Greetings from

Prerna Anesthesia & Critical Care Services

& Fernandez Hospital

Hyderabad

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

Algorithmic approach to Peripartum seizures

Dr. Kousalya ChakravarthyConsultant Prerna Anaesthesia & Critical Care Services

Asst Prof Anaesthesia; Niloufer Hospital

Osmania Medical College; Hyderabad. INDIA

Definition

Seizures can be defined as “abnormal

electrical activity associated with certain

behavioural and neurologic effects

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

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

? 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!

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!)

Magnesium Sulphate RegimeIV Infusion

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

1

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

Fluid volume regimes

75 -80ml of fluid /hr balancing input and output

3

4 Maternal EvaluationMINI PE* PROFILE

MINI PE* PROFILEPE* PROFILE

EXTENDED PE* PROFILE

5 Evaluation of Fetus CTG, Ultrasound

*Pre eclampsia profile

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

Protocol for Recurrent Seizures

Loading Dose of MgSO4

4 gm,20% Max 1 gm/min . Maintenance of 1gm/ hour

Second episode of SeizuresDraw a sample for Serum Magnesium

2 gm of MgSO4 IV, Increase maintenance to 2gm / hr

Third episode of SeizuresCheck 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

Protocol for Recurrent Seizures

Recurrence of SeizuresMidazolam

Dose 0.1 mg / kg body weight, slow IV

Still recurrencePhenytoin 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

Status epilepticus

Maintain oxygenation

Protect airway

Terminate seizure activity

Propofol / Thiopentone sodium / Succinyl cholineRSI if need arises!

Oxygen by maskGuedel’s AirwayEndotracheal 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

All simultaneously

But Our Dilemma..

Uneventful antenatal period

Successive normal BP recordings

Normal PE Profile

Both episodes of GTCS coincided with epidural dosing of the drug!!

? Local Anesthetic Toxicity

Not suggestive of Eclampsia!!

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!

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

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

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

Literature review

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

Our Statistics Over 7 Yrs

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

Systematic analysis

Early diagnosis especially of atypical presentations

Decreased morbidity due to early treatment modalities

Decreased overall hospital stay

More cost effective

Benefits of Algorithmic approach

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

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

Indications for radio diagnosis

1. Recurrent seizures despite MgSO4 & antihypertensives

2. Altered sensorium post seizures3. Presence of signs of localization4. All Atypical presentations5. Presence of blindness6. Onset <20wks gestation7. Onset of seizures >48hrs postpartum8. Seizures persisting >48hrs

Role of radio imaging

To R/o

CSVT

Cerebral infarcts

Leucoencephalopathy (PRES)

Mass lesions (IC-SOL)

Aneurysm / Bleeding

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

CT BrainBullet in the Brain!!!!

Case 2....

Emg LSCS & Emg Craniotomy same sitting

CT Vs MRI

Which is a better radiological tool in pregnancy?

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

CT BRAINCT BRAIN MRI BRAINMRI BRAIN

CT & MRI of a patient with Intra cerebral bleed & PRES

MRI showing thicker and better delineated PRES & haematoma

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 scansCT 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

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

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

Postpartum seizures D.D

Case 3.. Postpartum seizures MR Venogram was done to R/O CSVT

Posterior Reversible Encephalopathy Syndrome

Postpartum seizures

Anaesthetic Technique ??

VS

Regional techniques

SAB / EA / CSEA

General anaesthesia

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

Regional techniques in peripartum

Issues of concern with RA: Un co-operative patient Sacral Oedema- difficult landmarks Difficult technique Deranged Platelet & Coagulation profile

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

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

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

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!

Thank you