case presentation on pt with known epilepsy who develop eclampsia

1. Case presentation on
Eclampsia in known epilepsy
By Dr Zerihun W (Obgyn R2)
SPHMMC, September 2021

2. Outline the presentation
Objective
Case summery
Discussion
Comments
Reference
by Zerihun W. 2

3. objective
• To discuss about evaluation and management eclampsia on epilepsy
by Zerihun W. 3

4. Identification
• Name …. T . T
• Age …….. 29
• Sex ……… F
• MRN ……1026864
• DOA …….13/12/13 E.C
• DOD …….01/13/13 E.C
by Zerihun W. 4

5. Referral On 12/12/13
• She refered from K/H/C as a case of epilepsy + Twin pregnancy
• This is 29 yrs. old GII PI(Alive by VD) whose GA was 32W3D from
early ultrasound. She had regular ANC
PE
V/S BP 110/70
 Baseline investigation
VDRL
PICT Negative
HBSAg
BG O+ve
Reason for referral
For better management
by Zerihun W. 5

6. Duty R2 EVALUATION @ 12;30 PM 13/12/13
• This is 29 years old GII PI(alive by VD) whose clamed Amenorrhea for the
past 08 month GA form 22w5d ultrasound 32w4d. She had regular ANC
follow up at local HC where routine care given.
• She was referred as a case Twin + epilepsy and linked from regular ANC
with sever record of BP
• She is a know epileptic patient for the last 10 years started after delivery of
first baby. She had repeated attack of abnormal body movement which
involved all extremity with up roving of the eye & drooling of saliva
followed by loss of conscious of unknown duration.
• Before the attack she experience shortness of breath.
by Zerihun W. 6

7. • For this compliant She wanted to holy water for the first 06 years. Then
because of the repeated attack she was visit to HC and start unspecified
medication for about 02 years and discontinued because drug was not
available at HC and unafforded to buy outside.
• The pregnancy was followed at HC since 5 month this pregnancy. Until 8
month she had not attach through out the pregnancy. The first attack in this
px at home involved all extremity followed by loss of conscious, it was 5
day before arrival to our hospital
• Otherwise
She didn’t have fever, pushing down pain, leakage of liquor
She didn’t have known chronic illness in her family as well as herself
such as chronic hypertension, cardiac and family history
Previous pregnancy was uneventful
by Zerihun W. 7

8. P/E
• GA :- well looking
• V/S :- Bp :- 155113 PR:- 88 RR:- 20 T:- ATT
• HEENT :- Pink conjunctiva & NIS
• LG :- No Palpable LN
• CHEST :- Clear & Resonance
• CVS :- S1 & S2 Well heard, No M or G
• ABD :- term size gravid uterus
multiple fetal part palpable
FHR both twin normal
by Zerihun W. 8

9. • GUS :- no vaginal bleeding or leakage of liquor
• MUK :- No Edema
• CNS :- COTPP
9

10. Ass,t
pp
Early preterm px
Twin px (?MCDA)
Known Epilepsy (not on medication)
PE w SF (raised BP)
Plan
Do CBC, ECG, OFT, Bilirubin
Target scan
To consult medical side
Stabilized with mgso4 and start methyldopa 500 mg po TID
Dexamethasone started
Initiate antiepileptic after consultation
Consult R3
by Zerihun W. 10
normal

11. R3 evaluation 13/12/13
• HX and PE revised and the same
• Obstetric ultrasound done by Y3
Twin px
TA EFW 1.7 RBPP
TB EFW 1.5 RBPP
Single placenta
Intertwin membrane 1.8cm
Fetal sex the same
N Doppler
• Plan
Start anticonvulsant after consult medical side
Continues dexa, methyldopa, mgso4
Follow with preeclampsia chart
Admit to MW(14/12/13)
by Zerihun W. 11

12. • HX and PE revised and the same
She had one episode of abnormal body movement witnessed in EOPD
lasting than 1 mint
• Ass the same
• Plan
Phenytoin load with 1g po the 100 mg po TID
Continues obs follow-up
Consult neurologic side
Consult psychiatric side
by Zerihun W. 12
Medical side evaluation on 13/12/13

