PDF herunterladen
Semin Neurol 2007; 27(5): 405-410
DOI: 10.1055/s-2007-991124
© Thieme Medical Publishers

Physiological Adaptations of Pregnancy Affecting the Nervous System

Lydia K. Lee1
  • 1Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
16. Oktober 2007 (online)

    Lizenzen und Reprints

ABSTRACT

Physiological adaptations of pregnancy affect neurological function in health and disease. Women often experience self-limited sensory abnormalities that resolve shortly after delivery. More important, pregnancy can predispose to the onset or deterioration of permanent neurological disorders. Lastly, complications of pregnancy may develop in patients with preexisting neurological disease. Therefore, a basic knowledge of reproductive physiology can guide clinicians in the diagnosis and management of the pregnant patient with neurological symptoms. This clinical review highlights the modifications that affect the nervous system, including neuroanatomy, reproductive endocrinology, immunology, systemic and cerebral circulations, metabolism, and coagulation profile. The widespread role of sex steroids in many of these adaptations is addressed to illustrate the complex interactions of human reproductive biology.

KEYWORDS

Physiology - pregnancy - nervous system

REFERENCES

  • 1 Munson M L. Births, marriages, divorces, and deaths: provisional data for 2005. In: National Vital Statistics Reports. Vol. 54. Hyattsville, MD; National Center for Health Statistics 2006
    Google Scholar
  • 2 Cunningham F, Leveno K J, Bloom S L. Williams Obstetrics. 22nd ed. New York; McGraw-Hill Companies Inc 2005
    Google Scholar
  • 3 Hirabayashi Y, Shimizu R, Fukuda H, Saitoh K, Igarashi T. Soft tissue anatomy within the vertebral canal in pregnant women.  Br J Anaesth. 1996;  77 153-156
    PubMedGoogle Scholar
  • 4 Cibils L A, Hendricks C H. Uterine contractility on the first day of the puerperium.  Am J Obstet Gynecol. 1969;  103 238-243
    PubMedGoogle Scholar
  • 5 Eogan M, O'Brien C, Carolan D, Fynes M, O'Herlihy C. Median and ulnar nerve conduction in pregnancy.  Int J Gynaecol Obstet. 2004;  87 233-236
    CrossrefPubMedGoogle Scholar
  • 6 Speroff L, Fritz MA Clinical Gynecologic Endocrinology and Infertility. 7th ed. Philadelphia; Lippincott Williams & Wilkins 2005
    Google Scholar
  • 7 Albrecht E D, Aberdeen G W, Pepe G J. The role of estrogen in the maintenance of primate pregnancy.  Am J Obstet Gynecol. 2000;  182 432-438
    PubMedGoogle Scholar
  • 8 Albrecht E D, Aberdeen G W, Pepe G J. Estrogen elicits cortical zone-specific effects on development of the primate fetal adrenal gland.  Endocrinology. 2005;  146 1737-1744
    CrossrefPubMedGoogle Scholar
  • 9 Pepe G J, Davies W A, Albrecht E D. Activation of the baboon fetal pituitary-adrenocortical axis at midgestation by estrogen: enhancement of fetal pituitary proopiomelanocortin messenger ribonucleic acid expression.  Endocrinology. 1994;  135 2581-2587
    CrossrefPubMedGoogle Scholar
  • 10 Datta S, Hurley R J, Naulty J S et al.. Plasma and cerebrospinal fluid progesterone concentrations in pregnant and nonpregnant women.  Anesth Analg. 1986;  65 950-954
    PubMedGoogle Scholar
  • 11 Robinson B G, Emanuel R L, Frim D M, Majzoub J A. Glucocorticoid stimulates expression of corticotropin-releasing hormone gene in human placenta.  Proc Natl Acad Sci U S A. 1988;  85 5244-5248
