PREGNANCY WITH CINVULSIONS

1. PREGNANCY WITH CONVULSIONS
DR JAYA CHOUDHARY
PROFESSOR
DEPT. OF GYNAE & OBST
MAHATMA GANDHI MEDICAL COLLEGE &
HOSPITAL

2. Convulsions in pregnancy
Convulsions due to pregnancy
Eclampsia
Convulsions aggravated by
pregnancy
Epilepsy

3. Convulsions in pregnancy
Convulsions not Directly related to pregnancy
Infections
Meningitis
Encephalitis
Cerebral Malaria
Cerebral Absces
Febrile convulsions
Cerebrovascular
Accidents
Venous Thrombosis
Infarction
Haemorrhage
Cerebral tumours
Metabolic/Electolyte imbalance
Hypoglycemia
Hyperglycemia
Hyponatremia
Hypocalcemia
Trauma
Tetany
Drug Withdrawal
Cocaine
Alcohol
Psychiatric disorders

4. ECLAMPSIA
New-onset convulsions after 20wks of pregnancy
in a patient with Preeclampsia (PIH) with no
coincidental neurologic disease, is called
Eclampsia.
Criteria for Preeclampsia
Diastolic BP >90mmHg
Edema
Proteinuria

5. Eclampsia
The incidence of eclampsia in the developed countries is 1:2000
deliveries. while in developing countries estimate vary widely,
from 1 in 100 to 1 in 1700 deliveries .
ANTEPARTUM (50%)
INTRAPARTUM (30%).
POSTPARTUM (20%) within 48hrs-upto 7days.
INTERCURRENT (Rare) – pt becomes conscious after recovery
from convulsion and pregnancy continues beyond 48hrs.

6. Epilepsy
 Epilepsy is a chronic neurological disorder in which a
person has repeated seizures over time. Seizures are
episodes of disturbed brain activity that cause changes
in attention or behavior. Symptoms vary from person
to person

7. Convulsions in Pregnancy
Differential Diagnosis
Eclampsia Epilepsy
 History
 Occurs after 20wks of preg
 H/o PIH in this Pregnancy
 Prev H/o Eclampsia +/-
 H/o Tonic Clonic convulsion
 Clinical Exam
 H/o Hypertension,
Proteinuria,Edema,Oliguria,p
ulmonary Edema
 Occur anytime during preg
 H/o Prev Epileptic fits
 Fits may be Recurrent
 Fits Generalised/Focal
 No H/o
Hypertension,Proteinuria,
 Edema

8. Convulsion in Pregnancy
Differential Diagnosis
Investigations
Eclampsia Epilepsy
 Complete blood count
Haematocrit
 Platelet count
 Coagulation profile
 Serum creatinine
 Serum uric acid
 Liver function tests
 Complete urine
examination
 Fundoscopy
 EEG
 Cerebral Imaging (MRI)

9. Maternal Complications of Eclampsia
 Injuries –Tongue bite
 Pulmonary Edema.
 Aspiration Pneumonia(2%-
5%)
 Long Term Cardiovascular
Morbidity
 Abruptio- Placentae (1%-4%)
 Disseminated Coagulopathy.
 HELLP Syndrome (3-4%)
 Acute Renal Failure (1%-5%)
 Liver Failure OR Haemorrhage
(<1%)
 Cerebral haemorrhage
 Postpartum collapse
 Blindness
 Death (Rare)

10. Neonatal Complications of Eclampsia  Preterm delivery( 15-67% )
 IUGR(10-25%)
 Hypoxia- Neurologic Injury (<1%)
 Perinatal Death (1%-2%)
 Long Term Cardiovascular Morbidity Associated with
Low Birth Weight

11. AIMS OF MANAGEMENT OF ECLAMPSIA
 Control convulsions, prevent cerebro-vascular
accident
 Stabilise blood pressure
 Optimise patient
 Deliver fetus
19/10/2014 11

12. Management of eclampsia
Team approach
 O&G specialist
 Anesthesiologist
 Paediatrician
 Physician
 Nursing Staff
 Blood bank personnel

13. GENERAL MANAGEMENT OF ECLAMPSIA
 position patient to her side in railed cot
 Mouth gag placed between the teeth
 clear airway secretions
 maintain oxygenation 15 LIT/ MIN
 set up intravenous access
 Put self retaining catheter
 monitor vital signs - BP, PR, respiration 1/2hrly
 if diastolic BP > 110mmHg, consider antihypertensive
 monitor fetal heart rate for gestations > 28 weeks
 Antibiotic
19/10/2014 13

