Seizures during pregnancy can cause: Slowing of the fetal heart rate. Decreased oxygen to the fetus. Fetal injury, premature separation of the placenta from the uterus (placental abruption) or miscarriage due to trauma, such as a fall, during a seizure

1. Epilepsy in pregnancy
Mukesh Sah, MD

2. Epilepsy(1/3)
• Epilepsy is a chronic disorder or group of disorders characterized by
recurrent, unpredictable seizures. A seizure is a temporary physiological
dysfunction of the brain, in which neurons will produce excessive
electrical discharge.
• It is mainly presents in childhood, although there is a second peak of
incidence in older years and women of childbearing age account for 23%
of the population affected by epilepsy, with a prevalence in pregnancy of
0.35%.

3. Epilepsy(2/3)
 The complications associated with the epilepsy are:
• Trauma occurring during the seizure and include tongue biting and head or
limb injury
• Status epilepticus: a seizure lasting for > 30 minutes, or a series of seizures
without regaining consciousness in between.
• Sudden unexpected death in epilepsy (SUDEP) of which there is no cause
for sudden death.

4. Epilepsy(3/3)
• Maternal death: the risk of sudden maternal death in pregnancy
remains higher in women with epilepsy than those with other long-
term conditions.

5. Types of epilepsy
A. Partial
1. Simple:
Characteristics
• Remains conscious
• Experiences as aura (premonition)
• Pins and needles sensation in arms or legs
• Pallor, or alternatively a flushed face with sweating
• Muscle twisting in limbs with some stiffness

6. Cont…..
2. Complex:
Characteristics:
• Awareness of changes, loses of the memory of the event.
• Rubbing of the hands
• Chewing and smacking of lips
• Makes random noises
• Exhibits usual posture

7. Cont…..
B. Generalized:
1. Absence:
Characteristics:
• Staring and blinking, day dreaming, loss of awareness for 5-20
seconds (mainly affects children)

8. Cont…..
2. Myoclonic:
Characteristics:
• Brief muscle jerking in an arm or leg. Lasts for a fraction of a second
and individual remains conscious.
3. Tonic:
Characteristics:
• All body muscles contract for < 20 seconds, but there are no
convulsions. The individual falls.

9. Cont…..
4. Tonic-clonic:
Characteristics:
• The whole body contracts, arms and legs convulse. Incontinence is
possible. Last 1-2 minutes and the individual appears tired, wanting to
sleep. The most common type of seizure (60% of cases).
5. Atonic:
Characteristics
• All muscle tone is lost momentarily. The individual falls limply and
head injury is probable, but gets up immediately with no confusion.

10. Pathogenesis(1/2)
 Most cases: idiopathic and no underlying cause is found.
 30%: a family history of epilepsy.
 secondary epilepsy: may be encountered in pregnancy in patients who
have the following:
- Previous surgery to the cerebral hemispheres.

11. Pathogenesis(2/2)
- Intracranial mass lesions (meningioma's and arteriovenous
malformations enlarge during pregnancy. This should always be
considered if the first seizure occurs in pregnancy)
- Antiphospholipid syndrome

12. Other causes of seizures in pregnancy
 Eclampsia
 Cerebral vein thrombosis (CVT)
 Thrombotic thrombocytopenic purpura (TIP)
 Stroke
 Subarachnoid hemorrhage.

13. Cont….
 Drug and alcohol withdrawal
 Hypoglycemia
 Infections: tuberculoma, toxoplasmosis
 Gestational epilepsy: seizure are confined to pregnancy

14. Diagnosis
Most women have already been diagnosed, but when a first seizure
occurs in pregnancy, the following investigations are appropriate:
 Blood pressure, urinalysis, platelet count, clotting screen, blood film
 Blood glucose, serum calcium, serum sodium, liver function tests.
 CT or MRI of the brain.
Although this is not necessarily recommended for the first seizure in the
non-pregnant women, there is no doubt of its value in pregnancy.
 EEG

15. Effects of pregnancy on epilepsy
 The effects of pregnancy on epilepsy is uncertain.
 All anticonvulsants interfere with folic acid metabolism.
 folic acid deficiency has been associated with neural tube defects
and other congenital malformations.

