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Management of Restless Legs in Pregnancy: An Obstetrician, Internal Medicine Physician, and Perinatal Psychiatrist Work Together in an Obstetric Clinic

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Abstract

This chapter outlines the assessment and management of restless legs (RLS) during pregnancy using a fictional but clinically typical, case vignette. The importance of multidisciplinary assessment, diagnosis, investigation, and management is outlined, with consideration of both medical and psychiatric comorbidities. Fundamental principles of prescribing for the pregnant woman are discussed, including a consideration of the risks and benefits of appropriate treatment versus no or inadequate treatment for the woman, fetus, and neonate. This case demonstrates a partnership between the woman and her care providers with acknowledgment of the patient’s physiological and psychosocial context and ongoing communication and collaboration between the woman and her care providers.

Keywords

  • Restless legs
  • Restless legs in pregnancy
  • Anemia and restless legs
  • Restless legs and depression
  • Insomnia and restless legs

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References

  1. International Restless Legs Syndrome Study Group. Validation of the International Restless Legs Syndrome Study Group Rating Scale for restless legs syndrome. Sleep Med. 2003;4(2):121–32.

    CrossRef  Google Scholar 

  2. Burman D. Sleep disorders: restless legs syndrome. FP Essentials. 2017;460:29–32.

    PubMed  Google Scholar 

  3. Palagini L, Gemignani A, Bantia S, Manconic M, Mauria M, Riemannd D. Chronic sleep loss during pregnancy as a determinant of stress: impact on pregnancy outcome. Sleep Med. 2014;15(8):853–9.

    PubMed  CrossRef  Google Scholar 

  4. Oyieng' o DO, Kirwa K, Tong I, Martin S, Rojas-Suarez JA, Bourjeily G. Restless legs symptoms and pregnancy and neonatal outcomes. Clin Ther. 2016;38(2):256–64.

    CrossRef  Google Scholar 

  5. Berle JO, Mykletun A, Daltveit AK, Rasmussen S, Holsten F, Dahl AA. Neonatal outcomes in offspring of women with anxiety and depression during pregnancy. A linkage study from The Nord-Trondelag Health Study (HUNT) and Medical Birth Registry of Norway. Arch Womens Ment Health. 2005;8(3):181–9. https://doi.org/10.1007/s00737-005-0090-z.

    CAS  CrossRef  PubMed  Google Scholar 

  6. Ding XX, Wu YL, Xu SJ, et al. Maternal anxiety during pregnancy and adverse birth outcomes: a systematic review and meta-analysis of prospective cohort studies. J Affect Disord. 2014;159:103–10. https://doi.org/10.1016/j.jad.201.4.02.0.27.

    CrossRef  PubMed  Google Scholar 

  7. Mcelhatton PR. Pregnancy: (2) general principles of drug use in pregnancy. Pharmaceutical J. 2003;270(7236):232.

    Google Scholar 

  8. Gidai J, Acs N, Banhidy F, Czeizel AE. No association found between the use of very large doses of diazepam by 112 pregnant women for a suicide attempt and congenital abnormalities in their offspring. Toxicol Ind Health. 2008;24:29–39.

    CAS  PubMed  CrossRef  Google Scholar 

  9. Hartz SC, Heinonen OP, Shapiro S, Siskind JV, Slone D. Antenatal exposure to meprobamate and chlordiazepoxide in relation to malformations, mental development, and childhood mortality. N Engl J Med. 1975;292:726–8.

    CAS  PubMed  CrossRef  Google Scholar 

  10. Brandlistuen RE, Ystrom E, Hernandez-Diaz S, Skurtveit S, Selmer R, Handal M, et al. Association of prenatal exposure to benzodiazepines and child internalizing problems: a sibling-controlled cohort study. PLoS One. 2017;12(7):e0181042. https://doi.org/10.1371/journal.pone.0181042.

    CAS  CrossRef  PubMed  PubMed Central  Google Scholar 

  11. The Organization of Teratology Information Specialists (OTIS) MotherToBaby. http://mothertobaby.org/fact-sheets/benzodiazepines-pregnancy/US. Department of Health and Human Services. Accessed 20 Aug 2018.

