PREGNANCY WITH CONVULSIONS
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Transcript of PREGNANCY WITH CONVULSIONS
PREGNANCY WITH CONVULSIONS
DR JAYA CHOUDHARY PROFESSOR DEPT. OF GYNAE & OBST MAHATMA GANDHI MEDICAL COLLEGE & HOSPITAL
Convulsions in pregnancy
Convulsions due to pregnancy
Eclampsia Convulsions aggravated by pregnancy
Epilepsy
Convulsions in pregnancyConvulsions not Directly related to pregnancy
Infections
Meningitis Encephalitis
Cerebral Malaria Cerebral Absces
Febrile convulsions Cerebrovascular
Accidents Venous
ThrombosisInfarction
HaemorrhageCerebral tumours
Metabolic/Electolyte imbalance
Hypoglycemia Hyperglycemia
HyponatremiaHypocalcemia
TraumaTetany
Drug Withdrawal CocaineAlcohol
Psychiatric disorders
ECLAMPSIA New-onset convulsions after 20wks of pregnancy in a
patient with Preeclampsia (PIH) with no coincidental neurologic disease, is called Eclampsia.
Criteria for PreeclampsiaDiastolic BP >90mmHg EdemaProteinuria
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.
EpilepsyEpilepsy 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
Convulsions in PregnancyDifferential Diagnosis Eclampsia EpilepsyHistoryOccurs after 20wks of
pregH/o PIH in this PregnancyPrev H/o Eclampsia +/-H/o Tonic Clonic
convulsionClinical ExamH/o Hypertension,
Proteinuria,Edema,Oliguria,pulmonary Edema
Occur anytime during preg
H/o Prev Epileptic fitsFits may be RecurrentFits Generalised/Focal
No H/o Hypertension,Proteinuria,
Edema
Convulsion in PregnancyDifferential Diagnosis
InvestigationsEclampsia EpilepsyComplete blood count Haematocrit
Platelet count Coagulation profile Serum creatinine Serum uric acid Liver function testsComplete urine
examination Fundoscopy
EEGCerebral Imaging
(MRI)
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)
Neonatal Complications of EclampsiaPreterm delivery( 15-67% )IUGR(10-25%)Hypoxia- Neurologic Injury (<1%)Perinatal Death (1%-2%)Long Term Cardiovascular Morbidity
Associated with Low Birth Weight
AIMS OF MANAGEMENT OF ECLAMPSIA
Control convulsions, prevent cerebro-vascular accident
Stabilise blood pressureOptimise patientDeliver fetus
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Management of eclampsiaTeam approach
O&G specialist Anesthesiologist PaediatricianPhysicianNursing StaffBlood bank personnel
GENERAL MANAGEMENT OF ECLAMPSIA
position patient to her side in railed cotMouth gag placed between the teethclear airway secretionsmaintain oxygenation 15 LIT/ MINset up intravenous accessPut self retaining cathetermonitor vital signs - BP, PR, respiration 1/2hrlyif diastolic BP > 110mmHg, consider
antihypertensivemonitor fetal heart rate for gestations > 28 weeksAntibiotic
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Anticonvulsant TherapyMagnesium sulphate (MgSO4)
Diazepam
Phenytoin
MgSO4 Mechanism of actionSlowed neuromuscular conduction & decreased
CNS irritabilityCerebral vasodilatationIncreased production of endothelial prostacycline
and inhibition of platelet activationProtection of endothelial cells from injury
mediated by free radicals Dilatation of uterine arteries
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/b5gm IV in 500ml 5%Dextrose (1gm/hr IV infusion)Therpy is continued for 24hrs after last convulsion/Delivery. Maternal Mortality (0.4%)
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/LUrine Output >30 ml/ hr Every hour Respiratory rate > 12/min
every 15 minsRespiratory depression (serum Mg level >10
mEq/L)Respiratory arrest (serum Mg level > 12 mEq/L)
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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
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Effects of Mg sulphate on the newbornMgSO4 crosses the placenta freely
Minimal side effects if maternal serum levels are maintained
Hyporeflexia and Respiratory depression
Lethargy
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- 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 aspirationcauses prolonged depression of the neonate
PhenytoinCentrally 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 daysSE- Hypotension, Cardiac dysrhythmia &
Phlebitis
Fluid replacement Should not exceed 1-2 ml/kg/hour or 85
ml/hour whichever is lowerCrystalloid Solution (RL)Total Fluid =24hr urine +1000mlMaintain a urine output of more than 30
ml/hour CVP should not exceed 7 cm of H2OWhen patient is taking oral fluids, the
amount taken should be subtracted from the amount infused
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Anti hypertensive managementObjective is to prevent maternal cerebrovascular
accidentsHydralazine
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
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 , AntipyreticsHeart failure-O2 inhalation, IV Lasix, & Digitalis
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Obstetrical management of eclampsia
The Definative treatment
Is Delivery
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Indications of LSCS INEclampsiaUncontrolled fits in spite of therapyPoor prospects for vaginal DeliveryWorsening maternal disease processUncontrolled hypertension (>180/120mm
Hg)Obstetric indications
Epilepsy in Pregnancy
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 .
Effect Of Epilepsy On PregnancyIncreased 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.
Effect Of Epilepsy On LactationNo contraindication for breast feeding.Infant may be drowsy.Readjustment of the anticonvulsant doses
required
Management of Epilepsy during Antenatal PeriodCLINICAL HISTORY
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.
Antiepileptic Drugs in Pregnancy
Phenobarbitone (Gardenal ) 30 mg tab60-180 mg/d in 3 divided dosesSE- Maternal- Drowsiness , Ataxia and Nausea Fetal-Coagulopathy, Neonatal Depression and Withdrawal symptoms.Carbamazapine ( Tegretol ) 100,200&400 mg tab100-200mg 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 pregnancyInj Vit K 10 mg/day after 34 wksAntiemetics SOS
Labor and Delivery
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.
.
Labor and Delivery
Labour and delivery
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) orIntravenous 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
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.
Conclusions
1-Epileptic woman can get pregnant. They are not different than other women 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.
Conclusions (Cont.) 4-A woman should 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
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