Dr. RKJ~ Management of Seizure Disorders in Pregnengy~ in pregnency


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Dr. RKJ~ Management of Seizure Disorders in Pregnengy~ in pregnency

  2. 2. Q. You are enjoying with your friends in a party, when suddenly one of your friend’s Wife, who happened to be pregnant experiences a convulsive episode…… …… What do you do at that instant moment ??? <ul><li>DO NOT LEAVE HER ALONE !! </li></ul><ul><li>Bring her to a Safe, Non Toxic, and Clean Surrounding. </li></ul><ul><li>Place her in a LEFT LATERAL Position </li></ul><ul><li>Why? </li></ul><ul><li>(a) This position decreases the risk of aspiration. </li></ul><ul><li>(b) Relieves obstruction on the Vena cava by the gravid uterus, thus enabling </li></ul><ul><li>better uterine blood flow. </li></ul><ul><li>Ideally place a PADDED TONGUE BLADE between the teeth, but if you cant </li></ul><ul><li>find one, place a stick long enough to keep the mouth open and tongue retracted </li></ul><ul><li>away, to prevent fall back of tongue and thence obstructing the airways. </li></ul><ul><li>4. During the convulsive episode remember to guard the patient against Self </li></ul><ul><li>Induced Injuries. </li></ul><ul><li>5. RUSH the patient to a hospital. </li></ul><ul><li>NB: If the hospital is far enough or a Drug shop is nearby, give Injection Phenergan </li></ul><ul><li>25mg or Diazepam 10mg IM, maintaining Sedation untill reaches Hoaspital. </li></ul>
  3. 3. On Reaching The Hospital CALL FOR HELP - duty obstetric & anaesthetic registrars; senior midwife INFORM CONSULTANTS - obstetrician & anaesthetist on call Is it safe to approach the patient? - consider hazards around patient that will affect your safety Prevent maternal injury during convulsion – place in semi-prone position in a railed cot ,in an isolated room. • Airway: (a) Assess (b) Maintain patency (c) Apply oxygen • Breathing: (a) Assess and also auscultate Lungs for any aspiration. (b) Protect airway (c) Ventilate as required • Circulation: (a) Evaluate pulse & BP If absent, initiate CPR and call arrest team (b) Left lateral tilt (c) Secure IV access with a 16-18 gauge needle as soon as safely possible Attach pulse oximeter, ECG & automatic BP monitors Urinary catheter - hourly urinometer readings Fluid input / output chart (discussed later)
  4. 4. Patient Profiling and Approach : <ul><li>After Initial assesment, spend not more than 2-3 mins for the following: </li></ul><ul><li>Patient Profiling: ( From the patient Party) </li></ul><ul><li>(a) Name, Age, H/o Last child birth. </li></ul><ul><li>(b) L.M.P and Calculating Weeks of Gestation(WGA) </li></ul><ul><li>(c) If patient is reffered from some hospital. </li></ul><ul><li>(d) Ask for the number of fits occurred </li></ul><ul><li>(e) Nature of medication administered </li></ul><ul><li>(f) Any h/o of fever, with chills and rigor prior to convulsive </li></ul><ul><li>episode </li></ul><ul><li>(g) Any previous known medical or surgical ailment. </li></ul><ul><li>Patient examination: (a) General examination </li></ul><ul><li>(b) Abdominal and vaginal examination </li></ul><ul><li>(c) Other system examination: CVS, CNS (specially Knee </li></ul><ul><li>jerk), Respiratory system, Fundoscopic examination. </li></ul><ul><li>NB: (1)Take WRITTEN CONSENT For HIGH RISK PREGNENCY. </li></ul><ul><li>(2)Monitor Half hourly Pulse, Respiration, Blood Pressure and FHR. </li></ul><ul><li>(3)Monitor Hourly urine Output and uterine contraction. </li></ul>
  5. 5. Cont..Approach 3. Principles of fluid balance: BEWARE: Iatrogenic fluid overload is the main cause of maternal death in Pre-eclampsia/Eclampsia Maintenance fluids should be given as crystalloid but additional fluid (colloid) may be necessary prior to vasodilatation to prevent maternal hypotension and fetal compromise. Consideration should also be given to correcting hypovolaemia in women with oliguria 1. Accurate recording of fluid balance (including delivery and postpartum blood loss, input/output deficit) 2. Maintenance crystalloid infusion (R/L) - 85 ml/hour, or urinary output in preceding hour plus 30 ml 3. Selective colloid expansion - prior to pharmacological vasodilatation; oliguria with low CVP 4. Diuretics - only for women with confirmed pulmonary oedema 5. Selective monitoring of CVP- for patients of severe hypertension and reduced Urinary output. NB: Normally, fluid should not exceed 2litres in 24 hours.
