Chorea gravidarum: a case report

The Journof of Moternol-Fetolond NeonotolMedicine2002;122353-354

Chorea gravidarurn;a casereport A. Y. Korogeyim,B. Kors,R. Donsuk,E.Aygun,O. U"", ond M. C. Turon KortolReseorch HospitofDepartment of Obsfetrics andGynecology, Istonbul, Turkey

Chorea gravidarumis a rare syndromein pregnancy.The clinical picture is of exrrapyramidal symFtomssuchasinvoluntarymovemencs, lack of coorc{ination and slurredspeech.Neurolepricsor can be usedfor treatment.Vhen antiphospholipidanribodiesare shorvnto be benzodia:epines present,corticosteroids, and sometimesaspirin; addedto the treatment.lv{ovementdisorders can alsobe associated with an increased centraldoptrnrine level.In this reporr,we presentthe case of a patient rvith choreagravirlarumin u'homx6 ssi(rlogic factorhasnot L,eenobserved. We treated the symptomswith dopamine-blocking agenrssuch as haloperidol.We believe thar, if chorea gravidarumis not accompanied by other eriologicfactors(suchas antiphospholipidanribodies), tl-rereis no elevatedriskfor rhe motherand the fens. Key r,vords: CHOREAGRAVIDARUIVI; PREGN.\NCY; Ir{OVEN{ENT DISORDER

INTRODUCTION

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Chorea is a movement disorder characreri:edby rapid, irregularand involuncarymovenents.In the pre-antibioric era, chorea rvascommoniy observedarising from group A streptococcal infections and rheumatic fever. Chorea gravidarum,a subclassof the syndromeof acute chorea,is a rare maternal complication during pregnancy. The incidence of chorea gravidarum in pregnancyhas been reported as ranging from l/350C1to i/140 000, rvith a current matemalmortalityrareof l7o.The clinicalpicture is sirnilar to that of Sydenhanr'schorea, u'ith exrraplramidal s)'mpromssuchas involunrarymovemenls,lack of cooidination, sh-trredspeechand psychicdisordersl.The ner.rrological stateis nornralexceptfor a lossof nruscletone. The s1'mptonrs most conruronlybegin in the first trimester of pregnancyand usually resoh'espontaneouslyafter 2-3 months. Treatments include neuroldpricsfor symptom' atic relief and therapies targeted torvard the underlying pathology.

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CASE REPORT r"'

day. She had no symptons and complainrs rill 32 s'eeks of gestarion.Siuned speech, involrntary movemenm of her extremitiesand face rvereobserved afrcr 32 weeks of gestarion.In her laborarory analysis,anrisrreprolysin-O, rheumaroidfactor, anti-DNA ancibodies,arlri-cardiolipin, imrnunoglobulin M and G, activared parrial thromboplastin time and platelet counts tvere normal, bur C-reactive protein and sedimentation rate rvere high. ln addition, her electroenceprhalstrer.l and craniai colnprrted tomographyresultsrvereshou,nto be normal. A consulranr neurologist concluded that 6e diagnosis was chorea gravidarr.rm; haloperidol I mg/day rvas starred. Follorving delivery and 3 weeksof medicacion,the parient recovered completelyand medicarionwasterurinated. DISCUSSION ln orrr literature search,rvefound that approximately45o/o of episodesof chorea gravidarum begin during the first, 357oduring the secondand 207oduring the third trimester. in our parient, choreagravidarurnrvasobserveddlrring the rhird rrimester. The symproms disappear a ferv days after deiivery in nearly all patients,but in 30oloof parients they disappear before delivery. Or-rr patient recovered completely 3 rveeks after delivery. Chorea gravidarum nright develop from infections, cerebrovascular,autoimmune and ent-locrinediseases.Cen'era and coileagr-res analy:ed rhe clinical, radiological and immunological characteristics of 50 patients'rvithchorea2

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Or-rrpatient rvasa 19-year-oldprimigravida.She presenied for deiivery at 40 rveeksof gestation.There rvereinvoluntary n'rovementsof her face,arnisand legs.Her speechri'as slur:redand sheu'asanxiolrsat the presentation.On the da,v of admission,she delivered'ahealthybaby I'y the vaginal ror-rte. She lvasan active,healtlij'Nomanrvith no historyof rher-rrnaticfever or collagen vascrrlardiseases.Sl'rervasa srnoker,r'vichan averagecorrsumptionof for.rrcigarettesper

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Correspondence: Dr A. Y. Korogeyim,Kozyologil9 tv'\o'yis Moh. Okur Sok.LeyliApi. No:6/20 34736 Kodikoy,lstonbul,Turkey

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C A S ER E P O R T

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Chorea rvasobservedat a mean age of 21 years.Most patients presentedrvith only one episodeof chorea.For our patient, rhis ivas her first episocleof chorea.Cranial compLrredromographyand magneric resonarrceimaging sholvedcerebralinfirrcts in 357oof patients, but computecl tornograprhyscanswere normal in our patient. The safest and rnost efficient trearmenr for chorea gravidarum is haloperidol,but in order to minimize rhe risk of rardive dyskinesia,this treatment should be terminared after the shortest possible rime. Becar-rseour patient recovered completely, rve stopped haloperidol rherapy 3 weeks after delivery. We did nor find an eriologic factor for chorea gravidirrum in our patient. Oral contraieptivesand hormone replacementtherapy can induce chorea gravidaruml. Our patient rvasadvisednor ro use contraceptivepills and u'as also informed about the high possibiliry of recurrenceof the diseasein her subsequenr pregnancies.\Ue believe that,

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if choreagravidarumis not accornpanied by other etiologic factors(such as antiphospholipidanribodies),there rvill be no elevaredrisk for rhe morher and the ferus. REFERENCES 1. Kanasau'a I, MurataIv{,Kimuralvl.Rolesof dopamineand its receptorsin generationof choreaticmor.ements. Adt' Nleurol1993160: 107-12 2. CerveraR, AshersonRA, Fonr l, et al. Chorea in the antiphosphoiipidsyntlrome. Ciinical, radiologic,' and immunologiccharacteristics of 50 parientsfrom our clinics (Bahimore)7997;76, and the recent lirerarure.Jr{edicine -

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3. Omdal R, RoalsoS. Choreagravidarumand choreaassociated n'irh oral contraceptives- diseases due to antiphospholipidantibodies?Acr,a Neurol Scand 1992;86: 219-70