    PubMedGoogle Scholar
  • 12 Majzoub J A, McGregor J A, Lockwood C J, Smith R, Taggart M S, Schulkin J. A central theory of preterm and term labor: putative role for corticotropin-releasing hormone.  Am J Obstet Gynecol. 1999;  180 S232-S241
    PubMedGoogle Scholar
  • 13 Beyenburg S, Stoffel-Wagner B, Bauer J et al.. Neuroactive steroids and seizure susceptibility.  Epilepsy Res. 2001;  44 141-153
    CrossrefPubMedGoogle Scholar
  • 14 Murphy D D, Cole N B, Greenberger V, Segal M. Estradiol increases dendritic spine density by reducing GABA neurotransmission in hippocampal neurons.  J Neurosci. 1998;  18 2550-2559
    PubMedGoogle Scholar
  • 15 Murphy D D, Cole N B, Segal M. Brain-derived neurotrophic factor mediates estradiol-induced dendritic spine formation in hippocampal neurons.  Proc Natl Acad Sci U S A. 1998;  95 11412-11417
    CrossrefPubMedGoogle Scholar
  • 16 Landgren S, Aasly J, Backstrom T, Dubrovsky B, Danielsson E. The effect of progesterone and its metabolites on the interictal epileptiform discharge in the cat's cerebral cortex.  Acta Physiol Scand. 1987;  131 33-42
    PubMedGoogle Scholar
  • 17 Majewska M D, Harrison N L, Schwartz R D, Barker J L, Paul S M. Steroid hormone metabolites are barbiturate-like modulators of the GABA receptor.  Science. 1986;  232 1004-1007
    CrossrefPubMedGoogle Scholar
  • 18 Luisi S, Petraglia F, Benedetto C et al.. Serum allopregnanolone levels in pregnant women: changes during pregnancy, at delivery, and in hypertensive patients.  J Clin Endocrinol Metab. 2000;  85 2429-2433
    CrossrefPubMedGoogle Scholar
  • 19 Hsu F C, Smith S S. Progesterone withdrawal reduces paired-pulse inhibition in rat hippocampus: dependence on GABA(A) receptor alpha4 subunit upregulation.  J Neurophysiol. 2003;  89 186-198
    PubMedGoogle Scholar
  • 20 Moran M H, Smith S S. Progesterone withdrawal I: pro-convulsant effects.  Brain Res. 1998;  807 84-90
    CrossrefPubMedGoogle Scholar
  • 21 Smith S S, Gong Q H, Hsu F C, Markowitz R S, ffrench-Mullen J M, Li X. GABA(A) receptor alpha4 subunit suppression prevents withdrawal properties of an endogenous steroid.  Nature. 1998;  392 926-930
    CrossrefPubMedGoogle Scholar
  • 22 Meher S, Duley L. Progesterone for preventing pre-eclampsia and its complications.  Cochrane Database Syst Rev. 2006;  (4) CD006175
    PubMedGoogle Scholar
  • 23 Zeisler H, Sator M O, Joura E A. Serum levels of progesterone in patients with preeclampsia.  Wien Klin Wochenschr. 2000;  112 362-364
    PubMedGoogle Scholar
  • 24 Walsh S W. Progesterone and estradiol production by normal and preeclamptic placentas.  Obstet Gynecol. 1988;  71 222-226
    PubMedGoogle Scholar
  • 25 Colmers W F, El Bahh B. Neuropeptide Y and Epilepsy.  Epilepsy Curr. 2003;  3 53-58
    PubMedGoogle Scholar
  • 26 Petraglia F, Coukos G, Battaglia C et al.. Plasma and amniotic fluid immunoreactive neuropeptide-Y level changes during pregnancy, labor, and at parturition.  J Clin Endocrinol Metab. 1989;  69 324-328
    PubMedGoogle Scholar
  • 27 Murphy S P, Choi J C, Holtz R. Regulation of major histocompatibility complex class II gene expression in trophoblast cells.  Reprod Biol Endocrinol. 2004;  2 52
    CrossrefPubMedGoogle Scholar
  • 28 Moffett A, Loke C. Immunology of placentation in eutherian mammals.  Nat Rev Immunol. 2006;  6 584-594
