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Near-SUDEP in the Parturient: Post Ictal Respiratory Arrest and Asystole in a Pregnant Epileptic Patient, with Subsequent Resuscitation and Emergent Cesarean Section.
Abstract Number: T5C-4
Abstract Type: Case Report/Case Series
INTRO: Epilepsy increases the maternal mortality by 10 fold(1). We present a case highlighting the importance of recognizing epilepsy related cardiopulmonary complications to prevent adverse outcomes in pregnancy.
CASE: A 21-year-old gravida 2 para 1 at 34 weeks with known epilepsy, was brought to the hospital after having 3 episodes of witnessed seizures at home. Patient had not taken her anti-seizure medications that morning. On examination, she was post ictal but responsive and hemodynamically stable. She was put on magnesium therapy. Soon after, she had another episode of tonic clonic seizure. IV Lorazepam was administered, with brief cessation of the seizure activity followed by clenching of jaw and decline in oxygen saturation. Oxygen was administered via non-rebreather mask. She became cyanotic and lost palpable pulses. CPR was initiated. 6 minutes from the event, return of spontaneous circulation and the initiation of spontaneous agonal respiratory effort was noted. She was anesthetized and intubated. C-section commenced and a vigorous male infant, with Apgar scores of 7/7/9, was delivered. She was transferred to intensive care unit. She was extubated on post-operative day 1 and discharged home on day 4.
DISCUSSION: 80 deaths/100,000 pregnancies have been reported in women with epilepsy, as compared to 6 deaths/100,000 pregnancies without epilepsy(1). SUDEP accounts for 18% of deaths in epileptics(2). It refers to a sudden, unexpected, witnessed or unwitnessed, non-traumatic and non-drowning death in patients with epilepsy. Near SUDEP describes cases in which cardiopulmonary arrest was reversed by resuscitation with subsequent survival. The exact pathophysiology of SUDEP is unknown. Various mechanisms including respiratory, cardiac, cerebral and autonomic dysfunction have been postulated(3). The proceedings of this case are consistent with near SUDEP. Simultaneous drop in maternal and fetal heart rate can be attributed to maternal hypoxia resulting from cardiopulmonary arrest. Although, Ictal asystole and bradycardia are usually self-limiting(4), these should be promptly recognized and intervened upon in a gravid patient to avoid morbidity and mortality, as evidenced by favorable results in our case.
1.MacDonald SC, Bateman BT, McElrath TF, Hernández-Díaz S. Mortality and Morbidity During Delivery Hospitalization Among Pregnant Women with Epilepsy in the United States. JAMA Neurol 2015;72:981
2.Walczak TS, Leppik IE, D'Amelio M, Rarick J, So E, Ahman P, Ruggles K, Cascino GD, Annegers JF, Hauser WA. Incidence and risk factors in sudden unexpected death in epilepsy: a prospective cohort study. Neurology 2001;56(4):519
3. Shishir Nagesh Duble and Sanjeev V. Thomas. Sudden unexpected death in epilepsy. Indian J Med Res 2017 Jun;145(6):738–745
4.Marije van der Lende, Rainer Surges, Josemir W Sander, Roland D Thijs J. Cardiac arrhythmias during or after epileptic seizures. Neurol Neurosurg Psych 2016 Jan;87(1):69-74