This document discusses peripartum seizures and provides several case studies. It outlines an algorithmic approach for evaluating and managing peripartum seizures. Causes can include preeclampsia, eclampsia, epilepsy, or other neurological conditions. Initial treatment involves magnesium sulfate, controlling blood pressure and monitoring. Atypical presentations require further investigation like imaging to rule out conditions like cerebral venous sinus thrombosis. MRI is generally preferred over CT for imaging during pregnancy due to risks of radiation and better detection of conditions like posterior reversible encephalopathy syndrome. Management after delivery includes continued magnesium sulfate, antihypertensives, anticonvulsants and thromboprophylaxis as needed.

1. Greetings from
Prerna Anesthesia & Critical Care Services
& Fernandez Hospital
Hyderabad

2. 2 Isolation Rooms with
separate AHUs
220 Bed Tertiary care Perinatal Centre
 ADR – 7500 +
 Six bed dedicated Maternal CCU
 Six Bed HDU (LW)
 4 Bed Step Down Unit
 22 Bed NICU
 Fetal Medicine Unit
 Dedicated Obstetric Medicine Unit
 Critical Care Outreach teams /MOEWS / SMS
220 Bed Tertiary care Perinatal Centre
 ADR – 7500 +
 Six bed dedicated Maternal CCU
 Six Bed HDU (LW)
 4 Bed Step Down Unit
 22 Bed NICU
 Fetal Medicine Unit
 Dedicated Obstetric Medicine Unit
 Critical Care Outreach teams /MOEWS / SMS
Counseling Room with
A-V Facility

3. Algorithmic approach to
Peripartum seizures
Dr. Kousalya Chakravarthy
Consultant Prerna Anaesthesia & Critical Care Services
Asst Prof Anaesthesia; Niloufer Hospital
Osmania Medical College; Hyderabad. INDIA

4. Definition
 Seizures can be defined as “abnormal
electrical activity associated with certain
behavioural and neurologic effects

5. Peripartum Seizures Etiology
Obstetric cause Non Obstetric causes
 Hypertensive Disorders of
Pregnancy (HDP)
 Eclampsia
 Severe Pre eclampsia
with HELLP
 Epilepsy
 Secondary to neurologic
pathology
 Metabolic derangements
as a result of critical
illness

6. Case 1
 Primigravida /38 wks / normotensive / PROM
 Patient in labor requested epidural analgesia
 Developed GTCS when epidural dose was being
administered!!
 BP : 160/100mmHg post seizure
 ? Intrapartum eclampsia
MgSO4 given, Pre eclampsia (PE) Profile sent

7. ? Cause of convulsions
 There is a dictum that new onset of
convulsions in a pregnant patient should be
assumed to be caused by eclampsia unless
proved otherwise!

8. Management of Eclampsia
1. ABCs / Control of Convulsions
2. Control of Hypertension
3. Management of Fluid Balance
4. Maternal / Fetal evaluation
5. Delivery (if not delivered!)

9. Magnesium Sulphate Regime
IV Infusion
1
 Loading dose
 20% solution, 4 gm
 Slow IV, rate not more than 0.5 - 1 gm / min
 Maintenance regime
 As infusion, 1-2 gm / hr

10. Control of Blood Pressure
IV Labetolol
 20mg stat over 10min
 Intervals ½ hr: 20-20-40-40-80mg
 Max 220mg(2-3g/kg)
 2mg/ml infusion
2
Maintenance
 SR Nifedipine 10mg BD
 T. Labetolol 100 – 200 mg bid or tid max 600mg/day

11. 3
4 Maternal Evaluation
Fluid volume regimes
 75 -80ml of fluid /hr balancing input and output
MINI PE*
MINI PE*
PROFILE
PE* PROFILE PROFILE
EXTENDED PE*
PROFILE
5 Evaluation of Fetus
 CTG, Ultrasound
*Pre eclampsia profile

12. Case 1….Cont….
 Emergency LSCS in view of fetal compromise
 PE Profile was Normal
 Intra operatively epidural activated
- While giving epidural patient threw a GTCS
- Accompanied by vomiting