16. Effects of epilepsy on pregnancy(1/2)
 Relatively resistant to short episodes of hypoxia and there is no
evidence of adverse effects of single seizures on the fetus.
 No increased risk of miscarriage or obstetric complications in
women with epilepsy unless a seizure results in abdominal trauma.
 Incidence of fetal malformations, IUGR, oligohydramnios, pre-
eclampsia and stillbirths is increased.

17. Effects of epilepsy on pregnancy(1/2)
Birth defects are increased by two fold. This could be related to the
severity of the disease with its genetic predilection and also due to the
anticonvulsants.
 The malformations include- cleft lip and/ or palate, mental
retardation, cardiac abnormalities. Limb defects and hypoplasia of the
terminal phalanges.

18. Management (1/3)
1. Pre- pregnancy counselling:
 Control of epilepsy should be maximized prior to pregnancy with the
lowest dose of the most effective treatment that gives best seizure
control.
 Review of antiepileptic drugs (AED) should taken into account the
risk of teratogenesis and other adverse neurodevelopment effects.

19. Management (2/3)
 If a decision is taken to stop treatment, AEDs should be
withdrawn slowly in order to reduce the risk of withdrawal-
associated seizures. This is particularly important for
benzodiazepines and phenobarbitone.

20. Management (3/3)
 The current recommendations are to stop driving from the
commencement of the period of drug withdrawal and for a period of
six months after cessation of treatment, even if there is no recurrence
of seizures.
 All women receiving AEDs should be advised to take pre-conception
folic acid (5mg/day)

21. Antenatal management(1/3)
• The dose of the chosen drug should be kept as low as possible and to
be monitored regularly from the serum level. The commonly used
drugs are:
- Phenobarbitone 60-100mg daily in two to three divided doses.
- Phenytoin 150-300mg daily in two divided doses.

22. Antenatal management(2/3)
- Carbamazepine 0.8-1.2g daily in divided doses.
• Folic acid daily prior to conception, continues throughout pregnancy,
as there is also a small risk of folate-deficiency anemia.

23. Antenatal management(3/3)
• Relatives, friends and/or partners should be advised on how to place
the women in the recovery position to prevent aspiration in the event
of a seizure.
• Vitamin K 10 mg daily must be given orally in the last 2 weeks.

24. Intrapartum management(1/2)
• The risk of seizures increases around the time of delivery. Women
with major convulsive seizures should deliver in hospital.
• Anticonvulsant medication continue throughout the labor regular
review by the obstetric team is indicated.
• If seizures recur, short-acting benzodiazepines are administered.

25. Intrapartum management(2/2)
• The women should not be left alone in labor, and dehydration,
hyperventilation and exhaustion should be avoided as they can trigger
a seizure.
• The birth can be spontaneous facilitated by the midwife. Following
obtaining informed consent from the women , vitamin K should be
administered to the baby promptly after birth to protect against AED-
induced hemorrhage disease.
• Caesarean section is only required if there are recurrent generalized
seizure in late pregnancy or labor.

26. Postnatal management
• In the first 24 hours of birth the women has an increased risk of a
seizure and so should remain in hospital.
• Breast feeding is encouraged.
• The baby should be carefully observed and any concern reported to
the pediatrician immediately.
• Advice should be given about safety when caring for the baby in case
of maternal seizure.

27. Reference
• DC Dutta’s. Textbook of obstetrics including perinatology and contraceptive. 7th. New Delhi:
Jaypee brothers; Nov2013. p. 291
• Myles. Textbook for midwives. 16th edition. New York: Elsevier; 2014. p. 277-279.
• Annamma Jacob. A comprehensive textbook of midwifery and gynecological nursing. 4th
edition. New Delhi: Jaypee brothers; 2015. p. 381.
• https://www.slideshare.net/elnashar/epilepsy-and-pregnancy-49895122
• https://www.rcog.org.uk/globalassets/documents/guidelines/green-top-
guidelines/gtg68_epilepsy.pdf
• http://www.bioline.org.br/pdf?jp06020
• https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-
depth/pregnancy/art-20048417