14. Anticonvulsant Therapy
Magnesium sulphate (MgSO4)
Diazepam
 Phenytoin

15. MgSO4 Mechanism of action
 Slowed neuromuscular conduction & decreased CNS
irritability
 Cerebral vasodilatation
 Increased production of endothelial prostacycline and
inhibition of platelet activation
 Protection of endothelial cells from injury mediated by free
radicals
 Dilatation of uterine arteries

16. MgSo4 as anticonvulsant
Drug of choice
Prichard’s regimen (IM)
 Loading Dose-
4gm (20%) slow IV over 3-5mt f/b
10gm (50%) deep IM (5gm in each
buttock)
 Maintenance Dose-
5gm (50%) IM 4hrly in alternate buttock
Zuspan regimen (IV)
Loading Dose-
4-6gm slow IV in 100ml 5% Dextrose over 15-20
mt F/b
5gm IV in 500ml 5%Dextrose (1gm/hr IV
infusion)
Therpy is continued for 24hrs after last

17. Monitoring of patient on magnesium
sulphate
Therapeutic levels (if available)
 Serum magnesium levels between 4.0-7.0 mEq/L
Patellar reflex Present
(Lost at serum Mg Levels of 8 – 10 mEq/L
Urine Output >30 ml/ hr
Every hour
Respiratory rate > 12/min
every 15 mins
Respiratory depression (serum Mg level >10
mEq/L)
Respiratory arrest (serum Mg level > 12 mEq/L)
19/10/2014 17

18. Managing Magnesium Toxicity
 Respiratory depression
 Stop magnesium therapy
 Oxygen
 IV calcium gluconate 10% 10ml IV slow bolus
 Maintain airway
 Respiratory arrest
 Stop magnesium therapy
 IV calcium gluconate 10% 10 ml IV slow bolus
 Tracheal Intubation and ventilation
19/10/2014 18

19.  Effects of Mg sulphate on the newborn
 MgSO4 crosses the placenta freely
 Minimal side effects if maternal serum
levels are maintained
 Hyporeflexia and Respiratory depression
 Lethargy
19

20. - Anticonvulsant therapy
 Diazepam
 Useful for status seizures
 dosage – 10 -20 mg iv at a rate of 5 mg per min
 may be repeated at 10 to 15 minute intervals
 Maintainence – 40mg in 500ml of 5% Dextrose IV infusion,to
keep patient sedated
 Side effects - loss of consciousness, hypotension,
respiratory depression
 Caution - may increase risk of aspiration
 causes prolonged depression of the neonate

21. Phenytoin
 Centrally acting anticonvulsant
Dose ( with ECG monitoring )
10mg/Kg I/V (not more than50mg/mt) F/b
5mg/Kg I/V after 2hr
12 hr. — 500mg I/V
200mg 8hrly. X 5 days
SE- Hypotension, Cardiac dysrhythmia & Phlebitis

22. Fluid replacement
 Should not exceed 1-2 ml/kg/hour or 85 ml/hour
whichever is lower
 Crystalloid Solution (RL)
 Total Fluid =24hr urine +1000ml
 Maintain a urine output of more than 30 ml/hour
 CVP should not exceed 7 cm of H2O
 When patient is taking oral fluids, the amount
taken should be subtracted from the amount
infused
19/10/2014 22

23. Anti hypertensive management
 Objective is to prevent maternal cerebrovascular accidents
 Hydralazine
 5mg -10mg I/V at 15 – 20 mts. Interval till control is achieved.
Maximum dose 15mg – 20mg
 Labetelol
 Start with 200mg/100ml IV at 20mg/hr. I/v. Double the dose
every 30 min. till control is achieved or a dose of 160mg/hr. is
reached
 Nifedipine
 5mmg – 10mg S/L every 15 – 30 minutes until BP is contolled
A maximum 180mg can be used in a day

24. Treatment of complications of Eclampsia
 If pulmonary oedema develops, give intravenous
Frusemide 40mg, oxygen and manage patient in the ICU
 If oliguria develops or when urine output is less than
30ml/hour for 4 hours – challenge with 200 mls of
crystalloid over 5 minutes . Evaluate over a 4 hour period
 If oliguria persists despite a CVP of between 7 – 10 cm H2O
– refer to Nephrologist for further management.
 Hyperpyrexia- Cold sponging , Antipyretics
 Heart failure-O2 inhalation, IV Lasix, & Digitalis
19/10/2014 24

