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Advanced Neurology POTS and pregnancy: A case series

regional anesthesia (epidural) and fluids. No complications that her autonomic dysfunction worsened in the latter
occurred during delivery, which involved continuous stages of pregnancy, but postpartum was stable at her pre-
monitoring of her BP. At 6 weeks postpartum, the patient pregnancy level.
reported no complications. Her autonomic dysfunction At 6 months postpartum, the patient became pregnant
was stable at her pre-pregnancy level. with her second child. At the onset of hypertension, her

2.3. Case 3 pyridostigmine dose was reduced to 30 mg, 3 times a
day. Her BP peaked at SBP = 140. The patient started to
A 26-year-old primigravida presented to our neurology experience lower leg swelling, back pain, numbness,
clinic with a pregnancy complicated by POTS. Her medical tingling of the hands, nausea, and constipation during her
history was significant for cerebral palsy, at a moderate second trimester. At 38 weeks of gestation, the patient had
level requiring leg braces and crutches for ambulation. She a spontaneous vaginal delivery, resulting in the birth of a
was also diagnosed with POTS, 10 years prior with a tilt healthy female infant weighing 3316 g. After delivery, the
table test. At initial diagnosis, her POTS was reported as patient initially experienced hypertension of 136/90, which
severe, with symptoms altering between syncopal episodes stabilized 1 month postpartum. She subsequently reported
with hypotension and emesis occurring with hypertension. stability of her autonomic dysfunction issues compared to
Her symptoms stabilized and became more manageable her prepartum state.
with the assistance of pyridostigmine (30 – 60 mg, 4 times
daily). The patient was cleared for pregnancy and did not 2.4. Case 4
require any fertility treatments. A 29-year-old patient with an unspecific mitochondrial
Throughout the patient’s pregnancy, consistent disorder and autonomic dysfunction presented to our
monitoring of BP was performed under the direction neurology clinic. At initial diagnosis, her POTS was reported
of our autonomic neurology team. Her pregnancy was as severe, with symptoms alternating between hypotension
also closely followed by an MFM specialist. During the (~70/40) and hypertension (~140/90). Her symptoms
first trimester, the patient experienced worsening POTS worsened over 8 years but had become more manageable
symptoms, including increased nausea, palpitations, and with the assistance of IV fluids to provide volume support.
unstable BP, which resulted in mobility difficulties. The Due to side effects, she was not able to tolerate treatment
second trimester was similar to the first, but the patient with pyridostigmine and fludrocortisone. She did not seek
reported feeling physically the best during this stage of prepartum stabilization and presented in her first trimester
pregnancy. The third trimester consisted of increasing of pregnancy.
POTS symptoms, including intolerable headaches and Throughout the patient’s pregnancy, consistent
fluctuating BP. Her SBP increased to >140 for more than monitoring of BP was performed under the direction of
3 days. Considering her persistent hypertension, her our autonomic neurology team. Her pregnancy was also
pyridostigmine was decreased from 60 to 30 mg, 3 times closely followed by an MFM specialist. During pregnancy,
daily. the patient received up to 1.5 L of fluids daily for volume
An MFM specialist was aware of labor risks and stabilization and baseline hypotension (~80 – 90/40 – 60),
closely monitored her delivery, including providing which was managed by her primary team. During the
volume support with intravenous (IV) fluids. At 39 weeks first trimester, the patient experienced an increase in her
of gestation, the patient was induced and had a vaginal baseline pressures to ~100/70. Moving into her second
delivery with forceps assistance. She delivered a healthy trimester, her BP stabilized, and the patient reported
female infant weighing 3033 g. She received regional feeling physically the best during this stage of pregnancy.
anesthesia (epidural) at 3 cm dilation, Pitocin at 6 cm Her symptoms worsened during her third trimester with
dilation, and experienced a labor duration of 30 h. No the development of lower extremity edema and a BP of
complications occurred during delivery, which involved ~130/90. She was suspected by neurology to have pre-
continuous monitoring of her BP every 20 min due to her eclampsia due to the relative BP augmentation and the
issues with hypertension. edema she experienced in her third trimester.

After delivery, the patient experienced reoccurring At 38 weeks of gestation, the patient had a vacuum-
headaches, reported to be less severe than during the third assisted vaginal delivery, resulting in the birth of a female
trimester of pregnancy, and swollen legs. At 5 months infant weighing 3232 g. The patient did not receive regional
postpartum, the patient struggled with hypotension, anesthesia (epidural) but required bi-level positive airway
particularly in the morning. Her dose of pyridostigmine pressure during active delivery due to respiratory failure.
was increased to 60 mg, 3 times a day. The patient reported Immediately after delivery, the infant appeared hypertonic,

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