13. Protocol for Recurrent Seizures
Loading Dose of MgSO4
4 gm,20% Max 1 gm/min . Maintenance of 1gm/ hour
Second episode of Seizures
Draw a sample for Serum Magnesium
2 gm of MgSO4 IV, Increase maintenance to 2gm / hr
Third episode of Seizures
Check The S Magnesium reports, if wt > 70 kg
2 gm of MgSO4 IV 20% can be repeated again….
Clinical guideline for the management of a woman with
eclampsia and/or Severe pre eclampsia /august 2012

14. Protocol for Recurrent Seizures
Recurrence of Seizures
Midazolam
Dose 0.1 mg / kg body weight, slow IV
Still recurrence
Phenytoin Sodium
Loading Dose: 15 mg / kg body weight
(1000 mg in 100 ml of NS over 45 mins)
Maintenance dose of 5 mg / kg / day
(100 mg 8th hourly Slow infusion)
AIRWAY
has to be
maintained

15. Status epilepticus
All simultaneously
Maintain
oxygenation
Protect airway
Terminate seizure
activity
Propofol /
Thiopentone sodium /
Succinyl choline
RSI if need arises!
Oxygen by mask
Guedel’s Airway
Endotracheal
intubation Midazolam 2- 5 mg IV
Clonazepam 1 mg IV,
over 2 to 5 min, not
exceeding 0.5 mg /
min
Repeat once 15 minutes later if status epilepticus continues

16. But Our Dilemma..
 Uneventful antenatal period
 Successive normal BP
recordings
 Normal PE Profile
 Not suggestive of
Eclampsia!!
 Both episodes of GTCS coincided with epidural
dosing of the drug!!
 ? Local Anesthetic Toxicity

17. Case Details…
Intra Operatively:
 Regained consciousness in 3 minutes.
 Epidural block: Dermatomal level of T6 was
present
 Surgery done under EA uneventfully –
which rules out LA toxicity!

18. Case 1.. Postop Events..
 On the 1st POD Patient developed
 Dysarthria+
 Partial ptosis of Left eye, horizontal nystagmus
 Left LMN VII Nerve palsy
 History Revealed:
 Occasional slurring of speech, loss of balance
 Urgent Neuro consult / MR angio brain

20. Follow up….
 Tumor resection done after
delivery
 Post resection – Left occipital
pseudomeningocoele
 2yrs later admitted for second
delivery
 Had Functioning VP shunt / no
signs of raised ICP
 LSCS was done under
CSEA/Uneventful

21. South Australian Perinatal Practice Guidelines Seizures in pregnancy
© Department of Health, Government of South Australia.

23. Literature review
Maria Hirsch, CRNA, DNAPAANA Journal ; October 2011; Vol. 79, No. 5

24. Our Statistics Over 7 Yrs

25. Algorithmic approach…….
 We derived an algorithm keeping in mind
 Eclampsia should be considered in all cases
 Eclampsia may not be the cause in all
 Systematic approach needed for
Further investigations
Radio diagnosis
Follow up

26. Benefits of Algorithmic approach
 Systematic analysis
 Early diagnosis especially of atypical presentations
 Decreased morbidity due to early treatment
modalities
 Decreased overall hospital stay
 More cost effective

28.  Atypical presentations can be
 Focal deficits
 Refractory seizures
 Altered sensorium
 Seizures >7days of delivery

29. Atypical presentation ……
 Rule out
 Cerebro vascular
compromise
 SOL - Brain
 Infectious diseases
 Drug toxicity
 Metabolic causes
 Further
investigations
 ABG with Lactate
 S.Ca++, Mg++ levels
 Radio diagnosis
 Neuro consultation/
Neuro ICU

30. Indications for radio diagnosis
1. Recurrent seizures despite MgSO4 &
antihypertensives
2. Altered sensorium post seizures
3. Presence of signs of localization
4. All Atypical presentations
5. Presence of blindness
6. Onset <20wks gestation
7. Onset of seizures >48hrs postpartum
8. Seizures persisting >48hrs

31. Role of radio imaging
To R/o
 CSVT
 Cerebral infarcts
 Leucoencephalopathy (PRES)
 Mass lesions (IC-SOL)
 Aneurysm / Bleeding

32. Case 2
 Booked patient
 Term / BP: 130/90
 Proteinuria 1+
 Admitted with severe
headache…..EXCRUCIATING
 Pleading for pain relief
 GCS: 15
 Pupils NSRL/ VII CN Palsy
 ? Eclampsia ? IC bleed ? IC-SOL

