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Clinical case 023: Alarm Bell’s at 38 weeks

19 yo. woman G1P0 now 38/40 gestation, has been well throughout pregnancy aside from mild anaemia.  She presents to ED with “red eye”, and has a red eye, but more notably has a facial nerve palsy involving the upper and lower branches of VII.  Examination confirms Bell’s palsy and the slit lamp exam reveals a line of superficial fluorescein uptake consistent with exposure keratitis – her lids are not opposing well when she sleeps – so she has a dry, dessicated cornea.

So here are the 3 learning points for me:

Well, it is roughly 3 times as common in pregnancy than the general population.  Bell’s is associated with hypertensive diease of pregnancy and a ~ 5 fold increased risk of pre-eclampsia, hypertension and he associated outcomes of preterm birth, low birth weight and C-section delivery (Shmorgun et al).  What does this mean? Well you probably need to consider inducing a woman with Bell’s.  Where is the rsk:benefit break point – I guess it depends on the presence of other features of the eclampsia syndrome?  Love to hear your thoughts.

 There has been a change in the evidence in the past 2 years with new Cochrane reviews including a few new, high qualiy trials out in 2010.  So what do they say?

No benefit found in using anti-viral meds eg, valaciclovir. Not recommended.  Recent studies (Lancet Neurology) show no reduction in the time to recovery of facial function or prognosis.    So what about Steroids?  The last Cochrane review included 2 trials that showed a significant reduction in incomplete facial recovery at 6 months. Basically 75% got full recovery on steroids, whereas about 2/3 got better without steroids. There was no “cosmetic outcome” difference though between the 2 groups.  There was no additional benefit in adding anti-virals to steroids – love it when cheaper is better!

The evidence shows steroids help – but not dramatically – your patient is still at risk of eye injury due to corneal dessication over the coming weeks.

So the single most important intervention is to teach them to lubricate and tape the eye closed at night and use artificial tears by day. No evidence – just common sense I am afraid.

So what happened to our 20 yo @ 38/40.  Well, she got induced, and had a healthy baby, then started on a course of Prednisolone.

The interesting thing for me was that the Obs team seemed to employ some backward-logic here… they induced her so that they could start her on the steroids and not have to worry about exposing the fetus to the drugs!  It would seem to be a better idea to induce for the relative increased risk of eclampsia etc, as the steroids have a marginal benefit and well… we give steroids to women all the time in pregnancy for other reasons.. May be I missed something in translation?

 

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