13. Psychiatry evaluation 13/12/13
• Hx Revised and the same
She has no loss of interest, or mood change
She had no hx elevated mood, irritability or increase energy
She has no hx of suspiciousness, hearing voice or seeing other can't see
She has no aggressive behavior of disorganized behavior
She has no hx of suicidal attempt pt. self harm
She has no hx of excessive wariness or fear
She has no hx of head injury or family hx of seizures
• Ass the same
• Plan
Need frequent psychiatric screening
No current mental health disorder
Consult medical side and neurology
by Zerihun W. 13

14. R2 evaluation MW
• Hx & Px Revised and the same
• Ass
PP
Early preterm px
Twin px (MCDA)
Known Epilepsy
PE w SF (raised BP)
Selective IUGR of TB
• Target scan
TA 2 kg TB 1.3 kg discrepancy 35 %
MCDA
Doppler N
by Zerihun W. 14

15. • Plan
Update CBC, OFT 2x weekly
 Continue Phenytoin 100 mg po TID
 Continue methyldopa 500 mg po TID
 Dexa,, mgso4 :- completed
 Follow with preeclampsia chart
 Lung maturity test at 36 week
by Zerihun W. 15

16. R3 decision note 26/12/13 @ 4 pm
• This is 29 yrs. old Gll Pl whose GA 34w5d from 22w6d us kept MW for 02 wk.
with Ass of
 PP
 Early preterm px
 Twin px (MCDA)
 Known Epilepsy
 PE w SF (raised BP)
 Selective IUGR of TB
• She develop one episode of abnormal body movement involving the whole
extremity lasting less than 1 min and loss of consciousness which was
immediately regained. associated with this She has up roving of the eye.
Witnessed by health professional
• Otherwise
 She had droving of saliva
 She had no headache, blurred vision
 She had no nausea epigastric pain vomiting, change in mentation
by Zerihun W. 16

17. P/E
• GA :- ASL RBS 120
• V/S :- Bp :- 13090 PR:- 100 RR:- 20 T:- 36.9 spo2 96 and support w INo2
• HEENT :- Pink conjunctiva & NIS
• LG :- No Palpable LN
• CHEST :- Clear & Resonance
• CVS :- S1 & S2 Well heard, No M or G
• ABD :- term size gravid uterus
multiple fetal part palpable
FHR both twin normal
• GUS :- no vaginal bleeding or leakage of liquor
• MUK :- No Edema
• CNS :- COTPP, GCS 15/15
by Zerihun W. 17

18. • Ass
PP
Early preterm px
Twin px (MCDA)
Known Epilepsy
PE w SF (raised BP)
Selective IUGR of TB
Eclampsia
• Plan
Dexamethasone 6mg IM salvage dose
Load with mgso4
Catheterized
Transfer to LW for Emergency cs
Update CBC, OFT Serum e-
Involve consultant
by Zerihun W. 18

19. 26/12/13
• Emergency caesarean section done with outcome of
TA 1900 gram female alive neonate with APGAR score of 7 & 8
TB 1450 gram female alive neonate with APGAR score of 7 & 8
• IOF
Single placenta with two Dividing mm :- MCDA
by Zerihun W. 19

20. • Post op order
Ampicillin 2g IV QID
Put of MF 500 ml NS/DNS 5%/RL over 24hr
Continue Phenytoin 100mg po TID
Continue Mgso4 maintenance
Keep catheter for at least 12hr
Put on continues VS monitoring
Keep family in her bedside
Watch for vaginal bleeding
Transfer neonates to NICU for evaluation
by Zerihun W. 20

21. NICU evaluation
• Ass
TA :- TA + LBW + AGA + Discordant twin
TA :- TB + LBW + LGA + Discordant twin
• Plan
Send CBC determine BG
Attach baby to the Mather
Start breast feeding
• IVX
B/G B+
HCT TA 41 TB 39%
23% Discordant
by Zerihun W. 21