    CrossrefPubMedGoogle Scholar
  • 29 Lin H, Mosmann T R, Guilbert L, Tuntipopipat S, Wegmann T G. Synthesis of T helper 2-type cytokines at the maternal-fetal interface.  J Immunol. 1993;  151 4562-4573
    PubMedGoogle Scholar
  • 30 Yoneyama Y, Sawa R, Suzuki S, Yoneyama K, Doi D, Araki T. Relationship between adenosine deaminase activity and cytokine-secreting T cells in normal pregnancy.  Obstet Gynecol. 2002;  100 754
    CrossrefPubMedGoogle Scholar
  • 31 Somerset D A, Zheng Y, Kilby M D, Sansom D M, Drayson M T. Normal human pregnancy is associated with an elevation in the immune suppressive CD25 + CD4 + regulatory T-cell subset.  Immunology. 2004;  112 38-43
    CrossrefPubMedGoogle Scholar
  • 32 Szekeres-Bartho J, Kilar F, Falkay G, Csernus V, Török A, Pacsa A S. The mechanism of the inhibitory effect of progesterone on lymphocyte cytotoxicity: I. Progesterone-treated lymphocytes release a substance inhibiting cytotoxicity and prostaglandin synthesis.  Am J Reprod Immunol Microbiol. 1985;  9 15-18
    CrossrefPubMedGoogle Scholar
  • 33 Druckmann R, Druckmann M A. Progesterone and the immunology of pregnancy.  J Steroid Biochem Mol Biol. 2005;  97 389-396
    CrossrefPubMedGoogle Scholar
  • 34 Prieto G A, Rosenstein Y. Oestradiol potentiates the suppressive function of human CD4 CD25 regulatory T cells by promoting their proliferation.  Immunology. 2006;  118 58-65
    CrossrefPubMedGoogle Scholar
  • 35 Confavreux C, Hutchinson M, Hours M M, Cortinovis-Tourniaire P, Moreau T. Rate of pregnancy-related relapse in multiple sclerosis. Pregnancy in Multiple Sclerosis Group.  N Engl J Med. 1998;  339 285-291
    CrossrefPubMedGoogle Scholar
  • 36 Langer-Gould A, Garren H, Slansky A, Ruiz P J, Steinman L. Late pregnancy suppresses relapses in experimental autoimmune encephalomyelitis: evidence for a suppressive pregnancy-related serum factor.  J Immunol. 2002;  169 1084-1091
    PubMedGoogle Scholar
  • 37 Palaszynski K M, Liu H, Loo K K, Voskuhl R R. Estriol treatment ameliorates disease in males with experimental autoimmune encephalomyelitis: implications for multiple sclerosis.  J Neuroimmunol. 2004;  149 84-89
    CrossrefPubMedGoogle Scholar
  • 38 Pritchard J A. Changes in the blood volume during pregnancy and delivery.  Anesthesiology. 1965;  26 393-399
    CrossrefPubMedGoogle Scholar
  • 39 Wilson M, Morganti A A, Zervoudakis I et al.. Blood pressure, the renin-aldosterone system and sex steroids throughout normal pregnancy.  Am J Med. 1980;  68 97-104
    CrossrefPubMedGoogle Scholar
  • 40 van Oppen A C, van der Tweel I, Alsbach G P, Heethaar R M, Bruinse H W. A longitudinal study of maternal hemodynamics during normal pregnancy.  Obstet Gynecol. 1996;  88 40-46
    CrossrefPubMedGoogle Scholar
  • 41 Mabie W C, DiSessa T G, Crocker L G, Sibai B M, Arheart K L. A longitudinal study of cardiac output in normal human pregnancy.  Am J Obstet Gynecol. 1994;  170 849-856
    CrossrefPubMedGoogle Scholar
  • 42 Robson S C, Dunlop W, Boys R J, Hunter S. Cardiac output during labour.  Br Med J (Clin Res Ed). 1987;  295 1169-1172
    PubMedGoogle Scholar
  • 43 Robson S, Hunter S, Boys R, Dunlop W, Bryson M. Changes in cardiac output during epidural anaesthesia for caesarean section.  Anaesthesia. 1989;  44 475-479
    CrossrefPubMedGoogle Scholar