25. Obstetrical management of eclampsia
The Definative treatment
Is
Delivery
19/10/2014 25

26. Indications of LSCS IN
Eclampsia
 Uncontrolled fits in spite of therapy
 Poor prospects for vaginal Delivery
 Worsening maternal disease process
 Uncontrolled hypertension (>180/120mm Hg)
 Obstetric indications

27. Epilepsy in Pregnancy

28. Effects Of Pregnancy On Epilepsy
- Seizure frequency may increase: due to:
 Enhanced metabolism & increased drug clearance
 pregnancy can result in decreased serum drug
concentration.
 Decreased or non-compliance with medication.
 Nausea and vomiting.
 Dose requirement of Antiepileptic drug increases
to prevent Fit .

29. Effect Of Epilepsy On Pregnancy
 Increased incidence of Fetal hypoxia, IUGR,
cognitive dysfunction, microcephaly and perinatal
mortality (1.2 - 3 times normal).
 Increased incidence of congenital malformations
(2 fold)
eg cleft lip and / palate, cardiac abnormalities,
limb defects, mental retardation & hypoplasia of
terminal phalanges.

30. Effect Of Epilepsy On Lactation
 No contraindication for breast feeding.
 Infant may be drowsy.
 Readjustment of the anticonvulsant doses
required

31. CLINICAL HISTORY
Management of Epilepsy during Antenatal Period
A-Investigations:
 Metabolic: serum glucose, urea, electrolytes, Ca & Mg
 EEK
 MRI Brain
B-Prenatal Screening for Fetal Malformations
 Transvaginal U/S can be performed at 18-20 weeks to diagnose the
most severe defets (face - heart). However, sensitivity is better, for cleft
palate and lips, if U/S is repeated between 24-28 weeks.
 Screening for NTD: by combination of Maternal serum α –fetoprotein
at 15-22 weeks and Level II,structural Ultrasound, at 16-20 weeks.
 If results are equivocal, proceed with amniocentesis with
measurements of amniotic fluid α -fetoprotein and acetylcholine-esterase.

32. Antiepileptic Drugs in Pregnancy
 Phenobarbitone (Gardenal ) 30 mg tab
 60-180 mg/d in 3 divided doses
 SE- Maternal- Drowsiness , Ataxia and Nausea
Fetal-Coagulopathy, Neonatal Depression
and Withdrawal symptoms.
Carbamazapine ( Tegretol ) 100,200&400 mg tab
100-200mg BD, gradually increased to 800-1000mg/d in DD
SE- Maternal- Drowsiness , Ataxia ,Leucopenia, Hepatotoxicity-
Fetal – Craniofacial abnormalities, Limb defects.
Folic acid 1 mg daily throughout pregnancy
Inj Vit K 10 mg/day after 34 wks
Antiemetics SOS

33. The risk of developing seizures during labour is 9 times
than rest of the pregnancy.
 The majority of women who have epilepsy have a
safe vaginal delivery without seizure occurrence;
provided, the AED is taken before and throughout
labor.
 .

34. Generalized tonic clonic Seizures GTCSs needs aggressive
interference because of the high risk for the mother and fetus,
especially if they progress to status epilepticus.
 Manage seizures acutely with -
 intravenous benzodiazepines (10-20 mg of diazepam)
 or
 Intravenous Lorazepam 0.1mg/kg ( 2mg/mt)
 If seizures continue-
 Phenytoin 15mg/kg IV with ECG monitoring.
Patients having a seizure during labour must be observed
closely for the next 72 hours

35. Labor and Delivery
 Emergency C.S. should be performed when repeated
GTCSs cannot be controlled during labor or when the
mother is unable to cooperate.

36. Conclusions
1-Epileptic woman can get pregnant. They are not
different than otherwomen population.
2-Epilepsy and its medications increases the incidence
of malformations 2-3 times normal. However; there is
90% chance of having a normal child.
3-The most common malformations are cleft lip, left
palate and congenital heart diseases.

37. Co4-nAclwuosimonans (sChoonutl.d) not stop AED unless she has not had
seizures for 2 years; gradual discontinuation can then
be attempted.
5-A pregnant should not stops her AED Since most
malformations develop during the 1st trimester.
6-Current AEDs are considered to be Teratogenic .
However, the safest are: Phenobarbital and
Carbamazepine

38. 19/10/2014 38