About pregnancy in Parkinson's disease

We read with great interest the research article entitled “Pregnancy and delivery in women with Parkinson's disease: a case series” by Kapelle and colleagues. ¹ They report on a case series of women, diagnosed with Parkinson's disease (PD), that underwent pregnancy and tried to explore diverse issues concerning the disease, the medication, the pregnancy itself and the delivery.

Based on a a retrospective approach they identified a total of nine participants with diagnoses of early-onset PD (EOPD) who had gone through a total of twelve pregnancies after onset of motor symptoms. In 10 out of 12 pregnancies, participants did not use any PD medication; patient used pramipexole and anotherone used levodopa/carbidopa. Worsening of symptoms were reported in five pregnancies. Eleven pregnancies resulted in a live birth while one pregnancy resulted in a spontaneous abortion.

We would like to comment on our experience. We also reviewed medical records, over the last ten years, of PD patients who became pregnant after onset of motor symptoms. We collected data about the age of patients at the time of pregnancy, duration of disease, medication, change in motor symptoms during pregnancy, delivery type, birth outcomes and breastfeeding.

Ten patients were identified with EOPD who had undergone eleven pregnancies since their clinical diagnosis. The average age at onset of symptoms was 30.7 years old (range:12–40) and the average duration of illness at the time of pregnancy identification was 44.7 months (range: 3–96). Four patients were taking only levodopa/carbidopa at the time they were informed they were pregnant. One other patient was taking levodopa/carbidopa and pramipexole and another was taking only rasagiline. After finding out about the pregnancy two decided to keep levodopa/carbidopa and one decided to keep levodopa/carbidopa and pramipexole. The other patients decided to stop or not start the medication. The mode of delivery was reported in nine pregnancies and consisted of two vaginal deliveries and seven caesarian sections. The caesarian sections were performed because of history of the previous same procedure in two of them, preeclampsia in two, breech presentation in one, placenta previa in one, and an unknown reason in one. All patients had full-term gestation, and the children's psychomotor development was normal. After delivery, the three patients on levodopa/carbidopa, and one of them also on pramipexole, continued taking the same medication during lactation. All the patients breastfed their child. Four patients who were not taking any antiparkinsonian treatment reported an increase in motor symptoms (tremor in 2, bradykinesia in 2). The patient who discontinued rasagiline did not report worsening symptoms, and the patients who continued taking dopaminergic medication did not report any variation of symptoms.

From a comprehensive review of the literature over the last decades, we identified 40 articles including case reports, small cohorts and reviews in which at least one case of pregnancy in PD was described.^2–5 Although the information is not complete or homogeneous in all reports, we identified eighty-three pregnant women with PD and 111 pregnancies. Mean maternal age at conception was 33.6 years old (range: 23–44) and average disease duration at the time of conception was 4.5 years (range: 0.5–15).

Most of the patients were taking one or more antiparkinsonian drugs at the time they learned about their pregnancy and many of them decided to maintain them. Forty-eight continued taking levodopa (alone or in combination with other antiparkinsonian medication), 23 were on a dopaminergic agonist, 7 on anticholinergics, 4 on amantadine and 4 on MAO inhibitors . Twenty-eight decided not to take any medication during pregnancy and there is no data about 4 pregnancies. Forty-one vaginal deliveries (36.9%) have been reported as well as 23 caesarian sections (20.7%) and 8 abortions (7.2%) (3 electives, 5 spontaneous). There is no data on 37 pregnancies.

Even though 5% of patients diagnosed with PD are under 40 years old, pregnancy in women with PD is very uncommon with few published reports. Therefore, available data about the impact of pregnancy on PD as well as the safety of dopaminergic medication is scarce and inconclusive. Some case reports showed worsening during pregnancy or the postpartum period while some others reported no change or even some improvement. Five out of 12 pregnancies in Kapelle's study and 4 out of 12 in ours experienced worsening of motor symptoms.

It is important for neurologists to be aware of how to counsel women with PD and a childbearing potential to ensure optimal treatment. Maximal PD symptom control is necessary, especially in the post-partum period, for the demands of caring for an infant. The evidence suggests that being under treatment during pregnancy is associated with a more favorable outcome for the mother. The question which anti-PD medication should be preferred during pregnancy remains open. Nevertheless, a recently published review made by an interdisciplinary working group recommends an individualized approach in prescribing anti-PD medication. For patients with very early-stage disease who are on no pharmacological treatment this might be delayed until the end of the pregnancy. In patients who are well managed with levodopa they suggest keeping it stable and adjust dosing and/or frequency depending on clinical need. ⁵ Further prospective studies are need to answer additional questions related to the management of PD before, during and after pregnancy.