  12. Vythilingum B. Anxiety disorders in pregnancy and the postnatal period. CME. 2009;27(10):450–2.

    Google Scholar 

  13. Pichetti DL, Hensley JG, Bainbridge JL, Lee KA, Manconi M, McGregor JA, et al. Consensus clinical practice guidelines for the diagnosis and treatment of restless legs syndrome/Willis Ekbom disease during pregnancy and lactation. Sleep Med Rev. 2015;22:64–7.

    CrossRef  Google Scholar 

  14. Gupta R, Dhyani M, Kendzerska T, Pandi-Perumal SR, BaHammam AS, Srivanitchapoom P, Pandey S, Hallett M. Restless legs syndrome and pregnancy: prevalence, possible pathophysiological mechanisms, and treatment. Act Neurol Scand. 2016;133:320–9. https://doi.org/10.1111/ane.12520.

    CAS  CrossRef  Google Scholar 

  15. Berger K, Luedemann J, Trenkwalder C, et al. Sex and the risk of restless legs syndrome in the general population. Arch Intern Med. 2004;164(2):196–202. https://doi.org/10.1001/archinte.164.2.196.

    CrossRef  PubMed  Google Scholar 

  16. Sateia MJ. International classification of sleep disorders-third edition. Chest. 2015;146(5):1387–94.

    CrossRef  Google Scholar 

  17. Sikandrar R, Khealani BA, Wasay M. Predictors of restless legs syndrome in pregnancy: a hospital-based cross-sectional survey from Pakistan. Sleep Med. 2009;10(6):676–8.

    CrossRef  Google Scholar 

  18. Montplaisir J, Boucher S, Poirier G, Lavigne G, Lapierre O, Lesperance P. Clinical, polysomnographic, and genetic characteristics of restless legs syndrome: a study of 133 patients diagnosed with new standard criteria. Mov Disord. 1997;12(1):61–5.

    CAS  PubMed  CrossRef  Google Scholar 

  19. Neau JP, Marion P, Mathis S, Julian A, Godeneche G, Larrieu D, Meurice JC, Paquereau J, Ingrand P. Restless legs syndrome, and pregnancy: follow-up of pregnant women before and after delivery. Eur Neurol. 2010;64:361–6. https://doi.org/10.1159/000322124.

    CrossRef  PubMed  Google Scholar 

  20. Pantaleo NP, Hening WA, Allen RP, Early CJ. Pregnancy accounts for most of the gender differences in the prevalence of familial RLS. Sleep Med. 2010;11(3):310–3. https://doi.org/10.1016/j.sleep.2009.04.005.

    CrossRef  PubMed  Google Scholar 

  21. Hubner A, Krafft A, Esther Werth SG, Zimmermann R, Bassetti C. Characteristics and determinants of restless legs syndrome in pregnancy. Neurology. 2013;80:738–42.

    PubMed  CrossRef  Google Scholar 

  22. Grover A, Clark-Bilodeau C, D’Ambrosio CM. Restless leg syndrome in pregnancy. Obstet Med. 2015;8(3):121–5. https://doi.org/10.1177/1753495X15587452.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  23. Manconi M, Ulfberg J, Berger K, Ghorayeb I, Wesström J, Fulda S, Allen RP, Pollmächer T. When gender matters: restless legs syndrome. Report of the “RLS and woman” workshop endorsed by the European RLS Study Group. Sleep Med Rev. 2012;16(4):297–307.

    PubMed  CrossRef  Google Scholar 

  24. Pereira JC Jr, Rocha e Silva IR, Pradella-Hallinan M. Transient Willis–Ekbom’s disease (restless legs syndrome) during pregnancy may be caused by estradiol-mediated dopamine overmodulation. Med Hypotheses. 2013;80(2):205–8.

    CAS  PubMed  CrossRef  Google Scholar 

  25. Cesnik E, Casetta I, Turri M, Govoni V, Granieri E, Strambi LF, Manconi M. Transient RLS during pregnancy is a risk factor for the chronic idiopathic form. Neurology. 2010;75(23):2117.

    CAS  PubMed  CrossRef  Google Scholar 

  26. Balendran J, Champion D, Jaaniste T, Welsh A. A common sleep disorder in pregnancy: restless legs syndrome and its predictors. Aust NZ J Obstet Gynaecol. 2011;51:262–4.

