an interesting andimportant topic

1. Recurrent convulsions in pregnancy
Fatima usmani

2. Recurrent seizures in pregnancy
eclamptic Non eclamptic
Epilepsy
Neurologic pathology
Complications of critical illness

3. Neurologic pathology
Stroke
AVM
Cerebral venous
thrombosis
tumors
infection
Traumatic brain injury-
SAH or ICH

4. Complications of critical illness
Drug/alcohol
toxicity/withdrawlMetabolic
abnormalities
Hypo/hyperglycemia
Uremia
Electrolyte abnormalities
Pyridoxine deficiency
Hepatic failure
Vit B12 deficiency
Alcohol
Barbiturates(short acting)
Benzodiazepines(short acting)
Amphetamine
cocaine

5. Case scenario 1
• 25 year female, primi presented to labor ward with 9 months
pregnancy with convulsions 6-7 episodes. On examination her BP
was 170/100 and she was irritable.....What next

6. Maternal management
Stabilize patient-ABC
Turn women to left lateral
position
Is the cause Eclampsia
(Hypertension/proteinuria
Magnesium sulphate for seizures
(monitor Spo2,patellar reflex,UO)
Control BP(labetalol)
Benzodiazepines(Lz,MID,diazepam
First line AED-
phenytoin,leveracetam,valproate
Yes
No
Seizure
not
controlled
Until other causes are
excluded, however, all
pregnant women with
convusions should be
considered to be eclampsia

7. Intubation and anaesthetic agents: MID/propofol
/thiopentone sodium
Choice between additional AED or Intubation
and anaesthetic agents
First line AED-phenytoin, leveracetam, valproate

8. investigations

9. Maternal complications
• Injuries-Tongue bite
• Pulmonary oedema/Aspiration pneumonia
• Long term cardiovascular abnormality
• Abruptio placentae
• Disseminated coagulopathy /HELLP syndrome
• Acute liver Failure/kidney failure
• Cerebral haemorrhage
• Postpartum collapse
• Blindness
• Death

10. Fetal management
I,II trimester
Sev PE/
Use of drug with high
teratogenicity
MTP
Regular monitoring and
deliver near term
yes
no
III trimester
Sev PE/RSE
deliver Gestational age
yes no
24-32weeks 34-37 weeks 37 weeks
Regular monitoring
steroids
Steroids
Deliver after48hrs
deliver

11. Fetal complications
• Preterm delivery(15-67%)
• IUGR(10-25%)
• Hypoxia/neuronal injury(<1%)
• Perinatal death(1-2%)
• Long term cardiovascular abnormality associated with low birth
weight

12. Case scenario 2
• Primi, known epileptic ,16 weeks pregnant on
carbamazepine now complaining of 2-3 episode of
convulsions. on examination her BP was normal.
Neurological examination is normal. what next.....

13. Differences between epilepsy and eclampsia
• Eclampsia
• Occurs after 20 weeks of
pregnancy
• Convusions are tonic
clonic
• History of PIH in this
pregnancy
• History of
hypertension,proteinuria,
edema, pulmonary
edema
• Epilepsy
• Occurs at anytime in
pregnancy
• Convulsions can be
focal/generalised
• H/o of previous epileptic
fits
• No H/o of
hypertension/proteinuria

14. Increased seizure frequency due to
a. Decreased and subtherapeutic anticonvulsant serum levels
b. Lower seizure threshold
Decreased AED levels due to:
 Nausea and vomiting
 Decreased GIT motility
 Antacid use causing decreased absorbtion
 Pregnancy hypervolumia
 Increased hepatic and placental enzymes causing drug
metabolism
 Increased GFR causing drug clearance.(Williams 24
edition)
Effects of Epilepsy on mother

15. • Increased fetal malformations
 Women should be informed that the risk of congenital abnormalities in the
fetus is dependent on the type, number and dose of AEDs(RCOG June
2016).
 Monotherapy preferred over polytherapy.
 Prepregnancy folic acid 5 mg/day may be helpful in reducing the risk of
AED-related cognitive deficit.
 The fetal anomaly scan at 18+0–20+6 weeks of gestation can identify
major cardiac defects in addition to neural tube defects.
Effect of epilepsy on fetus

16. • Drug Abnormalities detected Affected
• Valproate NTD,cardiac an,dev delay 10%
• Phenytoin Fetal hydrantoin syndrome 5-11%
• Carbamazepine fetal hydrantoin syndrome 1-2%
• Phenobarbital clefts,cardiac an,UT malfo 10-20%
• Lamotrignine clefts 1 %
• Topiramate clefts 2-3%
• Levetiracetam theoreotical-skeletal abn preliminary
observations
Antiepileptic drugs

17. Antenatal
• Main goal is seizure prevention
• Accomplished by
 Treatment of nausea and vomiting
 Medication compliance emphasized
 Seizure provoking stimuli avoided
 Fewest necessary anticonvulsants are given at lowest effective
dose
• Fetal anomaly scan at 18-20 weeks.
management

18. Intranatal
o Continue seizure prophylaxis. If seizures manage acutely
with benzodiazepines and antiepileptics like phynetoin.
o epilepsy per se is not an indication for planned caesarean
section or induction of labour.
o To prevent haemorrhagic disease of the newborn babies born
to WWE taking enzyme-inducing AEDs should be offered 1
mg of intramuscular vitamin K.(RCOG June 2016)
o Adequate analgesia and appropriate care in labour should
be provided to minimise risk factors for seizures such as
insomnia, stress and dehydration.
o Long-acting benzodiazepines such as clobazam can be
considered if there is a very high risk of seizures in the
peripartum period.

19. • Postnatal
Breastfeeding not contraindicated
Contraception:
 IUCDs and MPA injections should be promoted as reliable methods of
contraception.(RCOG June 2016)
 Efficacy of hormonal contraceptives decreased if they are taking
enzyme-inducing AEDs (e.g. carbamazepine, phenytoin,
phenobarbital, primidone, oxcarbazepine and eslicarbazepine).
 All methods of contraception may be offered to women taking
non-enzyme-inducing AEDs (e.g. sodium valproate,
levetiracetam, gabapentin, vigabatrin, tiagabine and
pregabalin).