Q J Med 2002; 95:359362

Original papers

QJM
Association between Bells palsy in pregnancy
and pre-eclampsia
D. SHMORGUN, W.-S. CHAN and J.G. RAY
From the Department of Medicine, Sunnybrook and Womens College Health Science Centre,
Toronto, Ontario, Canada
Received 6 March 2002 and in revised form 12 March 2002

Summary
Results: Forty-one patients were identified. Mean
onset of Bells palsy was 35.4 weeks gestation
(SD 3.9). Nine (22.0%, 95%CI 10.835.7) were
also diagnosed with pre-eclampsia and three
(7.3%, 95%CI 1.4 17.1) with gestational hypertension, together (29.3%, 95%CI 16.543.9) representing nearly a five-fold increase over the
expected provincial/national average. There were
three twin births. The observed rates of Caesarean
(43.6%) and preterm (25.6%) delivery, as well as
low infant birth weight (22.7%), were also higher
than expected, although the rate of congenital
anomalies (4.5%) was not.
Conclusions: The onset of Bells palsy during
pregnancy or the puerperium is probably associated with the development of the hypertensive
disorders of pregnancy. Pregnant women who
develop Bells palsy should be closely monitored
for hypertension or pre-eclampsia, and managed
accordingly.

Introduction
In 1830, Sir Charles Bell described the association
between idiopathic facial palsy (Bells palsy) and
pregnancy.1 The prevalence rate of Bells palsy
in pregnancy is estimated at 45.1 cases per
100 000 women, considerably higher than in the

non-pregnant population.2 In a systematic review,

we observed that almost all cases of Bells palsy
were confined to the third trimester of pregnancy
and the immediate postpartum period.3 Furthermore, there was a significantly higher rate of

Address correspondence to Dr J.G. Ray. e-mail: jray515445@aol.com

Association of Physicians 2002

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Background: Previous published case series have

suggested an association between the onset
of Bells palsy in pregnancy and the risk of
pre-eclampsia and gestational hypertension.
Aim: To evaluate the period of onset of Bells
palsy in pregnancy and the associated risk of
adverse maternal and perinatal events, including
the hypertensive disorders of pregnancy.
Study design: Case series study of consecutive
female patients.
Methods: Women presenting with Bells palsy
during pregnancy or the puerperium were identified by a hospital record review at five Canadian
centres over 11 years. Information was abstracted
about each womans medical and obstetrical
history, period of onset of Bells palsy, and associated maternal complications, including preeclampsia and gestational hypertension as well
as preterm delivery and low infant birth weight
(-2500 g). These rates were compared to those
previously described for the province of Ontario
or for Canada.

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D. Shmorgun et al.

gestational hypertension and pre-eclampsia (22.2%,

95%CI 12.536.4) among these cases, more than
four times that found in the general obstetrical
population.4
A limitation to previously published research
into Bells palsy in pregnancy is the absence of any
systematic evaluation of important obstetrical and
perinatal outcomes.3 Accordingly, these studies
may have been biased toward underreporting of
such events. We undertook this multi-centre retrospective case series study with three principal
objectives. First, to evaluate the timing of onset of
Bells palsy in pregnancy; second, to investigate
the association between Bells palsy and the
hypertensive disorders of pregnancy; and third, to
determine the prevalence of peripartum and perinatal outcomes among women who developed
Bells palsy during or immediately after pregnancy.

or the puerperium. The rates from all studies were

pooled using a random effects model,5 and the
presence of significant heterogeneity for the pooled
estimate was defined at a p value -0.10 using
the Breslow and Day test.6
All abstracted data were entered into Microsoft
Excel version 5.0c. Calculation of the pooled
estimate of pre-eclampsia and gestational hypertension was done using Meta-Analyst 0.988.7
Permission to conduct this study was obtained
from the Ethics Review Board of each participating
medical centre. Permission to contact the women
was obtained from their family physicians or obstetricians, and once contacted, each woman provided
informed consent before being administered the
telephone questionnaire.

Results
Methods

Table 1 Pre-pregnancy characteristics of women with

onset of Bells palsy during the index pregnancy or
puerperium
Characteristic
Age (years)*
-19
1935
)35
Gravidity (G)
G1
G2
G3
G4
0G5
Type 1 or 2 diabetes mellitus**
Chronic hypertension**
Pre-eclampsia**
Gestational hypertension**
Previous Bells palsy**
Total

n (%)

3 (7.5)
33 (82.5)
4 (10.0)
15 (36.6)
13 (31.7)
6 (14.6)
3 (7.3)
4 (9.8)
1 (2.7)
1 (2.7)
0 (0.0)
2 (5.4)
1 (2.7)
41 (100.0)

*Data unknown for 1 case. **Data unknown for 4 cases.

