Severe Motor Deterioration of Young-Onset Parkinson's Disease in Pregnancy Following Medication Rationalisation: A Case Report

This is the authors' abstract. We don't add key points for this paper.

Parkinson's disease (PD) in pregnancy is rare, and there are no agreed guidelines for its management. We report a 34-year-old primigravida with a three-year history of young-onset PD who presented at eight weeks' gestation with an unplanned pregnancy. She had previously tolerated levodopa poorly, with nausea and early peak-dose dyskinesia, and before conception her symptoms were reasonably controlled on amantadine, selegiline and procyclidine. Because of the potential teratogenicity of amantadine and limited safety data for the other agents, her treatment was changed to co-careldopa (carbidopa/levodopa) with domperidone. Her condition deteriorated soon after the switch. Despite stepwise increases in levodopa to 400-450 mg/day, by 31 weeks she was wheelchair-dependent, with severe peak-dose dyskinesia alternating with "off" periods and freezing, and she relied on her husband for feeding and personal care. Other drug options and deep brain stimulation were deferred until after delivery. Her care involved neurology, obstetric medicine, obstetric anaesthesia, safeguarding midwives, physiotherapy and occupational therapy, and she received thromboprophylaxis for immobility. She presented in spontaneous labour at 37+5 weeks and underwent a category 2 caesarean section under general anaesthesia, as constant tremor precluded neuraxial anaesthesia. Estimated blood loss was 750 mL. Her daughter had Apgar scores of 4, 7 and 9 at 1, 5 and 10 minutes, respectively, and weighed 2250 g (3.4th centile). Postpartum, dyskinesia and tremor temporarily prevented her from holding her baby, and trihexyphenidyl was started; her symptoms were unchanged five weeks after delivery. In young-onset PD, withdrawal of an effective pre-pregnancy regimen may be followed by significant functional decline, and previous levodopa intolerance may be a warning sign. This case highlights the importance of pre-conception counselling, early multidisciplinary planning and postnatal support.