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PREGNANCY WITH CONVULSIONS

PREGNANCY WITH CINVULSIONS

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PREGNANCY WITH CONVULSIONS

  1. 1. PREGNANCY WITH CONVULSIONS DR JAYA CHOUDHARY PROFESSOR DEPT. OF GYNAE & OBST MAHATMA GANDHI MEDICAL COLLEGE & HOSPITAL
  2. 2. Convulsions in pregnancy Convulsions due to pregnancy Eclampsia Convulsions aggravated by pregnancy Epilepsy
  3. 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. 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. 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. 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. 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. 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. 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. 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. 11. AIMS OF MANAGEMENT OF ECLAMPSIA  Control convulsions, prevent cerebro-vascular accident  Stabilise blood pressure  Optimise patient  Deliver fetus 19/10/2014 11
  12. 12. Management of eclampsia Team approach  O&G specialist  Anesthesiologist  Paediatrician  Physician  Nursing Staff  Blood bank personnel
  13. 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. 14. Anticonvulsant Therapy Magnesium sulphate (MgSO4) Diazepam  Phenytoin
  15. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 25. Obstetrical management of eclampsia The Definative treatment Is Delivery 19/10/2014 25
  26. 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. 27. Epilepsy in Pregnancy
  28. 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. 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. 30. Effect Of Epilepsy On Lactation  No contraindication for breast feeding.  Infant may be drowsy.  Readjustment of the anticonvulsant doses required
  31. 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. 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. 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. 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. 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. 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. 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. 38. 19/10/2014 38

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