Dysautonomia and Pregnancy

 Short article in Dysautonomia International blog page: Link to the article

By Dr. Svetlana Blitshteyn

Guest author Svetlana Blitshteyn, MD is the Director of the Dysautonomia Clinic and a Clinical Assistant Professor of Neurology at the University at Buffalo School of Medicine and Biomedical Sciences.

Excerpts:

• POTS patients may have associated gynecologic issues such as endometriosis and fibroids. Therefore, needs careful evaluation by gynecologist, POTS physician and patient.
• During pregnancy, 60% women with POTS reported severe hyperemesis gravidarum and 40% fatigue. Higher rate of miscarriage is reported.
• During pregnancy, 30-50% women reported worsening of POTS symptoms. (50% had no change in their POTS symptoms.
• After delivery, 50% of women reported improved symptoms for 6 months after delivery. In a different study, 30% reported worsening symptoms after delivery. 70% reported stable symptoms after delivery.
• POTS medicines during pregnancy:
• There are no POTS meds in Class A list by FDA (these are considered safe during pregnancy).
• I have used low-dose beta-blocker during pregnancy to control tachycardia
• Florinef and Pyridostigmine (Mestinon) are continued during pregnancy if necessary.
• Less experience with Midodrine (its newer).
• Women on SSRI's may switch to Prozac.
• Medications that need to be weaned off or used sparingly include Benzodiazepines (e.g. Clonazepam, Ativan), Xanax (Alprazolam) and stimulants (Ritalin, Adderall).
• POTS Medicines, to be stopped during pregnancy
• Ideally, stop all medicines prior to conception. But, this may be unrealistic.
• Planned pregnancy: 1st trimester - stop meds or reduce dose to minimum. If planning a pregnancy, slowly wean benzodiazepines and stimulants.
• Unplanned pregnancy: wean above meds on a faster schedule.
• Risk to the baby (in utero or postpartum)
• 4 studies - no negative effects.
• Does fainting harm the baby? No
• But, recurrent syncope may reduce placental blood flow and therefore, may need an active management.
• Breastfeeding
• Metoprolol is safer than atenolol.
• Prozac which is acceptable during pregnancy may be more harmful to the baby via breastmilk (Zoloft is better).
• Will the child develop POTS?
• Not enough studies to answer this question. 
• Familial incidence occurs in 13-40% of patients.

References:

1. Blitshteyn S, Bett GL, Poya H. Pregnancy in Postural Tachycardia Syndrome: clinical course and maternal and fetal outcomes. J Matern Fetal Neonatal Med. 2012; 25: 1631-1634.

2. Kanjwal KK, Karabin B, Grubb BP. Outcomes of pregnancy in patients with Postural Orthostatic Tachycardia Syndrome. PACE 2009; 32:1000-1003.

3. Peggs, KJ, Nguen H, Enayat D, et al., Gynecologic disorders and menstrual cycle lightheadedness in postural tachycardia syndrome. Int J Gynaecol Obstet. 2012; 118: 242-246.

4. Kimpinski K, Iodice V, Sandroni P, Low PA. Effect of pregnancy on Postural Tachycardia Syndrome. Mayo Clin Proc 2010; 85: 639-644.

5. Powless CA, Harms RW, Watson WJ. Postural tachycardia syndrome complicating pregnancy. J Matern Fetal Neonatal Med 2010; 23: 850-853.