  6. 6. Cont... Approach & Coming to a diagnosis of Seizure.. <ul><li>4. Investigations to be done: </li></ul><ul><li>Immediate: (a) Hb% </li></ul><ul><li>(b) ABO, Rh </li></ul><ul><li>(c) GRBS </li></ul><ul><li>(d) Na+ , K+, Cl-, Ca++ levels </li></ul><ul><li>(e) Urine R/E (specially for Protenuria) </li></ul><ul><li>(f) Blood for Malarial Parasite </li></ul><ul><li>(g) Foetal Cardiotocography & USG on admission. </li></ul><ul><li>B. Later (but if feasiable can be sent early): </li></ul><ul><li>(a) Complete Haemogram </li></ul><ul><li>(b) L.F.T. </li></ul><ul><li>(c) Renal Profile I & II </li></ul><ul><li>(d) aPTT, and PT </li></ul><ul><li>(e) Uric acid levels. </li></ul><ul><li>(f) 24 hour urine for: (a) Total protein & creatinine clearance </li></ul><ul><li>(b) Catecholamine levels </li></ul><ul><li>C. If inspite of the above investigations no diagnosis is reached: </li></ul><ul><li>(a) C.T. scan, MRI </li></ul><ul><li>(b) C.S.F. analysis. </li></ul>
  7. 7. SPECIFIC MANAGEMENT > <ul><li>Commonest Seizure Disorders: </li></ul><ul><li>Hypoglycemia </li></ul><ul><li>Eclampsia </li></ul><ul><li>Epilepsy </li></ul><ul><li>Complicated Cerebral Malaria </li></ul>The vast majority of the initial seizures are self-limiting
  8. 8. ECLAMPSIA <ul><li>Seizure Mangement </li></ul><ul><li>Hypertension Mangement </li></ul><ul><li>Obstetrical Management. </li></ul>
  9. 9. MAGNESIUM SULPHATE is the anticonvulsant drug of choice MOA: (a) Reduces Motor end plate sensitivity to Ach hence reducing neuromuscular irritability. (b) Blocks Neuronal calcium Influx. (c) Dilates Cerebral and uterine vessels. (d) Prostacyclin production is increased with inhibition of platelet activation. Regimen: (Intravenous regimen) Loading Dose: 4 g IV over 10-15 minutes Add 8 ml of 50% MgSO4 solution to 12 ml of N Saline = 4 g in 20 ml = 20% solution Maintenance 1 g per hour Dose: Add 25 g MgSO4 (50 ml) to 250 ml N Saline 1 g MgSO4 = 12 ml per hour IV 1 g/hour is infused for 24 hours after last fit provided that: • respiratory rate > 16 breaths/minute • urine output > 25 ml/hour, and • patellar reflexes are present Administer via infusion pump A. SEIZURE MANGEMENT:
  10. 10. <ul><li>If seizure continues, or if seizures recur, give a second bolus of magnesium </li></ul><ul><li>sulphate: </li></ul><ul><li>2-4 g depending on weight of patient, over 5-10 minutes </li></ul><ul><li>(2 g if < 70 kg and 4 g if > 70 kg) </li></ul><ul><li>ONE STAT DOSE ONLY </li></ul><ul><li>If seizures continue despite a further bolus of magnesium sulphate or the patient </li></ul><ul><li>Is a known Myasthenic: (IInd Line Regimen): </li></ul><ul><li>Loading: Phenytoin 10mg/kg In 100 ml Normal Saline </li></ul><ul><li>After 2 hours: Phenytoin 5mg/kg in 100ml Normal saline </li></ul><ul><li>Then every 12hourly : 5mg/kg in NS </li></ul><ul><li>Continue the regimen : Upto 24 hours after delivery. </li></ul>Seizure continues
  11. 11. <ul><li>When using Magnesium Sulphate: </li></ul><ul><li>Monitor: (a) Hourly urine output </li></ul><ul><li>(b)Respiratory rate, oxygen saturation & patellar reflexes - every 10 minutes for first two hours and then every 30 minutes </li></ul><ul><li>(c)Check serum magnesium levels every day if infusion is continued for </li></ul><ul><li>24 hours </li></ul><ul><li>Request MgSO4 levels if: (a) Respiratory rate < 16 breaths/minute </li></ul><ul><li>(b)Urine output < 25 ml/hour for 4 hours </li></ul><ul><li>(c)Loss of patellar reflexes </li></ul><ul><li>(d)Further seizures occur </li></ul><ul><li>Magnesium Therapeutic Levels: 2.0-4.0 mmol/l </li></ul><ul><li>With increasing magnesium levels, the following may occur: </li></ul><ul><li>Feeling of warmth, flushing, double </li></ul><ul><li>vision, slurred speech....................................3.8-5.0 mmol/l </li></ul><ul><li>Loss of tendon reflexes.....................................>5.0 mmol/l </li></ul><ul><li>Respiratory depression......................................>6.0 mmol/l </li></ul><ul><li>Respiratory arrest..........................................6.3-7.1 mmol/l </li></ul><ul><li>Cardiac arrest..................................................>12.0 mmol/l </li></ul>MgSO4
