Facial Paralysis in Pregnancy

Developing a facial paralysis can be an isolating experience but never more so than when it occurs during pregnancy. This is a time when emotions are already intense and discovering you have a facial paralysis is frightening, as many people associate it with having a stroke. If a stroke is ruled out there is often initial relief, but the patient will still need to be considered for urgent treatment (within 72 hours). Support and good quality information are vital to the well-being of the person affected.

What causes facial paralysis in pregnancy?

The most common cause of facial paralysis in pregnancy is Bell’s palsy. Someone who is pregnant is at a higher risk of developing Bell’s palsy than the non-pregnant population. Studies have demonstrated that the majority of cases of Bell’s palsy in pregnancy occur during the third trimester or within seven days of delivery.

However, health professionals should never automatically assume it is Bell’s palsy until all other causes are ruled out. If your facial paralysis has developed slowly over weeks or months, this is highly unlikely to be Bell’s palsy. See ‘Causes of facial palsy’  for a comprehensive list.

Chronic high blood pressure and obesity are also considered risk factors for the development of Bell’s palsy so being pregnant may compound these existing problems making the risk higher.

What is Bell’s palsy?

Bell’s palsy is a condition whereby the inner ear becomes inflamed resulting in pressure on the facial nerve, which in turn causes facial paralysis on the affected side.

Bell’s palsy is an idiopathic condition meaning that no conclusive cause has been established. It has not yet been possible to find out why the facial nerve becomes compressed; however, links have been made with viruses (including herpes, influenza and respiratory tract infections) as well as a depleted immune system and stress.

The information on this page relates specifically to Bell’s palsy in pregnancy. Further information about Bell’s palsy.

Bell’s palsy peaks in two age groups, those less than 40 years of age and those above 60 years of age. The peak at the younger age is suspected to be due to the increased incidence of Bell’s palsy in pregnancy.

Bell’s palsy is the most common cause of facial paralysis with an estimated incidence of 11-40 persons per 100,000. Research states a frequency of Bell’s palsy in pregnancy at 45.1 per 100,000 births per year, compared to a non-pregnant incidence of 17.4 for the same age group.

What are the signs and symptoms of Bell’s palsy?

• Sudden onset (within hours) of symptoms
• The symptoms peak within 1-3 days
• No previous history of trauma, surgery or localised infection
• May have felt unwell in the days before the paralysis was observed
• May have noticed sounds seem louder, taste has changed and the eye is dry
• Difficulty raising the brow, blinking and closing the eye
• Watery eye
• Difficulty smiling and pouting the lips
• Food and drink falling/dribbling from the mouth
• Change in speech and facial appearance

How will a diagnosis of Bell’s palsy be made?

Your health professional will carry out a physical examination and will check the following:

• How well you can raise your brow, smile and pout your lips
• If you can open and close your eye(s)
• If you are having problems with eating, drinking and speech

They should also check for a rash over your ear, in your hairline or elsewhere on your face, as well as look for blisters in your mouth. They should ask questions about any pain you may be feeling. This is to rule out Ramsay Hunt syndrome.

They may carry out a scan to rule out other causes but this should be done after pregnancy unless absolutely unavoidable.

What is the treatment for Bell’s palsy in pregnancy?

No current NICE guidelines (National Institute for Health and Care Excellence) exist for diagnosis, starting treatment and monitoring of the mother and foetus when a pregnant patient also has Bell’s palsy. However there is evidence that corticosteroids, e.g. Prednisolone, are effective in improving recovery and limiting progression of facial paralysis. This treatment is considered most effective if it is started within 72 hours but is sometimes delayed during pregnancy because there is a perceived risk of using corticosteroids.

Corticosteroids are considered safe for the management of many medical conditions during pregnancy so this option should always be considered by a health care professional aware of the patient’s complete medical history. If possible steroids should therefore be started within the first 72 hours of developing facial palsy even during pregnancy. For more information refer to the sources at the end of this page.

Commonly, the peak onset of either complete or partial facial paralysis is reached within hours. Pregnant people with Bell’s palsy are thought to be more likely to progress to develop a complete facial paralysis on the affected side which can point to a poorer prognosis. The importance of starting appropriate treatment promptly is critical to ensure the patient’s best chance of a full recovery. GPs should also refer patients to specialist health professionals at an early stage for management.

Why is there an increased incidence of Bell’s palsy in pregnancy?

Theories exist as to why there is increased incidence of Bell’s palsy in pregnancy. Some physical changes are thought to cause or add to the onset, these include:

• Blood clotting disorders.
• High blood pressure.
• Eclampsia (onset of seizures in a woman with pre-eclampsia).
• Increased total body water – Where there is fluid retention there may also be perineural oedema (build-up of fluid surrounding a nerve).
• Changes in the level of oestrogen and progesterone.
• Impaired glucose tolerance – changes in the body during pregnancy and an increased appetite can lead to a risk of developing glucose intolerance or gestational diabetes (a form of diabetes that occurs during pregnancy and usually goes away after).
• Increased cortisol levels – cortisol is produced in the human body by the adrenal gland. Cortisol prevents the release of substances in the body that cause inflammation but it can also weaken the activity of the immune system. Cortisol starts to rise in the second trimester and peaks in the last few weeks before giving birth at levels two to three times higher than normal. It is thought to play a role in brain development and maturation of the lungs of the baby.
• During the third trimester of pregnancy or in the first week following childbirth, people are thought to be at particular risk of infection from herpes simplex virus (HSV). There is a higher rate of HSV re-activation during this phase of pregnancy than in the first trimester. This may be because the body’s immune system is weakened by higher cortisol levels.