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We reviewed the hospital charts of women diagnosed with Bells palsy in pregnancy between 1990
and July 2001. Participants were identified
through the Medical Records Departments of five
Ontario hospitals: the Hamilton Health Sciences
Corporation and St Josephs Hospital, both in
Hamilton; and the Sunnybrook and Womens
College Health Sciences Centre, University Health
Network, and Mount Sinai Hospitals, all in Toronto.
A search for these charts was made using the
ICD-9CM diagnostic codes related to Bells palsy
and any concurrent pregnancy within "12 months
of the diagnosis of Bells palsy.
From each hospital chart, we abstracted information on maternal demographics, past medical
history, maternal complications during the index
pregnancy, and mode of delivery. Gestational
hypertension was defined as a blood pressure
)140/90 mmHg after 20 weeks gestation, and
pre-eclampsia was defined as a blood pressure
)140/90 mmHg, with the additional presence of at
least 2q proteinuria on dipstick or )300 mg of
proteinuria over a 24-h period. Abstracted perinatal outcomes included neonatal gestational age
at birth, birth weight and the presence of any
fetal anomalies detected in utero or at birth. We
attempted to corroborate the chart data by contacting each patient by telephone. Perinatal outcomes
and delivery information for these women were
compared to rates previously described for the
province of Ontario or Canada.
Using the current study data, we updated our
previous systematic review3 to better estimate the
rate of gestational hypertension and pre-eclampsia
among women with Bells palsy during pregnancy

From the five hospitals, 41 women were diagnosed

with unilateral Bells palsy between 1990 and July
2001. The hospital charts were successfully
reviewed for all 41 cases, and 19 women (46%)
also had their information corroborated by telephone interview. For the remaining 22 women,
either their telephone number was no longer in
service, or written consent to contact them could
not be obtained from their family physician or
obstetrician.
The pre-pregnancy characteristics of all 41 participants are listed in Table 1. The mean maternal
age was 29.0 years (SD 6.0); the majority were
nulliparous (36.6%) and there were three twin

Bells palsy and pregnancy

361

Table 2 Maternal and perinatal outcomes among women with onset of Bells palsy during the index pregnancy or
puerperium, compared to those previously described within the general population
Outcome

Number affected/number
at risk (%, 95%CI)

Rate expected in general

population (%) and reference

Pre-eclampsia
Gestational hypertension
Pre-eclampsia or gestational hypertension
Induced vaginal delivery
Caesarean delivery
Preterm delivery before 37 weeks gestation
Neonatal birth weight -2500 g*
Congenital anomaly detected at birth*

9/41 (22.0, 10.835.7)

3/41 (7.3, 1.4 17.1)
12/41 (29.3, 16.5 43.9)
10/39 (25.6, 13.4 40.3)
17/39 (43.6, 28.6 59.2)
10/39 (25.6, 13.4 40.3)
10/44 (22.7, 11.736.1)
2/44 (4.5, 0.4 12.6)

3.58
58
68
139
209
7.19
5.810
2.911

*There were three twin pregnancies.

pregnancies. Few had a previous history of either

chronic (one woman, 2.7%) or gestational hypertension (two women, 5.4%), and none (0%)
had been diagnosed with pre-eclampsia. One had
experienced Bells palsy previously, with a full
recovery before the index pregnancy (Table 1).
The mean gestational age at the onset of Bells
palsy in the index pregnancy was 35.4 weeks
gestation (SD 3.9). Only one woman (2.4%)
presented before 27 weeks gestation, 33 (80.5%)
between 27 and 42 weeks, four (9.8%) within the
first week postpartum, while for three women
(7.3%) the period of onset was not defined.
Nine women (22.0%, 95%CI 10.835.7) were
diagnosed with pre-eclampsia and three (7.3%,
95%CI 1.417.1) with isolated gestational hypertension. Thus, out of 41 women with Bells palsy,
12 (29.3%, 95%CI 16.543.9) developed a hypertensive disorder, nearly five times the expected
rate for Ontario/Canada (Table 2).
The overall mean neonatal birth weight was
3003.3 g (SD 873.8). The corresponding rates of
Caesarean delivery (43.6%), preterm birth (25.6%)
and low neonatal birth weight (22.7%) were
comparably higher than expected (Table 2). Of
the two neonates (4.5%) born with a detectable
congenital anomaly, one had Downs syndrome
and the other lethal fetal hydrops.
Using the current study data, in conjunction
with those 11 studies included in our previous
systematic review,3 the pooled rate of combined
gestational hypertension or pre-eclampsia was
25.0% (95%CI 8.355.2) among 203 women with
Bells palsy in pregnancy or the puerperium.

of the hypertensive disorders of pregnancy and

operative delivery, while their infants experienced
higher rates of preterm birth and low birth weight,
compared to figures for the general population.

