You are called to the A & E department where a 27 yrs old primigravida has been admitted at 39 weeks gestation. She has had a witnessed grand mal convulsion whilst out in a local shop. She is known to have epilepsy. How would you manage the case?
A fit occurring in a pregnant woman is an obstetric emergency. Management will include initial stabilization of woman and further management including decision regarding conservative management or early delivery. Initial management will include care regarding airway breathing and circulation. Patient should be placed in left lateral position. Airway is maintained. Suction of mouth secretions. IV cannula is passed to give injection diazepam to control fits and blood is taken for full blood count, urea, electrolytes, coagulation studies. Oxygen inhalation given. Patient is catheterized and input output chart is maintained. Phenytoin infusion is started. Consultant obstetrician is informed as well as haematologist, lab and blood bank services. On duty anaesthetist is also called to review woman’s condition. Patients attendants are explained about the woman’s condition Monitoring is started like pulse oximetry, electrocardiography, BP, CVP, acid base status. Fetal condition is also checked by cardiotocography. After initial stabilization of patient her antenatal record is reviwed to find out which medications she had been taking for epilepsy, has she had consultation with physician regarding her epilepsy. Multidisciplinary input will be required in this case that is help of a physician.. Complications of epilepsy in pregnancy include preterm labour, antepartum hemorrhage , operative vaginal delivery and caesarean section. Perabdominal and pervaginal examination is done to check if she is in labour. Inj vitamin k should be given to mother. Further management will depend on maternal and fetal condition. If maternal condition is atable and fetal cardiotocography is also satisfactory conservative management can be adopted so that spontaneous labour can be awaited till 41 weeks. If however there is any sign of fetal distress present delivery will be indicated. Mode of delivery will depend on bishops scoring and the degree of urgency required for delivery. With woman not in labour and fetal distress present, safest route of delivery is caesarean section. A neonatologist should be present at the time of delivery. If however maternal condition is not stable, high dependency unit care may be needed. Baby should be given vit k and observed for signs of any neurological irritability present as a withdrawal sign. Examination should also be done to find any congenital abnormality present. Breast feeding is encouraged. Anticonvulsant medication is reduced to prepregnancy dose. Contraception can be given by progesterone only pills.
Posted by vijaya L.
Iam posting my version as well. I would be greatful if paul could correct this answer also
I would reach the A&E at the earliest, and position her on the left lateral position and clear the airway of the secretions and ensure breathing. An IV line would be secured taking blood for FBC, Blood sugar, electrolytes and U&E. I would also check for any injuries. Hypoglycemia should be looked for and corrected if present.
Usually she would recover with mild residual drowsiness and disorientation.
If the fit recurs, it can be managed by intravenous diazepam, and phenytoin infusion started to prevent further convulsions.
Her hospital records would be checked for the presence of any high risk factors like diabetes, hypertension etc and whether she is on medication for epilepsy or whether her epilepsy was under control without any medication.
A thorough physical and obstetric examination is done especially looking for her orientation, residual neurological signs, presence of labour pains, and presentation and lie of the fetus. Abruption should be ruled out which can sometimes complicate this situation.
Fetal heart would be heard and arrangement made for a CTG recording.
As soon as she is oriented enough to talk I would try to establish whether there is any reason for this episode like missing the medication, lack of sleep etc. she would be advised to take her usual dose of anti epileptic medication, sometimes rectal administration may be necessary.
If she was on regular medication and still had a fit, serum drug levels are necessary and the dosage adjusted.
In the presence of persistent neurological signs, a neurology consultation requested.
In the absence of labour pains and abruptio placentae and if CTG is normal, spontaneous labour can be awaited till 41 weeks. Else delivery is indicated.
She and the baby should be followed closely in the postnatal period as the fits can recur due lack of sleep and the neonate might be at the risk of injury.
Posted by velam K.
The initial management in this patient will be basic resuscitation.Her Glasgow coma scale should be assessed.She should be place in left lateral position and airway checked. Facial oxygen should be given. Intravenous access should be obtained, and blood should be obtained at the same time for full blood count, group and save, urea and electrolytes, liver function tests, coagulation screen, blood glucose, serum drug levels of her antiepileptic medications. she should be checked for evidence of any injury due to fall from her last convulsion. The consultant obstetrician and anaesthetist should be informed. The labour ward sister shoud be informed and she should be transferred to the high dependency room in labour ward. she should be catheterised and urine should be checked for protein and hourly urine output should be monitored. Her pulse, blood pressure, oxygen saturation should be monitored regularly.Fetal monitoring should be carried out with CTG.
Her further management plan should involve close discussion with consultant anaesthetist. she should be started on magnesium sulphate infusion based on local protocol. This will prevent the occurence of any further convulsions. Her blood pressure should be monitored carefully to assess for the need for antihypertensives. If she needs antihypertensives the dose should be titrated in such a way so that theres is no sudden drop in BP because it can precipitate intracerebral events. Her serum urate level and platelet count should be monitored. once she is stabilised plans should be made for her delivery. since she is 39 weeks gestation a cervical assessment should be carried out. If her assessment is favourable than labour can be induced. If she is not favourable than an elective caesarean section may be necessary. The paediatricians should attend the delivery. The baby should receive Vitamin K injection on birth. She should be monitored carefully in the postpartum period as she is at increased risk for developing eclampsia. Thromboembolic stockings should be provided and thromboprophylaxis can be prescribed if her coagulation screen is normal. continuous monitoring of her respiratory rate, deep tendon reflexes, urine output is essential. It is necessary to continue magnesium sulphate for 24 hours.
It may be necessary to arrange CT scan brain based on the presence of any neurological lesions as a result of the eclampsia. It is important to discuss with her neurologist about her further management. It may be necessary to adjust the dosage of her antiepileptic medications.The patient should be discussed about the method of contraception before discharge and full explanation of the entire events should be explained. contact numbers should be given.