22. Post op evaluation 27/12/13
• P1 :- 29 yrs. old PII lady on 1st post op day after LUTCS was done for the
indication of Eclampsia + Twin Px with outcome of TA 1900 gram female
alive neonate with APGAR score of 7 & 8 and TB 1450 gram female alive
neonate with APGAR score of 7 & 8. neonate in mother side after
evaluated by pediatric side
• P2 :- Eclampsia
• P3 :- Known epileptic
• S poorly adherent to medication
• Otherwise
She has no headache, blurred vision
She has no abnormal body movement
by Zerihun W. 22

23. P/E
• GA :- well looking
• V/S :- Bp :- 140102 PR:- 80 RR:- 20 T:- 36.1
• HEENT :- Pink conjunctiva & NIS
• LG :- No Palpable LN
• CHEST :- Clear & Resonance
• CVS :- S1 & S2 Well heard, No M or G
• ABD :- 20 wk. sided well contracted uterus
• GUS :- no vaginal bleeding
• MUK :- No Edema
• CNS :- COTPP
by Zerihun W. 23

24. • Ass
 smooth post op day
• Plan
 Continue phenytoin 100 mg po TID
 Nifedipine 10mg po daily
 Mgso4 completed
 Update CBC, OFT
 Follow with PE chart
 Advice the mother on drug adherence
 Psychiatric side consulted( plan is to link to psychiatric side after discharge
for frequent psychiatric screening)
 Folic acid 4 mg po daily
 Brain MRI, EEG up on discharge
 Next pregnancy follow up should be in hospital and require preconception
care
by Zerihun W. 24

25. INVESTIGATION SUMMERY
by Zerihun W. 25
13/19/13 20/12/13 27/12/13 29/10/20 01/10/20
WBC 4.3X103 4.6X103 6.8X103 7.8X103 6.9X103
HCT 32.8 36 34.6 9.2/25.5 8.5/24.5
PLT 160
u/a -ve
147 179 58 194
OFT Got – 6
Gpt – 13.3
Cr – 0.5
Bun – 15.1
Got – 7.8
Gpt – 13.8
Cr – 0.48
Bun – 18
D bil - <1.16,
T bil - <0.12
Got – 96
Gpt – 84
Cr – 0.58
Bun – 19
D bil – 0.11
T bil - 19
Got – 38
Gpt – 20
Cr – 0.42
Bun – 14
Electrolyte Na+ 138
K+ 4.9

26. U/S SUMMERY
by Zerihun W. 26
13/12/13 15/12/13 18/12/13 22/12/13 25/12/13 26/12/13
TA 1.5kg, SDP
3.8
TB 1.7 kg , SDP
3.8
Mm Thickness
1.8mm
Fetal sex the same
Index
RBPP
N Doppler
?MCDA
TA SDP
3.5CM
TB SDP 4
CM
Thick
dividing mm
Index
RBPP
TA 2kg
TB 1.3 kg
Index
RBPP
N
Doppler
TB
selective
IUGR
MCDA
TA SDP 3
CM
TB SDP
2.1 CM
Index
RBPP
TA SDP 2.7
CM
TB SDP 2.4
CM
Index
RBPP
N doppler
TA SDP 4
CM
TB SDP 3.5
CM
Index
RBPP
N doppler

27. by Zerihun W. 27
Pre OP Follow-up at MW
Post OP Followp-up

28. Summery
• This is 29 yrs. old GII PI lady a known epileptic patient for the last 10 yrs.,
she was took antiepileptic medication for 02 yrs. and discounted 02 yrs.
Back prior to this pregnancy because of finical reason. she had repeated
attack before this pregnancy .
• At GA of 32w3d she was referred as a case of epilepsy from KHC. She was
liked from ANC with sever range BP
• She was admitted PP + Early preterm px + Twin px (MCDA) + Known
Epilepsy + PE w SF (raised BP) + Selective IUGR of TB
• Prior 5 day of referral she has abnormal body movement and 01 episode
witnessed at EOPD, Phenytoin load and on 100 mg po TID
• She stay MW for two weeks. As GA of 34+5 she develop abnormal body
movement of one episode which last less than one minute and considering
eclampsia mgso4 loaded and emergency cs decided with outcome of TA 1.9
kg and TB 1.4 kg
by Zerihun W. 28

