Convulsions in pregnancy

DR: SOAD AJROUD

Introductions
WHO research prove that about million women have seizure in
pregnancy every year in middle east in the melinum
WHO study show increase in incidence of convulsion due to stress ,
nutrition's , increase incidence of HTN in pregnancy

Definitions
convulsions :- Abnormal involuntary contractions of muscles
Seizure :- abnormal brain activity
So convulsion may be not related to seizure and seizure not
necessary associated with convulsion
Epilepsy :- tendency to have seizure
( curtsy – neuropsychiatry 2011)

Patho-physiology
In normal action potions of nerve cell changes from –ve to +ve
charge occur in slow manner due to gradual open and close of ionic
channel
Sudden open and close of channel lead to sudden change in –ve and
+ve charges known as firing of neurons give abnormal brain activity
This mechanism initiated by brain tissue pathology , necrosis due to
ischemia , infections , abnormal electrolytes , drug or Alcoholic.

Causes of convulsions
1. Vascular as arterio-venous malformations or ischemia
2. Pre-eclampsia and eclampsia most common causes in pregnant
3. Idiopathic Epilepsy
4. Electrolytes disturbance
5. Infections
6. Head truma
7. Drug intoxications
8. Alcohol

Type of seizure

1. Generalized seizure involve :- tonic clonic ( grand –mal )

 abstance ( petit – mal ) , tonic , clonic
2. partial seizure :- divided to simple and complex in simple seizure
level of consciousness preserved but in complex consciousness
lost this type of seizure characterized by jerky movement of on
limb or certain muscle group known as jaksoian epilepsy
3. Secondary generalized :- start as partial and progress as
generalized

Diagnosis
Mainly on clinical basis
But some investigations can help in establish some causes
CBC, blood sugar, serum electrolytes, brain CT , EEG , sepsis workup
EEG finding show spike in brain wave even during sleep
EEG +ve in 30% of cases so if its –ve this not exclude epilepsy

Treatment
1. Deal with emergency seizure
2. Put the pt in left lateral positions
3. Establish oropharngeal airway
4. Give oxygen
5. Insert cannula draw blood for investigations
6. Start 5% dextrose infusions
7. Give diazepam 5mg IV at first or start magnesium sulfate if
eclampsia was suspected
8. If seizure continue give phynetone 15mg\kg diluted in normal
saline over one hour
9. If seizure continue start phenoparbetone 10mg \kg diluted in
normal saline
10. If seizure continue call anesthesiologist for mechanical
ventilations and propaful anesthesia
11. After control emergency case history , clinical examinations ,
full investigations should be done
And underlying causes should be treated
12. If epilepsy diagnosed anti-epileptic drug should be started
13. If eclampsia termination of pregnancy mandatory
14. Baby status should be evaluated
Drug used in seizure
Traditional drug :- as carbamazpin, benzodiazepine, ethouxmid,
lamotragin , phenytoin , valopric acid , gabapintin

Newly used drug :- dalantin , eslicarbazapine , zarontine ,

oxcarbazpine
Dalantin
Its newly used drug introduced to clinical practis in 2009 according
to FDA
Its most safe epileptic drug in pregnancy in first trimester proved in
volunteered women's
Incidence of side effect occurrence abut 3% in compare with other
medications

Pre-pregnancy counseling

• The diagnosis should be reviewed by a neurologist.

• Consideration should be given to stopping AEDs in those who
have seizure free for more than 2 years.

• Where possible, treatment regimens should be simplified to a

single AED and the lowest effective dose used to minimize the
risk of congenital abnormalities.

• The risks to the mother and the fetus of non- compliance with
prescribed medications esp status epileptics.

• Folic acid 5 mg should be taken daily, for women taken valproate

and carbamazine to reduce the risk of neural tube defects.

• The risk to the offspring of epilepsy should be discussed. Few

cases of epilepsy exhibit autosomal dominant inheritance,
however, having one parent with idiopathic epilepsy confers a 4
% risk of epilepsy in the offspring, increasing to 10% when a
parent and a sibling are affected and to 15% when both
parents have epilepsy.
 Antenatal management

• Care should be carried out by an obstetrician with a special

interest in epilepsy, jointly with a neurologist.

• Screening for fetal anomalies (cardiac anomalies at 22 weeks).

• Oral vit K supplements should be taken from 36weeks onwards
(10 mg per day) to prevent hemorrhagic disease of the
newborn.

• Dexamethasone 48 mg in stead 24mg in cases used enzyme

inducing AEDs.

• Women should be advised to take showers rather than baths

because the risk of death from drowning.
Intrapartum care
Induction of labour and caesarean section are indicated for usual
obstetric indications. Vaginal delivery should otherwise be the aim.
Labour carries a high risk of seizer due to sleep disturbance and
reduced intake and absorption of AEDs and hyperventilation.

Effect of anti-epileptic drugs on the fetus and new born

Many congenital anomaly can be caused by AEDs but commonest
anomalies
1. Neural tube defect
2. Spaced eye
3. Short finger
4. Clifte palate
5. Duodenal Artesia
6. Heart defect
7. Neonatal withdrawal effects.
8. Vitamin K deficiency with hemorrhagic disease of the new born.
9. Developmental delay or behavioral difficulties.
10. Increased in childhood malignancies
Breast feeding
Most of epileptic drug secreted in breast milk and absorbed by baby
and causes hypotonic baby and decrease GIT motility
But the most safe drug dalantin and valopric acid

Contraception's
Contraception pills interact with epileptic drug may decreased its
effect because of enzyme inducer AEDs. A combined oral
contraceptive pill containing 50 mcg of estrogen should be used.
Depoprovera should be given every 10b weeks instead of 12 weeks.
Mirena intrauterine system is ideal.

Special advice should be given to new mothers who also have

epilepsy
1. Ask extra help if you are not getting enough sleep.
2. Ensure that someone else is present when you bath your baby.
3. Surround yourself with cushions and pillows when you are
holding your baby.
4. Feed and change your baby on the floor whilst leaning against a
wall to prevent you falling onto the baby in the event of
aseizure.

Menstruations
Seizure increased during menstruations specially at start of bleed and
around ovulations
Women advised to increase drug dose
Mechanism of aggravation not fully understood but believed to
caused by hormonal change