  12. 12. Magnesium Toxicity: (a)Urine output < 100 ml in 4 hours: If no clinical signs of magnesium toxicity, decrease rate to 0.5 g/hour Review overall management with attention to fluid balance and blood loss (b)Absent patellar reflexes: Stop MgSO4 infusion until reflexes return (c)Respiratory depression: (i) Stop MgSO4 infusion (ii)Give oxygen via facemask and place in recovery position because of impaired level of consciousness (iii)Monitor closely (d)Respiratory arrest: Stop MgSO4 infusion Give IV Calcium gluconate Intubate and ventilate immediately (e)Cardiac arrest: Commence CPR Stop MgSO4 infusion Give IV Calcium gluconate Intubate and ventilate immediately If antenatal, immediate delivery Antidote: 10% Calcium gluconate 10 ml IV over
  13. 13. B. HYPERTENSION MANAGEMENT : <ul><li>Treat hypertension if: </li></ul><ul><li>- Systolic BP > 170 mmHg, or if </li></ul><ul><li>- Diastolic BP >110 mmHg, or if </li></ul><ul><li>Mean Arterial Pressure >125 mmHg </li></ul><ul><li>Aim to reduce BP to around 130-140/90-100 mmHg </li></ul><ul><li>Monitor FH with continuous CTG during and after administration of intravenous </li></ul><ul><li>Drugs for 30 minutes </li></ul><ul><li>Drugs: </li></ul><ul><li>(a)Hydralazine: 10 mg IV slowly </li></ul><ul><li>Repeat doses: 5 mg IV at 20 minute intervals may be given if necessary </li></ul><ul><li>(the effect of a single dose can last up to 6 hours) </li></ul><ul><li>If no lasting effect with boluses (assess over 20 minutes), consider an </li></ul><ul><li>infusion at 2.0 mg/hour increasing by 0.5 mg/hour as required </li></ul><ul><li>(2-20 mg/hour usually required) </li></ul>
  14. 14. (b)Labetalol : If BP still uncontrolled, Labetalol 50 mg IV slowly; if necessary repeat after 20 minutes or IV infusion of 200 mg in 200 ml N Saline, starting at 40 mg/hour, increasing dose at 1/2 hourly intervals as required to a maximum of 160 mg/hour If blood pressure does not respond to the above, discuss with senior renal physicians and anaesthetists. (c)Nifedipine: Oral route is safer and as effective as sublingual route Dose: 10 mg orally. Monitor FH with CTG NOTE: An interaction between nifedipine and magnesium sulphate has been reported to produce profound muscle weakness, maternal hypotension and fetal distress.
  15. 15. C. OBSTETRICAL MANAGEMENT A. Initiate steroids if gestation 34 weeks: Inj. Betamethasone 12mg IM two doses 24hour apart. B. If patient in labour: (a)A.R.M. : to cut short second stage of labour (b)C.S. : In case of Obstetrical indications C. If patient not in labour, and fits controlled or not, but baby alive: (a) Termination by A.R.M. or C.S. D. If Patient not in labour, and fits controlled or not, but baby dead: (a) Wait for spontanous expulsion.
  16. 16. Carry Home Message: <ul><li>Seizure disorder can be due to a varied reasons in a pregnant women </li></ul><ul><li>Act cautiously, and fast in a Convulsive patient. </li></ul><ul><li>Always consult Obstetrician and Anasthetist for management in refractory cases. </li></ul><ul><li>Remember Seizure disorders can occur even with Normotensive patients, specially </li></ul><ul><li>post Casearen and early Post partum periods. </li></ul><ul><li>MgSO4 is the drug of choice for eclamptic disorder. </li></ul><ul><li>Correction of Blood glucose and electrolytes for hypoglycemic and other </li></ul><ul><li>Dyselectolytemia must always be kept in mind. </li></ul><ul><li>Quinine can be safely given in a pregnant mother with Complicated Cerebral </li></ul><ul><li>Malaria </li></ul>