Diagnosis of Bell’s palsy requires the exclusion of other causes, accomplished primarily by taking a thorough history and performing a physical examination. Between 14% and 21% of pregnant patients who have acute facial paralysis have causes other than Bell’s palsy.16
Among the other causes of facial paralysis are herpes zoster oticus (Ramsay Hunt syndrome), in which varicella zoster virus reactivates at the geniculate ganglion.10 The patient with this disorder experiences facial nerve paralysis, skin eruption in the auricular canal, and cochleovestibular symptoms. Ramsay Hunt syndrome generally has a worse prognosis than Bell’s palsy for return of facial function.
Recurrent facial nerve paralysis can also be seen in Lyme disease, and prolonged paralysis may occur in Guillain-Barré syndrome.
When facial paralysis is accompanied by ear pain and purulent otorrhea, the cause may be acute otitis media. Cholesteatoma, trauma, neoplasm, myasthenia gravis, arteriovenous malformation, and mumps can all produce facial paralysis.
Treatment in pregnancy resembles treatment in the general population
Topical eye care, oral corticosteroids, and antiviral medications are the standard of care for Bell’s palsy. Surgical decompression may be utilized in the nonpregnant population, but reports of facial nerve decompression during pregnancy are extremely rare.
Eye care involves the use of preservative-free artificial tears, a viscous ocular ointment (Lacri-Lube) that must be applied at bedtime, with taping of the eyelids (shut) indicated at night for severe paralysis. Eye care plays a critical role in the prevention of ocular complications such as corneal abrasion.
Steroid treatment (i.e., prednisone at a dosage of 1 mg/kg for 5 days, followed by tapering) improves recovery in Bell’s palsy when it is initiated within 14 days after the onset of facial paralysis.17 However, use of steroids during the first trimester of pregnancy has been associated with an increased risk of cleft palate, and infants born to mothers who received exogenous steroids during gestation should be watched for adrenal hypofunction.
Antiviral medications represent another adjunctive treatment for Bell’s palsy. Nucleoside analogues, including valacyclovir (Valtrex) and famciclovir (Famvir) (both Category B), pose little risk to mother and fetus. In fact, these agents are commonly used to prevent outbreaks of herpes simplex virus late in pregnancy. Two double-blind, randomized, controlled trials in nonpregnant patients have demonstrated improved outcomes when Bell’s palsy is treated with steroids and antiviral agents within 3 days after onset of the paralysis, compared with steroids alone.18,19
Rapid diagnosis and treatment are critical for a good outcome. The potential benefits of treatment likely outweigh the limited fetal risks posed by these medications. Although there are conflicting reports, in general, pregnant patients who experience incomplete paralysis do extremely well, recovering with minimal residual deficits. The prognosis is less optimistic for patients who have complete paralysis, with persistent deficits observed in as many as 50% of cases.
Thyroid nodules are common in pregnancy; malignancy is a distinct possibility
Diffuse thyroid gland enlargement during pregnancy is common, occurring to varying degrees in nearly 50% of pregnant women. Pregnancy is also thought to promote the growth of existing thyroid nodules and induce the formation of new nodules.29 In both pregnant and nonpregnant patients, the majority (more than 90%) of these nodules are benign, although pregnant women appear to have a slightly higher likelihood that a solitary nodule is malignant.30
Diagnosis is straightforward
When a thyroid nodule is detected in a pregnant patient, the workup begins with a thorough history, noting age, family history of thyroid or endocrine disease, personal history of low-dosage head and neck radiation, and any recent hoarseness, dysphagia, and symptoms of hypermetabolism.
The physical exam should focus on the size and location of the thyroid abnormality, the degree of firmness of the nodule, the presence of any other nodules in the thyroid, any palpable cervical lymph nodes, and any vocal cord dysfunction.
US imaging is recommended
Because ultrasonography (US) of the thyroid is noninvasive, it is the initial imaging modality of choice. It can establish the size of any nodule (and serve as an objective baseline measurement) and identify any characteristics that suggest malignancy, such as microcalcifications, hypoechogenicity, and solid structure.
Consider fine-needle aspiration (FNA)
This technique, guided by US, is recommended when a nodule is discovered during the first trimester. However, when a nodule is discovered after 20 weeks’ gestation, the FNA option is not required. FNA can be deferred until after delivery because, even with a histologically confirmed, well-differentiated thyroid cancer, we would not operate during the third trimester—the elevated risk of preterm labor precludes that option.
When the diagnosis is cancer
The nonpregnant patient has several therapeutic options for management of thyroid cancer, but pregnancy restricts these options to close observation and surgical resection. The optimal timing of surgical management (either the second trimester or postpartum) remains unresolved.
Thyroid cancer is somewhat unique among malignancies. The majority of cancers are well-differentiated and exhibit indolent tumor biology. In one prospective study of nonpregnant patients who had small, papillary, thyroid cancers, more than 70% of those who bypassed surgical intervention had no tumor growth after 5 years of follow-up.31
Given that pregnancy is an independent risk factor for surgical complications, prolonged hospitalization, and higher hospital costs after thyroidectomy, it seems reasonable to carefully monitor, by serial US, pregnant women who have been given a diagnosis of small, well-differentiated thyroid cancer.32
In general, if a nodule is discovered during the first trimester and is larger than 1.5 cm, and if the diagnosis is cytology-proven, differentiated thyroid cancer, we would consider surgery during the second trimester if the patient were adamant. Other authors recommend second-trimester surgery more strongly.33 Regardless of the timing of resection, adjunctive treatment with radioactive iodine ablation (RIA) 3 to 6 months after delivery is an accepted component of complete oncologic therapy. Breastfeeding is prohibited with RIA, and patients are advised to wait 1 year after RIA before conceiving again.
If the patient chooses to undergo surgical resection of the thyroid during the second trimester, be aware of the transient hypothyroid state that immediately follows surgery (before the patient becomes euthyroid on replacement hormone). Because the fetus begins to synthesize its own thyroid hormone around the 18th week of gestation, we agree with the contention that the optimal time to operate is between week 19 and week 22 of gestation.34 Operating before 24 weeks also reduces the concerns related to fetal viability.
If a nodule is cytology-proven to be differentiated thyroid cancer and is smaller than 1.5 cm or is discovered late in the second trimester or beyond, most authors recommend delaying surgery until after delivery.
Outcomes are not worse in pregnancy
Pregnant women who have well-differentiated thyroid cancer and their nonpregnant counterparts have statistically identical outcomes. Moosa and Mazzaferri demonstrated no significant differences in the rate of recurrence, distant spread, or mortality.35 Their findings have been replicated in a larger, population-based study.36 There also appears to be no significant differences in maternal survival or fetal outcome between women who undergo surgical intervention during the second trimester and those who delay surgery to the postpartum period.35,37,38 After treatment, the risk of recurrence does not increase in subsequent pregnancies.35