PREGNANCY WITH CONVULSIONS

DR JAYA CHOUDHARY PROFESSOR DEPT. OF GYNAE & OBST MAHATMA GANDHI MEDICAL COLLEGE & HOSPITAL

Convulsions in pregnancy

Convulsions due to pregnancy

Eclampsia Convulsions aggravated by pregnancy

Epilepsy

Convulsions in pregnancyConvulsions not Directly related to pregnancy

Infections

Meningitis Encephalitis

Cerebral Malaria Cerebral Absces

Febrile convulsions Cerebrovascular

Accidents Venous

ThrombosisInfarction

HaemorrhageCerebral tumours

Metabolic/Electolyte imbalance

Hypoglycemia Hyperglycemia

HyponatremiaHypocalcemia

TraumaTetany

Drug Withdrawal CocaineAlcohol

Psychiatric disorders

ECLAMPSIA New-onset convulsions after 20wks of pregnancy in a

patient with Preeclampsia (PIH) with no coincidental neurologic disease, is called Eclampsia.

Criteria for PreeclampsiaDiastolic BP >90mmHg EdemaProteinuria

Eclampsia

The incidence of eclampsia in the developed countries is 1:2000 deliveries. while in developing countries estimate vary widely, from 1 in 100 to 1 in 1700 deliveries .

ANTEPARTUM (50%)

INTRAPARTUM (30%).

POSTPARTUM (20%) within 48hrs-upto 7days.

INTERCURRENT (Rare) – pt becomes conscious after recovery

from convulsion and pregnancy continues beyond 48hrs.

EpilepsyEpilepsy is a chronic neurological disorder

in which a person has repeated seizures over time. Seizures are episodes of disturbed brain activity that cause changes in attention or behavior. Symptoms vary from person to person

Convulsions in PregnancyDifferential Diagnosis Eclampsia EpilepsyHistoryOccurs after 20wks of

pregH/o PIH in this PregnancyPrev H/o Eclampsia +/-H/o Tonic Clonic

convulsionClinical ExamH/o Hypertension,

Proteinuria,Edema,Oliguria,pulmonary Edema

Occur anytime during preg

H/o Prev Epileptic fitsFits may be RecurrentFits Generalised/Focal

No H/o Hypertension,Proteinuria,

Edema

Convulsion in PregnancyDifferential Diagnosis

InvestigationsEclampsia EpilepsyComplete blood count Haematocrit

Platelet count Coagulation profile Serum creatinine Serum uric acid Liver function testsComplete urine

examination Fundoscopy

EEGCerebral Imaging

(MRI)

Maternal Complications of Eclampsia

Injuries –Tongue bite

Pulmonary Edema.

Aspiration Pneumonia(2%-5%)

Long Term Cardiovascular Morbidity

Abruptio- Placentae (1%-4%)

Disseminated Coagulopathy.

HELLP Syndrome (3-4%)

Acute Renal Failure (1%-5%)

Liver Failure OR Haemorrhage (<1%)

Cerebral haemorrhage

Postpartum collapse

Blindness

Death (Rare)

Neonatal Complications of EclampsiaPreterm delivery( 15-67% )IUGR(10-25%)Hypoxia- Neurologic Injury (<1%)Perinatal Death (1%-2%)Long Term Cardiovascular Morbidity

Associated with Low Birth Weight

AIMS OF MANAGEMENT OF ECLAMPSIA

Control convulsions, prevent cerebro-vascular accident

Stabilise blood pressureOptimise patientDeliver fetus

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Management of eclampsiaTeam approach

O&G specialist Anesthesiologist PaediatricianPhysicianNursing StaffBlood bank personnel

GENERAL MANAGEMENT OF ECLAMPSIA

position patient to her side in railed cotMouth gag placed between the teethclear airway secretionsmaintain oxygenation 15 LIT/ MINset up intravenous accessPut self retaining cathetermonitor vital signs - BP, PR, respiration 1/2hrlyif diastolic BP > 110mmHg, consider

antihypertensivemonitor fetal heart rate for gestations > 28 weeksAntibiotic

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Anticonvulsant TherapyMagnesium sulphate (MgSO4)

