Jun 6, 2003
from Medscape Ob/Gyn & Women's Health
A 28-year-old woman has had optic neuritis requiring intravenous methylprednisolone treatment immediately postpartum with both her previous pregnancies. She is asymptomatic currently and is concerned with regard to mode of delivery for her current pregnancy. Will an elective cesarean decrease the chances of her having a recurrence of her optic neuritis? She believes it will.
Dr. Warren Kennedy
from Karen L. Koscica, DO, Peter Bernstein, MD, MPH, 06/06/2003
Optic neuritis is a condition in which there is inflammation, degeneration, or demyelinization of the optic nerve resulting in an acute unilateral central vision loss. The most common cause in young women is multiple sclerosis. Other causes are idiopathic, collagen vascular diseases, nutritional deficiencies (eg, vitamin B12 deficiency), neurosyphilis, drug toxicity (eg, from quinine or ethambutol), or inherited disorders such as Leber's optic atrophy.[1,2] Whatever the cause, pregnancy does not seem to predispose the patient to this condition.
Patients will experience decreased visual acuity, defective color vision, central scotoma, or nerve fiber bundle visual field defect. Approximately 90% of patients will have pain with eye movement. When the unaffected eye is stimulated by light on exam, both pupils constrict, but when the affected eye is stimulated immediately after the unaffected one, both pupils dilate. Optic disk swelling resembling papilledema may occur in 35% of patients.
Management is the same as in the nonpregnant patient: intravenous methylprednisolone at a dose of 1000 mg/day for 3 days followed by oral prednisone for 8 days. This strategy provides more rapid recovery but not long-term benefit. Giving oral prednisone alone is contraindicated because of the risk of increasing new attacks.
Concerns during pregnancy largely relate to the cause of the condition. Leber's disease is an X-linked disorder, so male offspring of women carriers may be affected. There are other congenital causes that may be hereditary. As a result, genetic counseling and assessment may be important. Method of delivery of the child should be based on obstetric indications, as there are no published data to support that cesarean delivery can reduce the chances of an optic neuritis flare. Nevertheless, management of labor and delivery should relate to the underlying cause of the condition in any given patient.
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