Discussion

Evidence for an association between

Bells palsy and pre-eclampsia

This study was probably biased by the retrospective

collection of data, which was principally from the
hospital charts of five large urban obstetrical
centres. Since few clinicians were probably aware
of the possible association between Bells palsy
and hypertension in pregnancy, it is unlikely that
our estimates would have been much inflated by
the presence of diagnostic suspicion bias, especially since we used objective definitions for
the diagnosis of gestational hypertension and
pre-eclampsia. Although we included consecutive
patients, and attempted to corroborate their chart
data through telephone interviews, many could
not be contacted, so some adverse perinatal events
may have been missed or incorrectly recorded.
In the absence of a concurrent control group, we
had to rely upon national and provincial data
to estimate the expected rates of adverse maternal
and perinatal outcomes within the five participating
centres. Such comparisons cannot account for
possible differences between the women studied
herein and those previously selected for large
epidemiological studies. Finally, the presence of
statistical heterogeneity for the pool estimate of
pre-eclampsia and gestational hypertension could
be explained by the fact that previous investigators
did not systematically assess for these events, or
define them using standard criteria.3

Our results suggest that the vast majority of women

who develop Bells palsy in pregnancy had no

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Of these 41 consecutive women, the majority

presented with Bells palsy during late pregnancy
and the puerperium. They had an increased rate

Study strengths and limitations

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D. Shmorgun et al.

Clinical and research recommendations

Regardless of its aetiology, the notion that Bells
palsy in pregnancy may be associated with impending pre-eclampsia cannot be overlooked. For
these women, we recommend heightening maternal
and fetal surveillance for the remainder of pregnancy. Although our data do not permit us to
comment on the recovery of Bells palsy after
delivery, others have observed nearly 100%
recovery in women with incomplete palsy, but
only a 52% satisfactory outcome in the presence
of a complete facial paralysis.18 Thus, research is
needed to better characterize the association
between Bells palsy and pre-eclampsia, and the
relative rate of recovery of facial palsy in such
cases. Investigators might also consider whether
certain drugs used in the treatment of pre-eclampsia
(e.g. magnesium sulphate) can worsen the recovery
of Bells palsy,19 as well as the benefit of other
therapies, including corticosteroids.20

References
1. Bell C. The Nervous System of the Human Body. London,
Longman, Rees, Orme, Brown and Green, 1830.
2. Hilsinger Jr REL, Adour KK, Doty HE. Idiopathic facial
paralysis, pregnancy, and the menstrual cycle. Ann Otol
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3. Shapiro L, Yudin MH, Ray JG. Bells palsy and tinnitis during
pregnancy: predictors of pre-eclampsia. Acta Otolaryngol
(Stockh) 1999; 119:64751.
4. Sibai BM, Caritis SN, Thom E, et al. Prevention of
preeclampsia with low-dose aspirin in low dose healthy,
nulliparous pregnant women. National Institute of
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5. DerSimonian R, Laird N. Meta-analysis in clinical trials.
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12. Davison JM. Edema in pregnancy. Kidney Int 1997;
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15. Falco NA, Eriksson E. Idiopathic facial palsy in pregnancy
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known risk factors before pregnancy, including

diabetes mellitus or chronic hypertension. As with
previously published data, our findings support
the hypothesis of an association between Bells
palsy and pre-eclampsia.3 First, the observed rate
of pre-eclampsia was approximately five times
higher than expected. Second, both disorders
appeared late in pregnancy, and very rarely
before the second trimester. Third, more women
with Bells palsy developed pre-eclampsia (22%)
than gestational hypertension (7.3%), suggesting
that Bells palsy and pre-eclampsia may share
a common pathway in their manifestation and
pathogenesis, as outlined below.
Women in their third trimester of pregnancy
may be predisposed to Bells palsy due to the
increase in maternal extracellular fluid volume
during this period.12 Other nerve compression
syndromes, including carpal tunnel syndrome,13
are also seen more commonly in the latter part
of pregnancy.14 An increase in perineural oedema,
resulting in facial nerve impingement, may form
the underlying basis for facial nerve palsy.15
Pre-eclampsia often manifests with considerable
oedema within both subcutaneous and nervous
system tissues,16 probably creating a neurocompressive effect. A second possible explanation
may be the presence of a hypercoagulable state
associated with pre-eclampsia, resulting in thrombosis of the vasa nervorum, thereby leading to
nerve ischemia and paralysis.15 Since the aetiology
of Bells palsy remains unknown, but is probably multifactorial,17 these and other mechanisms
may provide insight into the treatment and recovery
of idiopathic facial palsy in pregnancy.