Dr. Chapa’s Clinical Pearls
Episode Summary: "Bell’s Palsy in Pregnancy"
Date: September 26, 2025
Host: Dr. Chapa
Episode Theme:
An engaging, clinically-focused discussion on Bell’s palsy in pregnancy, exploring incidence, pathophysiology, diagnosis, management, and psychosocial implications, with fresh insights from recent research. The episode aims to equip healthcare providers with practical knowledge and pearls to manage this condition in pregnant patients confidently and compassionately.
Main Topics & Insights
1. Setting the Scene: Why Bell’s Palsy?
- Dr. Chapa introduces the topic with humor and a tongue-in-cheek literary segue about "for whom the bell tolls."
- Real-life inspiration: A pregnant patient with sudden facial droop in clinic sparked the discussion, reinforcing the clinical relevance.
Quote: “You don’t listen to the show for the comedy. You listen because of the data… we are talking about Bell's palsy. Yeah, it’s a big deal, guys." [00:50]
2. Epidemiology & Relevance in Pregnancy
- Incidence:
- Non-pregnant general population: approx. 17.4 per 100,000 per year.
- Pregnant women: incidence increases to up to 45 per 100,000 per year.
- Trimester impact:
- Bell’s palsy is especially more common in the third trimester but can occur at any stage.
Quote: “Much more common, almost universally common in the third trimester, although it doesn’t exclude… first or second.” [09:39]
- Recent Research:
- July 2025: Journal of Plastic Reconstructive and Aesthetic Surgery highlighted the real functional, psychosocial, and peripheral complications—especially important in pregnancy.
- July 2024: ACOG’s Clinical Expert Series on neurological emergencies in pregnancy did not include Bell’s palsy, as it’s not technically an emergency—though new-onset facial droop is an emergency, since it might be stroke.
Quote: “Bell’s palsy is not in there. And I get that it’s not an emergency. At the same time, it can't be ignored.” [13:27]
3. Pathophysiology and Theories Behind Bell’s Palsy in Pregnancy
- Anatomy:
- Facial nerve is cranial nerve VII—a point Dr. Chapa humorously challenges listeners to recall from anatomy.
- Pathogenesis Theories:
- Inflammation or compression of the facial nerve as it exits the skull.
- Viral/paraviral etiology, herpes simplex virus hypothesized.
- Immune modulation in pregnancy potentially affecting nerve conduction.
- Takeaway:
- No single proven etiology—likely a combination of the above.
4. Why It Matters More in Pregnancy: Outcomes and Risks
- Pregnant patients have worse long-term facial outcomes than non-pregnant women or men:
- More pronounced weakness
- Lower rates of recovery
- Higher rates of persistent facial weakness
- No fetal implications are currently known.
5. Diagnosis: Distinguishing Bell’s Palsy from Stroke
- Key Bedside Pearls:
- Bell’s palsy: Entire half of the face (including forehead) involved. Can’t raise eyebrow or wrinkle forehead on the affected side.
- Stroke: Typically spares the upper third of the face (still able to wrinkle forehead/raise eyebrow), has sudden onset, and often associated with other neurological deficits (headache, weakness, speech issues, confusion).
- Time course:
- Bell’s: Develops over ~48 hours (“yesterday my face felt kind of weird… then it got worse”).
- Stroke: Very sudden.
- Essential Action:
- Always perform a thorough neuro exam and don’t dismiss new facial droop in pregnancy; bring patient in immediately.
Quote: “Facial droop is an emergency because that's stroke. All right, so you. It is and it isn't. Bells isn't. Facial droop is.” [13:47]
Bedside Test: “Bells typically involves the whole half of the face. However, with a stroke… that typically spares… the upper third.” [21:39]
- When in doubt:
- If any unusual features or concern for stroke, be quick to order MRI.
6. Special “Pearl:” Association with Hypertensive Disorders
- Strong association between Bell’s palsy and the development (or early sign) of hypertensive disorders of pregnancy like preeclampsia or gestational hypertension.
