Convulsions in Pregnancy

1. Convulsions in
Pregnancy
By: Omar Tarek F. Ahmed
151110101

2. • a 20-year-old G1P0 at 34 weeks and 1day gestational age admitted 2 hours ago
with abdominal pain. Her prenatal history is unremarkable except for heartburn
since the first trimester. She’s been unable to distinguish between epigastric pain
or contractions. She denies a headache. Her cervix was found to be 1 cm/long.
She’s contracting every 3-4 minutes.
• Her admitting blood pressure was 150/100, but she’s rested and it has come down.
Pulse 88, temp 98.6, resp rate 16, FHR 145, Category I. Her Hgb is admission was
11.8. She dipped 2+ protein in her urine.
Scenario

3. • Shortly after, she notifies the nurse that she is having a headache, who then
reassures her.
• About an hour later, the patient develops a tonic/clonic seizure, and you’re called
as the OB resident on call to assess the situation.
Pulse 60
BP 170/105
Temp 37.2
O2 Saturation 93% on room air
FHR 120 Category II with minimal variability and variable decelerations to 70
Generalized tonic/clonic seizure activity
What do you do? What is the cause of this condition?

4. • DDx of convulsion in pregnancy
• Eclampsia: -
• Definition
• Epidemiology
• Etiology and pathology
• Types
• Clinical features
• Investigations
• DD
• Complications
• Prophylaxis and Management
• Prognosis
ILOs

5. • Epilepsy
• Eclampsia
• Metabolic causes
• Hyperemesis gravidarum
• Electrolyte imbalance
• Acute hepatitis
• Metabolic diseases (e.g. acute intermittent porphyria)
• Structural causes
• Intracranial hemorrhage
• Cerebral venous sinus thrombosis
• Ischemic stroke
• Trauma
• Infections (e.g. malaria)
• Drug overdose/withdrawal
• Brain tumors
• Autoimmune disease (e.g. SLE, TTP)
DDx of a Seizing Pregnant Woman

6. Eclampsia

7. • Eclampsia is defined as the development of convulsions (grand mal or
tonic–clonic) and/or unexplained coma during pregnancy or
postpartum in patients with signs and symptoms of preeclampsia
Definition

8. • Incidence in developed countries is very low: 0.015-0.1%
• Incidence in developing countries is variable, however, still
considerable: 0.2- 1.4%
Epidemiology

9. Pathophysiology
• Most symptoms of eclampsia are a result
of the development of reversible
posterior leukoencephalopathy syndrome
(RPLS)

10. • Eclampsia has been subdivided according to the time it presents: -
1. Antepartum (higher rate of complications)
2. Intrapartum
3. Early postpartum
4. Late (>48 h) postpartum
• 44% of cases are postpartum (mostly late)
Types

11. • Typical presentation (variable in severity): -
• Hypertension (hallmark of eclampsia)
• Convulsions
• Generalized edema
• Proteinuria
• Other features (of pre-eclampsia) may have preceded:
epigastric pain/RUQ pain, frontal or occipital headache,
visual disturbance, photophobia, and mental disturbances
Clinical Features

12. • Eclampsia is a clinical diagnosis based upon the occurrence of new-
onset tonic-clonic seizures in the absence of other causative
conditions, typically in a woman with a hypertensive disorder of
pregnancy (preeclampsia, HELLP syndrome, gestational
hypertension)
• Cerebral imaging is indicated for patients with focal neurologic
deficits or prolonged coma.
Investigations

13. • The occurrence of preeclampsia/eclampsia before 20 weeks of
gestation is rare and should raise the possibility of an underlying molar
pregnancy or a cause of seizure unrelated to pregnancy
• Seizures + neurological deficit → think structural abnormalities
• Seizures w/o neurological deficit → think metabolic abnormalities
• Pregnancy is a precipitating factor for TTP & HUS (associated with
seizures) → Eclampsia (and HELLP) usually start to quickly improve
after delivery, but delivery does not affect the course of TTP and HUS
DDx

14. • Maternal: -
• Maternal death
• Hemorrhagic stroke
• HELLP syndrome (up to 20%)
• DIC
• Aspiration pneumonia
• Pulmonary edema
• Cardiopulmonary arrest
• Acute renal failure
• Fetal: -
• Fetal death (5.6% to 11.8%)
• Placental abruption
• Preterm delivery (50%)
• IUGR (severe)
Complications

15. • 5 key principles: -
• Prevention of maternal hypoxia and trauma
• Treatment of severe hypertension, if present
• Prevention of recurrent seizures
• Treat complications
• Evaluation for prompt delivery
Management

16. • Maternal oxygenation and protection from trauma: -
• Supportive care during convulsion
• Place lateral position
• Give O2 via nonrebreather face mask
• Raise bedrails to provide protection from trauma
• Treatment of hypertension: -
• Reduce BP to a target of systolic blood pressure between 140 and 160 mmHg and
diastolic blood pressure between 90 and 105 mmHg
• Guidelines recommend IV labetalol (also IV hydralazine & oral nifedipine)
continuous IV infusion of 1 to 2 mg/minute
Management

