Deep Brain Stimulation and Pregnancy: A Case Report and Literature Review.

Deep brain stimulation (DBS) is an invasive therapeutic option for medically refractory motor complications of Parkinson's disease (PD). Though, historically, DBS tended to be performed later in life, people with monogenic forms of PD have increased chances of motor complications earlier in the disease making them potential candidates for DBS. While this includes women of childbearing age, pregnant women are typically excluded from DBS trials, and current evidence on pregnancy safety in DBS patients, delivery plans and potential risks for both mothers and babies is limited. We report the case of a 37-year-old woman with young-onset PD (PARK2 compound heterozygous), whose symptoms first manifested at the age of 24. She was initially treated with ropinirole and rasagiline. The patient had been trying to conceive since the age of 26, and in vitro fertilization was attempted leading to tapering of ropinirole over concerns of potential teratogenicity (FDA advises its use to be avoided if possible). Severe motor fluctuations including dystonia and dyskinesias led to bilateral STN-DBS at age 31. A good motor response (UPDRS-III 23 (52% reduction) in the stimulation-ON/medication-ON state) with a decrease in motor fluctuations was obtained. Over time, stimulation adjustments were required due to left rigidity and bradykinesia, with a progressive increase in levodopa dosage in addition to rotigotine (FDA category C, risk cannot be ruled out). She finally became pregnant at the age of 37. During pregnancy, she reported increasing off periods and peak-dose dyskinesias from the second trimester onwards, alongside heightened fatigue and insomnia, despite an improvement in UPDRS-III motor score. A delivery plan was defined by the attending neurologist together with the patient, the obstetric and anesthetic teams. Concerns over bleeding risk with a C-section using mandatory bipolar cautery were balanced against the risks of a delayed expulsion in the advent of an unpredictable off and decision was made for the first. To offset the effects of turning off the stimulation, the rotigotine dose was increased from 6 to 8 mg on the planned delivery date. Epidural anesthesia was performed and the patient delivered a healthy baby 38 weeks, with 2610 g and 44.5 cm (Apgar score 9/10/10). Bromocriptine was administered due to concerns over excretion of dopaminergic therapy in breast milk and unknown drug toxicity. Exuberant dyskinesias were observed after delivery but the postpartum was otherwise unremarkable. We reviewed the literature in PubMed from inception through May 2025, with the following search terms: (deep brain stimulation OR DBS OR neuromodulation) AND pregnancy AND Parkinson's disease. The inclusion criterion was original research on DBS co-occurring with pregnancy. Only three case reports of DBS and pregnancy in PD patients were identified (Table 1).1 All four PD patients have juvenile onset PD due to pathogenic PRKN variants. Duplicate publications and reviews including the same cases were excluded. STN esq-1–3%, 2–27%, 3–26%, 5–19%, 6–15% 8–10%–2.3 ma/60 us/179 Hz STN dto–1-3%, 5–28, 6, 38%, 7–26%, 8–5%–3.4ma/60/143 STN esq, 2–17%, 3–16%, 5–36%, 6–20% 8–11%-2.4 ma/40 us/130 Hz. STN es1–1 (100%)–0.2/40/74 STN dto–5–57%10, 6 10%, 7–10%, 8–70–2.4 ma/50/174 STN dto −1–100% −0.4/40/74 STN esq, 2a-17%, 2b-16%, 3a-36%, 3b-20% 4–11%-2.4 ma/40 us/130 Hz. STN es1–1(100%)-0.2/40/74 STN dto-3a 10%, 3b-10% 3c 10%, 4–70%-2.4 ma/50/174 STN dto−1–100%-0.4/40/74 While data on conception was not available for the other three patients, our case's infertility journey lasted almost 11 years. No serious adverse outcomes specifically related to the DBS system were observed. In patients with abdominal neurostimulator implantation, placental growth has been associated with site discomfort.1, 2 The data available is insufficient to conclude on increased risk of preterm labor and child malformations in DBS patients. An increase in dopaminergic medication may be required due to aggravation of motor fluctuations towards the end of pregnancy, as in our case and case 4. Yet, physiological changes of the pregnancy itself (eg, neuronal and hormonal changes) may exert a transient positive effect on PD global motor scores as observed in our case and case 2, and described in other neurological disorders including migraine and multiple sclerosis.3, 4 Anecdotal data on DBS during pregnancy suggests increased rates of C-section in PD patients in comparison to the general population perhaps over anticipated fears of not being in control during the different stages of vaginal delivery.1, 4 Although C-section may be required due to obstetric criteria, DBS does not mandate it.4, 5 If this is required, stimulation needs to be turned OFF, and only bipolar cautery may be applied to avoid electromagnetic interference. Epidural local anesthetics appear safe. After delivery, motor symptoms may worsen mandating regular follow-up for early detection and management of troublesome symptoms. Our case and case 2 experienced an increase in dyskinesias and dystonia after delivery which might have been due to an increase in dopaminergic medication to avoid OFF periods interfering with delivery and withdrawal of medication during pregnancy due to teratogenic concerns, respectively. As of now, except for amantadine which bears teratogenic risk and should be discontinued, there are no well-controlled studies establishing the safety of dopaminergic medications during pregnant and breastfeeding.6 While levodopa monotherapy may be preferred,4 neuromodulation adjustments may represent a desirable alternative for PD symptom control during pregnancy and postpartum.5 Similar considerations may be extrapolated to other movement disorders including dystonia. In conclusion, DBS requirements evolve during disease progression and might need to be adapted to patients’ life stage, which includes pregnancy and postpartum. Best medical care for pregnant DBS-PD patients involves strong collaboration between neurologists and obstetricians. (1) Research project: A. Conception, B. Organization, C. Execution; (2) Statistical Analysis: A. Design, B. Execution, C. Review and Critique; (3) Manuscript Preparation: A. Writing of the first draft, B. Review and Critique. V.C.: 1A, 1B, 1C, 2A, 2B, 2C, 3A, 3B, 3C. M.J.R.: 1A, 1B, 1C, 3A, 3B, 3C. Ethics Compliance Statement: Written informed consent was obtained from the patient. Ethics committee review was not necessary for this work. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this work is consistent with those guidelines. Funding Sources and Conflict of Interest: No specific funding was received for this work. The authors declare that there are no conflicts of interest relevant to this work. Financial Disclosures for the Previous 12 Months: VC received funding from the ETUDE Marie-Curie fellowships H2020 European Comission, Grant agreement ID: 956673. VC was granted a bursary by the European Academic of Neurology. VC sat in a Bial Advisory Board. VC developed an App for patients with cognitive symptoms, that is freely available. MJR has no disclosures to declare. Open access publication funding provided by FCT (b-on). The data that support the findings of this study are available from the corresponding author upon reasonable request.