33. CT Brain
Bullet in the Brain!!!!

34. Case 2....
Emg LSCS & Emg Craniotomy same sitting

35. CT Vs MRI
Which is a better radiological
tool in pregnancy?

36.  A patient complains of postural headache, after an
uneventful epidural .
 Conservative treatment started
 With worsening of headache, plain CT scan brain done
 CT SCAN WAS NORMAL
 Epidural blood patch was given.
 After few hours, had a GCTS and later was pronounced
dead!!
Autopsy revealed bilateral subdural hematoma!!!
Fahad Aziz, MD New york Medical JournaNovember 2 2010l

37. CT & MRI of a patient with Intra cerebral bleed & PRES
CCTT B BRRAAININ MMRRI IB BRRAAININ
MRI showing thicker and better delineated PRES &
haematoma

38. CT vs. MRI
 CT is faster /readily available can be used in acute
conditions with unstable patients
 Deep CSVT is likely to be missed out on a plain CT
 Contrast CT brain carries a risk of AKI in hypertensive
disorders of pregnancy
 Even the contrast CT brain can miss out deep seated
CSVT
 Smaller haemorrhages may be missed on CT scans CT and MR imaging of chronic subdural haematomas: a comparative
study SWISS MED WKLY 2 010 ; 14 0 ( 2 3 – 2 4 ) : 3 3 5 – 3 4 0

39. MRI preferred over CT scan
 Decreased risk of radiation ( antenatal)
 High sensitivity and specificity
 Cytotoxic edema better diagnosed
 MR venogram brain is diagnostic of CSVT
DW MR images with T2 weighted FLAIR can be
extremely helpful in evaluation of women with new
onset peripartum seizures.
Brain MRI in peripartum seizures: usefulness of combined T2 and diffusion weighted MR
imaging Journal of the Neurological Sciences Volume 166, Issue 2, Pages 122–125, July 1, 1999

40. Case 3.. Postpartum seizures
 Primi / Post LSCS/ 1st POD
 Antenatal period - uneventful
 C/o ? Loss of vision since 1hour (not able to see!)
 Vitals –stable
 BP : 140/90mmHg/
 Had vomiting
 GTCS while shifting to ICU!
 ? Cause of the seizures
 ? Eclampsia

41. Postpartum seizures D.D

42. Case 3.. Postpartum seizures
MR Venogram was done to R/O CSVT
Posterior Reversible Encephalopathy Syndrome

43. Postpartum seizures

44. Anaesthetic Technique ??
VS
Regional techniques
SAB / EA / CSEA
General anaesthesia

45. General anaesthesia -Issues of Concern
 Level of consciousness
 Hypertension – Laryngo sympathetic response
 Sublingual Hematoma – difficult laryngoscopy
 Difficulty in Airway assessment
 RSI – Succinyl choline vs. Serum Potassium
 Intra op hypertension
 Increased intra operative Blood loss
 Delayed recovery

46. Regional techniques in peripartum
 Epilepsy per se is not a CI for RA
 Subarachnoid block is safe in HDP
 HELLP syndrome, altered coagulation profile, low GCS
score mandate GA
Issues of concern with RA:
 Un co-operative patient
 Sacral Oedema- difficult landmarks
 Difficult technique
 Deranged Platelet & Coagulation profile

47. Management post seizure
1. Continue ICU/ HDU Care for 24hrs
2. Close maternal & foetal (if not delivered)
observations
3. MgSO4 - 24hrs after delivery or last convulsion
4. Continue antihypertensive drugs / AEDs
5. Commence postpartum thromboprophylaxis
6. Follow up laboratory findings,
7. Proper Radiology Work-up

50. To Summarize
 The most common cause of ‘New-onset’ seizures in
pregnancy is eclampsia
 But.....
 Not all first time seizures occurring in the third
trimester are preeclampsia / eclampsia!!
 Atypical presentations should have a proper
workup and managed accordingly

51. Conclusion
 Unusual types of cerebrovascular pathology is
relatively common in pregnancy and the dictum
that all peripartum seizures should be regarded as
eclampsia until proved otherwise..
Should be wisely judged!

52. Thank you