29. by Zerihun W. 29

30. Problem list
• Eclampsia
• Epilepsy
• PE W SF
• Twin Pregnancy
• Selective IUGR
by Zerihun W. 30

31. Eclampsia
• the occurrence of new-onset, generalized, tonic- clonic seizures or coma in
a woman with preeclampsia in the absence of other neurologic condition
• Incidence
GHTN <0.1%
0.6 % PE with out severity feature
2 to 3 PE with severity feature
Developed : 1.5 to 10 cases per 10,000 Deliveries
Developing : 6 to 157 cases per 10,000 Deliveries
by Zerihun W. 31

32. • Risk factor
Nulliparity
Preeclampsia in a previous pregnancy
Age >40 years or <18 years
Family history of preeclampsia
Chronic hypertension
Chronic renal disease
Autoimmune disease (eg, antiphospholipid syndrome, systemic lupus
erythematosus)
Vascular disease
Diabetes mellitus (pregestational and gestational)
Multifetal gestation
Obesity
by Zerihun W. 32

33. Black race
Hydrops fetalis
Woman herself was small for gestational age
Fetal growth restriction, abruptio placentae, or fetal demise in a previous
pregnancy
Prolonged interpregnancy interval if the previous pregnancy was
normotensive; if the previous pregnancy was preeclamptic, a short
interpreg``1nancy interval increases the risk of recurrence
Partner-related factors (new partner, limited sperm exposure
[eg, previous use of barrier contraception])
In vitro fertilization
by Zerihun W. 33
In our case risk Factor for PE
Multiple gestation
Epilepsy

34. • Timing
 59 percent -antepartum,
20 percent - intrapartum, and
 21 percent -postpartum (90%-with in 1week
by Zerihun W. 34

35. • Supportive of eclampsia
Abnormal body movement typical of eclampsia
PE w SF.
Twin px
• Against eclampsia
She is a know epileptic patient
She had the some attach in this pregnance
Poor adherent to medication
Cerebral symptom absent before and after convulsion
by Zerihun W. 35
In our case

36. Epilepsy
• Seizure is defined as a paroxysmal disorder of the central nervous system
characterized by an abnormal neuronal discharge with or without loss of
consciousness.
• Epilepsy encompasses different syndromes whose cardinal feature is a
predisposition to recurrent unprovoked seizures
Focal Seizures
Generalized Seizures
by Zerihun W. 36

37. • Incidence
Epilepsy affects approximately 1 to 2%
is the most frequent major neurologic complication encountered in
pregnancy.
• Diagnosis
Two unprovoked seizures or
One seizure in a patient with clinical features that make a second seizure
likely
Findings on brain MRI
EEG that are consistent with a diagnosis of
epilepsy
A family history of epilepsy
by Zerihun W. 37

38. • Perinatal morbidity and mortality
increased among women with epilepsy
complications include
preeclampsia,
preterm labor,
bleeding,
placental abruption,
poor fetal growth,
prematurity,
fetal death, and
maternal mortality
by Zerihun W. 38

39. • Risk estimates derived from a population-based cohort study
Maternal death: 80 deaths per 100,000 pregnancies among women with
epilepsy, compared with 6 deaths per 100,000 pregnancies among
women without epilepsy
Cesarean delivery: 41 versus 33 percent
Pregnancy-related hypertension (11 versus 8 percent) and preeclampsia
(7 versus 4 percent)
Antepartum hemorrhage (2.1 versus 1.5 percent)
PPH,(0.7 versus 0.4)
Preterm labor (11 versus 7 percent)
Poor fetal growth (4 versus 2 percent)
Stillbirth (0.8 versus 0.6)
by Zerihun W. 39
In our case
Preeclapmsia
eclampsia

40. • Effect of pregnancy on seizures
For the majority of women with epilepsy (54% to 80%), seizure
frequency will remain similar to their baseline seizure frequency.
Across several studies, seizure frequency increased in 15.8% to 32% of
women and decreased in 3% to 24%.
Seizure free for 9 months prior to pregnancy is associated with an
84% to 92% chance of remaining seizure free during pregnancy.
increased seizure frequency among sleep deprived, stressed or
noncompliant
Labor and delivery are not usually associated with increased
complications.
increased prevalence of comorbid depression and anxiety
by Zerihun W. 40
In our case
She was not on medication
and she multiple seizure
attach so she will have 54 to
80 % risk of seizure

