Koshewara P*, Prasad M**, Gupta A.S***.
(* Senior Resident, ** Assistant Professor, *** Professor. Department of Obstetrics and Gynecology, Seth GS Medical college and KEM Hospital, Mumbai, India.)
Bell’s palsy is rare in pregnancy. Successful pregnancy outcome in a patient who developed acute onset Bell’s palsy in the later part of pregnancy, and continued to have the same during delivery, and marginal improvement post delivery is presented here.
Neurological disorders in pregnancy are rare. A patient of Bell’s palsy who had sudden onset of this condition during late third trimester is described below. She underwent successful vaginal delivery and her treatment was similar to that of a non-pregnant patient.
A 30 year old gravida 4 para 1 abortion 2 presented to our tertiary care center at 39 weeks of gestation. She was apparently well till 6 days prior when she developed tingling sensation at left side of face, difficulty on closure of left eye, loss of taste sensation, diplopia, vomiting and headache. She presented to the place of her registration, and evaluation by physician was performed. However, no specific treatment was initiated. Local symptomatic measures such as eye drops had been advised. She was referred to our hospital with labor pains.
History was reviewed and she had uneventful antenatal period with regular follow ups. She received three doses of iron sucrose intravenous therapy in view of iron deficiency anemia. Her first delivery was uneventful followed by two spontaneous abortions. Antenatal profile was otherwise normal. Blood sugar level (random blood sugar value of 90 mg/ dl) was normal. There was no other significant medical or surgical history. She was averagely built with a normal BMI. On examination, she was afebrile, with blood pressure of 130/80 mm of Hg, pulse of 86/ min, respiratory rate of 18/ min. Cardio-pulmonary examination was normal. Examination showed chemosis of the left eye, swollen lips, tongue deviated to right side, angle of mouth deviated to right side, and loss of wrinkling of forehead and face on the left side. All of these findings were suggestive of lower motor neuron palsy. (She did not consent for her photograph).
Abdominal examination showed a 36 weeks gestation with fetus in breech presentation with regular fetal heart rate of 130/ minute and good uterine activity of 3 to 4 contractions lasting 40 seconds in 10 minutes duration. Vaginal examination showed 4 cm dilated internal os suggestive of established labor. In view of breech presentation in active labor, preparation for cesarean section was initiated. However, in view of Bell’s palsy, neurologists and oto-laryngologists were consulted. In the mean while the labor progressed spontaneously and assisted breech vaginal delivery was performed, delivering a 2.3 kg male child with no complications.
Neurologists and oto-laryngologists re-examined, and confirmed the case to be Bell’s palsy. She was advised low dose steroid (tablet prednisolone 60 mg once a day for one week, and then gradual weekly tapering of the drug), multivitamins, ciprofloxacin eye drops and chloromphenicol eye ointment to prevent dry eye. Tablet acyclovir 800 mg three times a day was also started. Physiotherapists taught the patient facial massage and physiotherapy exercises. Neurologists and otolaryngologists advised continuation of steroid injection in the peripartum period. Post delivery course was uneventful. The signs and symptoms of Bell’s palsy improved and on day 5 of her admission she was discharged with advise to follow up with the physician, neurologist and us.
The condition of Bell’s palsy in pregnancy is an intriguing one. It is widely speculated that the famous Italian painting “Mona Lisa” by DaVinci was modeled on a lady who was suffering from this condition. Loosely, this condition is also referred to as “Mona Lisa syndrome”.
The incidence of Bell’s palsy is reported to be around 15- 40 per 100000 people. The incidence is approximately the same in pregnancy also (17 in 100000), as reported by Katz et al.The occurrence of Bell’s palsy in pregnancy is approximately 3 times more during the pregnant state when compared to non-pregnant state.
In this review, it was noted that occurrence of Bell’s palsy during pregnancy was associated with obesity, chronic hypertension and preeclampsia. However, our patient did not have any of the above conditions. Juan et al and Fawale et al have also reported the similar association of hypertension and Bell’s palsy.[5,6] Bilateral facial paralysis in pregnancy have been reported by Kovo et al and Vogell et al.[7,8] In the case by the latter, there was early onset bilateral Bell’s palsy with severe preeclampsia developing later after the onset of palsy.
It is reported to be more common in diabetics. However, our patient did not have this risk factor.Our patient came with spontaneous established labor. Induction of labor has also been reported, mainly for accompanying obstetric indication.
Our patient had good perinatal outcome. As reviewed by Katz et al, there is no association between Bell’s palsy and worsening of perinatal outcome. Presentation in the puerperium has also been described. Our patient was started on corticosteroids. Steroids for treatment of Bell’s palsy are evidence based. Our patient was started on antiviral treatment also. Evidence suggests that antiviral treatment for Bell’s palsy should be used only in combination with corticosteroids. Gillman et al followed up patients with Bell’s palsy upto one year after pregnancy completion. The recovery of this group of patients was worse when compared to Bell’s palsy occurring in non-pregnant patients. Our patient will be followed up regularly, to monitor the course of recovery.
While the management of this condition in pregnancy is almost similar to that of non-pregnant state, subtle differences have been highlighted in a review by Hussain et al.  In obstetric patients, the main differences were need for multidisciplinary involvement, a search for atypical causes of Bells palsy and earlier institution of corticosteroids. No specific anesthetic precautions are recommended if operative delivery is indicated. and this is also supported by Overall, Bell’s Palsy is a condition with good recovery rate. However, when it occurs during pregnancy it appears to have a longer time for recovery and probably worse long term outcomes, as reviewed by Philips et al.
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Koshewara P, Prasad M, Gupta A.S. Idiopathic Bell’s palsy in pregnancy. JPGO 2018. Volume 5 No.11. Available from: https://www.jpgo.org/2018/11/idiopathic-bells-palsy-in-pregnancy.html