Anti‐NMDA‐receptor encephalitis during pregnancy: A case report and literature review

Abstract

Anti-N-methyl-d-aspartate receptor (anti-NMDA-R) encephalitis is an autoimmune disorder that was first described by Dr Vitaliani in 2005. In 2007, Dalmau et al. found anti-NMDA-R antibody expressed both in the hippocampus and prefrontal nerve cell membrane, finally proposing the diagnosis of autoimmune anti-NMDA-R encephalitis. Most of the patients are female (91%), with ages ranging from 4 to 76 years. The average age is 23 years, a birth peak age, although anti-NMDA-R encephalitis is rare during pregnancy. The disorder is characterized by prominent psychosis, dyskinesias, seizures, autonomic disturbance, and central hypoventilation. We report a 24-year-old woman hospitalized at 28 gestational weeks with acute-onset psychosis. Over the course of 3 weeks, her mental status worsened until she fell into a coma. Both serum and cerebrospinal fluid anti-NMDA-R antibodies were found to be positive. At cesarean section, a healthy baby boy was born and a wedge-shaped bilateral ovarian resection was performed. Treatment with corticosteroids, intravenous immunoglobulin, and plasmapheresis can lead to improved outcomes for both mother and baby.

Anti–NMDAR encephalitis complicating pregnancy

“…Among the 14 previously described cases of anti-NMDAR encephalitis complicating pregnancy (table 1),2–13 nine healthy infants were delivered with no neurological sequelae. Two fetuses were miscarried and one fetus was aborted.…”

“…Maternal recovery was generally good, with six making a complete neurological recovery. One mother died from superimposed sepsis in intensive care and seven patients had some residual neurological deficit, with cognitive dysfunction being the most common sequel 2–13…”

“…However, rituximab has a low transplacental transfer rate in the first trimester of the pregnancy, and thus has been used preconceptually and antenatally in various autoimmune conditions, with good pregnancy outcomes 23. Some literature suggests that termination of pregnancy can hasten recovery, but more recent case analysis suggests that an elective preterm delivery may improve maternal and fetal prognosis 13. While pregnancy is a potential trigger of anti-NMDA receptor encephalitis relapses in certain case series, several reports have suggested that good maternal and newborn outcome may follow anti-NMDAR encephalitis 13…”

Pregnancy outcomes in anti-NMDA receptor encephalitis

“…A review of the English literature identified 19 publications reporting 21 cases of anti-NMDAR encephalitis during pregnancy (table 1). [2][3][4][5][6][7][8][13][14][15][16][17][18][19][20][21][22][23][24] Median maternal age was 25 years (range, 18-36 years), and 18 (85.7%) patients required intensive care. A teratoma was found and removed in 10/21 (47.6%) patients.…”

“…1,2 Several reports have suggested that dysautonomia, seizures, or central hypoventilation play important roles in the potential complications that pregnant patients may develop. [3][4][5][6][7] Other studies proposed that transplacental transfer of NMDAR antibodies can result in acute encephalopathy or death of the newborn or eventually result in autistic-spectrum disorders. 3,[8][9][10] In a study based in an experimental animal model of transplacental transfer of a human monoclonal NMDAR antibody, Jurek et al 11 suggested that antibodies of asymptomatic seropositive pregnant women (without evidence of anti-NMDAR encephalitis) caused developmental and cognitive deficits in the offspring.…”