Neurological Issues in Pregnancy

It is my great pleasure to introduce this issue of Seminars in Neurology on Neurological Issues in Pregnancy. As with many fields of medicine, the importance of recognizing differences between male and female physiology is increasingly being recognized and researched. During pregnancy and the puerperium, women experience rapid physiological changes, yet so little is known about how pregnancy contributes to and impacts neurological disease. This lack of knowledge is likely because research on pregnant women is technically difficult, challenging, and highly regulated due to ethical concerns. In addition, unlike other areas of medicine, contact with and collaboration between obstetricians and neurologists are limited. Therefore, our knowledge of neurological disease in pregnancy comes largely from small retrospective or observational studies and case reports. Due to this limited information, many neurologists are hesitant about treating pregnant women with neurological disease and opt to wait until after delivery for evaluation and treatment. This delay is usually not in the best interest of the patient or the child she is carrying, and waiting often leads to unnecessary suffering by the pregnant woman as well as needless peripartum procedures performed primarily for precaution. Our ignorance about the physiological impact of pregnancy on neurological processes is only the tip of the iceberg in our lack of understanding of many natural and artificial hormonal alterations that women experience, such as puberty, oral contraceptives, menopause, and hormone replacement therapy. It is my hope that introducing these articles will stimulate further discussion on these other unexplored areas.

This edition of Seminars in Neurology only briefly addresses the neurological changes that occur in pregnancy. Most of the authors are current and former Brigham and Women's colleagues who have served as my role models. They developed an interest in women's issues in neurology during their time at the Brigham and still have these interests, both academic and clinical, today.

This issue begins with an introduction to the physiological changes of pregnancy and their impact on neurological disease. Lydia Lee, a maternal fetal medicine fellow at Brigham and Women's Hospital and a colleague with whom I recently shared the experience of pregnancy, has done an exceptional job of summarizing the amazing process of pregnancy. For those of us who last experienced obstetrical issues in the third year of medical school, her article is an excellent, succinct refresher. Drs. William Copen and Steven Brass follow with an outstanding section on neuroimaging practices and procedures in pregnancy as well as stellar images of neurological issues encountered in pregnancy. The following sections detail the impact of pregnancy on neurological disease processes. Dr. Loder, who is trained in internal medicine, is incredibly knowledgeable in all aspects of hormonal influences of headache in women. She is a role model for promoting women in medical careers as well as a leader in handling clinical issues specifically impacting women. Dr. Maria Houtchens is an expert in multiple sclerosis at the Partners Multiple Sclerosis Center at Brigham and Women's Hospital. Because multiple sclerosis is a prevalent disease that affects young women during their reproductive years, Dr. Houtchens has the formidable task of counseling and treating these women during pregnancy and the puerperium. Dr. Steve Feske, the director of the stroke division at Brigham and Women's Hospital, is a scholar in the areas of pre-eclampsia, eclampsia, and stroke in pregnancy. Dr. Feske has written an outstanding article uniquely summarizing the many large studies of stroke in pregnancy. Dr. Cynthia Harden, professor of neurology at the Comprehensive Epilepsy Center at Cornell University, is renowned for her interest in women's issues in epilepsy. She is a leading research clinician in this ever-changing area, and she is widely published on the subject. She provides us with the latest results of the pregnancy registries. Dr Hannah Briemberg, a dear colleague who trained at the Brigham and was staff there until recently when she moved back to her native Canada, has eloquently and succinctly covered the broad topic of the peripheral neuropathies and neuromuscular diseases. Drs. Yvette Bordelon and Marsha Smith, my senior residents and continued dear friends, are now far away from the Brigham, but they continue to enlighten me with their vast knowledge of movement disorders in pregnancy. Finally, I am indebted to Dr. Rabia Qaiser, neurosurgical trainee in the Department of Neurosurgery at Brigham and Women's and Children's Hospitals, and Dr. Peter Black, long-standing neurosurgeon and chief of neurosurgery at the Brigham and Women's Hospital, who took time away from his busy, international travels to graciously submit a wonderful review of neurosurgical issues in pregnancy. This edition of Seminars in Neurology represents the hard work and dedication of a select group of physicians with a unique interest in the understudied area of pregnancy and neurology. I thank all the contributing authors for their time and effort in such an outstanding collection of articles.

I also want to thank those at the Brigham and Women's Hospital who have nurtured my interest in women's issues in neurology and pregnancy, Dr. Martin Samuels, the Chief of Neurology, and Dr. Paula Johnson, Chief of the Division of Women's Medicine, for their continued encouragement and support in working toward establishing the first ever Program in Women's Neurology. Additionally, I am grateful to Dr. Edward Bromfield and Dr. Barbara Dworetzky for fostering my interests in women's epilepsy. Lastly, I am indebted to Dr. Karen Roos for the opportunity to be a Guest Editor for such an important subject. I have benefited from her guidance and encouragement throughout this process. Her compassion and her interest in furthering the education and promotion of women in neurology while balancing editorial positions, clinical responsibilities, and the greatest honor of all, motherhood, are astounding. She is an exemplar role model for all young female neurologists.