    CrossRef  Google Scholar 

  27. Suzuki K, Ohida T, Sone T, Takemura S, Yokoyama E, Miyake T, Harano S, Motojima S, Suga M, Ibuka E. The prevalence of restless legs syndrome among pregnant women in Japan and the relationship between restless legs syndrome and sleep problems. Sleep. 2003;26(6):673–7.

    PubMed  CrossRef  Google Scholar 

  28. Uglane MT, Westad S, Backe B. Restless legs syndrome in pregnancy is a frequent disorder with a good prognosis. Acta Obstet Gynecol Scand. 2011;90:1046–8. https://doi.org/10.1111/j.1600-0412.2011.01157.x.

    CrossRef  PubMed  Google Scholar 

  29. Manconi M, Govoni V, De Vito A, Economou NT, Cesnik E, Casetta I, Mollica G, Ferini-Strambi L, Granieri E. Restless legs syndrome and pregnancy. Neurology. 2004;63(6):1065–9. https://doi.org/10.1212/01.WNL.0000138427.83574.A6.

    CAS  CrossRef  PubMed  Google Scholar 

  30. Becker JB. Direct effect of 17β-estradiol on striatum: sex differences in dopamine release. Synapse. 1990;5:157–64. https://doi.org/10.1002/syn.890050211.

    CAS  CrossRef  PubMed  Google Scholar 

  31. Dzaja A, Wehrle R, Lancel M, Pollmächer T. Elevated Estradiol plasma levels in women with restless legs during pregnancy. Sleep. 2009;32(2):169–74.

    PubMed  PubMed Central  CrossRef  Google Scholar 

  32. Daubian-Nose’ P, Frank MK, Maculano-Esteves A. Sleep disorders: a review of the interface between restless legs syndrome and iron metabolism. Sleep Sci. 2014;7:234–7. http://creativecommons.org/licenses/by-nc-nd/3.0/

    CrossRef  Google Scholar 

  33. Ozer I, Guzel I, Orhan G, Erkılınç S, Öztekin N, Ak F, Taşçı Y. A prospective case-control questionnaire study for restless leg syndrome on 600 pregnant women. J Matern Fetal Neonatal Med. 2016;30(24):2895–9. https://doi.org/10.3109/14767058.2016.1170801.

    CAS  CrossRef  Google Scholar 

  34. Çakmak B, Metin ZF, Karatafl A, Özsoy Z, Demirtürk F. Restless leg syndrome in pregnancy. Perinatal J. 2014;22(1):1–5. https://doi.org/10.2399/prn.14.0221001.

    CrossRef  Google Scholar 

  35. Mehmood T, Auerbach M, Earley CJ, Allen RP. Response to intravenous iron in patients with iron deficiency anemia (IDA) and restless leg syndrome (Willis–Ekbom disease). Sleep Med. 2014;15(12):1473–6. https://doi.org/10.1016/j.sleep.2014.08.012.

    CrossRef  PubMed  Google Scholar 

  36. Grim K, Lee B, Sung AY, Kotagal S. Treatment of childhood-onset restless legs syndrome and periodic limb movement disorder using intravenous iron sucrose. Sleep Med. 2013;14(11):1100–4. https://doi.org/10.1016/j.sleep.2013.06.006.

    CrossRef  PubMed  Google Scholar 

  37. Vadasz D, Ries V, Oertel WH. Intravenous iron sucrose for restless legs syndrome in pregnant women with low serum ferritin. Sleep Med. 2013;14(11):1214–6. https://doi.org/10.1016/j.sleep.2013.05.018.

    CrossRef  PubMed  Google Scholar 

  38. Trenkwalder C, Paulus W. Restless legs syndrome: pathophysiology, clinical presentation, and management. Nat Rev Neurol. 2010;6:337–46.

    PubMed  CrossRef  Google Scholar 

  39. Winkelmann J, Barbara Schormair B, Meitinger T. Genome-wide association study of restless legs syndrome identifies common variants in three genomic regions. Nat Genet. 2007;39:1000–6.

