Bell's palsy in pregnancy: underlying HELLP syndrome or pre-eclampsia?

Abstract

Bell's palsy is not uncommon during pregnancy. An association with pre-eclampsia (PE) has been reported previously. Furthermore, it has even been suggested that Bell's palsy could be a predictor of PE. We report three cases illustrating various possible aspects of this association, one of them including the features of HELLP (haemolysis, elevated liver enzymes, and low platelets) syndrome.Keywords general medicine, high-risk pregnancy, maternal-fetal medicine, neurology Case reportsThe main features of Bell's palsy and pre-eclampsia (PE) in the three cases are summarized in Tables 1 and 2. Case 1A 29-year-old gravida 1, para 0 woman was admitted to hospital at 39 weeks of gestation with a history of sudden onset of severe epigastric pain. At admission, blood pressure was normal and there was no proteinuria but HELLP (haemolysis, elevated liver enzymes, and low platelets) syndrome was diagnosed: the platelet count had fallen from 133 Â 10 9 /L at 36 weeks to 83 Â 10 9 /L, aspartate aminotransferase was 362 IU/ L, alanine transaminase was 282 IU/L and total bilirubin level was 10 mmol/L (normal range: 1-17). Corticosteroids were given because of low platelet count (betamethasone, 20 mg intravenously/12 hourly) and labour was induced. Four days after delivery, a left facial weakness occurred and progressed to complete isolated Bell's palsy over two days. Methylprednisolone was given intravenously (60 mg/day) for eight days, followed by oral prednisolone (30 mg/day) for four days. There was a moderate improvement over the next few months but permanent residual left facial palsy remained. Serological examination was negative for viruses as well as for antiphospholipid (lupus anticoagulant, anticardiolipin, anti-2 -glycoprotein type I) and antinuclear antibodies. Three years later, a subsequent pregnancy was completed without any complication except for late slight gestational thrombocytopenia. Case 2A 35-year-old gravida 2, para 0 woman was admitted to hospital at 31 weeks of gestation because of right facial weakness. The pregnancy was a twin gestation following intracytoplasmic sperm injection. Facial weakness progressed to complete facial paralysis within two days. Steroid therapy (prednisone 60 mg/day for 5 days) was followed by complete remission of the palsy within eihjt days. At 33 weeks, a diagnosis of PE was made, leading to a decision to perform a caesarean section: the first newborn weighed 1530 g; the second one was growthrestricted (1170 g). Viral serology was negative for varicella zoster (VZV), cytomegalovirus (CMV), parvovirus B19, HIV and hepatitis B. Treponema pallidum particle agglutination assay and Venereal Disease Research Laboratory tests for syphilis were negative, as were antinuclear and antiphospholipid antibodies. Case 3A 27-year-old gravida 1, para 0 woman was admitted to hospital at 34 weeks of gestation because of right facial weakness. A diagnosis of complete idiopathic right facial palsy was made. She was given oral corticosteroid therapy (prednisone 40 mg/day) and acyclovir fo...

Idiopatic facial nerve palsy in pregnancy – facts and myths

“…Differences in the incidence of Bell's palsy depending on the period of pregnancy were also confirmed. The vast majority of cases concern the third trimester of pregnancy (71%) and the early stage of puerperium (21%) [5]. Pathophysiological background for such a distribution of diseases have not been established so far, but taking into account a number of different physiological changes taking place in the female body during pregnancy, the most important factors may be: an increase in total body water content and edema tendency, immunosuppression and increased susceptibility to viral infections, in particular, reactivation of herpes virus (HSV), significantly elevated levels of estrogens and progesterone in the blood, increased blood clotting, and in some women, pregnancy-induced hypertension or impaired glucose tolerance [1].…”

“…ways have concerns about the adverse effects of drugs on the course of pregnancy and hence their avoidance or postponement of treatment. The prognosis for patients with incomplete facial nerve paralysis is very good -almost complete recovery, with minimal impairment of facial muscle function [5].…”

Acute Onset Neurological Disorders during Pregnancy: A Literature Review

“…75,76 As so, more studies are warranted to define the real risk of thromboembolism in subsequent pregnancies and anticoagulation therapy to prevent complications and risk of recurrence in future pregnancies; the risk of thromboembolism should be discussed with women at risk and the reasons for individual recommendations explained. 13,43,47,51,54,55 Arteriovenous malformation complications are more frequent in the first trimester, contrasting to aneurysm rupture, which occurs more commonly in the second half of pregnancy; 6,56 both can lead to SAH. It is consensual that imaging investigation is vital and, during pregnancy, MRI is preferable to CT scan because of its higher resolution, sensitivity, and lack of ionizing radiation.…”

“…It may be preceded or accompanied by ipsilateral retroauricular pain; some studies reveal that the increased incidence in pregnancy may be related to hypertensive disorders of pregnancy (preeclampsia, gestational hypertension). 9,13,14 There are no specific treatments studied for peripheral facial palsy. The affected eye must be kept patched and moist to prevent corneal abrasions.…”

“…[49][50][51][52] Anticoagulation during pregnancy must be individualized according to the co-existence of risk factors. 13,43,47 Evidence suggests the use of maintenance anticoagulation for a period of 3 months in presence of high risk factors, and for at least 6-12 months in patients with idiopathic cases (potential etiologies include paroxysmal atrial fibrillation, patent foramen ovale, atherosclerotic plaques of the aortic arch, congenital and acquired prothrombotic states) and women with mild hereditary thrombophilia (heterozygous factor V Leiden or prothrombin G20210A mutation). Indefinite anticoagulation should be reserved to patients with idiopathic cases, recurrent episodes, and to those with high-risk thrombophilia (antithrombin, protein C or protein S deficiency, homozygous factor V Leiden or prothrombin G20210A mutation, antiphospholipid antibodies and combined abnormalities).…”