17. • Prevention of recurrent seizures: -
• IV magnesium sulfate is the drug of choice
• 6 g over 15–20 min, followed by a maintenance dose of 2 g/h as a
continuous intravenous infusion
• An excellent drug that reduces the rate of recurrent seizures by
one-half to two-thirds and the rate of maternal death by one-third
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• Amobarbital or phenytoin for seizures refractory to MgSO4
Management

18. • Treat complications: -
• DIC: maintain blood volume and blood pressure with aggressive
replacement (crystalloids and/or blood products)
• Pulmonary edema: administer O2 and 20–40 mg of IV
furosemide over 1–2 min
Management

19. • Evaluation for PROMPT delivery: -
• Development of eclampsia is an absolute indication for immediate delivery regardless of gestational
age; delivery is the definitive diagnosis for eclampsia
• Begin induction/delivery within 24 h of the onset of eclampsia
• It is considered to be advantageous to the fetus to allow in utero recovery from hypoxia and
hypercarbia due to maternal convulsions
• However, if the bradycardia and/or recurrent late decelerations persist beyond 10–15 min despite all
resuscitive efforts, then a diagnosis of placental abruption or nonreassuring fetal status should be
considered
• The presence of eclampsia is NOT an indication for cesarean delivery
• The decision to perform cesarean delivery should be based on fetal gestational age, fetal condition,
presence of labor, and cervical Bishop score
Management

20. • Postpartum management: -
• After delivery, patients with eclampsia should receive close monitoring
of vital signs, fluid intake and output, and symptoms for at least 48 h
• There is increased risk for pulmonary edema and exacerbation of severe
hypertension postpartum
• Parenteral magnesium sulfate should be continued for at least 24 h after
delivery and/or for at least 24 h after the last convulsion
Management

21. • Maternal mortality is up to 14%, and vary greatly
with management
• 10% eclamptic women have repeated seizures if
not treated, but a similar percentage will have
repeated seizures even when treated with
magnesium sulfate.
• 20% maternal deaths are attributable to
intracerebral hemorrhage
• Hepatic, renal, and pulmonary damage largely
reverse with treatment of hypertension and
delivery of the baby, in the absence of intraorgan
hemorrhage. Similarly, cerebral edema reverses
Prognosis

22. • Eclampsia is a complication of severe pre-eclampsia and is an obstetric
emergency.
• It is defined as one or more new onset tonic-clonic seizures in the presence of
pre-eclampsia.
• The majority of seizures occur within 4 days’ post-partum.
• Investigations are to exclude other diagnosis and assess for complications e.g.
DIC, HELLP syndrome, fetal distress. Neurological imaging is not routine.
• Delivery of baby only when mother stabilized, regardless of fetal compromise.
• Postpartum monitoring and post-natal follow-up are important.
Take Home Message

23. • Beckmann, C., et al. 2014. Obstetrics and gynecology. 7th ed. Philadelphia:
Wolters Kluwer Lippincott Williams & Wilkins.
• Kenny, L. and Myers, J., 2017. Obstetrics by ten teachers. 20th ed. Boca Raton,
FL: CRC Press.
• Hart LA, Sibai BM. Seizures in pregnancy: epilepsy, eclampsia, and
stroke. Semin Perinatol. 2013;37(4):207-224.
doi:10.1053/j.semperi.2013.04.001
• Beach RL, Kaplan PW. Seizures in pregnancy: diagnosis and management. Int
Rev Neurobiol. 2008;83:259-271. doi:10.1016/S0074-7742(08)00015-9
• Norwitz, E., 2020. Eclampsia. [online] uptodate.com. Available at:
https://www.uptodate.com/contents/eclampsia [Accessed 23 February 2021].
References

24. • Which of the following is TRUE regarding
magnesium sulfate in eclampsia?
A. If used properly it prevents all seizure activity.
B. Oral administration is the route of choice.
C. A loading dose of 40 mg is recommended.
D. Loss of deep tendon reflexes indicates the need
for further magnesium sulfate.
E. Acts by relieving cerebral vasospasm.
SBA Question

25. • Which of the following is TRUE regarding
magnesium sulfate in eclampsia?
A. If used properly it prevents all seizure activity.
B. Oral administration is the route of choice.
C. A loading dose of 40 mg is recommended.
D. Loss of deep tendon reflexes indicates the need
for further magnesium sulfate.
E. Acts by relieving cerebral vasospasm.
SBA Question

26. A. Cerebral Infarction
B. Cerebral venous
thrombosis
C. Drug/alcohol withdrawal
D. Eclampsia
E. Hemorrhagic stroke
F. Epilepsy
G. Thrombotic
thrombocytopenic
purpura (TTP)
EMQ (MRCOG J)
= 1.15 mg/dL
= 0.97 mg/dL

27. A. Cerebral Infarction
B. Cerebral venous
thrombosis
C. Drug/alcohol withdrawal
D. Eclampsia
E. Hemorrhagic stroke
F. Epilepsy
G. Thrombotic
thrombocytopenic
purpura (TTP)
EMQ (MRCOG J)
= 1.15 mg/dL
= 0.97 mg/dL
G
F