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Advanced Neurology POTS and pregnancy: A case series

prompting ultrasonography of the brain a few days after Although the exact mechanism by which gluten influences
birth, which confirmed a diagnosis of perinatal stroke. Due POTS symptoms remains unknown, it may be related to
to early intervention therapy, the infant experienced no local cytokine-induced inflammation in the gut mucosa, or
major complications related to the stroke. During delivery, overall higher carbohydrate intake leading to postprandial
the patient experienced a vaginal tear. The patient felt that vasodilation, both of which can exacerbate sympathetic
her autonomic difficulties increased after delivery, with activity. 11
increasing BP fluctuations. Medications utilized for treating POTS include

3. Discussion fludrocortisone as a volume expander and pyridostigmine
to optimize acetylcholine levels, which helps with the
This is a retrospective clinical series of POTS-affected optimization of both sympathetic and parasympathetic
women in pregnancy, delivery, and postpartum. All functioning, stabilizing BP and HR. Supplemental
patients included in our case series had a diagnosis of POTS interventions include the administration of midodrine, a
before becoming pregnant. A summary of demographical vasoconstrictor, and IV fluids. 10,12,13 In our study, all but
characteristics of POTS patients in pregnancy is included one patient continued pharmacological treatment during
in Table 1. Treatment of POTS in pregnancy is variable their pregnancies. When medications were adjusted,
due to each patient having a unique POTS history and most patients required dosage decreases, with no patients
set of symptoms. 1,5-7,10 Within our cohort, each patient in needing medication additions or dosage increases until the
pregnancy experienced changes in their pre-pregnancy postpartum period (Table 2).
POTS symptoms (Table A1).
All women consulted with our autonomic neurology
The goal of treating pregnant women with POTS is team before or at the start of their pregnancies, and most
the management of autonomic dysfunction throughout were followed by an MFM specialist. Regular BP and HR
gestation while reducing pharmacological interventions monitoring were performed by autonomic specialists every
when feasible. Non-pharmacological treatment of POTS 1 – 3 months, and some patients monitored their BP and
includes the use of compression stockings, vitamin HR at home between visits. Our patients often reported
supplementation, and increased hydration. For patients worsening fatigue and an increase in BP fluctuations in the
who struggle with dysautonomia associated with first trimester, stabilization of autonomic symptoms during
gastrointestinal inflammation, establishing gluten-free the second trimester, and the development of hypertension
diets has been known to decrease symptom burden. during the third trimester.

Table 1. Demographical profile of patients with POTS in pregnancy

Patient Age at POTS Pregnancy history Comorbidity Age at pregnancy Fertility Pregnancy outcome Peak SBP
diagnosis (years) (years) treatment (mmHg)
1 21 Gravida 2, parity 1 Ehlers–Danlos syndrome 32 None Unsuccessful; ectopic -
33 IVF Successful 124
2 27 Gravida 1, parity 1 None 29 None Successful >140
3 16 Gravida 2, parity 2 Cerebral palsy 26 None Successful >140
27 None Successful >140
4 19 Gravida 1, parity 1 Mitochondrial disorder 29 None Successful -
Abbreviations: IVF: In vitro fertilization; SBP: Systolic blood pressure; POTS: Postural orthostatic tachycardia syndrome.

Table 2. Medication properties and dosage changes for patients with POTS before and during pregnancy
Medication Category Excreted in milk Patients on Patients on medication Change to a daily dosage
medication during pregnancy
pre‑pregnancy
Fludrocortisone C Unknown 25% (1/4) 25% (1/4) Decreased from 0.1 to 0.05 mg
Pyridostigmine bromide B Yes 75% (3/4) 75% (3/4) Decreased from 60 to 30 mg (3×/
day) for one patient; no change for
two patients
None - - 25% (1/4) 25% (1/4) No change
Abbreviation: POTS: Postural orthostatic tachycardia syndrome.

Volume 3 Issue 2 (2024) 4 doi: 10.36922/an.3164