- Sometimes, Bell’s can be a harbinger for high blood pressure within days.
Quote: "There is a very strong association between Bell’s palsy and hypertensive disorders of pregnancy… Watch them because within the next week or so, they may have high blood pressure documented that wasn’t there before." [23:01]
7. Treatment: Act Fast, Use Combination When in Doubt
- Initiate therapy ASAP—ideally within 48–72 hours. Delays reduce efficacy.
- Medications:
- Steroids (Prednisone 50–60mg daily x 5 days, then 5 day taper; or Medrol Dosepak)
- Antivirals (Valacyclovir): Data mixed, but possibly beneficial and does not hurt.
- Eye Care:
- Essential to prevent corneal desiccation/abrasion because eyelid closure is impaired.
- Use lubricating eye drops (at bedtime and if up at night), eye patch at night, sunglasses or patch outdoors.
Quote: “Eye care is big with Bell’s palsy. …At night… get a little eye patch to cover that eye…put another eye drop if they wake at night…direct sunlight can damage the eye.” [24:07]
- Chewing and Oral Care:
- Warn about potential for biting tongue or cheek.
8. Take-Home Practice Guidelines
- All new facial droop in pregnancy = URGENT office visit
- Classic Bell’s: Clinical diagnosis, no imaging unless atypical
- Start steroids + antivirals quickly (within 72 hours)
- Educate on eye protection
- Educate and monitor for hypertension
Quote: “Somebody calls the office, has facial droop? Bring them in. I mean, that’s a hard stop… ideally start treatment within 72 hours.” [28:11]
Notable Quotes & Memorable Moments
- On teaching pearls:
“The cranial nerve 7. Cranial nerve 7 is the facial nerve. Come on, guys!” [14:55] - On humility among impressive colleagues:
“One of our internal medicine physicians is also, by the way, an astronaut… Like, legit astronaut. …You can never win… But thankfully, she’s super humble. She’s actually brilliant. Brilliant.” [25:43] - On minimizing Bell's palsy:
“Don’t minimize this as just a minor issue… Functional and psychosocial impacts… are real.” [11:51]
Key Timestamps
| Timestamp | Topic / Quote | |---------------|------------------------------------------------------------------------------------------------------| | 00:50 | Introduction to Bell’s palsy, humorous segue, real patient story | | 09:39 | Epidemiology, third-trimester risk, increased incidence in pregnancy | | 13:27 | Noted omission from ACOG neurological emergencies, importance of not dismissing facial droop | | 14:55 | Anatomy pop quiz: "Which cranial nerve is the facial nerve?" | | 21:39 | Differentiating Bell's vs. stroke at the bedside | | 23:01 | Association with hypertensive disorders, warning for preeclampsia risk | | 24:07 | Detailed eye care recommendations for Bell’s palsy patients | | 25:43 | Memorable aside about having an astronaut physician as a colleague | | 28:11 | Urgent practice pearl: all new facial droop in pregnancy = in-office evaluation and quick initiation |
Overall Takeaway
Bell’s palsy in pregnancy, though not rare nor technically an emergency, merits urgent assessment due to its higher incidence in pregnant women (especially in the third trimester), notable risk for persistent facial weakness, and clear association with hypertensive disorders. Prompt distinction from stroke and rapid initiation of therapy (steroids with or without antivirals), along with vigilant eye care, are the cornerstones of management. The episode reinforces the need for attentive, data-driven, and empathetic care, while keeping medical education both informative and fun.
For further reading: References noted in the episode:
- July 2025 Journal of Plastic Reconstructive and Aesthetic Surgery
- July 2024 ACOG Clinical Expert Series on Neurological Emergencies in Pregnancy
Next Steps for Listeners:
- Don’t dismiss new-onset facial droop in pregnancy—evaluate promptly.
- Brush up on cranial nerves… and always be ready with an eye patch!
End Note:
Dr. Chapa reminds listeners of the podcast’s mission: to deliver clinical pearls with levity, practicality, and up-to-date evidence, because “medical education should NOT be boring!”