Fits in Pregnancy (Eclampsia, Epilepsy).pdf

Presentation Title: Fits in Pregnancy: Understanding Epilepsy and Eclampsia
Introduction:

Seizures during pregnancy present a unique and multifaceted challenge in obstetric care. The intersection of epilepsy and eclampsia—two distinct but critical conditions—requires a thorough understanding to ensure optimal maternal and fetal outcomes. This presentation aims to provide a comprehensive overview of seizures in pregnancy, focusing on the distinctions and management strategies for epilepsy and eclampsia.

1. Overview of Seizures in Pregnancy

Seizures during pregnancy can be alarming and pose significant risks to both mother and child. Understanding the underlying causes and appropriate management strategies is crucial for improving patient outcomes. Seizures in pregnant individuals are broadly categorized into two main types: those associated with pre-existing epilepsy and those related to obstetric complications, notably eclampsia.

2. Epilepsy in Pregnancy

Epilepsy is a chronic neurological disorder characterized by recurrent, unprovoked seizures. It affects a substantial number of women in their childbearing years. Managing epilepsy during pregnancy involves balancing the control of seizures with minimizing risks to both the mother and fetus.

2.1. Pathophysiology and Epidemiology

Epilepsy is caused by abnormal electrical activity in the brain, leading to various seizure types, including generalized tonic-clonic seizures, focal seizures, and others. The prevalence of epilepsy in pregnant women is approximately 0.3% to 0.5%, but this can vary based on the population and specific epilepsy syndrome.

2.2. Antiepileptic Drugs (AEDs) and Pregnancy

The management of epilepsy during pregnancy often involves the use of antiepileptic drugs (AEDs). However, many AEDs have potential teratogenic effects that can impact fetal development. Common AEDs used include levetiracetam, lamotrigine, and valproate. Each of these drugs has a different risk profile regarding congenital malformations and developmental issues. For example, valproate is known to carry a higher risk of neural tube defects compared to other AEDs.

2.3. Pregnancy-Related Changes and Their Impact

Pregnancy induces various physiological changes that can affect epilepsy management. Hormonal fluctuations, changes in drug metabolism, and increased blood volume can alter the effectiveness of AEDs. For instance, the clearance of some AEDs can increase during pregnancy, necessitating dose adjustments. Regular monitoring and individualized treatment plans are essential to maintain seizure control and minimize adverse effects.

2.4. Risks and Complications

Seizures during pregnancy can lead to several complications, including maternal injury, preterm labor, and increased risk of fetal distress. In severe cases, uncontrolled seizures may result in adverse neonatal outcomes. Therefore, a multidisciplinary approach involving obstetricians, neurologists, and other healthcare professionals is crucial

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2. FITS IN PREGNANCY
(ECLAMPSIA/EPILEPSY)
BY; Dr. SM

3. FITS IN PREGNANCY
Fits due to pregnancy
Eclampsia
Fits aggravated by pregnancy
Epilepsy

4. ECLAMPSIA
New-onset convulsions after 20 weeks of pregnancy in a
patient with Preeclampsia (PIH) with no coincidental
neurologic disease, is called Eclampsia
❖ANTEPARTUM (50%)
❖INTRAPARTUM (30%)
❖POSTPARTUM (20%)

5. EPILEPSY
Epilepsy is a chronic neurological disorder in which a
person has repeated seizures overtime. Seizures are
episodes of disturbed brain activity that cause changes
in attention or behavior.
Symptoms vary from person to person

6. FITS IN PREGNANCY
➢In pregnant women presenting with seizures in the
second half of pregnancy which cannot be clearly
attributed to epilepsy, immediate treatment should
follow existing protocols for eclampsia management
until a definitive diagnosis is made.
➢Other cardiac, metabolic and intracranial conditions
should be considered in the differential diagnosis.

7. DIFFERENTIAL DIAGNOSIS
ECLAMPSIA EPILEPSY
History + Examination
Occurs after 20 weeks of
pregnancy
Occurs anytime during
pregnancy
h/o PIH in pregnancy h/o previous epileptic fits
Previous h/o eclampsia +/- Fits maybe recurrent
h/o tonic clonicconvulsion Fits generalized/focal
h/o hypertension, proteinuria,
edema, oliguria, pulmonary
edema
No h/o
Hypertension, proteinuria,
edema

8. FITS IN PREGNANCY
INVESTIGATIONS:
Eclampsia
Complete blood count
Hematocrit
Platelet count
Coagulation profile
Serum creatinine
Serum uric acid
Liver function tests
Complete urine examination
Fundoscopy
Epilepsy
EEG
Cerebral Imaging (MRI)

