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Advanced Neurology POTS and pregnancy: A case series

pregnancy are limited. Pregnancy can both exacerbate At 37 weeks of gestation, the patient underwent a
and alleviate POTS symptoms, sometimes both within cesarean section, resulting in the birth of a healthy female
the same patient, varying by trimester. This is not infant weighing 2438 g. The delivery was scheduled 1 week
6,7
unexpected given the multi-systemic physiological earlier than expected due to concerns with fetal circulation.
changes that occur during gestation. Women with mild- During the delivery, the patient received regional anesthesia
to-moderate POTS typically experience an improvement (epidural) and fluids. No complications occurred during
in their symptoms during their pregnancy compared to delivery, which involved continuous monitoring of her BP.
their pre-pregnancy baseline. In contrast, women with An maternal-fetal medicine (MFM) specialist was present
severe POTS symptoms tend to experience persistent during her operation. After birth, her infant was diagnosed
worsening of their symptoms throughout their pregnancy. with pulmonary hypertension and required neonatal
8
Variations, including improvement of symptoms in the intensive care unit care for respiratory monitoring over
second and third trimesters, are sometimes observed even 24 h. At 3 months postpartum, the patient experienced BP
in patients with severe POTS, which may be explained by fluctuation and pre-syncope, and her medications were
the physiological increase in blood and plasma volumes reinitiated.
during these trimesters. 9
2.2. Case 2
Herein, we discuss the cases of four different patients
with previously diagnosed POTS throughout different A 29-year-old primigravida presented to our neurology
phases of pregnancy, all of whom are now in the clinic with a pregnancy complicated by POTS. Her medical
postpartum stage of their first or second pregnancy. This history was significant only for POTS, diagnosed 2 years
case series aims to further our understanding of the effect prior with a tilt table test; her HR increased >30 points
of pregnancy on patients with POTS to aid in establishing from a baseline of 53 bpm without change in BP within
standards of prenatal, intrapartum, and postpartum care. 5 min of upright tilt. At initial diagnosis, her POTS was
reported as very severe. She was bedridden with symptoms
2. Case presentation of dizziness, palpitations, hypotension, temperature

2.1. Case 1 dysregulation, and near-syncopal episodes. She was
initiated on supportive measures of compression stockings,
A 32-year-old patient presented to our neurology clinic vitamin supplementation, and a gluten-free diet to reduce
for guidance for a second pregnancy. Her first pregnancy gastrointestinal inflammation and promote absorption. She
was complicated by an ectopic pregnancy 8 months prior. was then started on pyridostigmine (60 mg, 4 times a day)
Her medical history was significant for POTS and Ehlers– and fludrocortisone (0.1 mg, once daily) with BP and
Danlos syndrome, a connective tissue disorder. Her POTS HR stabilization. Before pregnancy, the patient consulted
diagnosis was confirmed 11 years before her pregnancy with our autonomic neurology team about pregnancy,
with a tilt table test. At initial diagnosis, her POTS was delivery, and post-delivery autonomic expectations and
severe, with frequent syncope, headache, dizziness, and management. She was approved for pregnancy and did not
fatigue. Her symptoms improved when she was started require any fertility treatments.
on conservative treatment with compression stockings,
optimized hydration, and electrolytes. She was prescribed Throughout the patient’s pregnancy, consistent
30 mg pyridostigmine, 4 times daily for her autonomic monitoring of BP and HR was performed under the
dysfunction with good results. guidance of our team. Her pregnancy was also closely
followed by an MFM specialist. During the first trimester,
One year later, the patient underwent in vitro the patient experienced a slight worsening of her POTS
fertilization (IVF) treatment with a fertility specialist to symptoms, including exhaustion and fatigue. Her BP
assist in a successful second conception. The patient had began to increase. When her systolic BP (SBP) was >140
a successful outcome of pregnancy after one cycle of IVF. for more than 3 days, fludrocortisone was decreased from
Throughout the patient’s pregnancy, consistent monitoring 0.1 mg (once daily) to 0.05 mg (once daily). This change
of BP and HR was performed under the guidance of our normalized her BP to SBP <120 and was well tolerated.
autonomic team. During the first two trimesters, the During the second and third trimesters, her BP and HR
patient experienced fluctuating HR, vomiting 1 – 3 times were stable, with only mild tachycardia with physical
every few days, and digestion difficulties. Her BP also began activity. There were no sustained HRs >130 bpm.
to increase, with an overall measure of 124/79. During her
third trimester, she reported exhaustion and intermittent At 39 weeks of gestation, the patient was induced and
hypotension (~90/60). She was recommended to have a had a vaginal delivery resulting in the birth of a healthy
cesarean section by her obstetrician-gynecologist. female infant weighing 3583 g. The patient received

Volume 3 Issue 2 (2024) 2 doi: 10.36922/an.3164