Diazepam

Phenytoin

MgSO4 Mechanism of actionSlowed neuromuscular conduction & decreased

CNS irritabilityCerebral vasodilatationIncreased production of endothelial prostacycline

and inhibition of platelet activationProtection of endothelial cells from injury

mediated by free radicals Dilatation of uterine arteries

MgSo4 as anticonvulsant Drug of choice Prichard’s regimen (IM)Loading Dose- 4gm (20%) slow IV over 3-5mt f/b 10gm (50%) deep IM (5gm in each buttock)Maintenance Dose- 5gm (50%) IM 4hrly in alternate buttock Zuspan regimen (IV) Loading Dose-4-6gm slow IV in 100ml 5% Dextrose over 15-20 mt F/b5gm IV in 500ml 5%Dextrose (1gm/hr IV infusion)Therpy is continued for 24hrs after last convulsion/Delivery. Maternal Mortality (0.4%)

Monitoring of patient on magnesium sulphate

Therapeutic levels (if available)Serum magnesium levels between 4.0-7.0 mEq/L

Patellar reflex Present (Lost at serum Mg Levels of 8 – 10 mEq/LUrine Output >30 ml/ hr Every hour Respiratory rate > 12/min

every 15 minsRespiratory depression (serum Mg level >10

mEq/L)Respiratory arrest (serum Mg level > 12 mEq/L)

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Managing Magnesium Toxicity Respiratory depression

Stop magnesium therapy Oxygen IV calcium gluconate 10% 10ml IV slow

bolus Maintain airway

Respiratory arrest Stop magnesium therapy IV calcium gluconate 10% 10 ml IV slow

bolus Tracheal Intubation and ventilation

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Effects of Mg sulphate on the newbornMgSO4 crosses the placenta freely

Minimal side effects if maternal serum levels are maintained

Hyporeflexia and Respiratory depression

Lethargy

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- Anticonvulsant therapy

Diazepam Useful for status seizures dosage – 10 -20 mg iv at a rate of 5 mg per min may be repeated at 10 to 15 minute intervals Maintainence – 40mg in 500ml of 5% Dextrose IV

infusion,to keep patient sedated

Side effects - loss of consciousness, hypotension, respiratory depression

Caution - may increase risk of aspirationcauses prolonged depression of the neonate

PhenytoinCentrally acting anticonvulsant

Dose ( with ECG monitoring ) 10mg/Kg I/V (not more than50mg/mt)

F/b 5mg/Kg I/V after 2hr 12 hr. — 500mg I/V 200mg 8hrly. X 5 daysSE- Hypotension, Cardiac dysrhythmia &

Phlebitis

Fluid replacement Should not exceed 1-2 ml/kg/hour or 85

ml/hour whichever is lowerCrystalloid Solution (RL)Total Fluid =24hr urine +1000mlMaintain a urine output of more than 30

ml/hour CVP should not exceed 7 cm of H2OWhen patient is taking oral fluids, the

amount taken should be subtracted from the amount infused

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Anti hypertensive managementObjective is to prevent maternal cerebrovascular

accidentsHydralazine

5mg -10mg I/V at 15 – 20 mts. Interval till control is achieved. Maximum dose 15mg – 20mg

Labetelol

Start with 200mg/100ml IV at 20mg/hr. I/v. Double the dose every 30 min. till control is achieved or a dose of 160mg/hr. is reached

Nifedipine 5mmg – 10mg S/L every 15 – 30 minutes until BP is

contolled A maximum 180mg can be used in a day

Treatment of complications of Eclampsia

If pulmonary oedema develops, give intravenous Frusemide 40mg, oxygen and manage patient in the ICU

If oliguria develops or when urine output is less than 30ml/hour for 4 hours – challenge with 200 mls of crystalloid over 5 minutes . Evaluate over a 4 hour period

If oliguria persists despite a CVP of between 7 – 10 cm H2O – refer to Nephrologist for further management.