9. FetomaternalComplications
➢HELLP syndrome
➢Disseminated coagulopathy
➢Placental abruptions
➢Acute renal failure
➢Pulmonary edema
➢Preterm delivery
➢Perinatal death
➢IUGR
➢Low birth weight

10. Management of eclampsia
First Step:
➢Communication
➢Call for help
◦Inform consultant on call
◦Senior Registrar
◦Anesthetist
◦Hematologist/Blood Bank
◦Neonatologist if antenatal

11. Second Step:
➢Resuscitation
◦Position →Turn to left lateral (semiprone)
◦Assess CAB
➢Assess circulation
◦If no B.P/ Pulse -start CPR
◦if present -double i/v line (14G)
◦Draw 20 ml of blood for investigation (Blood Group, FBC, LFTS, RFTS, Coagulation
Profile)
➢Assess airway: maintain patency
➢Assess breathing: give 100% O2 by face mask
◦Catheterize the patient
◦Control fit with Mg SO4 according to unit protocol
◦Control B.P with fast acting antihypertensive

12. ➢Do side by side monitoring:
◦Vital sign record every 5 minutes until B.P is stable
◦Monitor for Mg SO4 toxicity with reflexes R/R,
◦Urine output in ml/hour.
➢Ideally CVP line -if no coagulopathy
➢If coagulopathy -give FFPs, Cryoppt, Platelets.
➢If fetomaternalcondition is stable do Bishop
◦If Bishop is favorable and quick delivery is anticipated→ do IOL
◦If fetomaternalcondition is unstable; immediate C/Section
➢Continue intensive monitoring in the postnatal period
◦Keep in HDU for 48-72 hours
◦Maintain vigilancyfor PPH

13. MgSO4 as anticonvulsant
Drug of Choice
➢Prichard's regimen (IM)
➢Zuspanregimen (IV)
➢SibaiProtocol

14. Monitoring of patient on magnesium
sulphate
◦Respiratory rate >12
◦Urine output should be >30 ml per hour
◦Reflexes (patellar, ankle) should be present

15. MgSO4 levels and its toxicity
◦4-8 mg/dl Normal therapeutic level
◦9-12 mg/dl patellar reflex absent
◦15-17 mg/dl respiratory depression
◦30-35 mg/dl cardiac arrest
Antidote:
Calcium gluconate

16. Effect of MgSO4 on Newborn
◦Cross placenta freely
◦Minimal side effects if maternal serum level are maintained
◦Hyporeflexia and repiratorydepression
◦lethargy

17. Treatment of complication 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 then give fluid challenge
◦If oliguria persists despite a CVP of between 7-10 cm H.O refer to
Nephrologist for further management.
◦Hyperpyrexia-Cold sponging, Antipyretics
◦Heart failure-O2 inhalation, IV Lasix,&Digitalis

18. Obstetrical treatment of eclampsia
The definitive treatment is
delivery

19. Epilepsy in pregnancy

20. 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 increase topreventFits

21. Fetal abnormalities
◦Microcephaly
◦Cleft lip and palate
◦Neural tube defects
◦Congenital heart defects
◦Intrauterine growth restriction
◦Developmentaldelay

22. Effects of epilepsy on lactation
◦No contraindication for breast feeding.
◦Infant may be drowsy
◦Readjustment of the anticonvulsantdosesrequired

24. Management of epilepsy during
antenatal period
◦Care should be taken by obstetrician jointly with a neurologist
◦Screening of anomalies should be offered 18-22 weeks
◦Phenobarbital, Phenytoin, Carbamazepine cause vitamin k deficiency
◦(by inducing liver enzymes responsible for its oxidative degradation
reduced level of Vitamin k leads to factor 2,7,9,10 deficiency in
neonate result in hemorrhagic disease of new born)
◦Oral vitamin k given from 36 week onwards
◦Tab folic acid 5mg daily throughout pregnancy
◦Antiemetics sos
◦Current AEDs are considered to be teratogenic. However, the safest
are:
Phenobarbital and carbamazepine

25. ◦The risk of developing seizures during labouris 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

26. Manage seizures acutely with:
intravenous benzodiazepines (10-20 mg of diazepam)
ог
Intravenous Lorazepam o.1mg/kg
If seizures continue:
◦Phenytoin 15mg/kg IV with ECG monitoring.
(Patients having a seizure during labourmust be observed closely
for the next 72 hours)

27. Labor and Delivery
Emergency C.S. should be performed when repeated GTCSs
cannot be controlled during labor or when the mother is
unabletocooperate.

28. Thanks for listening