Interesting fact:

Carpal tunnel syndrome (CTS) also occurs in greater frequency in the final trimester and the first few days after giving birth. CTS is a common condition that causes tingling sensations, numbness and sometimes pain in the hands and fingers. It is also a result of compression of a nerve and has an unknown cause.

What is the prognosis of Bell’s palsy in pregnancy?

If a complete facial paralysis develops during pregnancy, historically the recovery rates have been poorer compared to those of the general population. There is an estimated recovery of 52% compared to 77-88% in a similar age group of the non-pregnant population.

Important note: Poorer outcomes reported in pregnant patients with Bell’s palsy are likely to relate to health professionals’ past reluctance to prescribe corticosteroids such as Prednisolone.

What are the physical effects of Bell’s palsy in pregnancy?

Inability to close or blink the eye

Female patients in general are more susceptible to having dry-eye symptoms. This is suspected to be due to hormonal alterations and the cornea can be at significant risk with secondary damage or loss of sight. Symptoms of dryness can include grittiness, burning, redness of the eye, reflex watering, blurred vision and frequent infections.

Difficulty eating and drinking

With a complete facial paralysis on the affected side it is difficult to hold food and drink in the mouth, and chew.

Speaking

It may be difficult to speak clearly. This and the inability to eat normally can be tiring.

How your health care provider can help:

• Assess whether corticosteroid treatment is suitable as research shows this improve chances of a full recovery, this will depend on personal medical history. Corticosteroids have historically been used safely in pregnancy to manage respiratory conditions, such as asthma and dermatological conditions. If your health care provider is unsure, ask them to refer to the sources at the bottom of this page.
• Prescribe preservative-free eye lubricants for regular use during the day and thicker ointments for use at night.
• Explain how to tape the eye closed for sleep.
• Refer for urgent ophthalmology review.

How friends and family can help:

• Ensure the person affected is drinking plenty of water.
• Keep the environment humid.
• Supply plenty of drinking straws.
• Source a padded eye mask for night-time.
• Refer to Facial Palsy UK’s video demonstrating how to tape the eye closed at night.
• Be aware that the patient’s vision may be affected, when the eye doesn’t blink properly it is similar to having a faulty window wiper on your car. They may need help with making up bottle feeds if they are not breast feeding.
• Prepare easy to eat meals. Soft easy chew foods include pasta dishes, fish, well cooked meats and vegetables.

What are the psychological effects of Bell’s palsy in pregnancy?

Expectations of parents, family and friends are high when a new baby is arriving and for the most part parents anticipate sharing this amazing experience with everyone. The details will be documented and photographs often shared on the internet for everyone to enjoy. The pose of parents and baby is probably one of the most photographed events of a life time. We always recommend having plenty of photographs taken as you cannot get these moments back. However, it’s important for the person with Bell’s palsy to have control over use of the photographs. When the shock of being diagnosed with Bell’s palsy has worn off, the person with Bell’s palsy may regret not having photographs taken at the time.

Bell’s palsy will prevent the mother from expressing emotion in the way they usually do. This is a difficult time mixed with great happiness but also anxiety, especially when events don’t go according to plan. It is a time when those concerned need high quality advice, information, support and encouragement. It is a time when they may feel vulnerable and least able to help themselves.

Help following an incomplete recovery

Important note: this information also applies to people who had Ramsay Hunt syndrome in pregnancy.

If you have made no recovery by four weeks we recommend seeking referral via your GP to a specialist centre. Early appropriate management by a specialist is important to reduce the risk of complications such as synkinesis developing.

Physiotherapy can be difficult to access in some areas of the UK and general physiotherapists do not necessarily have the skills to treat the face. If you are struggling to find a local physiotherapist with expertise in treating facial palsy please contact us.

As the face is still in a period of recovery, albeit at a very slow pace, surgery is rarely a recommendation at this early stage. The main exception to this may be to protect the eye.

Treatment of an unresolved Bell’s palsy may involve Botox and a facial exercise plan. Please note that it is vitally important you do not follow exercises found on the internet as some of these will do more harm than good. Any exercise plan must be devised by an expert to suit the individual, one plan does not suit all.

We also do not recommend the use of electrical stimulation as the nerve is still recovering at this stage and over-stimulation can lead to complications such as synkinesis.

Facial Palsy UK Bell’s in Pregnancy Support Network – this is a network of people who have not made a full recovery. If you are newly diagnosed bear in mind there will be many people who have made a full recovery who have had no need to contact the charity and are therefore not part of this network.

Facial Palsy UK Facial Palsy in Pregnancy Support Network Facebook group – this group is open to people who had facial palsy in pregnancy or just after giving birth, and their partners.

Sources:

https://www.diabetes.org.uk/Diabetes-the-basics/Gestational-diabetes/

Ahsen Hussain, Charles Nduka, Philippa Moth & Raman Malhotra (2017):
Bell’s facial nerve palsy in pregnancy: a clinical review, Journal of Obstetrics and Gynaecology,
DOI: 10.1080/01443615.2016.1256973