41. • Effect of pregnancy on AED
Altered protein binding,
Delayed gastric emptying,
Nausea and vomiting,
Changes in plasma volume,
Changes in the volume of distribution, and
Even folic acid supplementation can affect the levels of
anticonvulsant medications.
by Zerihun W. 41

42. • Lamotrigine is the most common AED prescribed in pregnancy.
• Given the interindividual variation in AED metabolism and
susceptibility to changes during pregnancy, checking AED drug levels
monthly is recommended for all AEDs.
by Zerihun W. 42

43. • Supportive epilepsy
She is a know epileptic patient
Multiple attach before
Poorly adherent
• Against of epilepsy
PE w SF
by Zerihun W. 43
In our case

44. Epilepsy or Eclampsia: A Diagnostic Dilemma?
• While eclampsia is the serious complication of the preeclampsia specific
for gestational period and epilepsy is a preexisting pathology of pregnancy.
• Both syndrome are characterized by neuroconvulsive syndrome. On the
other hand, epilepsy can be aggravated by the association of preeclampsia
and eclampsia during the pregnancy, both by increasing the number of
convulsive seizures.
• Seizures are diagnosed for the first time during pregnancy, they should
be evaluated as eclampsia until proved otherwise
by Zerihun W. 44

45. • Clinical symptoms helpful in establishing the diagnosis of eclampsia, at
least one of these symptoms in 59% to 75% of the cases
Excessive weight gain
Persistent occipital or frontal headaches 50% to 75%
Blurred vision 19% to 32%
Photophobia,
Epigastric or right upper quadrant pain 19%
Altered mental status.
• 20% to 40% of eclamptic women do not have any premonitory signs or
symptoms before the onset of convulsions.
by Zerihun W. 45

46. • The initial management active seizure in pregnancy should include
maintenance of the airway, oxygenation, and support of adequate perfusion.
• Seizure mgt:
Convulsive seizures be treated promptly with intravenous
benzodiazepines; Lorazepam(0.1-0.2mg/kg) is considered the drug of
choice.
Intravenous phenytoin is also highly effective and has a longer duration
of action.
Mgso4 should be consider if the seizure recurred despite of conventional
anticonvulsant agent
• Monitoring-
Close monitoring for maternal condition and continuous fetal heart rate
monitoring is recommended in the event of a seizure, as well as for a
period of at least an hour after administration of benzodiazepines
by Zerihun W. 46
Literature review in Magnesium sulfate for non-eclamptic status epilepticus
Seizure reduction/control with IV MgSO4 occurred in 14 of the 28 patients
(50.0%), with 2 (7.1%) and 12 (42.9%) displaying partial and complete
responses respectively. Seizures recurred upon withdrawal of MgSO4 therapy
in 50% of the patients whom had reduction/control
Conclusions
Routine use of IV MgSO4 in non-eclamptic SE/RSE cannot be recommended
at this time. Further prospective study of this drug is required in order to
determine its efficacy as an anti-epileptic in this setting.

47. by Zerihun W. 47
Case Report
A 41-year-old pregnant woman Who is a known epilepsy for 15 years and managed with
antiepileptic and PE. At the 34w GA, she had an episode of seizures
• Intravenous diazepam (10 mg), following which seizures subsided.
• After 5 hours, the seizure recurred, and an injection of diazepam (10 mg) and a loading
dose of phenytoin were administered intravenously.
• She again had an episode of seizures. Midazolam given & A loading dose of valproate was
administered over 30 minutes, followed by 400 mg 3 times daily.
• Later A diagnosis of eclampsia and epilepsy was made. An injection of Mgso4 &
emergency cesarean delivery and seizure controlled.
Conclusions
• The initial management administration of a parenteral benzodiazepine, followed by
intravenous phenytoin at conventional doses, is a reasonable approach.
• If the is recurrent generalized tonic-clonic seizures with features suggestive of eclampsia
along with a history of epilepsy then eclampsia with epilepsy should Consider and
termination of pregnancy and Mgso4 treatment require.

