years, we will have made great strides in “neuro-obstetrics.”

I especially want to thank Karen Roos and her colleagues at Thieme for asking me to be a Guest Editor again and for having infinite patience with me in producing this edition during my move to Pittsburgh.