How is restless leg syndrome (RLS) treated during pregnancy?

Updated: Nov 08, 2018
  • Author: Carmel Armon, MD, MSc, MHS; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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Answer

Answer

RLS may occur throughout life but is unusually prevalent during pregnancy. [30] In this disorder, the patient reports a distinctly unpleasant, nearly continuous urge to move her legs late in the day and at night. The symptoms can be a major obstacle to falling asleep. Once asleep, a patient may have periodic leg movements that can cause several arousals.

Data from epidemiologic and other investigations support the notion that iron deficiency may play a role in the genesis of RLS. Iron is a cofactor in the endogenous production of dopamine in the central nervous system (CNS). Dopamine, in turn, plays a role in modulating movement. The altered dopaminergic balance can result in restlessness. This is seen in association with Parkinson disease and in the akathisia that may accompany the use of neuroleptic drugs, which are known to block dopamine receptors.

Folate is another nutrient that may play a role in the prevention of RLS. In a group of pregnant women, those with low serum folate levels were most likely to have restless legs.

Dopamine receptor agonists have been highly effective in relieving RLS, but their safety during pregnancy has not been demonstrated; other proven treatments include narcotics, benzodiazepines, certain antiepileptic drugs (AEDs), and clonidine. These agents are associated with varying levels of risk to the fetus (see Table 3 below).

Table 3. Risks of Drug Therapies for Restless Leg Syndrome in Pregnancy (Open Table in a new window)

Drug Class

Generic Name

level of Risk in Pregnancy

Dopaminergic

Carbidopa-levodopa

C

Bromocriptine

B

Pergolide (removed from US market March 29, 2007*)

B

Pramipexole

C

Ropinirole

C

Opioid

Oxycodone

B

Propoxyphene

C (D for long-term use)

Tramadol

C

Benzodiazepine

Clonazepam

D

Diazepam

D

Lorazepam

D

Antiepileptic

Gabapentin

C

Carbamazepine

D

Alpha-agonist

Clonidine

C

* Pergolide was withdrawn from the US market on March 29, 2007, because of heart valve damage resulting in cardiac valve regurgitation. It is important not to stop pergolide abruptly. Healthcare professionals should assess patients’ need for dopamine agonist therapy and consider alternative treatment. If continued treatment with a dopamine agonist is needed, another dopamine agonist should be substituted for pergolide.

Because RLS has a benign prognosis and often resolves after pregnancy, most women are reluctant to receive pharmacologic treatment. Increased supplementation of iron and folate may be the best approach. In addition, because the serum ferritin level may not directly reflect the availability of iron in the CNS, iron supplementation to achieve a ferritin level above the minimal normal level should be considered. Additional folate intake beyond the recommended daily allowance of 400 µg may also be warranted.


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