2 The cause of narcolepsy is unknown, but it is thought that both environmental and genetic factors may play apart. It may be caused by the loss of a relatively few neurons that are responsible for producing hypocretin- a neuropeptide in the CNS. It is also associated with speciﬁc HLA allele, DQB1∗0602. Possible triggers include head trauma, infection, and change in sleeping habits [2]. Diagnostic criteria including excessive daytime sleepiness, almost daily for greater than 3 months, and cataplexy triggered by emotion, conﬁrmed by diagnosis with nocturnal polysomnography followed by a multiple sleep latency test (MSLT) and alternatively conﬁrmed by CSF hypocretin-1 levels <110 pg/mL or one-third of mean control values [3]. Patient with narcolepsy should be referred to a sleep disorder service and managed by a clinician with experience of narcolepsy management. This involves largely symptom relief with nondrug treatment such as good sleep hygiene, daytime naps, regular exercise, and patient’s/family edu- cation. Drug therapy includes use of stimulant such as amphetamines and methylphenidate (2nd line), modaﬁnil (1st line), antidepressants, or SSRIs (selective serotonin reuptake inhibitors) to improve symptoms of sleep paralysis or hypnagogic hallucination. Benzodiazepines may be used sometimes to consolidate nighttime sleep in refractory cases [4]. It was noticed that our patient’s symptoms were resistant to modaﬁnil (none reported in the literature to date). Cataplexy can be managed with sodium oxybate and antide- pressants such as clomipramine, SSRIs (venlafaxine), and selegiline [5]. Most of these drugs have signiﬁcant adverse eﬀects and should be used under specialist recommendation. It is worth noting that there is little guidance as to the management of this condition in pregnancy as well as the mode of delivery with only two reports in the literature of pregnant narcoleptics with cataplexy undergoing Caesarean delivery. Due to the risk of labour-induced cataplexy, a pregnant woman with narcolepsy and clinically signiﬁcant cataplexy should discuss the option of elective Caesarean delivery with the physician and obstetrician [6]. Regional anaesthesia including neuraxial opioids for Caesarean section is a suitable technique in patients with narcolepsy [1]. After delivery, safety precautions are indicated to enhance safety of the mother and the new born if no medication was used during pregnancy or continued in the postnatal period. This is as a result of the exacerbation excessive daytime sleepiness (EDS) in the narcoleptics caused by the physical demands and sleep deprivation of childcare [6]. If medication were used in pregnancy, a neonatal abstinence syndrome (NAS) would be required. Babies presenting with symptoms such as high-pitched cry, tremor, jittery, irritability, and sleeping diﬃculty should be assessed. When there is a combination of these symptoms, a diagnosis of NAS is made, and appropriate review and management by the paediatrician would be required [7]. On discharge from the hospital, mothers should watch out for symptoms such as diﬃculty with attachment during breastfeeding, colic, poor sleeping pattern, and slow weight gain. The importance of safe sleeping should also be discussed and appropriate support oﬀered [7]. Case Reports in Obstetrics and Gynecology In summary, we have presented a successful management of a patient with narcolepsy and cataplexy in pregnancy. This was achieved with good multidisciplinary care involving the obstetrician, neurologist, anaesthetist, paediatrician, and midwife with each professional contributing to patient’s care. Acknowledgments The authors would like to acknowledge Dr. A. Monks, Dr. R. Cross, Consultant Anaesthetists, Dr. Boothman, Consultant Neurologist, Blackpool Teaching Hospital, and the patient who gave consent to publication of this paper. References [1] S. Soltanifar and R. Russell, “Neuraxial anaesthesia for cae- sarean section in a patient with narcolepsy and cataplexy,” International Journal of Obstetric Anesthesia, vol. 19, no. 4, pp. 440–443, 2010. [2] J. Peacock and R. M. Benca, “Narcolepsy: clinical features, co- morbidities & treatment,” Indian Journal of Medical Research, vol. 131, no. 2, pp. 338–349, 2010. [3] F. Khan, R. Hazin, and M. Iqbal, “Narcolepsy: clinical decision making for the primary care physician,” Southern Medical Journal, vol. 102, no. 12, pp. 1246–1252, 2009. [4] A. Zeman, T. Britton, N. Douglas et al., “Narcolepsy and excessive daytime sleepiness,” British Medical Journal, vol. 329, no. 7468, pp. 724–728, 2004. [5] EFNS Guidelines on Management of Narcolepsy, European Federation of Neurological Societies, 2006. [6] R. Hoque and A. L. Chesson, “Conception, pregnancy, delivery, and breastfeeding in a narcoleptic patient with cataplexy,” Journal of Clinical Sleep Medicine, vol. 4, no. 6, pp. 601–603, 2008. [7] Neonatal Abstinence Syndrome (NAS) information booklet- King Edward Memorial Hospital, Australia, http://kemh.health .wa.gov.au/brochures/consumers/wnhs0197.pdf.