  • 44 Bucklin B A, Hawkins J L, Anderson J R, Ullrich F A. Obstetric anesthesia workforce survey: twenty-year update.  Anesthesiology. 2005;  103 645-653
    CrossrefPubMedGoogle Scholar
  • 45 Robson S C, Boys R J, Hunter S, Dunlop W. Maternal hemodynamics after normal delivery and delivery complicated by postpartum hemorrhage.  Obstet Gynecol. 1989;  74 234-239
    PubMedGoogle Scholar
  • 46 Salonen Ros H, Lichtenstein P, Bellocco R, Petersson G, Cnattingius S. Increased risks of circulatory diseases in late pregnancy and puerperium.  Epidemiology. 2001;  12 456-460
    CrossrefPubMedGoogle Scholar
  • 47 Belfort M A, Tooke-Miller C, Allen Jr J C et al.. Changes in flow velocity, resistance indices, and cerebral perfusion pressure in the maternal middle cerebral artery distribution during normal pregnancy.  Acta Obstet Gynecol Scand. 2001;  80 104-112
    CrossrefPubMedGoogle Scholar
  • 48 Williams K, Wilson S. Maternal middle cerebral artery blood flow velocity variation with gestational age.  Obstet Gynecol. 1994;  84 445-448
    PubMedGoogle Scholar
  • 49 Zeeman G G, Hatab M, Twickler D M. Maternal cerebral blood flow changes in pregnancy.  Am J Obstet Gynecol. 2003;  189 968-972
    CrossrefPubMedGoogle Scholar
  • 50 Sarrel P M. The differential effects of oestrogens and progestins on vascular tone.  Hum Reprod Update. 1999;  5 205-209
    CrossrefPubMedGoogle Scholar
  • 51 Ferro J M, Canhao P, Stam J, Barinagarrementeria F. Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT).  Stroke. 2004;  35 664-670
    CrossrefPubMedGoogle Scholar
  • 52 Kim R J, Becker R C. Association between factor V Leiden, prothrombin G20210A, and methylenetetrahydrofolate reductase C677T mutations and events of the arterial circulatory system: a meta-analysis of published studies.  Am Heart J. 2003;  146 948-957
    CrossrefPubMedGoogle Scholar
  • 53 Cumming A M, Tait R C, Fildes S, Yoong A, Keeney S, Hay C R. Development of resistance to activated protein C during pregnancy.  Br J Haematol. 1995;  90 725-727
    CrossrefPubMedGoogle Scholar
  • 54 Clark P, Walker I D, Greer I. Acquired activated protein-C resistance in pregnancy and association with increased thrombin generation and fetal weight.  Lancet. 1999;  353 292-293
    PubMedGoogle Scholar
  • 55 Davison J M, Lindheimer M D. Volume homeostasis and osmoregulation in human pregnancy.  Baillieres Clin Endocrinol Metab. 1989;  3 451-472
    CrossrefPubMedGoogle Scholar
  • 56 Lindheimer M D, Davison J M. Osmoregulation, the secretion of arginine vasopressin and its metabolism during pregnancy.  Eur J Endocrinol. 1995;  132 133-143
    PubMedGoogle Scholar
  • 57 Dahlman T, Sjoberg H E, Bucht E. Calcium homeostasis in normal pregnancy and puerperium. A longitudinal study.  Acta Obstet Gynecol Scand. 1994;  73 393-398
    PubMedGoogle Scholar
  • 58 Pitkin R M, Reynolds W A, Williams G A, Hargis G K. Calcium metabolism in normal pregnancy: a longitudinal study.  Am J Obstet Gynecol. 1979;  133 781-790
    PubMedGoogle Scholar
  • 59 Sanders R, Konijnenberg A, Huijgen H J, Wolf H, Boer K, Sanders G T. Intracellular and extracellular, ionized and total magnesium in pre-eclampsia and uncomplicated pregnancy.  Clin Chem Lab Med. 1999;  37 55-59
    CrossrefPubMedGoogle Scholar

Lydia K LeeM.D. 

Clinical Fellow of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School

75 Francis Street, Boston, MA 02115

eMail: Lydia.Lee@cshs.org