Hyperpyrexia- Cold sponging , AntipyreticsHeart failure-O2 inhalation, IV Lasix, & Digitalis

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Obstetrical management of eclampsia

The Definative treatment

Is Delivery

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Indications of LSCS INEclampsiaUncontrolled fits in spite of therapyPoor prospects for vaginal DeliveryWorsening maternal disease processUncontrolled hypertension (>180/120mm

Hg)Obstetric indications

Epilepsy in Pregnancy

Effects Of Pregnancy On Epilepsy- Seizure frequency may increase: due to:Enhanced metabolism & increased drug clearance

pregnancy can result in decreased serum drug concentration.

Decreased or non-compliance with medication. Nausea and vomiting. Dose requirement of Antiepileptic drug

increases to prevent Fit .

Effect Of Epilepsy On PregnancyIncreased incidence of Fetal hypoxia, IUGR,

cognitive dysfunction, microcephaly and perinatal mortality (1.2 - 3 times normal).

Increased incidence of congenital malformations (2 fold)

eg cleft lip and / palate, cardiac abnormalities, limb defects, mental retardation & hypoplasia of terminal phalanges.

Effect Of Epilepsy On LactationNo contraindication for breast feeding.Infant may be drowsy.Readjustment of the anticonvulsant doses

required

Management of Epilepsy during Antenatal PeriodCLINICAL HISTORY

A-Investigations: Metabolic: serum glucose, urea, electrolytes, Ca & Mg EEK MRI Brain

B-Prenatal Screening for Fetal Malformations

Transvaginal U/S can be performed at 18-20 weeks to diagnose the most severe defets (face - heart). However, sensitivity is better, for cleft palate and lips, if U/S is repeated between 24-28 weeks.

Screening for NTD: by combination of Maternal serum α –fetoprotein at 15-22 weeks and Level II,structural Ultrasound, at 16-20 weeks.

If results are equivocal, proceed with amniocentesis with measurements of amniotic fluid α -fetoprotein and acetylcholine-esterase.

Antiepileptic Drugs in Pregnancy

Phenobarbitone (Gardenal ) 30 mg tab60-180 mg/d in 3 divided dosesSE- Maternal- Drowsiness , Ataxia and Nausea Fetal-Coagulopathy, Neonatal Depression and Withdrawal symptoms.Carbamazapine ( Tegretol ) 100,200&400 mg tab100-200mg BD, gradually increased to 800-1000mg/d in DD SE- Maternal- Drowsiness , Ataxia ,Leucopenia, Hepatotoxicity- Fetal – Craniofacial abnormalities, Limb defects.Folic acid 1 mg daily throughout pregnancyInj Vit K 10 mg/day after 34 wksAntiemetics SOS

Labor and Delivery

The risk of developing seizures during labour is 9 times than rest of the pregnancy.

The majority of women who have epilepsy have a safe vaginal delivery without seizure occurrence; provided, the AED is taken before and throughout labor.

.

Labor and Delivery

Labour and delivery

Generalized tonic clonic Seizures GTCSs needs aggressive interference because of the high risk for the mother and fetus, especially if they progress to status epilepticus.

Manage seizures acutely with - intravenous benzodiazepines (10-20 mg of

diazepam) orIntravenous Lorazepam 0.1mg/kg ( 2mg/mt) If seizures continue-Phenytoin 15mg/kg IV with ECG monitoring.

Patients having a seizure during labour must be observed closely for the next 72 hours

Labor and Delivery Emergency C.S. should be performed when

repeated GTCSs cannot be controlled during labor or when the mother is unable to cooperate.

Conclusions

1-Epileptic woman can get pregnant. They are not different than other women population.

2-Epilepsy and its medications increases the incidence of malformations 2-3 times normal. However; there is 90% chance of having a normal child.

3-The most common malformations are cleft lip, left palate and congenital heart diseases.

Conclusions (Cont.) 4-A woman should not stop AED unless she has not had seizures for 2 years; gradual discontinuation can then be attempted.

5-A pregnant should not stops her AED Since most malformations develop during the 1st trimester.

6-Current AEDs are considered to be Teratogenic . However, the safest are: Phenobarbital and Carbamazepine

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