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PREGNANCY WITH CONVULSIONS
DR JAYA CHOUDHARY
DEPT. OF GYNAE & OBST
MAHATMA GANDHI MEDICAL COLLEGE &
Convulsions in pregnancy
Convulsions due to pregnancy
Convulsions aggravated by
Convulsions in pregnancy
Convulsions not Directly related to pregnancy
New-onset convulsions after 20wks of pregnancy
in a patient with Preeclampsia (PIH) with no
coincidental neurologic disease, is called
Criteria for Preeclampsia
Diastolic BP >90mmHg
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 .
POSTPARTUM (20%) within 48hrs-upto 7days.
INTERCURRENT (Rare) – pt becomes conscious after recovery
from convulsion and pregnancy continues beyond 48hrs.
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
Convulsions in Pregnancy
Occurs after 20wks of preg
H/o PIH in this Pregnancy
Prev H/o Eclampsia +/-
H/o Tonic Clonic convulsion
Occur anytime during preg
H/o Prev Epileptic fits
Fits may be Recurrent
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
MgSO4 Mechanism of action
Slowed neuromuscular conduction & decreased CNS
Increased production of endothelial prostacycline and
inhibition of platelet activation
Protection of endothelial cells from injury mediated by free
Dilatation of uterine arteries
MgSo4 as anticonvulsant
Drug of choice
Prichard’s regimen (IM)
4gm (20%) slow IV over 3-5mt f/b
10gm (50%) deep IM (5gm in each
5gm (50%) IM 4hrly in alternate buttock
Zuspan regimen (IV)
4-6gm slow IV in 100ml 5% Dextrose over 15-20
5gm IV in 500ml 5%Dextrose (1gm/hr IV
Therpy is continued for 24hrs after last
Monitoring of patient on magnesium
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
Respiratory rate > 12/min
every 15 mins
Respiratory depression (serum Mg level >10
Respiratory arrest (serum Mg level > 12 mEq/L)
Managing Magnesium Toxicity
Stop magnesium therapy
IV calcium gluconate 10% 10ml IV slow bolus
Stop magnesium therapy
IV calcium gluconate 10% 10 ml IV slow bolus
Tracheal Intubation and ventilation
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
- Anticonvulsant therapy
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,
Caution - may increase risk of aspiration
causes prolonged depression of the neonate
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
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
Anti hypertensive management
Objective is to prevent maternal cerebrovascular accidents
5mg -10mg I/V at 15 – 20 mts. Interval till control is achieved.
Maximum dose 15mg – 20mg
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
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 , Antipyretics
Heart failure-O2 inhalation, IV Lasix, & Digitalis
Obstetrical management of eclampsia
The Definative treatment
Indications of LSCS IN
Uncontrolled fits in spite of therapy
Poor prospects for vaginal Delivery
Worsening maternal disease process
Uncontrolled hypertension (>180/120mm Hg)
Effects Of Pregnancy On Epilepsy
- Seizure frequency may increase: due to:
Enhanced metabolism & increased drug clearance
pregnancy can result in decreased serum drug
Decreased or non-compliance with medication.
Nausea and vomiting.
Dose requirement of Antiepileptic drug increases
to prevent Fit .
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
eg cleft lip and / palate, cardiac abnormalities,
limb defects, mental retardation & hypoplasia of
Effect Of Epilepsy On Lactation
No contraindication for breast feeding.
Infant may be drowsy.
Readjustment of the anticonvulsant doses
Management of Epilepsy during Antenatal Period
Metabolic: serum glucose, urea, electrolytes, Ca & Mg
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 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
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
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)
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
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.
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.
Co4-nAclwuosimonans (sChoonutl.d) not stop AED unless she has not had
seizures for 2 years; gradual discontinuation can then
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