    CAS  PubMed  CrossRef  Google Scholar 

  40. Schormair B, Kemlink D, Juliane Winkelmann J. PTPRD (protein tyrosine phosphatase receptor type delta) is associated with restless legs syndrome. Nat Genet. 2008;40:946–8.

    CAS  PubMed  CrossRef  Google Scholar 

  41. Earley CJ, Silber MH. Restless legs syndrome: understanding its consequences and the need for better treatment. Sleep Med. 2010;11:807–15. https://doi.org/10.1016/j.sleep.2010.07.007.

    CrossRef  PubMed  Google Scholar 

  42. Lee KA, Zaffke ME, Baratte-Beebe K. Restless legs syndrome and sleep disturbance in pregnancy. J Womens Health Gend Based Med. 2001;10(4):335–41.

    CAS  PubMed  CrossRef  Google Scholar 

  43. Minár M, Habánová H, Rusňák I, Planck K, Peter Valkovič P. Prevalence and impact of restless legs syndrome in pregnancy. Neuroendocrinol Lett. 2013;34(5):366–71.

    PubMed  Google Scholar 

  44. Liu G, Li L, Zhang J, Xue R, Zhao X, Zhu K, Wang Y, Xiao L, Shangguan J. Restless legs syndrome and pregnancy or delivery complications in China: a representative survey. Sleep Med. 2016;17:158–62.

    CAS  PubMed  CrossRef  Google Scholar 

  45. Neau JP, Porcheron A, Mathis S, Julian A, Meurice JC, Paquereau J, Godeneche G, Ciron J, Bouche G. Restless legs syndrome and pregnancy: a questionnaire study in the Poitiers District, France. Eur Neurol. 2010;64:268–74.

    PubMed  CrossRef  Google Scholar 

  46. Nodine PM, Matthews EE. Common sleep disorders: management strategies and pregnancy outcomes. J Midwifery Womens Health. 2013;58:368–77.

    PubMed  CrossRef  Google Scholar 

  47. Tan M, Bourjeily G. Shaking up perspectives on restless legs syndrome in pregnancy: commentary on Dunietz et al Restless legs syndrome and sleep-wake disturbances in pregnancy. J Clin Sleep Med. 2017;13(7):857–8.

    PubMed  PubMed Central  CrossRef  Google Scholar 

  48. Aukerman MM, Aukerman D, Bayard M, Tudiver F, Thorp I, Bailey B. Exercise and restless legs syndrome: a randomized controlled trial. J Am Board Fam Med. 2006f;19:487–93.

    PubMed  CrossRef  Google Scholar 

  49. Western Australian Department of Health. Perinatal and infant mental health model of care – a framework. Perth: North Metropolitan Health Service, Western Australian Department of Health, Western Australia; 2016.

    Google Scholar 

  50. Snellen M, Thompson G, Murdoch N. The process of obtaining informed consent when prescribing psychopharmacology in pregnancy. In: Galbally M, et al., editors. Psychopharmacology and pregnancy. Berlin: Springer-Verlag; 2014. https://doi.org/10.1007/978-3-642-54562-7_7.

    CrossRef  Google Scholar 

  51. Taylor D, Paton C, Kapur S. Maudsley prescribing guidelines in psychiatry. 12th ed. Oxford UK: Wiley Blackwell; 2015.

    Google Scholar 

  52. Garcia Borreguero D, Ferini-Stranbi L, Kohnen R, O’Keefe S, Trenkwaider C, Hogyl B, et al. European guidelines on management of restless legs syndrome: report of a joint task force by the European Federation of Neurological Societies, the European Neurological Society and the European Sleep Research Society. Eur J Neurol. 2012;19:1385–96.

    PubMed  CrossRef  Google Scholar 

  53. Saxen I, Saxen L. Association between maternal intake of diazepam and oral clefts. Lancet. 1975;2:498.

    CAS  PubMed  CrossRef  Google Scholar 

  54. Lin AE, Peller AJ, Westgate MN, Houde K, Franz A, Holmes LB. Clonazepam use in pregnancy and the risk of malformations. Birth Defects Res A Clin Mol Teratol. 2004;70:534–6.

