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Anesthesia management in a patient with seizure activity in the third trimester for emergency C-section, Epilepsy vs Eclampsia?
Abstract Number: F-74
Abstract Type: Case Report/Case Series
Introduction: Seizure disorders are present in less than 1% of all pregnancies1. If seizures have been under control, it is rare that they will occur later in gestation and seizure presentation in the third trimester of pregnancy or in the early postpartum period may be difficult to distinguish from eclampsia. We present a case of previous head trauma and subsequent seizure disorder that had been under control until the patient presented to the emergency room with neurologic symptoms and subsequent seizures in the third trimester.
Case presentation: A 26 year old G1P1001 @ 38 weeks+5 day presented to the ER with hypertension and left sided weakness. She was started on LMWH and Aspirin with concerns of a possible stroke (?). The patient’s pertinent history included a traumatic fall from a horse in 2014 and required a cranioplasty and tracheostomy with a prolonged hospital stay. Subsequent sequelae from the trauma included subglottic stenosis and vocal cord dysfunction in 2015, and seizures treated with Zonisamide since 2014. Symptoms seemed to resolve but she had problems with fine motor movements. 36 hours after admission, patient noticed fullness of the head and headache. She had 2 episodes of seizure activity and was admitted to the Neuro ICU. When she discovered that she was pregnant, she stopped her anti-epileptics and Folic acid. She was treated with lorazepam and levetiracetam for epilepsy. She was also loaded with 2 grams of MgSO4 and started on an IV infusion of MgSO4 due to the possibility of eclampsia. She was electively intubated with 7.0 size ETT, concerned with her airway mainly her subglottic stenosis. An MRI was performed with no evidence of a bleed or acute pathology, which was followed by an emergent C-section. The patient was induced with propofol and vecuronium on arrival to the labor and delivery OR. Sevoflurane was also administered along with a BIS monitor during the procedure. After the delivery of a viable male infant with Apgar’s of 3 and 5, Midazolam and fentanyl were administered. Patient was transported to Neuro ICU intubated. Patient was stable during the transport and was extubated in Neuro ICU on the next day. The patient was discharged home on the fifth postpartum day.
Discussion. Seizures during the latter part of pregnancy is commonly due to eclampsia, however, the effect of pregnancy on previous seizure disorder is variable, but can increase due to the increased volume of distribution and increases in renal and hepatic clearance during gestation and lack of patient compliance due to concerns of potential fetal anomalies. Although, the likelihood of eclampsia in this case was small, it could not be ignored especially with hypertension and a prolonged seizure-free period during gestation and prior to admission.
References. 1. Perks A, Cheema S, Mohanraj R. Anaesthesia and epilepsy. British Journal of Anaesthesia 2012;108:562-571.