48. Intrapartum
• Mode of delivery:
most women have a normal vaginal delivery. elective cesarean section
may be justified in selected cases.
• Epidural analgesia:
Although no evidence exists to support or challenge epidural analgesia
in patients with epilepsy, it is typically utilized to decrease stress and
allow the mother to rest during a long labor.
by Zerihun W. 48

49. postpartum
• Dose adjustment
if the antiseizure drug dose has been altered during pregnancy, a return
to prepregnancy levels should be considered during the first few weeks
after delivery.
Advice on the importance of adequate rest, sleep and compliance with
drug therapy.
Precautions need to be taken to protect the infant if the mother has a
seizure.
by Zerihun W. 49

50. • Breast feeding
All of the antiseizure drugs are measurable in breast milk.
 The reported percentage of maternal plasma levels in breast milk varies
from 5 to10% with valproate to 90 percent with ethosuximide.
Most experts believe that taking antiseizure drugs does not generally
contraindicate breast feeding, as probable benefits outweigh risks.
by Zerihun W. 50

51. Twin Px Vs Preeclapmsia, IUGR
• DZ twins arise in about 1% to 1.5% of pregnancies, and MZ twins occur in
0.4% of pregnancies
• There are Certain complications anticipated in the management of labor
and delivery of multiple gestations
Except post Term and macrosomia
by Zerihun W. 51

52. • Maternal complications
GHTN and preeclampsia
Rates of gestational hypertension and preeclampsia were twice as
high in twin compared with singleton pregnancies (13 percent in
twins versus 5 to 6 percent in singletons for both disorders).
Early severe preeclampsia and HELLP syndrome tended to occur
more frequently in multiple gestations.
Other
Gestational diabetes –
Acute fatty liver –
APH, PPH
Manual placenta extraction
iron deficiency anemia,
hyperemesis gravidarum
thromboembolism.
by Zerihun W. 52

53. • Fetal complications
All twins
Growth restriction
Congenital anomalies
Preterm delivery
Monochorionic twins
Selective fetal growth restriction
Single fetal demise of one twin
Twin-twin transfusion syndrome (TTTS) –
Twin anemia-polycythemia sequence (TAPS) –
Twin reversed arterial perfusion sequence (TRAP) –
Monoamniotic twins
Intertwin cord entanglement
Conjoined twins
by Zerihun W. 53
In our case
Maternal and fetal complication of twin px
• Preeclapmsia
• Selected IUGR(there was no poly-oligo
sequence, doppler normal & wight
discrepancy 30% and post natal evaluation
wight discrepancy 21.6%, Hct 41 & 39)

54. Time of termination
• ACOG
Twin Px
Complicated
MCDA with isolated fetal growth restriction termination at 32 to
34 wk.
DCDA with isolated fetal growth restriction termination at 36 to
37 wk.
Uncomplicated MCDA twin is between 34 and 37 6/7 wks.
PE W SF with stable maternal and fetal condition termination at 34 wk.
or at diagnosis if diagnosis later after 34 wk. of GA
by Zerihun W. 54
In our case
lung maturity test planed at 36
wk.

55. Contraception
• LARC such as IUCD will not be affected by enzyme inducing drugs
Can be given to all patients
• OCP, implants, vaginal rings are affected by enzyme inducing AED
Better avoided
• Women taking lamotrigine monotherapy and oestrogen-containing
contraceptives should be informed of the potential increase in seizures due
to a fall in the levels of lamotrigine
by Zerihun W. 55
In our case
She was opted for Implanon and
provided

56. COMMENT
• Referral from HC should be earlier and Feedback should be given
• Documentation and follow up suboptimal
• Termination should be individualized
• Multidepartment involvement in management plan appreciable
• Choice of contraceptive
• Choice of anti epileptic
• Discharge plan good
by Zerihun W. 56

57. by Zerihun W. 57

58. REFERENCES
• Williams Obstetrics, 25th Edition
• Gabbe Normal and problem pregnancy, 7th edition
• ACOG. May 2016
• Gabbe 7th Edition
• Uptodate 2018
by Zerihun W. 58

59. by Zerihun W. 59