    CAS  PubMed  CrossRef  Google Scholar 

  55. Freeman MP, Goez-Mogolion L, McInerney KA, Davies AC, Church TR, Sosinsky AZ, et al. Obstetrical and neonatal outcomes after benzodiazepine exposure during pregnancy: results from a prospective registry of women with psychiatric disorders. Gen Hosp Psychiatry. 2018;53:73–9.

    PubMed  CrossRef  Google Scholar 

  56. Kallen B, Reis M. Neonatal complications after maternal concomitant use of SSRI and other central nervous system active drugs during the second or third trimester of pregnancy. J Clin Psychopharmacol. 2012;32(5):608–14. https://doi.org/10.1097/JCP.Ob013e3182668568.

    CrossRef  PubMed  Google Scholar 

  57. Kallen B, Borg N, Reis M. The use of central nervous system active drugs during pregnancy. Pharmaceuticals. 2013;6(10):1221–86. https://doi.org/10.3390/ph6101221.

    CAS  CrossRef  PubMed  PubMed Central  Google Scholar 

  58. Calderon-Margalit R, Qui C, Ornoy A, Siscovick DS, Williams MA. Risk of preterm delivery and other adverse perinatal outcomes in relation to maternal use of psychotropic medication during pregnancy. Am J Obstet Gynecol. 2009;201(6):579.e1–8. https://doi.org/10.1016/j.ajpg.2009.06.061.

    CrossRef  Google Scholar 

  59. Iqbal MM, Tanveer Sobhamn T, Ryals T. Effects of commonly used benzodiazepines on the fetus, neonate and the nursing infant. Psychiatr Serv. 2002;53:39–49.

    PubMed  CrossRef  Google Scholar 

  60. Birnbaum CS, Cohen LS, Bailey JW, Grush MD, Robertson LM, Stowe ZN. Serum concentrations of antidepressants and benzodiazepines in nursing infants: a case series. Pediatrics. 1999;104:e11. PMID: 10390297

    CAS  PubMed  CrossRef  Google Scholar 

  61. Dostal M, Weber-Schoendorfer C, Sobesky J, Schaefer C. Pregnancy outcome following use of levodopa, pramipexole, ropinirole, and rotigotine for restless legs syndrome during pregnancy: a case series. Eur J Neurol. 2013;20:1241–6.

    CAS  PubMed  CrossRef  Google Scholar 

  62. Allen RP, Earley C. Augmentation of the restless legs syndrome with Carbidopa/levodopa. Sleep. 1996;19(3):205.

    CAS  PubMed  CrossRef  Google Scholar 

  63. Silver N, Allen RP, Senerth J, Earley CJ. A 10-year, longitudinal assessment of dopamine agonists and methadone in the treatment of restless legs syndrome. Sleep Med. 2011;12:440–4.

    PubMed  CrossRef  Google Scholar 

  64. Walters AS, Winkelmann J, Trenkwalder C, Fry JM, Kataria V, Wagner M, et al. Long-term follow-up on restless legs syndrome patients treated with opioids. Mov Disord. 2001;16:1105–9.

    CAS  PubMed  CrossRef  Google Scholar 

  65. Yang C, White DP, Winkelman JW. Antidepressants and periodic leg movements of sleep. Biol Psychiatry. 2005;58:510–4.

    CAS  PubMed  CrossRef  Google Scholar 

Suggested Reading

  • Pichetti DL, Hensley JG, Bainbridge JL, Lee KA, Manconi M, McGregor JA, et al. Consensus clinical practice guidelines for the diagnosis and treatment of restless legs syndrome/Willis Ekbom disease during pregnancy and lactation. Sleep Med Rev. 2015;22:64–7.

    CrossRef  Google Scholar 

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Watt, F., Uku, A., Akers, A.S. (2021). Management of Restless Legs in Pregnancy: An Obstetrician, Internal Medicine Physician, and Perinatal Psychiatrist Work Together in an Obstetric Clinic. In: Khawaja, I.S., Hurwitz, T.D. (eds) Sleep Disorders in Selected Psychiatric Settings. Springer, Cham. https://doi.org/10.1007/978-3-030-59309-4_8

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  • DOI: https://doi.org/10.1007/978-3-030-59309-4_8

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